A Conversation with Dr. Leslie Buckley 

BRIA spoke to Dr. Leslie Buckely, an expert psychiatrist and Chief of Addictions Division at the Centre for Addiction and Mental Health. Lesley specialises in providing care for women with substance use with a special interest in substance use and mental health issues, as well as public health and prevention around substance use issues. She sheds light on the importance of opening up the conversation on what it means to struggle with substance use, and how to support someone fighting addiction.

BRIA: Can you give us a big picture about some of the data amongst trends in women and substance use? 

Leslie: Yes, we are seeing two very important trends related to women and substance use. First, the gap for substance use between sexes is closing. When looking at the numbers, especially in younger women, we see that both womens and mens use in alcohol and cannabis are converging. There is a slight decrease in alcohol use in younger people and I believe this may be a result of a switch from externalising disorders to now internalising disorders. We see more internalising symptoms of disorders in youth than externalising, which shows itself in activities like substance use. This internalising is mainly all in male numbers and has stayed the same for women. There is also a slight increase in cannabis use, which is not surprising due to the recent legalisation of cannabis. On the contrary, we are actually seeing a larger disparity between men and women in opioid overdose rates. With a staggering 80% in men and 20% in women. 

The second trend we are seeing in women and substance use is a quite dramatic change in public health advice around drinking, specifically what constitutes safe drinking. There has been a shift in moving from making recommendations for how many drinks you can have per week, to really saying that there is actually no safe amount of alcohol. 

BRIA: Can you rank some of the most common substances and most troublesome substances for women that you are seeing now?

Leslie: The first one is definitely alcohol, because it is the most ubiquitous. When we think about alcohol I like to picture an iceberg. The very tip of the iceberg represents the people who are drinking quite heavily and the very bottom of the iceberg is the people who do not drink at all. The big space in the middle is where the people who drink between the range of heavily to none at all and this is where we actually see the most amount of harm coming from alcohol use. The reason being because this is where the majority of alcohol related accidents happen (i.e., car crashes, falls, head injuries, assaults, violence, DUI, etc.). The placement of these harms on the iceberg is why we may not always see the harms of alcohol because they are not always associated with heavy use. 

The second most common substance is cannabis. There has been an increase in heavy users since 4 years ago when we saw the legalisation of cannabis. Cannabis use can be tricky though because it causes more harm than we realise, and more harm than cannabis producers let on. Specifically, there has been a lot of misinformation surrounding cannabis use and driving. 

The third substance is stimulants like cocaine, crystal meth, or the misuse of prescription stimulants (i.e., ritalin, concerta, etc.). These stimulants are more common than you know, yet a lot of people do not know or understand the harmful effects because they are not talked about enough. 

The fourth substance is opioids, the reason this is not number one is because it is not as common but it still is the substance we are most worried about. The biggest step we are advocating for is pushing people to treatment as soon as possible. 

The fifth substance is designer drugs, this is the last on the list but definitely not the least important. Designer drugs include psilocybin mushrooms, MDMA (ecstasy), Ketamine, GHB, which are most commonly used at a party scene or big events. Many people think you cannot get dependent on them but that is not true which is something we definitely worry about.

BRIA: What impact do these substances have on women’s physical and mental health, both with casual occasional use and more long standing ongoing use?

Leslie: Every substance’s effect on women’s physical and mental health is so different so I will break it down between short term and long term impacts. We will talk about alcohol first.

The short term impacts of alcohol use can vary but we know that is a depressant. This means alcohol slows down our cognition so we are not thinking as fast, our executive function is also slowed down so we cannot put cause and effect together which is why there can be coordination issues. There can also be interpersonal conflict with relationships because people can also say impulsive things when under the influence. Some other impacts include, tiredness, hangovers, impact on work ethic, gastrointestinal issues like heartburn or nausea. Another impact which many people do not realise is that alcohol can impact your sleep negatively. Yes, it is a depressant so it does make you tired but only for a short time and then hours later your body goes into hyperarousal which is a bodily reflex of reversing what the alcohol did to your system until you body has maintained homeostasis.

The long term impacts of alcohol use are liver issues, which are most common, specifically sorosis of the liver. I have some friends at the liver clinic and sometimes they are getting people coming in for liver issues who have not been drinking in the numbers you think would be required for that level of issue. For those who think their drinking may be on the heavier side of the iceberg, they can ask their family doctor to run labs and see how their liver is doing. We also see impacts on heart health, issues like cardiac arrhythmias for example. Alcohol can cause changes in muscle function of the heart which can make it less healthy. The biggest and most drastic long-term impact of alcohol use is in the brain, issues such as memory impairment, and other cognition issues as someone ages. 

In the last 30 years we have learned a lot about what is happening in the brain to make us want substances that will knowingly end up causing us harm. But it wasn’t until we learned about the reward pathway that we really started to understand. Each substance has its own receptor and as they interact the brain gets used to them being there, this is what causes feelings of withdrawal and no matter what substance or receptor there is one common final pathway, and that is the reward pathway.

When substances enter the brain they make that reward pathway fire and the more you use a substance the more it fires, and when something is firing a lot in the brain the brain acts by down regulating which means you need more of the substance to get that  same level of pleasure.

As our reward pathway fires we also learn.It is our belief  that because people learn in different ways, some may be more prone to this process of becoming dependent on a substance. Whether that is genes, or just being a quick learner, these factors can elicit different responses to their reward pathway. Overall, this reward pathway explains why it’s so hard to cut back as someone is becoming severely dependent on a substance.

The short-term cannabis harms include negative impact on appetite, anxiety, mood dysregulation, memory impairment, confusion and tiredness. Other impacts can be within the actual experience of the high. For example, sometimes it is a positive experience when someone uses cannabis, and other times it can be a really negative or anxiety provoking experience. The biggest thing psychiatrists are afraid of is the long term impact of developing psychosis. Psychosis is hearing or believing things that are not there or true. Usually, when there is someone in the family tree who has experienced psychosis we generally advise them not to use cannabis, or if they choose to then it should be less potent and less frequent. 

BRIA: So when it comes to using a substance, what comes first, do people use it to feel good or do they use it because they already do not feel good and want to boost that reward pathway or take the edge off of the symptoms they are experiencing? How do we unpack that and understand the whole self-medication piece versus the underlying substance use disorder as the primary focus, because a lot of the time they are intertwined. 

Leslie: Intertwined is the right word to use in terms of what came first because we know it works both ways. So it really goes both ways. For example, we see someone who doesn’t really want to talk about their alcohol use because they started using for their anxiety and their anxiety is what they want to focus on. However, we always try to help them understand that when it is being used in this way both alcohol and anxiety become their own issues so we try to address both at the same time.

I think a great example of this is when comedian Kathy Griffin was talking about her recovery. She says it first started out as magic as she used it to her benefit and didn’t see the cost, but then it turned into medication, which then quickly turned into a third stage, which she named misery. The three stages Kathy references, magic, medicate, and misery, highlight the fact that substances can be affecting us more now than they did at first.

BRIA: People ask a lot about microdosing substances, which seems to be quite popular for those wanting to take charge of their mental health symptoms. Can you talk a little bit about that and is there any evidence surrounding that, and what are the risks and benefits? 

Leslie: Microdosing which is when the person doesn’t feel intoxicated. Microdosing is most popular with psilocybin mushrooms and over time we’ve seen people actually reporting their mood improving because of it. Recently,  the phase microdosing is entering now is people asking for real research on its effects. There is also use of microdosing Psilocybin or ketamine in substance assisted psychotherapy, which is where you go in for the whole day and take the substance under supervision and then usually process trauma afterwards. 

It is a really elaborate process when done well but again we do not have enough research or evidence on it yet so we do not advise or suggest it. But when people talk about it we stay involved and supportive. 

BRIA: On that note of people taking matters into their own hands sometimes we get the inclination to look for other options of treatment or relief from suffering. But there’s such a fine line between what is helpful or harmful. How would you look at those substances and guide people in asking about what may be safe to try versus what’s risky?

Leslie: People often wonder what medical cannabis does to help and what does it harm, and it is really hard to find solid information. There was a good meta-analysis on studies that had been done on cannabis’s effect on PTSD, mood, anxiety and other disorders and there was absolutely no benefit found. What they did find was that women are significantly more affected in cannabis withdrawal than men and this is not talked about enough. Withdrawal symptoms include: irritability, anxiety, low mood, nausea, insomnia and intense dreams. The height of these symptoms makes it hard to get off cannabis because using it gets rid of them. I like to encourage people to give sobriety a longer time, because a lot of people say they feel clearer after a week and after 2 weeks you can get a rough idea of what your real baseline mood is.

BRIA: Can you talk a little bit about what the recent news and guidelines are regarding alcohol? 

Leslie:The old guideline used to be that women can have 10 drinks per week and men have 15 drinks per week, it was also rather binary in the sense that if ur under the limit your good, and if your over there risk. Although it was very convenient and easy to follow. The newer rules are very different, they say now there is no safe alcohol use and even smaller amounts of alcohol have led to an increased cancer risk.  

• 0 drinks per week = no risk
• 1-2 per week = very low risk
• 3-6 per week = increased cancer risk
• Higher than  drinks per week = higher risk for all sorts of diseases (heart, liver etc)

BRIA: I think the mental health part of it isn’t as scary to people as the physical health, once someone realises that something may be negatively impacting their physical health it stops them in their tracks. I liked how you help someone to look at their health in a more comprehensive way and the different facets between the substances and their activity level which is a very non-stigmatising and much more positive way for a person to look at their life as a whole, opposed to a very black or white approach. Less daunting for people

Leslie: there is always this plan that we have but then what happens in reality and the hurdles that can get in your way

• One of the factors is stress
  • We can do things that are healthy (i.e., go for walks, face our issues, see people, get better sleep) or unhealthy ways (i.e., blaming behaviour, procrastinating or using substances)
  • And when we get more stressed we do more of those behaviours and if we are on the unhealthy side of things we do more unhealthy things
  • We don’t really think about it though and it is something you can plan on how you can reduce your stress and nudge yourself to using the healthy activities 

BRIA: How can someone identify when they are consuming too much of something? 

Leslie: First is to think about the numbers (like in the old guideline), so that could look like counting your drinks for the week. Also to pay attention to see if aspects of your life like your work, school or relationships are affected by your substance use. Or if you are doing less activities and have difficulty cutting down. 

BRIA: So when that moment comes that a person recognizes they need help, what should they do? 

Leslie: It always starts with self analysis to get an idea of what is happening behind the scenes and exactly how and what you can change. The changes do not need to be drastic at all, it could look like replacing habits, so taking a walk instead of having a drink, or changing activities like socialising without alcohol or changing social environment. You can also experiment to see how long you can go without a substance, or switch to drinks that you do not prefer. I always remind people though, when you are going through this process it is absolutely necessary to be a good coach to yourself, do not get mad at yourself for not being able to meet your goals because it’s all about learning and finding a healthy coping plan. You can also reach out to available resources and try what works best for you. Like talking to family doctors, reaching out to addiction counselling, either group or individual, and step programming like AA meetings.

BRIA: Can you speak a little bit about the trajectory of recovery because people do tend to be discouraged, and what are some of the ways people find success?

Leslie: Part of the process is figuring out whether you can reduce your intake or stop completely. So be gentle with yourself when you are making changes. I find most success follows when someone makes the mindset shift that abstinence is an opportunity and you feel grateful for your sobriety, rather than the “i wish i could stop drinking because its not good for me” mindset. A big part of the shift, feeling good rather than regretting. 

BRIA: What is the best way for people to approach those in their lives who they worry about their substance intake? 

Leslie: Lets focus on friends and partners in your personal life and use a staged approach.  

Before I get into the stages though it is crucial to preface that you do not know what response you are going to get, whether that be defensive or open. 

Stage 1: Inquiring gently stage

• We see this in partners, sometimes they feel good but your partner is no longer feeling connected to you and they are unaware of that

Stage 2: I’m concerned stage 

• Try this many times as you need, but if it is not being received well then you can move on to stage 3

Stage 3: setting boundaries 

• This isn’t working for me
• This is a whole different level and can elicit a stronger response

BRIA: How do you advise someone in the relationship to set their boundaries but be supportive?

Leslie: The ultimatum doesn’t have to be asking your partner to completely stop but rather tell them you want them to see someone or at least make an attempt to stop. Reminder that everyone is different at this point so some will gradually support and some will want their partner to stop altogether.