2015 National Conference for Lawyer Assistance Programs October 20-22, 2015 Albuquerque, NM Addiction Recognition, Understanding and Intervention

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1 2015 National Conference for Lawyer Assistance Programs October 20-22, 2015 Albuquerque, NM Addiction Recognition, Understanding and Intervention Michael E. Larson, Esq., Director, Montana Lawyer Assistance Programs Maryann Rosenthal, Ph.D., Executive Director, Recovery Ways

2 Addiction Recognition, Understanding and Intervention Connecting the Continuum: Prevention, Early Intervention and Recovery The chains of habit are too weak to be felt until they are too strong to be broken. Samuel Johnson Maryann Rosenthal, Ph.D Executive Director What is addiction? Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. American Society of Addiction Medicine April 19, 2011 STAGES OF ADDICTION Primary Illness: There may be associated problems, but until the Substance Abuse is addressed, other problems cannot be resolved. Progressive Illness: The illness will with time become worse. Almost all chemically dependent persons exercise some measure of control over their addictive use until the day they die. Chronic Illness: There is no known cure for chemical dependency. To date, no methodology has been able to clinically prove long term success. Fatal Illness: Chemical Dependency is thought to be the third most deadly illness. Binge Drinking, Alcoholism and Drug Addiction have reached Epidemic proportions and become America's Number One Public Health Issue Alcohol and drug problems present in transient and chronic forms. The course of severe substance use disorders and their resolution (addiction treatment and recover) can span years, if not decades. Severe SU disorders have been depicted as a chronic, progressive disease for more than 200 years and yet; Treatment resembles interventions into acute health conditions. Acute models of treatment are not the best framework for treating severe and persistent SU disorders. People discharged from treatment are balanced between recovery and relapse in the weeks, months and years following treatment.

3 THE ACCIDENTAL ADDICT Prescription drug abuse is the Nation s fastest growing drug problem 25 million prescriptions written every year 6 million Americans abuse prescription medication 50 Americans die each day from unintentional opioid overdoses (70% of those were from friends and relatives ) Prescription drug related deaths higher than those from heroin and cocaine combined PHASES OF USE:»Experimentation»Social»Abuse»Dependency Friel & Friel Iceberg Model of Addictions and Compulsive Behaviors Ways to be Out of Control Alcohol & Drugs Food Work Gambling $$$ Spending Relationships Sex Caretaking Religion Exercise Internet, TV Rage Worry Seek Relief / Check Out Self-soothe / Feel Alive Codependency - Identity & Intimacy Issues Fears Guilt Anger Shame

4 THE HIDDEN COST OF ADDICTION Substance Abuse in the workplace has been described as the $125 Billion hangover. EARLY INDICATORS 15% of individuals who drink or use drugs will develop disease of addiction. Often the drinker or drug user will be a High Energy performer. General Behaviors Attendance Over reacts to advice Late returning from lunch Co-workers complain/ comment Leaves work early Frequent medical complaints; cold, flu Occasional unexplained absences MIDDLE PHASE Overall efficiency drops to 70% Growing tolerance Ingenuity about source of supply MIDDLE TO LATE PHASES Overall efficiency drops to no more than 50% General Behaviors Attendance Grandiose or belligerent Increased tardiness Personal financial problems Failure to return from lunch Domestic Problems Increased medical leave Legal Problems (DUI) Relies on others to cover Trust account irregularities LATE PHASE At this point the firm has few options remaining with a member. General Behaviors Attendance Virtually unreliable Missed appointments Pronounced Physical Decline Unexplained absences Recurrent personal and legal problems Even when physically present, Excessive use of breath mints not able to contribute High stress and irritability

5 The New Paradigm for Recovery Making Recovery - and Not Relapse - the Expected Outcome of Treatment Important to take the time to do full and accurate assessments: Motivational Interviewing / SOCRATES Mental Status Exam - looked at as a whole / not just the parts Suicide Assessment (Beck Suicide Assessment) Data that is collected can include: Signs - which are observable Symptoms - which are reportable Signs and Symptoms = DISORDER Patients are often invested in their disorder Concerns Treatment Center LAP counselor Fears Addictive Patient Worry Anger Shield Love

6 1950 s Dr. Murray Bowen introduced a transformational theory, Family Systems Theory Families are systems of interdependent and interconnected individuals To understand the individual, we must understand the family system of that individual People cannot be understood in isolation from one another Stages of Recovery A neurobehavioral model that affects behavior, emotions, thinking and relationships Stage Withdrawal Duration 1-2 weeks Honeymoon 4 weeks The Wall weeks Adjustment 20 weeks + The Wall Lasts about 12 to 16 weeks Hardest stage of recovery / cravings may return Depression and irritability Low energy and loss of enthusiasm High risk of relapse

7 Adjustment 20 weeks or longer The person in recovery and the family begin returning to more normal lifestyle After extended abstinence, the person in recovery and family members begin working on professional, marital, emotional, and psychological issues that will strengthen the family Normal Brain SPECT Images Before and Aer Recovery Active substance abuse One year alcohol and drug free Marijuana ~ 18 year old ~ 3 years use 4 times a week

8 Before and Aer Recovery Active substance abuse One year alcohol and drug free How Recovery Management Differs from Traditional Treatment Moving from Disease Management to Recovery Management Working with existing level of change and motivation: (Motivational Interviewing / SOCRATES), S s Outcomes Remission Societal benefits measures Financial benefits measures CLINICAL CONTINUOUS IMPROVEMENT COMPONENTS Patient Assessment Intake and ongoing assessments Treatment Response / Progress Biopsychosocial Treatment Process measurements Adjustments to treatment plan as needed Norman G. Hoffman, Ph.D Evince Clinical Assessments Treatment Plan Define Problems Treatment priorities Treatment Placement

9 SOCRATES The Stages of Change Readiness and Treatment Eagerness Scale Version 8 SOCRATES is an experimental instrument designed to assess readiness for change in alcohol abusers. The instrument yields three factorially-derived scale scores: Recognition (Re), Ambivalence (Am), and Taking Steps (Ts). It is a public domain instrument and may be used without special permission. Answers are to be recorded directly on the questionnaire form. Scoring is accomplished by transferring to the SOCRATES Scoring Form the numbers circled by the respondent for each item. The sum of each column yields the three scale scores. Data entry screens and scoring routines are available. These instruments are provided for research uses only. Version 8 is a reduced 19-item scale based on factor analyses with prior versions. The shorter form was developed using the items that most strongly marked each factor. The 19-item scale scores are highly related to the longer (39 item) scale for Recognition (r =.96), Taking Steps (.94), and Ambivalence (.88). We therefore currently recommend using the 19-item Version 8 instrument. Psychometric analyses revealed the following psychometric characteristics of the 19-item SOCRATES: Cronbach Test-retest Reliability Alpha Intraclass Pearson Ambivalence Recognition Taking Steps Various other forms of the SOCRATES have been developed. These will be migrated into shorter 8.0 versions as psychometric studies are completed. They are: 8D 7A-SO-M 7A-SO-F 7D-SO-F 7D-SO-M 19-item drug/alcohol questionnaire for clients 32-item alcohol questionnaire for significant others of males 32-item alcohol questionnaire for SOs of females 32-item drug/alcohol questionnaire for SOs of females 32-item drug/alcohol questionnaire for SOs of males The parallel SO forms are designed to assess the motivation for change of significant others (not collateral estimates of clients' motivation). The SO forms lack a Maintenance scale, and therefore are 32 items in length. Prochaska and DiClemente have developed a more general stages of change measure known as the University of Rhode Island Change Assessment (URICA). The SOCRATES differs from the URICA in that SOCRATES poses questions specifically about alcohol or other drug use, whereas URICA asks about the client's problem and change in a more general manner. Source Citation: Miller, W. R., & Tonigan, J. S. (1996). Assessing drinkers' motivation for change: The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behaviors 10,

10 CASAA Research Division* 8/95 Personal Drinking Questionnaire (SOCRATES 8A) INSTRUCTIONS: Please read the following statements carefully. Each one describes a way that you might (or might not) feel about your drinking. For each statement, circle one number from 1 to 5, to indicate how much you agree or disagree with it right now. Please circle one and only one number for every statement. 1. I really want to make changes in my drinking. NO! Strongly Disagree No Disagree? Undecided or Unsure Yes Agree 2. Sometimes I wonder if I am an alcoholic. 3. If I don't change my drinking soon, my problems are going to get worse. 4. I have already started making some changes in my drinking. 5. I was drinking too much at one time, but I've managed to change my drinking. 6. Sometimes I wonder if my drinking is hurting other people. 7. I am a problem drinker. 8. I'm not just thinking about changing my drinking, I'm already doing something about it. 9. I have already changed my drinking, and I am looking for ways to keep from slipping back to my old pattern. 10. I have serious problems with drinking. YES! Strongly Agree

11 11. Sometimes I wonder if I am in control of my drinking. NO! Strongly Disagree No Disagree? Undecided or Unsure Yes Agree 12. My drinking is causing a lot of harm. 13. I am actively doing things now to cut down or stop drinking. 14. I want help to keep from going back to the drinking problems that I had before. 15. I know that I have a drinking problem. YES! Strongly Agree 16. There are times when I wonder if I drink too much. 17. I am an alcoholic. 18. I am working hard to change my drinking. 19. I have made some changes in my drinking, and I want some help to keep from going back to the way I used to drink.

12 CASAA Research Division* 9/95 Personal Drug Use Questionnaire (SOCRATES 8D) INSTRUCTIONS: Please read the following statements carefully. Each one describes a way that you might (or might not) feel about your drug use. For each statement, circle one number from 1 to 5, to indicate how much you agree or disagree with it right now. Please circle one and only one number for every statement. 1. I really want to make changes in my use of drugs. NO! Strongly Disagree No Disagree? Undecided or Unsure Yes Agree 2. Sometimes I wonder if I am an addict. 3. If I don't change my drug use soon, my problems are going to get worse. 4. I have already started making some changes in my use of drugs. 5. I was using drugs too much at one time, but I've managed to change that. 6. Sometimes I wonder if my drug use is hurting other people. 7. I have a drug problem. YES! Strongly Agree 8. I'm not just thinking about changing my drug use, I'm already doing something about it. 9. I have already changed my drug use, and I am looking for ways to keep from slipping back to my old pattern. 10. I have serious problems with drugs.

13 11. Sometimes I wonder if I am in control of my drug use. NO! Strongly Disagree No Disagree? Undecided or Unsure Yes Agree 12. My drug use is causing a lot of harm. 13. I am actively doing things now to cut down or stop my use of drugs. 14. I want help to keep from going back to the drug problems that I had before. 15. I know that I have a drug problem. YES! Strongly Agree 16. There are times when I wonder if I use drugs too much. 17. I am a drug addict. 18. I am working hard to change my drug use. 19. I have made some changes in my drug use, and I want some help to keep from going back to the way I used before.

14 SOCRATES Scoring Form - 19-Item Versions 8.0 Transfer the client's answers from questionnaire (see note below): Recognition Ambivalence Taking Steps TOTALS Re Am Ts Possible Range:

15 SOCRATES Profile Sheet (19-Item Version 8A) INSTRUCTIONS: From the SOCRATES Scoring Form (19-Item Version) transfer the total scale scores into the empty boxes at the bottom of the Profile Sheet. Then for each scale, CIRCLE the same value above it to determine the decile range. DECILE SCORES 90 Very High Recognition Ambivalence Taking Steps High Medium Low Very Low RAW SCORES (from Scoring Sheet) Re= Am= Ts= These interpretive ranges are based on a sample of 1,726 adult men and women presenting for treatment of alcohol problems through Project MATCH. Note that individual scores are therefore being ranked as low, medium, or high relative to people already presenting for alcohol treatment.

16 Guidelines for Interpretation of SOCRATES-8 Scores Using the SOCRATES Profile Sheet, circle the client s raw score within each of the three scale columns. This provides information as to whether the client s scores are low, average, or high relative to people already seeking treatment for alcohol problems. The following are provided as general guidelines for interpretation of scores, but it is wise in an individual case also to examine individual item responses for additional information. RECOGNITION HIGH scorers directly acknowledge that they are having problems related to their drinking, tending to express a desire for change and to perceive that harm will continue if they do not change. LOW scorers deny that alcohol is causing them serious problems, reject diagnostic labels such as problem drinker and alcoholic, and do not express a desire for change. AMBIVALENCE HIGH scorers say that they sometimes wonder if they are in control of their drinking, are drinking too much, are hurting other people, and/or are alcoholic. Thus a high score reflects ambivalence or uncertainty. A high score here reflects some openness to reflection, as might be particularly expected in the contemplation stage of change. LOW scorers say that they do not wonder whether they drink too much, are in control, are hurting others, or are alcoholic. Note that a person may score low on ambialence either because they know their drinking is causing problems (high Recognition), or because they know that they do not have drinking problems (low Recognition). Thus a low Ambivalence score should be interpreted in relation to the Recognition score. TAKING STEPS HIGH scorers report that they are already doing things to make a positive change in their drinking, and may have experienced some success in this regard. Change is underway, and they may want help to persist or to prevent backsliding. A high score on this scale has been found to be predictive of successful change. LOW scorers report that they are not currently doing things to change their drinking, and have not made such changes recently.

17 Dollars & Sense The Hidden Cost of Addiction Substance Abuse (alcohol /tobacco/drugs) in the workplace has been described as the $125 Billion hangover. This staggering cost is felt in all areas of productivity. The longer a person s use of alcohol or drugs continues, the more difficult it becomes to assist them, and the more expensive it becomes for family, friends and employers. Early Indicators Alcohol and drug use are very common forms of socializing, networking, and stress reduction. Approximately 15% of individuals who drink or use drugs will develop the disease known as addiction. Often, the drinker or drug user will be a High Energy performer. The individual s capacity for hard work and hard play seem amazing. It is not uncommon at this point to hear a drinker boast of the amount he or she can hold, or the frequency in which drinking occurs. When a problem is developing, you are likely to see changes in the following areas: General Behaviors Attendance * Over reacts to advice * Late returning from lunch * Co-workers complain/comment * Leaves work early * Frequent Medical complaints ie: colds, flu, etc. * Occasional unexplained absences Middle Phases At this point in the chemical use, the changes you are likely to observe become more apparent. The chemical user will show wide mood swings. Frequent complaints of stress are often given as a cause for irritability. Although still capable of exceptional performance at times, the overall efficiency of the individual is about 70%. Middle to Late Phases The overall efficiency of the individual drops to no more than 50% General Behaviors Attendance * Grandiose or belligerent * Increased tardiness * Personal financial problems * Failure to return from lunch * Domestic problems * Increased medical leave * Legal Problems (DUI) * Relies on others to cover * Trust account irregularities

18 Late Phase At this point a firm has few options remaining with a member. If the member is close to retirement, a common reaction is to carry the member. This is done by quietly moving the individual into responsibilities that lessen exposure for client contact or malpractice liability. Younger member are generally terminated. General Behaviors Attendance * Virtually unreliable * Missed appointments * Pronounced physical decline * Unexplained absences * Recurrent personal & legal * Even when physically present, problems interfering with work not able to contribute * Excessive use of breath mints to cover the smell of alcohol *High stress and irritability These signs are present in varying degrees in most instances of chemical dependence. This list is meant as a guide only, and not for diagnostic purposes. References: Miller, T. and Hendrie, D. Substance Abuse Prevention Dollars and Cents: A Cost-Benefit Analysis, DHHS Pub. No (SMA) Rockville, MD: Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, National Center on Addiction and Substance Abuse at Columbia University (CASA). Addiction Medicine: Closing the Gap Between Science and Practice. June, 2012.

19 UNDERSTANDING THE NATURE OF ADDICTION AND ITS DENIAL Dr. Kubler-Ross identified 5 steps before acceptance of an illness occurs. All major illness includes these 5 stages to acceptance, as a component of the illness: 1st Simple denial - A statement by the patient that they do not have an illness; 2nd Anger - The patient lashes out at doctors, family, and co-workers to get people to stop talking about the illness; 3rd Negotiation - Promises to God, to family, the Firm; promising to be a better person in exchange for not being sick; 4th Depression - As the seriousness of an illness begins to take hold, the patient begins to experience a psychological low; and, 5th Acceptance - The final stage of the process is coming to grips with the reality that the patient really does have a significant illness, and most take affirmative action. In Addiction, the patient experiences the first 4 of these stages, but does not naturally come to a point of acceptance because Euphoric recall precludes the normal function of a memory. Our brains function by chemical reaction. Euphoric recall is the tendency for people to remember things in a positive light, while overlooking negative experiences associated with that event. A person can literally be so intoxicated that they cannot stand up, but because of euphoric recall, they will remember having spoken clearly and walked a straight line, while there is really is accurate memory. Because the patient s memory is so badly distorted, but they rely on their memory, family, friend s, and healthcare professionals need to intervene into this denial. Dr. Ross s 5 steps of acceptance also apply to the stages required for Family Recovery: Accept the reality of the loss Working through the pain Adjustment to the environment Emotional relocation of the loss (shock, denial, bargaining) (anger and depression) (beginning of acceptance) (acceptance and recovery)