Lesson 11: Sedative and Hypnotic Use Disorder
Attention
Lucy in the Sky with Diamonds - The Beatles
Click HERE to view this directly on YouTube
Learning Outcomes
Upon completion of this lesson's material, students will be able
- Understand risks and benefits of sedatives and hypnotics
- Understand use of other substances: hallucinogens, inhalants, club drugs, etc.
- Be able to describe treament issues for substances covered in this lesson
Teaching
Chapters 18 and 19 in The Thirteenth Step
Hallucinogens and Deliriants
Dr. Timothy Leary
A new attitude toward drugs that began with the counter culture movement. Drugs were seen as "psychedelic" (mind-opening) and many leading intellectuals advocated their use to get beyond the phoniness and conformity of mainstream culture. In many ways this overly positive valuation of drugs is still with us. But not all drugs are created equal in the eyes of this movement and a distinction was made between "head" drugs that created new consciousness and "body" drugs that only made you feel good. These drugs are primarily hallucinogens and are different than the substances we have discussed so far because they don't usually create a big release of dopamine in the limbic system. So the problems that people develop with the substances are different than those found with the substances we have been discussing. Since there is not a big jolt of pleasure some researchers even question whether they are truly addictive. And there is a tendency for users to simply stop using after a period of time without struggle. Use peaks in the teens and twenties and begins to taper off after that.
Marijuana is a mild hallucinogen (changes perceptual experience) but also is associated with dopamine release in the limbic system and is addictive and use often continues throughout a lifetime.
Primary risk with hallucinogens is hallucinogen induced psychiatric disorders which usually clear up with abstinence but also may include flashbacks which may be associated with more persistent and serious psychiatric problems.
Some hallucinogens (e.g. PCP) may cause very severe reactions and result in death. PCP is an example of a dissociative hallucinogen which causes an alteration of consciousness characterized by a sense of somehow being in a different place physically and mentally. PCP was originally developed as an anesthetic for surgery that had an advantage over traditional anesthetics in not causing sedation so that the patient did not need respiratory and cardiac support. It is still used by veterinarians. Another dissociative anesthetic is nitrous oxide or 'laughing gas" which is still used by some dentists and abused especially by teens . There has been some research suggesting that ketamine, another dissociative, may be helpful in treatment resistant depression. Another dissociative abused primarily by young people is the Dextromethorphan found in over the counter cough syrup. Usually teens abusing this are the “geeks” who are into games and who see themselves as different from others. There are medical risks with heavy use and motivational interviewing is a useful tool to help the person consider what is best for them.
Some mental health consumers are especially prone to abusing medications used to control the extrapyramidal side effects of anti-psychotic medication. Artane and Benadryl are examples and are classified as deliriants which work as anticholinergics causing hyperactivity and overstimulation. Substances such as these are interesting because most people would not be tempted to abuse them because they don't like the feeling they produce. But for consumers with psychotic issues they seem to overcome the anhedonia and flat affect that are negative symptoms of schizophrenia. Consequently the consumer may be resistant to changing the behavior even though there may be health consequences such as cardiac arrhythmias.
Generally people who use hallucinogens do not seek substance abuse counseling and simply stop when they lose interest. Motivational interviewing is helpful in assisting the consumer to consider their own best interest and what really works for them and to try making small changes to see if things improve.
Barbiturates and benzodiazepines: relief for the troubled multitudes.
Barbiturates widely used for sedation and sleep during the first half of the twentieth century. Now the primary use is as anticonvulsant for epilepsy. Primary risk with barbiturates is addiction and both barbiturates and benzodiazepines have very serious withdrawal syndromes like that of alcohol. This is because they affect the GABA/Glutamate balance in the body. Valium developed in the 1950's and was seen as a miracle drug for anxiety which was part of the spirit of the age with the cold war and nuclear holocaust looming on the horizon. Very profitable for Roche Pharmaceutical and this is part of the reason that the addictive potential was not recognized until the mid-1970s. Benzodiazepines are still very useful for short-term management of anxiety disorders but long-term use not only carries the risk of addiction but also exacerbation of anxiety by causing imbalance in the GABA/Glutamate system (alcohol does this too). Long term use of benzodiazepines may very occasionally be necessary for some people with alcohol or benzodiazepine addiction who do not seem to be able to maintain sobriety. In such cases, a long lasting medication such as klonopin which also has a slow onset of action and consequently doesn't produce much of a high may be the best choice. Treatment for these sedatives and hypnotics is the same as for Alcohol Use Disorder because of the very similar physiology.
Inhalants (e.g. glue, gasoline)
Primarily seen among early teens. Big risk for brain damage and death and best approach is prevention of use through education. Often the kids who use these are very troubled and so the primary issue in counseling is addressing the issues in their lives (dysfunctional families, alienation, being bullied) that are leading them to engage in this dangerous behavior
Ecstasy and other club drugs
These are used in social settings which is why they are called "club" drugs. Ecstasy is an hallucinogen/tranquilizer/antidepressant that was originally developed for treatment of mood disorders but was withdrawn as too risky. Has the risk in a club setting of hyperthermia and users drink water liberally to prevent this. These drugs are not used very much by mental health consumers so that there are rarely treatment issues but Motivational Interviewing would be the right approach when they are encountered.
Synthetic drugs. Spice, bath salts, flacca, a new drug every day. Developed by rogue chemists to elude laws against marijuana, cocaine, etc. Because they are chemically slightly different, they are perfectly legal until state legislatures catch up. Often sold in head shops and even at convenience stores, Primary danger is that you really don't know what you are using and can be ingesting some really bad stuff. These are widely used by young people and may be seen in the population served by MHRT/Cs. Education is an important tool helping people to understand the risk they are taking. Motivational Interviewing helpful to help consumer evaluate risks and benefits of continued use.
Assessment
Lesson 11 Quiz
- List and describe the risks and benefits associated with benzodiazepenes and barbiturates (5 points for each item listed and described up to a total of 40 points).
- Enumerate and discuss the differences between hallucinogens and substances discussed in previous lessons in terms of how they work (10 points), why they are used (10 points) and treatment issues (10 points).
- Who uses inhalants (10 points) and what are the special treatment issues (10 points).
- Name two “club drugs” and the risks associated with each (5 points each)
Possible Class Discussion
Option 1
Remembering that we have all agreed to keep one another's confidentiality, write a paragraph or two discussing your own use of substances especially considering what you have learned in the Lessons so far. Write another paragraph or two describing how you think your personal experience will affect your work as an MHRT/C
Option 2
If Option 1 is too uncomfortable for you, do this: Go to an AA meeting and listen to the sharing. Then write a few paragraphs about how having the experiences of the people who shared at the meeting would help and/or hurt your work as an MHRT/C
Click HERE to visit the Portland Central Service Office which has information on AA meetings across the State of Maine. Anyone can go the ones listed as "open" just as a member of the public.