Drug Counseling Research Articles

Drug counseling by pharmacists: The need for legal recognition

Pharmacists are increasingly being expected to counsel patients about the proper use of drugs because of their role in the distribution of prescription medications. However, many recent court cases have upheld the view that only physicians may counsel patients about prescription drug therapy because they are “learned intermediaries” between manufacturers and patients. These legal decisions fail to distinguish between risk assessment, or drug choice decisions, and risk management, or drug use decisions. Risk assessment occurs prior to prescribing and is an appropriate function for physicians, while risk management may be performed by both physicians and pharmacists. The legal impact of changes in the standards of practice for the pharmacy profession and the advent of “clinical pharmacy” are explored. Cases involving pharmacists' duty to warn patients are analyzed with particular emphasis on the case of Riff v. Morgan Pharmacy. This decision describes the safety net of overlapping responsibilities of health care providers necessary to provide good patient care.

NCPIE conference sheds light on drug counseling in different patient populations

NCPIE conference sheds light on drug counseling in different patient populations

Twelve-month follow-up of psychotherapy for opiate dependence [published erratum appears in Am J Psychiatry 1989 Dec;146(12):1651

To provide information on the long-debated issue of the value of psychotherapy as an addition to paraprofessional counseling services for opiate addicts receiving methadone maintenance, the authors obtained 12-month follow-up data on 93 such patients randomly assigned to a 6-month course of either paraprofessional drug counseling or counseling plus professional psychotherapy. The psychotherapy patients had a significantly better overall status at 7-month follow-up and also at 12-month follow-up, 6 months after the psychotherapy ended. The authors conclude that psychotherapy can be evaluated by using scientific methods and that it can have measurable and sustained benefits in the treatment of opiate addiction.

Psychoanalytically oriented psychotherapy of substance abuse (with observations on the Penn-VA Study).

The Penn-VA psychotherapy project was designed to test the hypothesis that the addition of supportive expressive or cognitive behavioral psychotherapy might add a differential benefit to the usual drug counseling of opiate addicts. The results indeed showed that the patients who had treatment administered by the trained psychotherapists did better than those who had only the regular drug counseling. This author describes his experiences as one of the psychoanalytically oriented psychotherapists. Important aspects of this technique and common themes that emerge in the course of treatment are discussed. It is suggested that this treatment approach can be successfully applied to the treatment of the abuse of other substances including alcohol and outside the research setting.

The relationship of drug program environmental variables to treatment outcome.

The Moos Community Oriented Program Environment Scale (COPES) was administered to 244 adolescent clients and 131 drug counselors in 30 "drug-free" outpatient drug treatment programs. Four of the COPES factor scores were found to predict significantly to treatment outcome (as measured by reduction in drug use): client ratings of "Spontaneity", and staff ratings of "Personal Problem Orientation", "Practical Problem Orientation", and "Order and Organization". The more positive the ratings of the program environments, the greater the reduction in client-reported drug use from admission to discharge. The "discrepancies" (differences) between staff and client perceptions of the programs on two of the COPES factors ("Autonomy" and "Staff Control") were also found to predict significantly to treatment outcome (as measured by reduction in drug use). The greater the discrepancy, the less successful was the treatment outcome. In the programs in which the clients tended to perceive the staff as less encouraging of client autonomy and as exercising more control over the clients relative to the staff's perceptions of these relationships, the clients tended to have less successful treatment outcomes. One possible interpretation of this finding might be that in the programs which have client populations that are more poorly motivated and more resistant to treatment, the clients will not only tend to have poorer treatment outcomes but will also perceive the program environment more negatively and thus will tend to disagree more with the staff's perceptions of the program.

Municipal Employee Assistance Programs: Managing Troubled Employees

It is almost commonplace today to read front-page stories of damage done by substance abuse to professional careers of athletes, entertainers, and public officials. It is estimated that 10 percent of the nation's work force struggles with alcoholism, 2 percent with drug addiction, and another 6 percent with emotional problems. ' Many public managers may be aware of employees whose personal problems adversely affect job performance. It is debatable, however, whether many are knowledgeable about their organization's policy toward troubled employees, aware of what can be done for them, or are informed about employees' legal rights. A 1978 U.S. General Accounting Office survey of 81 federal installations confirmed this; it also found that top management officials possessed negative feelings about their organizations' rehabilitative programs.2 Some did not believe they were in the hand-holding business, and others were concerned with the cost of social actions such as alcohol and drug counseling relative to the resources invested in the installation's primary mission. This latter feeling was articulated despite the GAO's finding that funding and office space devoted to such programs were often limited and inadequate. 3 The most common approach to managing troubled employees, that of employee assistance programs (EAPs), evolved from industrial alcoholism programs. Consequently, the EAP literature (and practice) is dominated by a concern with alcoholism and alcoholrelated issues, and, with very few exceptions, draws from private sector experience.4 Differences exist, however, between public and private sector personnel rules, employment practices, and legal obligations to employees. Differences may even exist between those who seek public sector employment and those who seek work in the private sector.5 The EAP literature provides inadequate information about the likely incidence of troubled employees in the public work force, the identification and counseling of public employees, and the problems of EAP implementation in public organizations. This article seeks to sensitize public managers to the issue of troubled employees, and discusses the employee assistance program as one approach to managing this type of employee. Although one must be cautious in extending findings reported in this article to other cities,

The effects of drug counseling and other educational strategies on drug utilization of the elderly.

The medication behavior of 183 elderly apartment residents was assessed for problems in medication regimen compliance, regimen comprehension, drug interactions, and drug storage. Following an initial assessment, the residents were given instructions in drug utilization and access to drug counseling was provided intermittently for almost 2 years. Approximately 1 year after the educational intervention a final assessment of a sample of 39 residents, who initially were found to have the greatest numbers of problems, revealed a significant 11% decrease in the number of prescriptions taken and a significant 39% decrease in the number of medication behavior problems. The initial average was 3.7 prescriptions currently used and 2.7 problems per person that subsequently decreased to 3.3 prescriptions and 1.6 problems for the same residents at the end of the study. Results suggest that pharmacist consultation provides an effective health prevention strategy in elderly resident settings. Educational strategies used in this study appear to be well adapted for use with elderly home-based populations.

When the client is pregnant: Information for counselors

This article explores the issues raised by methadone maintenance during pregnancy with a focus on intervention techniques for the drug counselor. Establishing and maintaining the appropriate dose of methadone is discussed. Prenatal care issues are reviewed and the counselor is suggested as a liaison with traditional sources of prenatal care and education. Postpartum experiences in the intensive care nursery are presented and recommendations about breast feeding offered. Specific activities are suggested for the drug program.

Urine Cannabinoid Analysis: An Integrated Multi-Method Approach

The Enzyme Multiplied Immunoassay Technique (EMIT) Urine Cannabinoid Assay (Syva) was adapted for automated analysis on a centrifugal analyzer allowing for cost-effective, rapid, high-volume urine testing. Confirmation of positive EMIT results was accomplished by a modification of a recently published high performance liquid chromatographic (HPLC) technique for 11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid (THC-COOH). Further confirmation of the presence of THC-COOH was achieved by high efficiency thin layer chromatography (HETLC). The reported protocol was applied to urine samples obtained from an emergency toxicology population and a drug counseling population. Results indicated that specimens testing positive by all three methods suggest valid forensic evidence for the presence of THC-COOH.

Paraprofessional versus professional drug counselors: the progress of clients in treatment.

The progress in treatment of 302 methadone maintenance and drug-free outpatient clients was examined as a function of the background of their 82 counselors. Counselors were either ex-addict paraprofessionals (EXAs), non-ex-addict paraprofessionals (NEAs), or degreed professional counselors (PROs). Client progress was assessed in five areas: drug use, criminality, educational activities, employment, and life quality. In the first four areas, status at treatment entry contrasted with that at two subsequent measurement points: the first interview and a 4-month follow-up. In no area of evaluation were outcomes substantially more favorable for clients of one counselor group over another. It was concluded that the three counselor groups were equally effective.

Paraprofessional Versus Professional Drug Counselors: Diverse Routes to the Same Role

The backgrounds and roles of ex-addict ( EXA ) and non-ex-addict (NEA) paraprofessional methadone maintenance and drug-free out-patient counselors were contrasted with those of degreed professional counselors (PRO). There was no evidence of differential assignment of clients to counselors based on drug use, drug treatment, criminal, educational, and employment histories. The three counselor groups were remarkably similar in their participation in 11 areas of job activities ranging from counseling duties per se through administrative support functions. The only reliable difference was the greater involvement of EXAs in counseling and community education activities which took them outside the program.

Evaluation of drug counselor training: a pilot study.

A pilot evaluation study was conducted to explore the impact of a training course aimed at helping drug counselors establish effective therapeutic relationships with their clients. Counselor abilities to reflect accurate empathy, sensitivity to client values and attitudes, and use of specified problem-solving techniques were measured before and after training through counselor self-ratings and ratings of counselor behaviors provided by clients and supervisors. The preliminary findings reveal a trend toward improved drug counselor functioning along these dimensions following training. However, the findings also suggest that the greatest impact of training may be a shift in drug counselor self-perceptions toward more confidence in their own capability to establish effective therapeutic relationships.

Group psychotherapy with alcoholics: special techniques.

I approached the article on group psychotherapy for alcoholics by Vannicelli (1) from three perspectives. First, as a recovering alcoholic of almost 10 years sobriety I was acutely aware of the positive impact of group therapy in my own treatment. Second, as a clinician currently in part-time outpatient private practice I concur with Vannicelli that group therapy is invaluable in working with alcoholics and their families. Third, as the director of a training program for potential alcohol and drug counselors I was impressed with the work done by Vannicelli and plan to include as required reading for students taking the course Principles, Methods, and Techniques in the Treatment of Alcoholics. My faculty agreed that provided a useful learning tool in its clear presentation of the six key issues: (1) Questions regarding the group leader's drinking, (2) group meetings missed because of drinking, ($) expectations possibly conflicting with a second group, such as A.A. or an educational group, (4) confidentiality, (5) drinking contracts, and (6) talking about drinking as a defense against group work. It is helpful for the group leader to be familiar with these issues as well as the meaningful suggestions made by Vannicelli for implementing them. However, there is one major point which I believe was presented in a misleading manner; namely, the role of direct confrontation in group psychotherapy with alcoholics. Although in the introductory paragraph Vannicelli cites confrontation as the second of the three unique opportunities afforded by group psychotherapy, she states that it should be remembered that direct confrontation, though sometimes necessary, should be used sparingly (italics added) and with a clear idea of the intended purpose .... The therapist who sees his task primarily as learning 'to invite' and 'encourage' discussion will do more to help his group grow than the one who learns only to confront (pp. $$-$4). My own conclusion is that there is a need for the generous use of confrontation as a method, albeit not the only one, in working with alcoholics. I will try to clarify the meaning of confrontation especially in relationship to tough love. It has been my experience that much of the confusion about confrontation comes from three major sources. First,

Drug counselors' perceptions of clients: Demographic, personality and psychopathology correlates

Counselors' interpersonal perceptions of their clients in outpatient drug treatment were studied. Factor analysis produced three general factors, interpreted as perceptions of manageability, treatment readiness, and suitability for group treatment. Counselor perception of client interpersonal attractiveness did not emerge as a separate factor, but appeared equally significantly related to each of the first two factors. Correlates of counselor perceptions were sought among measures of client program performance, demographic and drug use history, psychopathology, and counselor background and personality. With one exception, measures of clients' actual program performance were the best predictors of counselors' perceptions of clients. Clinical implications are discussed.

Effects of short-term intensive hospital psychotherapy on youthful drug abusers: I. Preliminary MMPI data.

Pre- and post-hospital treatment MMPI scores of 85 young substance abusers were compared. All patients participated 4 to 6 wk. in psychotherapy consisting of daily individual and group psychotherapy, meetings with drug counselors, psychodrama, supervised physical and academic activities, and some family therapy. Significant posttest reductions of scale scores ≥ 70 occurred on Scales P, D, Hs, Pd, Pa, Pt, and Sc, but not Ma. Number of other clinical scale scores ≥ 70 was quite low. Psychological testing accurately documented observed clinical changes in the patients noted by hospital personnel.

Psychotherapy for opiate addiction: some preliminary results.

In summary, this preliminary analysis suggests two important points. First, that narcotic addicts enrolled in a methadone treatment program are receptive to psychotherapy. Secondly, that psychotherapy may add something to routine counseling services. As seen, the psychotherapy patients, in this very preliminary analysis, are using fewer drugs (including prescription drugs, methadone and illicit drugs) and they report fewer psychiatric symptoms than those receiving drug counseling alone. We do not think that the design of this project rules out the possibility that these results are nonspecific effects (seeing a "doctor," having an opportunity to see two helpers rather than one), however, we also see nothing here to support the idea that narcotic addicts cannot benefit from the services of professionally trained psychotherapists. These early analyses represent only a very small portion of the entire range of data collected. We will be especially interested in identifying reasons for improvement in those patients who respond. Preliminary analysis of segments of tapes by the independent rates shows that the raters correctly identified 80% of the therapy tapes. Comparing these independent taped ratings with outcome measures may be a valuable way to assess possible relationships between amount and kind of therapy and treatment outcome. Finally, patient ratings of therapists including the patient's views of the helping relationship may supply additional important information regarding why improvement occurs.

Principles of Clinical Psychiatry

HOSPITAL & COMMUNITY PSYCHIATRY He presents the reader with a burn-out questionnaire and scale of severity; with multiple clinical vignettes of successfuly treated patients who manifest certain aspects of the syndrome; and with useful and commonsense approaches to combating burn-out. Both volumes are well-edited books that adequately deal with a contemporary pathology from the perspective of a nonmedical therapist. However, Dr. Freudenberger’s conception of burn-out is broad almost to the point of diffuseness. He appears to be including all aspects of psychological perturbation that do not subsume psychosis. His Burn-out is written for a lay population and offers palatable nostrums for a modernday malady without benefit of index. Edelwich, on the other hand, focuses on the more job-related pathology. Unfortunately his analysis does not go beyond conditions related to job stress. From a medical standpoint it would have been useful to differentiate his four states either from the clinical states of depression or paranoia or from the existential problem of an intrusion on one’s narcissistic expectations Qf changelessness, safety, and control of one’s space and time. Burn-out syndrome, in many ways, may be a contemporary equivalent of the concepts of alienation and anomie in which the individual confronts the vicissitudes of the modern-day institution and feels defeated by some arcane malady of the times. However, of the two books, Edelwich’s better addresses the burn-out syndrome as it is found within the mental health services field. It will be useful reading for staff members ranging from drug counselors to medical directors.

Marathon Group Therapy with Former Drug Users

This article deals with a study that assessed the effects of marathon group therapy on the attitudes of the participants in a 16‐hour‐long marathon group. The participants were all former drug users who were transferred from prison to a residential drug treatment center. The volunteer residents, who were randomly divided into control and experimental groups, completed posttests that included the following semantic differential concepts: kindness, reality, the future, anger, guilt, my real self, drug treatment programs, counselors, counseling, and group counseling. Evaluative (E) and Potency (P) scales were obtained for each concept. The results showed that experimental group members responded higher on the Group Counseling (E) subscale and lower on the guilt (E) subscale than the control group members.

Applying nutritional concepts in alcohol and drug counseling.

Applying nutritional concepts in alcohol and drug counseling.

The other side: counselor roles.

The problem of treating a narcotic-dependent person is probably one of the most difficult confronting those attempting to provide rehabilitation services. Often emphasis has been placed on those persons receiving the services provided rather than those who provide them. In this paper the drug counselor is focused upon, for after all it is he or she who plays the many roles necessary to accomplish this task at hand. The roles include psychotherapist, crisis intervention agent, medical counselor, and client advocate for the addict in treatment. Behaviors, expectations, and responsibilities involved in these counselor roles influence the development of a "healing partnership" involving both the counselor and the client.