19455910-1

Relationship between Anxiety andAddiction to a Depressant Drug

James F. Scorzelli, Ph.D.* & Saleha Z. Chaudhry, B.A.**

AbstractA systematic random sample of 267 patients who were involved in outpatient detoxificationwas surveyed. Their records were evaluated, and the demographics, psychiatric diagnoses, and type(s)of substance of abuse of each patient were recorded. The results indicated that there was a significantrelationship between an anxiety disorder and whether the patient was addicted to an opioid. A follow-up was conducted on 79 patients who were addicted to an opioid, and had an anxiety diagnosis. Ofthis group, 54 (70%) responded, of which only 22 (40%) said that they were receiving some type oftreatment for their disorder. All of these patients reported that they were sober and that their anxietydisorder significantly decreased.

Keywordsaddiction, anxiety, co-occurring disorder, depressive drug, relationship

Among persons who are chemically dependent, manyhave psychiatric diagnoses (Wilens et. al. 2005; Mitra 2000;Bums & Teeson 2002; DeHaas, Calamari & Bair 2002;Stewart & Kushner 2001; Strakowski & DelBello 2000).Among 500 opioid dependents, Ahmadi and Ahmadi (2005)found that 105 (21%) of the clients had anxiety disorderswhile 274 (54.8%) had depressive disorders. This is referredto as co-occurring disorders (Goldsmith & Garlaapati 2004).The presence of a psychiatric disorder can often compli-cate the treatment and counseling of the client who is drugdependent (Craig 2004). That is, research suggests thatco-occurring disorders can be treated separately or througha hybrid approach in which the treatment is mixed andmatched dependent on the individual (Craig 2004; Minkoff2001). Furthermore, it is unclear why some people developmental disorders with addiction. There are a number ofdifferent views that attempt to explain this. Roberts (2000)and Ayyad and Al-Mashaan (2003) describe the separate

Professor, Northeastern University, Boston, MA.*Graduate Assistant, Northeastern University, Boston, MA.Please address correspondence and reprint requests to James F.

Scorzelli, Ph.D.. Dept of Counseling and Applied Ed Psych, 203 LakeHall, Northeastern University, Boston MA 02115.

etiologies and course of both disorders, yet feel that commonfactors increase the risk for mental disease and substanceabuse. These common factors often pertain to gender, race,low self-esteem, antisocial personality, and genetic variables.Based on this, it has been proposed that mental disorderscan increase the risk of drug addiction, or substance abusecan increase the risk of mental illness (Sullivan et al. 2005;Green et al. 2002; DiNitto & Webb 2001).

Muesser, Drake and Wallach (1998) felt that the twodisorders are bidirectional and reciprocal. If one believesthat mental disorders increase the risk of substance abuse,then the person abuses the substance to relieve his or hersymptoms. When under the influence of alcohol or an opioid,one cannot experience anxiety or the related symptoms.Depressants slow down heartbeat and breathing and lowerblood pressure, essentially acting as a short-term cure of thesymptoms of anxiety. This belief in self-medication has beenproposed by many researchers (Goeders 2003; Khantzian1997). If one believes in the self-medication hypothesis, thenit is very important for professionals who deal with addic-tion to focus on the client's underlying psychiatric disorder.There are a number of research articles that support the view

Journal of Psychoactive Drugs 61 Volume 41(1), March 2009

Scorzelli & Chaudhry Relationship Between Anxiety and Addiction

that drug addiction is positively associated with negativeaffect, such as depression and anxiety (Ahmadi & Ahmadi2005; Sbrana et. al. 2005; Ahmadi et al. 2003; Ayyad & Al-Mashaan 2003; Ramirez 2002; Nutt 2000). Further, there issubstantial support for linking opiate dependency to stress oranxiety (Goeders 2004, 2003; Ahmadi et al. 2003; Roberts2000). This linkage indicates that a person with co-occur-ring disorders often uses an opioid to cope with the tensionsassociated with life Stressor or to relieve the symptoms ofanxiety (Pitman & Delahanty 2005).

In terms of treating the patient with co-occurring disor-ders, research has indicated that there are beneficial affects ofbenzodiazepines and methadone in reducing anxiety (Calsynet al. 2000; O'Brien, 2005; Wren et al. 2005; Schuurmanset al. 2005; Pandit, Argyropoulos & Nutt 2001). However,Drummond (1998) stated that benzodiazepines have somepotential for abuse and may cause dependency, but only afew cases of addiction arise from legitimate use of the drugs.Further, he felt that due to the chronic nature of anxiety, thelong-term low dosage of benzodiazepine treatment may benecessary. Calsyn, Wells, Heming and Saxon (2000) admin-istered the Milln Clinical Multiaxial Inventory (MCMI)to 122 men and 86 women who entered a methadonemaintenance program within a month of admission and 18months later. The results indicated an overall decrease onscales measuring anxiety during the interim between initialassessment and follow-up.

Mitra (2000) reported that social anxiety was sig-nificantly higher among substance abusers and a follow-uprelapsed group with low social approval when compared tothose persons who were successfully rehabilitated. Based onthese findings. Mitra suggested that social cue componentsmay be helpful in counseling the person who is drug depen-dent. Goeders (2004) reported that there is a link betweensubstance abuse and stress, and that stress reduction aloneor in combination with pharmacotherapy may be helpfulin reducing drug cravings or providing abstinence. Thebeneficial affects of therapeutic communities in reducinganxiety among drug abusers was shown in studies by Am-ram (2002) and Craig (2004). Pardini, Plante, Sherman andStump (2000) examined the relationship between religiousfaith, spirituality, and the mental health of persons recover-ing from substance abuse. The researchers found that higherlevels of religious faith and spirituality were associated withlower levels of anxiety and positive mental health outcomesof the sample.

With this in mind, the purpose of the present article is todetermine if there is a relationship between anxiety disordersand substance abuse, and if such a relationship does exist,the effects of treatment.

METHOD

A systematic random sample of 267 patients of agroup of physicians who specialize in addiction medicine

were selected. All the patients were involved in outpatientdetoxification from 2001 to 2004. Because the medicalpractice has an affiliation with a major university, all thepatients signed a release that indicated that their records(maintaining personal confidentiality) could be used inresearch. Further, the study was approved by the HumanSubjects Committee. Each record was examined and thedemographics, type of drug abused, and diagnoses of thepatients were recorded. The type of drug abused by thepatient came from the results of a urinalysis given to himor her during the initial and subsequent visits. Further, thepractice did not differentiate between drugs that causedphysical dependence (i.e., opioids and alcohol) and thosethat did not (i.e., cocaine) with respect to their treatmentapproach. Specifically, all patients, regardless of the drug(s)of abuse, were provided with medication to counteract theaffects of drug deactivation. Expressly, a person addicted toa depressant drug (i.e., opioid) was prescribed anti-anxietydrugs or benzodiazepines, and medication to help him or herdeal with muscle and joint pain, nausea, chills and to preventseizures. For hallucinogens, marijuana or stimulants (i.e.,cocaine), the patient was prescribed benzodazepines and/orantidepressants. The diagnoses were taken from a diagnosticevaluation conducted by a clinical psychologist who hadbeen employed with the practice for eight years, and theseevaluations were in the patients' files. So as to corroboratethe diagnoses, psychiatric/psychological evaluations fromother sources and hospital records were examined. Basedon this review, the diagnoses of 147 (55%) of the patientswere corroborated. The remaining patients only had thediagnostic evaluation in their files. The diagnoses of thepatients were taken from a diagnostic evaluation in each ofthe files. These psychiatric disorders were initially groupedinto the general categories of anxiety and depression. Thespecific diagnoses of the anxiety and depressed disorderswere also recorded.

If a relationship was established between drug abuseand a psychiatric disorder, those patients with co-occurringdisorders would be contacted to dtermine if they soughttreatment for their disorder.

Descriptive statistics were used to summarize the dataand chi square analysis conducted to determine if there wasa relationship between addiction and type of diagnosis, andgender and the type of diagnosis.

RESULTS

As seen in Table 1, the average age of the patientswas 32.3 years. They ranged in age from 16 to 71 years.Most were White males who were opiate dependent. Infact, both the youngest and oldest patients were opiatedependent. Alcohol was the second most frequent drug ofabuse (16.1%). Only 19 patients (7.1%) were identified aspolydrug abusers (two or more drugs). Further, 41.2% ofthe participants had an anxiety-related diagnosis. The types of

Journal of Psychoactive Drugs 62 Volume 41(1) , March 2009

Scorzeili & Chaudhry Relationship Between Anxiety and Addiction

TABLE 1Demographic Characteristics of the Patients (N = 267)

Gender

Male

Female

Race

White

Frequency

191

76

250

African American 10

Latino

Marital Status

Single

Married

Divorced

Widowed

Age

7

198

48

16

5

Mean = 32.3 years

Percentage

71.6%

28.4%

93.6%

3.7%

2.7%

74.1%

18.0%

6.0%

1.9%

anxiety disorders ranged from panic attacks to acute stress(see Table 2). Of the anxiety disorders, generalized anxiety(16.1%) and panic disorder (13.9%) were the two mostfrequently identified in the case records. It was also foundthat 22.8% of the patients had a diagnosis of depression. Thetypes of depressive disorders were either major depressive(13.5%) or dysthymic (9.7%). Only 34 patients (12.7%) hadno psychiatric diagnosis. Finally, 94.6% of the women inthe sample had a psychiatric disorder.

The chi square analysis between gender and diagnosiswas significant (x^ = 1.2, p = .001), and indicated that therewas a higher proportion of women than men with a psychi-atric diagnosis (see Table 2). When the anxiety disorderswere compared to opiate dependence it was significant atthe .05 level {x^ = 5.19, p - .023). However, the relation-ships between anxiety and alcoholism (x^ - .870, p = .351),depression and alcoholism (x^ = .245, p .620), and opiatedependence and depression (x^ = 2.5, p = .114) were notsignificant.

There were 79 (29.6%) patients who were opiate de-pendent and had an anxiety disorder. These persons werecontacted by letter, and followed up with a phone call. Ofthis group, 54 (68%) responded, of which only 22 (40%)said that they sought out treatment for their anxiety disorder.The other 32 persons who had anxiety disorders relapsed; 20were receiving treatment for the second time, while 12 werereceiving outpatient detoxification for the third time. All ofthe 22 patients who were opiate free were interviewed bythe principal investigator. Of this group, 10 reported having

a panic disorder, and 12 were diagnosed with a generalizedanxiety disorder. When asked about treatment, five personssaid that they were in methadone maintenance and receivedcounseling weekly (drug counseling is a requirement of theserelapse prevention programs). They were all diagnosed witha panic disorder, and told the investigator that they had notexperienced any attacks since entering methadone mainte-nance. These patients were all tested with a urinanalysis tocheck for potential methadone abuse and all of them werecleared and allowed take-home prescriptions at six months.Three of the patients, who also had panic disorders, were see-ing psychiatrists, who prescribed benzodiazepines. Althoughthe patients said that they still had panic attacks, they statedthat the panic episodes had significantly decreased, andthat when they did occur," taking a benzodiazepine quicklystopped them. Of the remaining 14 patients (12 with a gen-eralized anxiety disorder and two with panic disorders), 10said that they were still in counseling. The four who werenot in counseling stated that they received counseling forat least six months before they left. All of these 14 patientsreported that their anxiety had significantly decreased whilein therapy.

DISCUSSION

The results of this study appear to support the beliefthat some forms of drug abuse may be related to anxietyreduction. As indicated, there was a significant relationshipbetween anxiety disorders and patients who abused opioids.

Journal of Psychoactive Drugs 63 Volume 41 (1), March 2009


TABLE 2Diagnosis and Substance Abused by Patients (N = 267)

Diagnosis

Anxiety

Depression

Adjustment DisordersAttention Deficit Disorder

Psychosis

Explosive

Bipolar

None

Drug Abused

Opiate

Alcohol

Cocaine

Benzodiazepines

MarijuanaInhalants

Poly Drug

Specific Anxiety Disorders

Generalized Anxiety

Panic

Post Traumatic Stress Disorder

Obsessive Compulsive

Acute Stress

Specific Depressive Disorders

Major Depressive DisorderDsythymic

Gender and Diagnosis

Male Anxiety Disorder

Female Anxiety Disorder

Male Depression

Female Depression

Frequency

110

61

50

4

4

2

2

34

192

43

7

3

2

1

19

43

37

8

4

1

36

26

67

43

44

17

Percentage

41.2%

22.8%

18.7%

1.5%

1.5%

.7%

.7%

12.7%

71.9%

16.1%

2.6%

1.1%

.7%

.4%

7.1%

16.1%

13.9%

3%

1.5%

.4%

13.5%

9.7%

61%

39%

72%

28%

Journal of Psychoactive Drugs 64 Volume 41 (1), March 2009


This was especially identified in the follow-up of the 32persons who had anxiety disorders and relapsed. This sup-ports the literature that indicates that some people who areaddicted to opioids take the drug to reduce their anxiety orto help them cope with stress (Ahmadi et al, 2003; Goeders2003; Roberts 2000), However, the significance was at the,05 level {p = ,023) and not at the ,01 level. Surprisingly,there was no relationship between alcohol and anxietydisorders. Although many researchers believe that one rea-son people abuse alcohol is to reduce stress, this was notsupported by the study, A reason for this may pertain to thesmall number of patients who were alcoholics (16,1%) whencompared to those who were opiate dependent (71,9%), Thesample of alcoholics in the study was too small to effectivelyinvestigate the relationship between alcohol and anxiety.Other studies have shown that alcohol use is comorbid withanxiety and depression. Bums and Teeson (2002) foundthat respondents with an alcohol use disorder (abuse or de-pendence) were three times more likely to have an anxietydisorder. The National Comorbidity Study also has similarfigures (Kessler et al, 1994), In the nationally representativesample, 55% of those patients with an alcohol dependencewho received treatment in the previous 12 months also hadat least one affective or anxiety disorder during that sametime period (Watkins et al, 2004),

Unlike the anxiety disorders, there was no relationshipbetween depression and abuse of opiates or alcohol. Therelationship between a psychiatric diagnosis and genderwas the result of the small number of women in the sample(28,4%), In fact, 94,6% of the women had a psychiatricdiagnosis, while 65,2 % had an anxiety diagnosis (Table 2),

There were only a small number of patients who wereopiate dependent, had an anxiety disorder and sought treatment.

The treatment ranged from methadone maintenance tocounseling. However, of those patients who were in counsel-ing, the methods of anxiety reduction (i,e,, desensitization,emotive imagery, etc) were not identified. In all cases, thepatients reported that the treatment was effective in de-creasing or eliminating their anxiety. This finding seems tosupport the beneficial effects of anxiety reduction for thosepersons who are opiate dependent (O'Brien 2005; Goeders2004; Amram 2002),

It should be mentioned that there were possible adverseeffects for the three patients who were prescribed benzodi-azepines. Chronic benzodiazepine usage can cause physicaldependency, as well as depression, the dulling of emotions,and a paradoxical stimulant effect that can provoke aggres-sion and hyperactivity (Drummond 1998), Instead ofthe useof benzodiazepines for the treatment of anxiety disorders,the antidepressants Buspar and Paxil, and the gabapentinNeurotin have been shown to be very effective in reducinganxiety (Drummond 1998),

In closing, the results of this study support the relation-ship between an anxiety disorder and opioid dependence.Therefore, it may be beneficial for counselors to use anxietyreduction when treating those clients who have co-occur-ring disorders. Even though the group that sought treatmentfor their anxiety disorders was too small to generalize theresults, they all indicated that treatment was helpful. How-ever, this information was obtained from self-reports, whichcould have been biased. Also, it would have been helpful todetermine the type of counseling methods that were usedfor anxiety reduction.

REFERENCES

Ahmadi, M, & Ahmadi, J, 2005, Substance-induced anxiety disorderin opioid dependents. Addictive Disorders and Their Treatment 4:157-59,

Ahmadi, J,; Toobaee, S,; Kharras, M, & Radmehr, M, 2003, Psychiatricdisorders in opioid dependents. International Journal of SocialPsychiatry A9: 185-91,

Amram, Y, 2002, The small group method in therapeutic communities fordrug addicts. Therapeutic Communites 23 (3): 159-73,

Ayyad, F, & Al-Mashaan, O, 2003, Self-esteem, depression and anxietyamong addicts. Journal of Social Sciences 31: 637-59,

Bums, L, & Teeson, M, 2002, Alcohol use disorders comorbid with anxiety,depression and drug use disorders; Findings from the AustralianNational Survey of Mental Health and Well Being, Drug and AlcoholDependence 68: 299-307,

Calsyn, D,A,; Wells, E,A,; Fleming, C, & Saxon, A,J, 2000, Changes inMilln Clinical Multiaxial Inventory scores among opiate addictsas a function of retention in methadone maintenance treatment andrecent drug use, American Journal of Drug and Alcohol Abuse 26(2): 297-,309,

Craig, P,J, 2004, Counseling the Alcoholic and Drug Dependent Client: APractical Approach. Boston: Pearson,

DeHaas, R,A,B,; Calamari, J,E, & Bair, J,P, 2002, Anxiety sensitivity andthe situational antecedents to drug and alcohol use: An evaluation

of anxiety patients with substance use disorders. Cognitive Therapyand Research 26: 335-53,

DiNitto, D,M, & Webb, D,K, 2001, Clinical practice with clients who abusesubstances. In: R,G, Sands (Ed,) Clinical Social with Practice inBehavioral Mental Health. Second Ed. Boston: Allyn and Bacon,

Drummond, E, 1998, Benzo Blues. New York: Plume,Goeders, N,E, 2004, Stress, motivation and drug addiction. Current

Directions in Psychological Science 13: 33-35,Goeders, N,E, 2003, The impact of stress on addiction, European

Neuropsychopharmacology 13: 435-41,Goldsmith, R,J, & Garlapati, V, 2004, Behavioral interventions for

dual-diagnosis patients. Psychiatric Clinics of North America 27:709-25,

Green, A, I,; Salomon, M,S,; Brenner, M,J, & Rawlins, K, 2002, Treatmentof schizophrenia and comorbid substance use disorder. Current DrugMarkets: CNS & Neurological Disorders 1: 129-39,

Kessler, R,C,; McGonagle, K,A,; Zhao, S, & Nelson, C,B, 1994, Lifetimeand 12-month prevalence of DSM-111 -R psychiatric disorders in theUnited States: Results ofthe National Comorbidity Study, Archivesof General Psychiatry 5\ (1): 8-11,

Khantzian, E,J, 1997, The self medication hypothesis of substance abusedisorders: A reconsideration and recent implications. Harvard Reviewof Psychiatry 4: 231-44,



Minkoff, K. 2001. Developing standards of care for individuals withco-occurring psychiatric and substance use disorders. PsychiatricServices 52: 597-99.

Mitra, G. 2000. Psychological factors in drug addicts and normals: Acomparative study. Journal of Projective Psychology and MentalHealth 7: 53-78.

Muesser, K.T.; Drake, R.E. & Wallach, M.A. 1998. Integrated mentalhealth and substance abuse treatment for severe psychiatric disorders.Journal of Practical Psychiatry 4: 129-39.

Nutt, D.J. 2000. The psychobiology of posttraumatic stress disorder Journalof Clinical Psychiatry 61: 24-32.

O'Brien, C.P. 2005. Benzodiazepine use, abuse and dependence. Journalof Clinical Psychiatry 66 (Suppl 2): 28-33.

Pandit, S.A.; Argyropoulos, S. & Nutt, D.J. 2001. Current status ofanxiolytic drugs. Primary Care Psychiatry 1: 1-5.

Pitman, R.K. & Delahanty, D.L. 2005. Conceptually driven pharmacologieapproaches to acute trauma. CNS Spectrums 10: 99-106.

Ramirez, J. 2002. Chemical addictions and anxiety disorders: Whenadaptive mechanisms go awry. In: D. O'Connor & E. Beyer (Eds.)Managing the Dually Diagnosed Patient: Current Issues and ClinicalApproaches. Second Ed. New York: Haworth Press.

Roberts, A. 2000. Psychiatric comorbidity in white and African-Americanillicit substance abusers: Evidence for differential etiology. ClinicalPsychology Review 20: 667-77.

Sbrana, A.; Bizzarri, J.V.; Rucci, P.; Gonnelli, C ; Doria, M.R.; SpagnoUi,S.; Ravani, L.; Raimondi, R; Dell'Osso, L. & Cassano, G.B. 2005.The spectrum of substance use in mood and anxiety disorders.Comprehensive Psychiatry 46: 6-13.

Schuurmans, J.; Comijs, H.C.; Beekman, A.T.F.; De Beurs, E.; Deeg,D.J.H.; EmmerUcamp, PM.G. & van Dyck, R. 2005. The outcomeof anxiety disorders in older people at 6-year follow-up: Resultsfrom the longitudinal aging study in Amsterdam. Acta PsychiatricaScandinavica 111: 420-28.

Strakowski, S.M. & DelBello, M.P. 2000. The co-occurrence of bipolar andsubstance use disorders. Clinical Psychology Review 20: 191-206.

Stewart, S.H. & Kushner, M.G. 2001. Introduction to the special issueson anxiety sensitivity and addictive behaviors. Addictive Behaviors26: 775-85.

Sullivan, M.D.; Edlund, M.J.; Steffick, D. & Unutzer, J. 2005. Regularuse of prescribed opiates: Association with common psychiatricdisorders. Pain 119: 95-103.

Watkins, K.E.; Hunter, S.B.; Wenzel, S.L.; Tu, W; Paddock, S.M.; Griffin,A. & Ebener, P. 2004. Prevalence and characteristics of clients withco-occurring disorders in outpatient substance abuse treatment.American Journal of Drug and Alcohol Abuse 4: 749-64.

Wilens, T.E.; Kwon, A.; Tanguay, S.; Chase, R.; Moore, H.; Faraone,S.V. & Biederman, J. 2005. Characteristics of adults with attentiondeficit disorder hyperactivity disorder plus substance use disorder:The role of psychiatric comorbidity. American Journal on Addictions14: 319-27.

Wren, F.J.; Scholle, S. H. & Comer, D.M. 2005. How do primarycare clinicians manage childhood mood and anxiety syndromes.International Journal of Psychiatry 35: 1-12.


19455910-1

Documents