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Medication nonadherence has been one of the major barriers in patient care for psychiatrists managing patients with chronic mental health disorders.

 This has resulted in multiple negative outcomes including a protracted course of illness, worsening disease symptoms severity, risk of relapse suicide risk, illness exacerbation, mortality, and frequent hospitalizations.

 In addiction, medication nonadherence-related hospital readmissions increased the health care cost burden of the early 21st century to more than $100 billion per year, continuing to rise annually.

 However, one of the modifiable risk factors for medication nonadherence with possible interventions gaining traction is substance use disorder (SUD), particularly 

Cannabis is one of the most frequently used drugs worldwide, and CUD has been rising substantially globally, especially in the Americas and Asia.

 CUD has become a growing problem in the United States since the passing of legislation permitting the medical use of cannabis in more than 33 states and recreational use in 11 additional states as of 2020.

 The overall percentage of patients who are nonadherent to their psychotropic medication was estimated to be 49% (56% with schizophrenia, 50% with major depressive disorders, and 44% with bipolar disorders).

patients with first-episode psychosis who use cannabis

 were more prone to medication nonadherence and illness relapses compared to those who stopped using substances.

 A systematic review of 3678 patients with psychiatric illnesses also found cannabis users to have 2.5 times higher medication nonadherence to antipsychotic medications compared to non-cannabis users.

Nonadherence is very challenging to tackle in the clinical setting, given its high prevalence. 

 is usually identified after multiple relapses, misinterpretation data of medication efficacy, and several changes to prescription medications.

 However, there is evidence that cannabis use can be an early warning sign for future nonadherence and may be a good source for early intervention before a patient relapses.

Typically, a urine drug screen (UDS) is done for screening patients who might have been using 

 for several weeks in cases of chronic cannabis use. Delta-9-tetrahydrocannabinol (THC) and other cannabinoids metabolites can be detected in the urine of chronic heavy users of cannabis for up to 6 weeks. However, other active cannabinoids such as cannabidiol have less sensitivity to testing. What is crucial for clinicians to know is that a therapeutic alliance between the physician and the patient is key to managing patients with cannabis use and medication nonadherence.

Despite the availability of UDS tests, physicians should feel comfortable asking their patients about history of drug use utilizing techniques such as motivational interviewing. The interaction of cannabis and psychotropic medications should be described in clear terms to patients. Evidence has shown that the efficacy of antipsychotics in patients with psychosis and comorbid cannabis use is limited in the treatment of psychosis.

 There should be intentional education for patients about the negative effects of cannabis use. Clinicians must understand that CUD, like other SUDs, is a chronic relapsing disorder and some patients may have a difficult time attaining or maintaining 

. Sometimes it is helpful to offer patients shorter appointments to monitor periods of sobriety or complete abstinence during their treatment course. This also goes a long way to make patients feel like part of their treatment decisions.

Here we present 2 cases of patients with a history of chronic cannabis use and medication nonadherence to highlight the need for clinicians to spend more time educating their patients about substance use and offer other interventions to increase chances of abstinence.

“Ms Monroe” is a young female patient with a history of anxiety disorder and major depressive disorder. Ms Monroe was diagnosed and prescribed with 

 and anxiolytic in the outpatient setting but reported multiple relapses due to poor compliance with her medications and heavy daily use of cannabis. She feels that smoking cannabis gives her relief from symptoms of anxiety and depression. Her increased use of cannabis over the years resulted in further deterioration of her mental health, as she was reported to be very paranoid and acting bizarre at presentation.

In the ER, she initially had hallucinations, then suddenly became completely mute and did not participate in any assessment. Ms Monroe was admitted to the inpatient, placed on appropriate precautions for the initial portion of hospitalization, and introduced to a therapeutic milieu. All labs and imaging studies were found to be within normal limit. She was diagnosed with catatonia. Ms Monroe responded to Ativan challenge and Ativan along with the addition of an antidepressants and antipsychotics. She responded well to the treatment, her catatonia completely resolved, her psychotic symptoms lessened, and her oral intake improved. While on the unit, she actively engaged in all aspects of treatment including individual and group/milieu therapy. Ms Monroe was educated about the negative physical and emotional effects of cannabis use. The team recommended she stop due to possible exacerbation of psychotic symptoms and concern for effects on efficacy of her medications. Motivational interviewing was employed and found to be very helpful. A significant improvement in patient insight regarding medication adherence and adverse effects of cannabis use was appreciated at the time of discharge.

“Mr Walker” is a middle-aged male patient diagnosed with schizophrenia. Mr Walker was treated with antipsychotics for several years. He has a history of multiple relapses and hospitalization in the context of poor medication adherence and chronic cannabis use. Each time this patient is discharged with antipsychotic medications, he defaults on his care and goes back on the street to acquire 

. His chronic cannabis use has often resulted in a relapse and therefore made him a frequent user of the mental health facility closest to him.

During his most recent admission, Mr Walker was asked if he would continue to use cannabis. He stated that he would not be able to say definitively until discharge from the hospital. Mr Walker was initially adamant about his care in the hospital but later started to participate in the treatment plan on the inpatient service. He was offered individual and group therapy sessions along with restarting his psychiatric medications. He was able to meet with the drug and alcohol use counsellor, who, over the duration of his stay in the hospital, was able to speak to him about quitting cannabis use, given his history of relapse and multiple hospitalizations. Different modalities were employed, including counseling, and scheduling short outpatient clinic appointments. At discharge, Mr Walker was sober and willing to engage with his psychiatric treatment while staying sober. He had a better insight into his psychiatric condition and understood the need to stop taking cannabis and be adherent to medication to prevent subsequent hospital admissions.

These 2 cases bring to light poor insight into a major issue among these patients. Often, patients do not think cannabis has anything to do with their mental illness. If anything, they think it helps their current mental health status improve. If clinicians spend more time educating their patients about substance use, its effects, and interactions with their medications, negative outcomes might be prevented. Both patients in these cases responded to antipsychotic and therapeutic milieu, but the problem is that patients often relapse once they get back on cannabis.

Different approaches have been implemented to improve psychotropic medication adherence among patients with chronic cannabis use. These include motivational interviewing (MI), 

 (CBT), use of smartphone apps, and augmentation with telepsychiatry. Implementation of evidence-based MI Style Adherence Therapy was found to be clinically significant in improving adherence to psychotropic medication (82% to 85%) in a Veterans Affairs Mental Health Clinic.

 MI intervention has shown improvement in psychotropic medication adherence from 43.9% to 70.7% in adolescents taking antidepressants and mood stabilizers.

The usage of CBT strategies has shown to improve medication adherence and treatment outcomes in patients with bipolar disorder by increasing knowledge about medication and changing attitude toward treatment.

 Moreover, CBT use in another bipolar population study was shown to increase medication adherence and reduce relapse rates.

 Another study explored a combination of medication monitoring and CBT in increasing medication compliance in patients with bipolar disorder and comorbid SUD over 12 weeks compared to medication monitoring alone.

 The study found that adding CBT showed improved medication adherence and mood symptoms.

Another possible intervention could be smartphone appsin using different modalities to enhance medication adherence. For instance, a study explored the use of smartphone app intervention in managing patients with type 2 diabetes medication nonadherence.

 The study showed that the smartphone app was user-friendly and had improved awareness of medication adherence. However, the app usage did not improve clinical outcomes in the population. The usage of smartphone apps in assisting with mental health medications adherence is still in its infancy due to lack of an evidence-based approach and the need for cocreation with patients, which might increase the impact on medication nonadherence. The lack of social cognition models in ensuring patients’ education, motivation, skills, beliefs, and type of adherence while developing the apps makes it very challenging to use in mental health interventions.

 A systematic review of 13 articles assessing the studies that investigated these apps showed a lack of standardized measures of adherence.

Finally, another approach that could be beneficial is 

. A recent systematic review including 17 articles showed that telemedicine improved medication adherence in patients with depression, bipolar disorder, or schizophrenia.

 Telemedicine, such as telephone call and text messaging intervention, has been shown to improve medication adherence in patients with severe mental illnesses,

 but not much research has been done to see if it can help patients with CUD. However, a randomized controlled trial found that using text messages as reminders may contribute to improving medication adherence in patients with comorbid depression and substance use.

 More research needs to explore patients with mental health conditions and comorbid cannabis use disorder, given the impact of cannabis on medication adherence.

Treating mental illness when patients are medication-nonadherent in the context of cannabis use is a complex process. Choosing the right intervention is important, as psychopharmacology, MI, CBT, telepsychiatry, and smartphone app interventions each pose their own individual challenges. In addition, factors that also influence medication adherence in CUD such as treatment modalities, self-motivation to treatment, self-coping capacity, and social support to influence changing behavior are things to consider when hoping for change.

Multiple research approaches have provided evidence-based findings, including integrated and multifaceted approaches to help and support current practices, but further research is needed as current options continue to pose implementation challenges.

is a psychiatry resident physician in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Houston, Texas. 

is an attending physician and assistant professor of psychiatry at Yale School of Medicine in New Haven, Connecticut.

If you're interested in hearing more about cannabis, there's still time to register for the 

2022 Annual Psychiatric Times™ World CME Conference

Barriers to treatment: describing them from a different perspective.

2. Higashi K, Medic G, Littlewood KJ, et al. 

Medication adherence in schizophrenia: factors influencing adherence and consequences of nonadherence, a systematic literature review.

4. Foglia E, Schoeler T, Klamerus E, et al. 

Cannabis use and adherence to antipsychotic medication: a systematic review and meta-analysis.

5. UNODC. United nations office on drugs and crime. world drug report 2017. 2017. Accessed August 5, 2022. 

6. Map of marijuana legality by state. DISA Global Solutions. 2020. Accessed August 5, 2022. 

https://disa.com/map-of-marijuana-legality-by-state

Psychotropic medication non-adherence and its associated factors among patients with major psychiatric disorders: a systematic review and meta-analysis.

8. Oladunjoye AF, Kaleem SZ, Suresh A, et al. 

Cannabis use and medication nonadherence in bipolar disorder: a nationwide inpatient sample database analysis.

9. Schoeler T, Petros N, Di Forti M, et al. 

Effect of continued cannabis use on medication adherence in the first two years following onset of psychosis.

Compliance with medication regimens for mental and physical disorders.

Antipsychotic efficacy in psychosis with co-morbid cannabis misuse: a systematic review.

12. Hughes F, Vess J, Johnson E. Increase adherence to psychotropic medication through motivational adherence therapy: a quality improvement project. 

Evaluation of motivational interviewing to improve psychotropic medication adherence in adolescents.

Preventing medical noncompliance in the outpatient treatment of bipolar affective disorders.

15. Lam DH, McCrone P, Wright K, Kerr N. 

Cost-effectiveness of relapse-prevention cognitive therapy for bipolar disorder: 30-month study.

16. Schmitz JM, Averill P, Sayre S, et al. 

Cognitive-behavioral treatment of bipolar disorder and substance abuse: a preliminary randomized study.

A smartphone app to improve medication adherence in patients with type 2 diabetes in Asia: feasibility randomized controlled trial.

18. Kassianos AP, Georgiou G, Papaconstantinou EP, et al. 

Smartphone applications for educating and helping non-motivating patients adhere to medication that treats mental health conditions: aims and functioning.

19. Patoz M-C, Hidalgo-Mazzei D, Pereira B, et al. 

Patients’ adherence to smartphone apps in the management of bipolar disorder: a systematic review.

Telemedicine interventions for medication adherence in mental illness: a systematic review.

21. Schulze LN, Stentzel U, Leipert J, et al. 

Improving medication adherence with telemedicine for adults with severe mental illness.

22. Agyapong VI, Ahern S, McLoughlin DM, Farren CK. 

Supportive text messaging for depression and comorbid alcohol use disorder: single-blind randomised trial.

Cannabis use disorder and nonadherence: How can we best educate patients? 

The Impact of Cannabis Use on Medication Nonadherence in Psychiatry

, we worked with experts from multiple psychiatric areas to bring you thoughtful articles about a wide variety of psychiatric issues, from the new 988 suicide hotline to the role of antipsychotic selection in reducing nonadherence in schizophrenia. Here are some highlights from the issue.

The National Suicide Prevention Lifeline is getting an upgrade. On July 16, 2022, the Lifeline will change from its previous number (800-273-8255) to just 3 digits: 988. Although the old number will remain available for calls, individuals may call, text, or chat 988, where they will be connected with trained counselors.

Additionally, if functioning as intended, operators will be able to counsel callers 24 hours a day and dispatch specially trained responders, hopefully reducing armed law enforcement interventions and emergency department (ED) visits. 

It's Time to Think of Women: Mental Health Services for First-Episode Psychosis

As the World Health Organization reminds us, gender is a critical determinant of health, including mental health. Psychosis affects 3 in 100 individuals worldwide and typically develops around age 21 years. It includes diagnoses such as those of the schizophrenia spectrum and affective disorders. Early intervention services hold the promise of changing the trajectory of psychosis by providing specialized, coordinated care to individuals experiencing their first episode of psychosis (FEP). Evidence shows that FEP services can improve short-term and long-term outcomes for the individual (eg, employment) and for their community (eg, reduced disruptive public behavior, legal charges). What remains unknown, and maybe overlooked, is that women experiencing FEP might encounter gender-based disparities in accessing and receiving specialized care. 

Antipsychotic Selection is Important for Reduced Nonadherence in Schizophrenia

“Mr Spear” is a white man, age 43 years, with a 20-year history of schizophrenia who presents for an initial outpatient appointment with a primary complaint of insomnia. Upon further questioning, he explains that he is afraid to sleep due to paranoia because there are individuals outside his home at night who want to kill him. He will not take any medication that makes him drowsy. His mental status is otherwise unremarkable. He denies any suicidal or homicidal ideations and does not appear to attend to internal stimuli. He reports several previous psychiatric hospitalizations, but none in the past 3 years. He works full-time in construction and denies any work-related problems. After a discussion of risks and benefits, he agrees to a trial of daily low-dose aripiprazole (morning) and to return to the clinic in 4 weeks. However, Mr Spear does not show up for his follow-up appointment, he does not return a phone call to reschedule, and he never returns to the clinic. 

Caregiving: Walking the Personal and Professional Tightrope

August 16, 2019, in New Haven, Connecticut, was a beautiful summer evening. A delicious dinner at the Study at Yale hotel, where we were staying for the night, wrapped up a packed day of activities. These included a presentation and conversations about evidence-based addictions treatment modalities. The day could not have been better. I remember thinking that this was addiction treatment done right. A colleague invited a group of us to walk over to the Arethusa Farm Dairy store for their famous “designer” ice cream. I asked for a minute to go to my room and slip on some comfortable shoes for the 5-minute walk. I never returned. Instead, I called my colleague to tell him and everyone else to go ahead—I had to handle an urgent matter. I had at least 10 missed calls and several text messages from 2 neighbors. 

. And be sure to stay up-to-date by subscribing to the 

Do you have a comment on any of these or other articles? Have a good idea for an article and want to write? Interested in sharing your perspectives? Write to us at 

The experts weighed in on a wide variety of psychiatric issues for the July 2022 issue of Psychiatric Times.

From the Pages of Psychiatric Times: July 2022

Successful results were announced from the ONWARD trial, a phase 3 clinical study evaluating the efficacy, safety, and tolerability of 

AD04 in patients with alcohol use disorder

 (AUD) and selected polymorphisms in the serotonin transporter and receptor genes. AD04 achieved statistically significant mean reduction in heavy drinking days among the prespecified group of “heavy drinkers,” and showed a better safety and tolerability profile compared with placebo. Adial Pharmaceuticals conducted the study.

Professor Hannu E.R. Alho, Emeritus Professor of Addiction Medicine at the University of Helsinki and Principal Investigator for the ONWARD trial, said, “These study results may provide hope to millions of people worldwide suffering from AUD, as well to the families of those impacted by this devastating disease. Among heavy drinkers, which make up the majority of my practice, we saw a clear and statistically significant reduction in heavy drinking days for those patients receiving AD04 versus placebo. These results demonstrate the effectiveness of AD04 for heavy drinker AUD patients.”

Participants who received AD04 achieved a statistically significant reduction from baseline at month 6 in heavy drinking days for the prespecified patient group of heavy drinkers who averaged less than 10 drinks per drinking day at baseline; p=0.03. A similar trend was seen in the combined month 5 and 6 analysis in the reduction from baseline (p =0.07). In the last month of the trial, patients who were heavy drinkers and received AD04 had a mean reduction of approximately 79% in heavy drinking compared with baseline.

In addition, AD04 resulted in a reduction from baseline at month 6 compared with placebo in heavy drinking days for the combined trial population of heavy and very heavy drinkers (p=NS). At conclusion of the trial, compared with placebo, AD04 in the heavy drinking group resulted in an overall significant difference in the severity of the AUD diagnosis (p=0.04) under the DSM-5. For the group of those who no longer met AUD criteria ( less than 2 symptoms), the comparisons were 27.4% versus 14.9% (ie, an 84% decrease), of AD04 and placebo, respectively. These data underscore the clinical relevance of the findings that patients who are heavy drinkers who receive AD04 appear more likely to recover from the disease by the end of the treatment regimen.

“It has been my life mission to develop new therapies that provide patients with a means to either curb the impulse to drink, or abstain from alcohol entirely,” said Bankole Johnson, MD, Chief Medical Officer of Adial. “AUD accounts for more than 5% of deaths worldwide and is the number one indicator of death for men and women ages 15 to 49, the prime of their lives. The ONWARD study reinforces that AUD is a multi-factorial disease with a diverse set of neurobiological components. The ONWARD data appears to support our earlier findings that AD04 is a genetically targeted medical treatment addressing the biology of AUD. We believe our finding that AD04 appears as safe as placebo should increase its acceptability in general practice and eventually lead to widespread adoption of AD04 for treatment of AUD.”

The safety and tolerability profile was similar to placebo and consistent with the phase 2b trial. Adverse effects reported with a frequency of 5% or more of patients in either group were headache (11% on placebo, 12% on AD04), insomnia (3% on placebo, 7% on AD04), blood magnesium decreased (5% on placebo, 6% on AD04), and fatigue (3% on placebo, 6% on AD04). All were reported as mild to moderate.

William Stilley, Chief Executive Officer of Adial, commenting on the trial results, said, “Alcohol use disorder is an unmet medical need that affects tens of millions of people each year, and, based on the strength of these ONWARD results in heavy drinking patients that have the target genetics, and the fact that AD04 demonstrated an exceptional safety profile, and was well-tolerated during the trial, we intend to advance AD04. We will work with regulatory authorities in Europe and the US to achieve this goal.”

1. Adial Pharmaceuticals announces topline results for Onward™ phase 3 trial for AD04 in patients with alcohol use disorder. Adial. July 20, 2022. 

https://www.adial.com/adial-pharmaceuticals-announces-topline-results-for-onward-phase-3-trial-for-ad04-in-patients-with-alcohol-use-disorder/

Positive results from the phase 3 trial of AD04 show a 79% reduction in heavy drinking.

Reducing Heavy Drinking Days: Positive Results From Trial for Medication Treating Alcohol Use Disorder

August 16, 2019, in New Haven, Connecticut, was a beautiful summer evening. A delicious dinner at the Study at Yale hotel, where we were staying for the night, wrapped up a packed day of activities. These included a presentation and conversations about evidence-based addictions treatment modalities. The day could not have been better. I remember thinking that this was addiction treatment done right. A colleague invited a group of us to walk over to the Arethusa Farm Dairy store for their famous “designer” ice cream. I asked for a minute to go to my room and slip on some comfortable shoes for the 5-minute walk. I never returned. Instead, I called my colleague to tell him and everyone else to go ahead—I had to handle an urgent matter. I had at least 10 missed calls and several text messages from 2 neighbors.

As clinicians, we are trained and encouraged to have an objective approach to treatment, especially with addictions—substance use addictions in my case. In the 

Substance Abuse and Mental Health Services Administration 

(SAMHSA) Technical Assistance Publication (TAP) series (

), the addiction counseling competencies stress the importance of this approach. The knowledge, skills, and attitudes of professional practice are all structured around preserving the patient’s autonomy and promoting the clinician’s need for objectivity.

Traditionally, evidence-based modalities including 

(MI), motivational enhancement therapy (MET), cognitive behavioral therapy (CBT), contingency management interventions, and community reinforcement and family therapy (CRAFT), to mention a few, all advocate for openness and giving patients the benefit of the doubt—even when the reported interventions seem counterintuitive and deviate from our personal beliefs and values.

Succinctly, clinicians should prioritize the patient’s needs and well-being while “keeping a lid” on whatever frustrations may arise. After all, there may or may not be professional consequences. As clinicians, we are conditioned to not cross these boundaries regardless of our feelings. Often, this is so we can preserve the 

, which in turn facilitates desired treatment outcomes and prevents contention or confrontation with the patient. When it comes to chronic disease prevention and health promotion, the Centers for Disease Control and Prevention’s (CDC) National Center for Chronic Disease Prevention and Health Promotion identifies social connectedness as one of the 5 pillars of their framework.

 Additionally, throughout our training, the need to preserve a therapeutic alliance with our patients is emphasized, particularly because a healthy relationship is one of the major protective factors. But what happens if the patient is a loved one?

We are not trained how to respond when the individual struggling with a substance use disorder or addictions is a loved one. There is no manual on how to help ourselves when we are faced with the challenges of the caretaking role for our loved ones. Although we can apply the same skill set to manage and contain our emotions (ie, regulate ourselves and convey self-control), when it comes to disappointment, frustration, or betrayal by a loved one, those emotions hit a different nerve altogether. Fulfilling the clinician role is entirely different when that patient is not related to us. The shift in dynamics from a professionally trained caregiving role to complex family relationships presents its own set of challenges—all of which amplify the above-mentioned feeling with an almost visceral pain.

Shame and Guilt: Stepsisters of Fear and Control

In 2016, I embarked on a journey to use my training as a psychiatric nurse practitioner to give back to the communities I hail from. With a passion for substance use treatment, I set out to volunteer in Uganda. By 2018 it was clear that for me to contribute in a tangible manner, I needed to become licensed to practice in Uganda (which I did). Part of the licensing process required me to undergo 8 weeks of orientation at the main mental health and substance use referral hospital—

Butabika National Referral Mental Hospital

—in Kampala. It was during that training and orientation that the state of substance use in the country became clear to me.

Although there were systems and structures to provide care and support to individuals who struggle with substance use conditions, support for caregivers and family members was nonexistent. In fact, shame and guilt were all I saw. Using fear to scare individuals off substances was normalized, although not fruitful. The whole notion of “no one brings meals when your child is struggling with substance use addictions” was and continues to ring true.

as “a process of change through which people improve their health and wellness, live self-directed lives, and strive to reach their full potential.” Further outlined in the 

 are the 4 major dimensions that support recovery.

For the purpose of this article, I will dwell on the community part. To clarify, my formative years were spent in a strict evangelical household in which alcohol consumption was demonized. The little exposure to alcohol use and related dysfunction that I vaguely remember occurred when I was 10 or 11 years old. I do remember that whenever my stepmother consumed alcohol, there was palpable tension in the home. That said, my early childhood exposure to 

–related dysfunction was minimal. In my youth, I was introduced to shaming and ridiculing those who consumed alcohol. My father and stepmother converted to evangelical 

. As part of expressing our newfound faith, we as a family bore witness to how Jesus can make a difference “if we turn to him and confess our sins”; we then become born again. As such, I will not claim to have been in involved in any caretaker role for family or friends until my marriage.

Little did I know that in 2019 I would be on the receiving end of the same isolation experienced by family members caring for their loved ones who struggle with substance use disorders and/or other addictions. Having a loved one in the throes of alcohol addiction is a uniquely subjective experience. Not one experience is the same as another. Shame and guilt are powerful tools that can shake even the most grounded of us. Now I am happy to report that my husband is more than 2 years into his recovery and he continues to work at it. I will also add that we (because addiction affects the whole family) continue to work through the hiccups and hang-ups. I will also add that the experience of dealing with my spouse’s alcohol addiction was and continues to be my motivation for the nonprofit I founded at the end of 2019.

When I used the term visceral pain before, I meant that the frustration, perceived betrayal, hopelessness, anger, and disgust all took on a different tone when it came to my loved one’s addiction. I must admit, I was not graceful at all. I teetered between intellectualizing his addiction and minimizing the impact on us all as a family unit. The denial took on a life of its own. I would convince myself that he only overdrank and binged when he was not happy, and that he was far from meeting the criteria for alcohol use disorder. If it were someone else, with the evidence at hand and long history of telling events, I would not hesitate to diagnose them with severe alcohol use disord

The screeching wheels came to a stop on August 16, 2019. While I was away at the previously mentioned addictions-related event (go figure), an incident happened at my home. This time I could not intellectualize it and I could not wish it away. I remember going into full damage-control mode, something I had trained my brain to default to. I thought to myself, Contain the damage; what happens in the house stays in the home. Deal with this and handle the rest later. Except this time, I was not physically present to contain the damage. In hindsight, this incessant need to control aspects of my life is what perpetuated my denial all along—even with the “glaring open secret” out there for all to see.

I now realize how oblivious I was to the bitterness that had consumed me. The bitterness in turn triggered my childhood trauma that had been locked away safely (or so I thought). Reflecting on this, I was frustrated at my inability to tap into the same skill set I utilize with my patients as a trained clinician. One might wonder why I could not apply the same empathetic skills to my loved one that I apply to my patients. When it came to my own family member, those skills had waned. I now know that the underlying emotion was fear. Fear of losing my spouse and our children growing up without their dad. Fear of others finding out that my spouse was in fact deep in the vicious cycle of alcohol use disorder. Whenever he had his “episodes,” I reacted with anger. Why was he destroying us and everything we had built? To remind you, I have hundreds of hours of training on addictions, the psychopathology of addictions, the resultant behavioral consequences, and much more. That knowledge was readily available to me as a professional—but not as a wife. By the way, I have no trouble helping patients and their loved ones understand the multifactorial contributors to addictions, especially substance use. However, while I was actively navigating the trying times, that knowledge eluded me.

The events that followed were humbling and brought me to my knees. In the immediate days and weeks after the incident, we had the support of my in-laws, who wrapped their arms and resources around us. We were able to get my loved one treatment in an intensive outpatient treatment center that also provided intensive therapy. This enabled him to address the underlying issues. I will also add that the support left as quickly as it came. That is when the deep sense of loneliness set in for me. Except for 1 friend (who had accompanied me to the Connecticut event and was abreast of what had transpired), others who knew about the incident related to the night of August 16 chose to excuse themselves from our lives (and who can blame them?). Those who would have offered support did not know the full extent of what was going on. This was partly due to my conditioned containment strategies. That said, at this point, it was not my place to tell anyone. I also had to discern between respecting my loved one’s privacy and giving him the space to tell his story, without shaming him.

I often tell my patients that detox and intensive treatment are a gateway to treatment, but the real hard work—aka treatment— is ahead of them. This is because interventions often happen when patients are living in structured or controlled environments. If I thought the events of August 16 had broken me, I was in for a rude awakening in the months to come. With the onset of the pandemic, work and life balance strategies went out the window. My fear was seeing my loved one’s efforts come undone, especially by the collective 

that we were all feeling as a society. My overbearingness (rooted in trauma) went into overdrive. Even with minimal alcohol in the house, I developed a certain paranoia about the 1 to 2 bottles of wine we had (which we used for cooking).

This experience clouded my clarity regarding all the work that my loved one had put into his recovery. It was then that I knew I needed help. I underestimated the compounded effects of taking care of others in my professional life, as well as taking care of a loved one. Self-help books, therapy, exercise, and sleep hygiene all helped, but the effects were fleeting. I distracted myself with work; however, the triggers were ever present. It did not take much to get me into that negative space where I never want to be.

In summer 2021, a friend—a therapist himself—introduced me to the 

(CMC) as a resource for my patients. By this time, as a society, we knew things were not good. Before long I was invited to visit the CMC in the Berkshires in Massachusetts. It was through CMC that I was introduced to the Invitation to Change (ITC) model and the Foundation for Change. In November 2021, I completed the level 1 training as a clinician. The goal of the Foundation for Change is to offer a compassionate approach to substance use disorders through their ITC approach, which is “a holistic helping framework designed for the families and loved ones of people struggling with substances, as well as the professionals who support them.” Simply put, the ITC approach combines science and kindness. Its bedrock is that “evidence-based strategies are combined with compassion and care, making a wealth of research-supported and clinically tested knowledge accessible, practical, and understandable for everyone who needs it.”

Combining science and kindness—that was it! It occurred to me that while I was busy taking care of everyone, the truth was that I was also starting to show signs of compassion fatigue, which in turn affected my kindness and empathy scales. I had convinced myself that all was under control. Going through the ITC training helped validate my feelings, without taking away or adding anything. I know that I am a better spouse, mother, and clinician today than prior to the training. To put it bluntly, ITC has not given me the tools; rather, it holds all the tools together. ITC is my toolbox in which I continue to gather and store the tools that help me stay organized and feel secure in my capacity as an effective clinician while recognizing my brokenness.

I now have new lenses through which I view addictions treatment and support for families, and my empathy scale has been recalibrated. This has helped me clean up my relationships and find new meaning in what it means to be an ally—the very word I chose as the name of the nonprofit organization I founded in 2019. I like to tell people that we were allies before being an ally was trendy.

I will close by reflecting on a direct quote from the SAHMSA website

“The process of recovery is supported through relationships and social networks. This often involves family members who become the champions of their loved one’s recovery. Families of people in recovery may experience adversities that lead to increased family stress, guilt, shame, anger, fear, anxiety, loss, grief, and isolation. The concept of resilience in recovery is also vital for family members who need access to intentional supports that promote their health and well-being. The support of peers and friends is also crucial in engaging and supporting individuals in recovery.”

is an advanced practice nurse with an interest in addictions and trauma. She is the founder and president of Your Ally Foundation, Inc. Additionally, she is a clinical preceptor at Boston College William F. Connell School of Nursing in Chestnut Hill and Regis College in Weston, both in Massachusetts.

1. Addiction counseling competencies: the knowledge, skills, and attitudes of professional practice. SAMHSA. Updated 2017. Accessed April 11, 2022. 

https://store.samhsa.gov/sites/default/files/d7/priv/sma12-4171.pdf

2. Foote J, Wilkens C, Kosanke N, Higgs S. 

Beyond Addiction: How Science and Kindness Help People Change

3. Social determinants of health. CDC. Updated March 29, 2022. Accessed April 11, 2022. 

http://cdc.gov/chronicdisease/programs-impact/sdoh.htm

4. Recovery and recovery support. SAMHSA. Updated April 4, 2022. Accessed April 11, 2022. 

https://www.samhsa.gov/find-help/recovery

5. Our approach: invitation to change. CMC: Foundation for Change. Accessed November 12, 2021. 

What happens when a clinician is faced with addiction in their own family?

Adial Pharmaceuticals announced it plans to report topline results from their ONWARD phase 3 clinical trial on Wednesday, July 20, 2022.

 The ONWARD phase 3 clinical trial is a 24-week, multicenter, randomized, double-blind, placebo-controlled, parallel group, clinical study to evaluate the efficacy, safety, and tolerability of AD04 in patients with alcohol use disorder and selected polymorphisms in the serotonin transporter and receptor genes.

Study participants were genetically screened prior to enrollment to ensure that only genetically positive patients were enrolled. Approximately one-third of the screened participants tested positive for the targeted genetics. Patients were also stratified by the severity of drinking into heavy drinkers and very heavy drinkers, which was defined by an average of less than 10 or greater than or equal to 10 drinks per day, respectively. Approximately, two-thirds of the patients in the ONWARD trial were in the heavy drinking group and one-third in the very heavy drinker group.

ONWARD was conducted in 25 clinical sites across 6 countries in Scandinavia, Sweden, Finland, Poland, Latvia, Bulgaria and Croatia. Professor Hannu E.R. Alho, MD, Emeritus Professor of Addiction Medicine at the University of Helsinki, is the principal investigator.

1. Adial Pharmaceuticals to announce topline results of ONWARD™ phase 3 trial for AD04 in patients with alcohol use disorder. Adial. July 18, 2022. 

https://www.adial.com/adial-pharmaceuticals-to-announce-topline-results-of-onward-phase-3-trial-for-ad04-in-patients-with-alcohol-use-disorder/

New results are coming for AD04, a potential treatment for patients with alcohol use disorder. 

Upcoming Release of Phase 3 Trial Results for Medication Treating Alcohol Use Disorder

locations and vulnerable communities across the United States could lead to disruptions in care for patients in times of disaster, according to a new study.

 The research is a result of collaboration across the 

Healthy Regions & Policies Lab at the Center for Spatial Data Science

 and natural disasters, such as tornados, hurricanes, and wildfires, could disrupt access to buprenorphine, methadone, and extended-release naltrexone—all medications for opioid use disorder (MOUDs), lead study author Paul Joudrey, MD, MPH, said in a press release.

 Joudrey is assistant professor of medicine and a Yale Drug Use, Addiction, and HIV Research scholar at Yale School of Medicine in New Haven, Connecticut.

“In plain terms, we are not placing enough services in communities that are more vulnerable to disasters and pandemics,” Joudrey further explained. “If a disaster disrupts medication services, people living within these communities are less likely to receive treatment.”

This mismatch between community vulnerability during disaster and the availability of services was the worst for vulnerable suburban communities—a particularly unique finding, Joudrey added. “We also found that in rural communities, because the availability of services was just bad all around, there was no association between vulnerability and access to medications.”

The study compared treatment facility locations with residents’ social vulnerability across 32,434 zip codes in the United States. The social vulnerability index measured 4 issues: socioeconomic status, household composition and disabilities, racial and ethnic minority status and language, and housing type and transportation.

The investigators found that “zip codes with greater

did not have greater geographic access to each of the 3 MOUDs, showing the degree to which the United States falls short of ensuring equitable access to all MOUDs, especially during natural disasters.”

In addition, almost 25% of the US continental population lives without access to the medications within a 30-minute drive. The study authors put it in perspective: “Drive times were significantly longer for methadone and extended-release naltrexone relative to dialysis centers, despite the prevalence of OUD being greater than that of ESKD [end-stage kidney disease],” the authors wrote, noting their results were consistent with the emerging literature on these “opioid treatment deserts.”

Sadly, the study findings confirm what has been reported in recent natural disasters.

, Hurricane Sandy, and Hurricane Maria showed that part of the deaths that occur following disasters such as those are because people’s health services were disrupted,” noted coauthor Emily Wang, MD, professor of medicine and of public health and director of the SEICHE Center for Health and Justice. “Our results show that preparedness has too long been only a practice for the middle and upper class. We need to think more deliberately about how preparedness for hurricanes and for COVID-19 includes those placed at highest risk.”

The authors called for MOUD policy and delivery innovations “to address urban-rural inequities and better match the location of services to communities with greater social vulnerability to prevent inequities in opioid overdose deaths during future disasters.”

1. Joudrey PJ, Kolak M, Lin Q, Paykin S, Anguiano V Jr, Wang EA. 

Assessment of community-level vulnerability and access to medications for opioid use disorder

2. Parry J. Disasters could disrupt care for opioid use disorder in most vulnerable communities. News release. Yale School of Medicine. April 19, 2022. Accessed April 27, 2022. 

https://medicine.yale.edu/news-article/disasters-could-disrupt-care-for-opioid-use-disorder-in-most-vulnerable-communities/

Treatment deserts are adding fuel to the fire of the opioid crisis.

Opioid Treatment “Mismatch” Threatens Vulnerable Communities 

“Anna” is a 24-year-old Latina single transwoman (male to female) who has struggled with symptoms related to posttraumatic stress disorder (PTSD) for the past 5 years and was recently diagnosed with opioid use disorder (OUD). She is currently being treated with buprenorphine for her OUD and has been referred to you for treatment of her psychiatric symptoms. Her trauma symptoms began following a sexual assault that occurred when she was in her teens.

As a mental health professional, you are acquainted with stigma and how it can impact treatment. Psychiatric patients often experience stigma in the general community, including in health care settings. In this case, you would not be surprised that Anna has experienced stigma related to her PTSD and OUD. She has also been discriminated against because of her race and gender. Unfortunately, this is not an unusual presentation in many clinical settings. Anna’s treatment and recovery program will need to deal directly with these complex issues of stigma and discrimination.

This article will spell out how treatment can be structured around respect for patients and the building of a healthy sense of self-esteem as a central element in the recovery process. This overarching issue will be the central issue that pulls together all the elements of a complex treatment program.

Stigma can be found in any environment and can be directed toward any subgroup. There is an automatic neurobiological brain reaction that leads individuals to distinguish themselves from unfamiliar “others.” This is a protective biologic function that enhances the safety of the core group and generates fear of strangers. This reaction has been localized as a preferential activation of the amygdala—the brain region that generates precognitive reactions of aggression, fear, and anxiety.

 A few hours of CME lectures are unlikely to reverse such deep-seated biologic functions. Many religious and philosophical traditions have recommended a focus on compassion and exercises for placing yourself in the position of the “other,” as remedial techniques. Models for “walking in the shoes of the other” have long been identified as effective techniques for change.

Overcoming the Effects of Stigma in the Clinical Setting

Unfortunately, it is relatively easy to generate stigma and to direct it toward any subgroup that is “different” and easily identified. Reversing such a primal brain function requires significant effort. This may require intensive exposure to new experiences and new information. How can a mental health service design its training program to address this problem? Ronald W. Pies, MD, has 

 that we use our brains “to think and feel our way out of that mindset, and to behave with compassion and decency.”

Getting to know and respect our patients as individuals is at the core of standard psychiatric practice. It is already standard practice to collect a careful longitudinal patient history as the first step in an assessment. Listening techniques that are empathetic, nonjudgmental, and kind are critical, as is getting to know our patients through attention to verbal and nonverbal cues. Writing up a comprehensive history with a dynamic formulation and presenting it to your peers and supervisors should be a central part of any training program. None of this is new, but it requires that clinicians and trainees have the time to both perform these evaluations and provide intensive treatment if needed.

With any patient, treatment must begin with a thorough history and assessment. In this case, it is important to clarify her self-image. How does she see herself? What are her goals? The patient and her clinicians must share a common sense of aspirational goals. Where does she wish to go, and how can we facilitate that process? No matter how grave her current situation, her therapist must be able to recognize her potential for recovery and focus her efforts on goals that will restore her self-esteem. Trabian Shorters has described this process as asset framing.

 This is the beginning of the recovery process.

Most of the typical components of a psychiatric treatment plan can be utilized in these cases. Patients with substance use disorders (SUDs) and cooccurring psychiatric disorders will respond to the same psychopharmacology interventions and psychosocial treatments that are utilized in the general population. With the exception of benzodiazepines, most medications can be safely prescribed to such patients.

 Cognitive behavioral therapy (CBT), contingency management (CM), and motivational interviewing (MI) have also been used effectively in these patients.

 It is important to recognize however that the successful treatment of other psychiatric disorders will not resolve cooccurring SUDs. To achieve effective recovery for both the mental illness and cooccurring SUDs, it is important that specific elements of SUD treatment be integrated into the treatment program for any mental health condition. Fortunately, US Food and Drug Administration (FDA)-approved medications for addiction treatment (methadone, buprenorphine, naltrexone, disulfiram, acamprosate, varenicline, and nicotine replacement therapies) have all been prescribed successfully in this these populations.

What is the clinician’s role in reversing stigma for better outcomes?

Addiction & Substance Use

The Impact of Cannabis Use on Medication Nonadherence in Psychiatry

From the Pages of Psychiatric Times: July 2022

Reducing Heavy Drinking Days: Positive Results From Trial for Medication Treating Alcohol Use Disorder

Caregiving: Walking the Personal and Professional Tightrope

Upcoming Release of Phase 3 Trial Results for Medication Treating Alcohol Use Disorder

Opioid Treatment “Mismatch” Threatens Vulnerable Communities

Impact of Stigma for Patients With Dual Diagnosis

From the Pages of Psychiatric Times: June 2022

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A Broken Healer: Navigating the Personal/Professional Tightrope of Caregiving