Drugs play an increasingly large role in civilization, and especially among the patients or clients who are seen by mental health professionals. The drugs that counselors may encounter fall into two major categories, therapeutic and recreational. Therapeutic drugs may facilitate the clinical goals of the patients, but can also present unique problems that must be addressed in the therapeutic setting. Drugs used for nontherapeutic reasons may contribute to the problems of the patient, or otherwise interfere with the therapeutic relationship. The major classes of medical and nonmedical drugs that counselors are likely to encounter in their practice are discussed in this entry, including their primary effects and side effects, and the clinical issues that may arise.
The most widespread therapeutic drugs include those used to treat anxiety disorders, depression, psychotic illnesses, and attention deficit/hyperactivity disorder (ADHD). Agents used in treating these disorders can interact with psychosocial treatments. A psychotropic medication provides symptomatic relief that may increase the effectiveness of psychosocial treatment. For example, a patient suffering from an acute psychiatric illness may be withdrawn, apathetic, and unable to interact with the counselor. Medications ameliorate these symptoms so that the patient can then develop the skills and abilities necessary for a functional recovery. On the other hand, under some circumstances psychotherapeutic agents may hinder the delivery and application of psychosocial treatment, as in the case of drugs with severe sedative and amnesia-causing actions. Therefore, counselors consider the side effects of common psychotherapeutic drugs, and the possibility that these effects may present further psychological problems that must be addressed.
Anxiolytic (antianxiety) agents are among the most frequently prescribed psychiatric medications. Benzodiazepines, such as diazepam (Valium) and alprazolam (Xanax), are widely used for the treatment of generalized anxiety and panic disorders. At low doses, these drugs produce calming effects and mild sedation. Therefore, they are prescribed to treat both daytime anxiety and insomnia. At high doses, these drugs prolong sleep and, in the presence of other central nervous system (CNS) depressants, they can cause life-threatening respiratory depression (slowed breathing). The main side effects of these drugs are drowsiness, confusion, and impaired coordination. Benzodiazepines also have strong memory-impairing effects.
Although these drugs are effective for a variety of anxiety-related problems, there is some concern regarding their long-term use and potential for dependence. Some patients report that physical and psychological withdrawal symptoms make it difficult to stop taking benzodiazepines. Patients may also experience short-term rebound anxiety after stopping their medication. The risk of dependence on benzodiazepines is greater in individuals with severe mental illness or co-occurring substance-use disorders. Nevertheless, the long-term risk-benefit ratio of benzodiazepines in other patient populations remains controversial. Newer nonbenzodiazepine anxiolytic agents, such as sertraline (Zoloft), appear to have a better risk-benefit ratio.
Antidepressants are also widely prescribed, and may be used with psychosocial treatment. Currently, the first line of treatment for major depression are selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), sertraline (Zoloft), and escitalopram (Lexapro). These drugs may also be used to treat anxiety disorders such as panic disorders and obsessive-compulsive disorder.
Antidepressant effects of SSRIs are typically manifest only after at least 2 weeks of treatment. Side effects include nausea, anorexia, insomnia, sexual dysfunction including loss of libido and failure of orgasm, and increased suicidal thoughts in the first month of treatment. The use of some SSRIs with children and adolescents is contraindicated as there is some evidence that they increase suicidal thoughts in this age group.
Another class of agents used to treat depression is tricyclic antidepressants, although their use is usually reserved for individuals who do not respond to treatment with SSRIs. Tricyclics nonselectively block reuptake of both serotonin and norepinephrine and are more likely than SSRIs to produce side effects, including sedation and impaired psychomotor performance on tasks requiring attention, low blood pressure, confusion, and difficulty coordinating movements. Overdose with tricyclics is dangerous, particularly in combination with alcohol.
An important category of psychiatric medications is antipsychotic drugs, also called neuroleptics. These drugs are used to treat schizophrenia, psychotic depression, and mania. The two major classes of neuroleptics are referred to as typical antipsychotics (e.g., haloperidol such as Haldol), and atypical antipsychotics (e.g., clozapine such as Clozaril and, risperidone such as Risperdal). These drugs produce immediate sedation and are considered major tranquilizers. However, their antipsychotic action is delayed and requires up to 3 weeks treatment before effects are seen.
Despite their beneficial effect in reducing psychotic symptoms such as thought disorders, hallucinations, and delusions, these drugs also produce sedation, apathy, and reduced initiative and cognitive functioning. Patients’ dislike of these side effects may lead to nonadherence with medication and relapse.
These drugs also produce motor disturbances including Parkinson-like tremor, muscular rigidity, and sudden spasms of the head, neck, limbs, or trunk. These motoric effects are more pronounced in typical antipsychotics than in atypical ones.
Stimulant medications used for the treatment of ADHD are a further class of therapeutic agent used in the clinic, especially with children and adolescents. These include methylphenidate (Ritalin, Concerta), amphetamine (Adderall), dextroamphetamine (Dexedrine), and atomoxetine (Strattera). These drugs reduce hyperactivity, increase attention span, and improve concentration, vigilance, and activity in ADHD patients. However, they also have some adverse effects, including palpitations (abnormal heart beats), insomnia, weight loss, tics, and impotence. These agents also have a potential for abuse. Although they do not cause euphoria or feeling high at therapeutic doses, they can produce cocaine-like effects when crushed and injected. Despite concerns to the contrary, there is little evidence that treatment with ADHD drugs leads to later drug abuse. Children treated with stimulant medications are less likely to develop later substance abuse problems.
Agents used recreationally, including illegal substances and prescription medications, can adversely affect counseling care. Problematic drug use can generate psychological problems, exacerbate underlying psychiatric disorders, and interfere with attempts to change behavior. Therefore, screening for drug abuse is essential as part of the initial evaluation of any new client.
Psychiatric diagnoses of substance abuse and dependence are made using specific objective criteria listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). The main criteria for substance abuse are drug use that interferes with performing work, domestic, or social duties; exacerbates interpersonal or social problems; causes legal problems; and/or is used in a situation that is physically dangerous. The criteria for substance dependence include additional features such as tolerance or withdrawal, a loss of control over use, and persistent use in spite of knowledge of its detrimental effects. Briefer diagnostic tools are available to the clinician, such as the four-item CAGE questionnaire used to assess alcohol abuse (i.e., “Have you ever felt you should Cut down on your drinking?”; “Have people Annoyed you by criticizing your drinking?”; “Have you ever felt bad or Guilty about your drinking?”; and “Have you ever had a drink first thing in the morning (as an ‘Eye opener’) to steady your nerves or get rid of a hangover?”).
Counselors may take several steps to address the issue when drug use has been identified as a problem. The first and traditionally the hardest step is to help the individual to recognize that his or her pattern of use causes or intensifies existing problems. The second step is to work with the client on his or her motivation to change. Only then can steps be taken to decrease use. If dependence exists, the individual may be referred to an addiction service. For example, in the case of severe alcoholism, or dependence on opiates and sedative drugs, withdrawal symptoms can be life threatening and may require inpatient treatment. Counselors’ knowledge of the current status of psychosocial and pharmacological treatments available to treat substance abuse enables them to select the approach that is most appropriate for the client. Options may vary according to the specific drug of abuse. Because drug dependence is a chronic, relapsing disorder, most substance abuse clients require continued monitoring, even after long periods of successful abstinence. More broadly, this means it is important for counselors to ascertain whether any client has previously had a drug problem, whether or not he or she presents with drug-related complaints. The most prevalent drugs of abuse are alcohol, marijuana, stimulants, sedatives, and painkillers.
Alcohol is one of the most widely accepted forms of recreational drug use. Alcohol is a CNS depressant that was used as a general anesthetic until the late 19th century. At low doses, it produces feelings of well-being, reduces anxiety, and reduces behavioral and social inhibitions. At moderate doses, it impairs motor function and reaction times. Higher doses of alcohol produce severe motor and sensory depression, and at toxic concentrations unconsciousness, coma and lethal respiratory depression may occur. The withdrawal syndrome associated with alcohol dependence is severe and can cause fatal seizures.
Marijuana is derived from the Cannabis sativa plant, which contains cannabinoid compounds such as delta-9 tetrahydrocannabinol (THC), cannabidiol, and cannabinol. Cannabinoids typically increase heart rate and blood pressure and produce feelings of relaxation, heightened sensory awareness and distorted perception of time. However, marijuana also produces impairments in memory and some individuals experience panic reactions and paranoia, even at relatively low doses. Long-term use may produce dependence, and there are anecdotal reports that prolonged use can produce apathy (“amotivational syndrome”) or exacerbate psychotic symptoms.
Stimulant drugs, such as amphetamine, methamphetamine, Ecstasy, and cocaine, are frequently used as recreational drugs by young adults. These agents stimulate the CNS, thus increasing motor activity and producing excitement. At high doses, stimulants increase body temperature and produce repetitive stereotyped behaviors, insomnia, and anorexia. Repeated use of high doses of stimulants may produce a form of psychosis that closely resembles schizophrenia. Anxiety and paranoia are common adverse effects associated with the use of stimulant drugs.
MDMA (3,4 methylenedioxymethamphetamine), or Ecstasy, is a synthetic drug that has both stimulant and hallucinogenic properties. Throughout the 1990s, it was a popular drug in the youth culture for its euphoric and energizing effects and enhancement of tactile sensations. MDMA also increases empathy, but there have been reports that long-term use is associated with depression.
Caffeine, which is also a mild stimulant drug, is the most widely consumed psychoactive drug in the world. It is present in coffee, tea, soft drinks such as Coca-Cola, and chocolate. Although low doses are benign, increasing alertness and decreasing fatigue, caffeine can also produce nervousness at high doses or even at low doses in sensitive individuals. Caffeine may worsen existing anxiety disorders and precipitate panic attacks, particularly in individuals with panic disorder.
Sedative drugs, such as the barbiturates amobarbital (Amytal) and phenobarbital (Nembutal), are misused for their intoxicating effects. Typically, they are used in conjunction with other drugs, either to augment the pleasurable effects of those drugs (e.g., alcohol) or to counteract their unpleasant effects (e.g., to decrease nausea among opiate users). Low doses of barbiturate drugs produce relaxant effects similar to alcohol and higher doses impair motor coordination and produce sedation. Barbiturate overdose produces unconsciousness and death via respiratory failure. The risk of physical dependence on barbiturates is high even with relatively short-term use of high doses, and abrupt withdrawal may be fatal. Benzodiazepines are also used recreationally by a relatively small subset of young adults. As previously noted, despite public concern about their potential for misuse, the prevalence of abuse or dependence is low in clinical use and their safety profile is excellent.
Another class of abused drugs is opioids, such as heroin, oxycodone (OxyContin), and codeine (Tylenol with codeine). These drugs are CNS depressants that produce feelings of euphoria, but also sedation, nausea, vomiting, and constipation. Overdose with opioid drugs is particularly dangerous because it can result in coma and death by respiratory failure. Tolerance to these drugs develops rapidly and users must increase the dose to obtain the same effect. Physically dependent individuals who discontinue opioid use may experience irritability, weight loss, fever, nausea, diarrhea, and insomnia. Psychological dependence produces an intense craving for the drug upon abstinence that lasts for many months after detoxification. Oxycodone is an opioid drug used to treat pain that is twice as potent as morphine, and recently there has been a sharp rise in abuse and diversion of this drug for illicit use.
Hallucinogenic drugs, including d-lysergic acid diethylamide (LSD), mescaline, and psilocybin, cause sensory distortion or hallucinations that may be visual, auditory, tactile, gustatory, and/or olfactory in nature. The positive subjective effects of hallucinogens include stimulation, increased sensory awareness, and increased associative and creative thinking. Users describe their experiences as enlightening and life changing. There have been trials of hallucinogenic drugs to treat alcoholism and the pain and depression associated with terminal cancer. However, reactions and experiences vary across individuals and hallucinogens are equally likely to cause acutely unpleasant sensory experiences. Adverse effects of hallucinogens include panic reactions, prolonged psychosis, depression, and so-called flashbacks whereby transient perceptual disturbances recur weeks or months after intoxication.
Mental health professionals licensed to prescribe drugs and those who specialize in the treatment of substance abuse are familiar with the beneficial effects and adverse side effects of the most commonly used drugs. They are knowledgeable about the advantages and potential drawbacks of treating psychological disorders using a combination of psychopharmacological and psychotherapeutic interventions. Potentially, the use of drugs may increase the effectiveness of psychosocial treatment. They can reduce psychiatric symptoms so that patients are more available to treatment, and in some disorders may strengthen attention, speech, and memory. In turn, counseling can improve the relationship between the patient and care provider and improve treatment compliance. On the other hand, drugs can interfere with the long-term resolution of psychological problems because they relieve the immediate symptoms and reduce the patient’s motivation to confront the underlying problems. Furthermore, they may produce psychological dependence or intensify a patient’s perceptions of being ill. Thus, there are complex considerations surrounding the use of therapeutic drugs in a counseling context.
Mental health professionals are likely to encounter clients who use drugs nonmedically, and must make decisions about the extent to which this drug use contributes to the presenting problems. Recreational drug use is very common, especially among people with high levels of life stress, adjustment difficulties, and life transitions, who are most likely to seek counseling. Therefore, the counselor should always include a thorough assessment of the level of drug use to determine whether the use is in itself a source of problems, whether it contributes to other existing problems, and whether it might interfere with the counseling process.
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