First the Man Takes a Drink... Texas Lawyers Assistance Program September, 2014 Marilyn J Vaché MD, Medical Director, Austin Recovery

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1 First the Man Takes a Drink... Texas Lawyers Assistance Program September, 2014 Marilyn J Vaché MD, Medical Director, Austin Recovery Everyone who drinks alcohol is at risk of losing control of drinking, of drinking more than intended, which is the definition of alcoholism. About a third of adults in the U.S. don t drink alcohol. Of the remaining two-thirds one out of seven will become alcoholic, but it s estimated that one out of five attorneys who drink become alcoholic. Alcohol is by far the major addictive substance among attorneys, but many also have problems with marijuana, amphetamines, cocaine, drugs prescribed for wakefulness, attention deficit disorder, pain, sleep, and anxiety. Heroin is rarely a drug of abuse among lawyers. Diagnosis and Stages The development of alcoholism is colorfully illustrated in the Chinese proverb, First the man takes a drink, then the drink takes a drink, then the drink takes the man. In that first phrase, the man takes a drink, we include social drinking, drinking associated with celebrations and parties. There are guidelines, primarily from the National Institutes of Alcohol and Alcoholism, for determining if one is drinking at a level that is considered social, or safe. The guidelines for men are a maximum of four drinks in one day and fourteen in a week. The guidelines for women, who are at much higher risk of liver disease, are a maximum of three drinks in one day and seven in a week. That second phrase, the drink takes a drink, points to the phenomenon that occurs in vulnerable individuals, the automatic consumption of more and more drinks or other substances even when one is already intoxicated. In the language of Western medicine the hallmark criterion is described as loss of control: A substance is often taken in larger amounts or over a longer period than was intended.

2 Related to that loss of control is the symptom of cravings or urges to use, with a persistent desire or unsuccessful efforts to cut down or control use. An important warning sign is the pattern of controlling use for a while by limiting amounts, e..g., I will only have a half bottle of wine, followed by unpredictable loss of control, or binges. A variation of this is crossaddiction, when one successfully quits one substance but then finds oneself addicted to another one. The second major criterion for addiction is preoccupation with the drug -- spending a great deal of time procuring, using, or recovering from drug effects, as well as failing to fulfill major role obligations at work, school, or home. Important activities are given up or reduced because of use. The third major criterion is continued use in spite of adverse consequences -- social, occupational, legal, psychological, physical. At first these can be subtle, like hangovers, being late on deadlines, irritability and fights with near ones, deterioration in healthy eating, sleeping, and exercise habits. Signs of addiction can be dismissed as anxiety, depression, fatigue, or poor sleep, and inexplicable illnesses with aches and pains may cause multiple trips to the doctor. Consequences are sometimes obvious and dramatic, like using the substance when it is physically hazardous, such as driving, and suffering the consequences of an accident or arrest. The fourth criterion is physical dependence on a drug, characterized by tolerance (needing more of the substance to achieve the desired effect) and withdrawal (physical or psychological symptoms that are only relieved by taking more of the substance). In mild, early stages of alcohol or drug dependence, only two to three signs are present, but as the problem escalates (which can occur in a few years for some, and over decades for others) more and more problems arise. There is a big benefit in admitting or identifying the problem in the early stage, when there is an 80% chance of recovery, rather than in the late stage, when there is only a 20% chance of recovery. That is when the drink takes the man.

3 Intervention and Care If the addicted individual doesn t recognize the problem and seek care, what can be done to help? The most effective strategy is the intervention, an organized effort by important individuals in the person s life to clearly state the problem and insist on treatment. For lawyers, especially, where a license and a career is on the line, it is best to have a professional interventionist or organization such as TLAP organize and prepare the participants. During an intervention each person, including loved ones and professional associates, tell the alcoholic or addict what they ve seen (missed appointments, poor production, missed family events or inappropriate anger), how they feel (angry, scared, sad), and what the person must do to stop the cycle (typically to go to treatment of some sort, and preferably a treatment plan that has already been arranged by the group). Such interventions lead to a high degree of treatment compliance and completion, followed, especially with ongoing monitoring body such as TLAP, by a high percentage of long-term recovery. The options for care are individualized, and often depend on the stage and complications already experienced. Detoxification -- occasionally outpatient but usually inpatient -- will be needed for mid- to late-stage alcohol use, as that is the withdrawal that is most likely to result in medical complications or even death. Twelve-step or other self-help programs by themselves can be very effective, and are most often chosen by the person who self-identifies a problem and seeks help even without an intervention. There is a lot of stigma about Alcoholics Anonymous s religious or spiritual approach. The ground-breaking psychologist Carl Jung, however, very early in the history of Alcoholics Anonymous identified the correlation between the words spirit and spirits, and felt AA s spiritual approach addressed the same need that alcohol seems to satisfy, a need for transcendence of self. Its principles also incorporate what we would now call cognitive-behavioral therapy, lessening of stigma, and strong social support. Self-referred individuals may seek out psychotherapy, which can also be very helpful, but it relies on the addict or alcoholic being very honest about drug or alcohol use, which is often difficult in early recovery. Psychotherapy can also help address the common condition known as dual diagnosis,

4 when psychiatric and substance use disorders (SUD) occur together. Depression is present in 50% of SUD clients, and SUD is present in 50% of depressed clients. Other strong associations are between bipolar disorder and alcoholism and between psychotic and memory symptoms in marijuana users. A very common approach to recovery, especially in the early and midstages (before there have been a lot of negative consequences) is an intensive outpatient program (IOP), usually delivered in twenty three-hour sessions. These include education, support, psychotherapy, and introduction to twelve-step programs. For those with more serious consequences or persistent addiction residential treatment of 30 to 90 days may be in order, and occasionally, when the alcoholic or addict has significant medical or psychiatric complications, this may be hospital-based. In some cases, sober living homes may be the next step, and last up to 18 months. At every stage of addiction ongoing support through individual and group therapy and twelve-step programs are usually recommended at the beginning of treatment and indefinitely. One other important point to make is that addiction, although it might be called a disease of isolation because of the stigma and shame that accompany it, never occurs in isolation. Family members, friends, colleagues, staff, partners, and others will have gone through this experience with the recovering alcoholic or addict, and may also carry burdens of shame, resentment, helplessness, and grief. Fortunately, there are programs for them as well, such as family weeks during residential treatment, self-help groups such as Al-Anon or Nar-Anon, and -- new on the scene -- family focused outpatient programs such as Austin Recovery s Center for Recovering Families. When collateral damage is addressed directly, the chances of sobriety improve and the natural support system in one s life is likely to stick together rather than fall apart when most needed. And one more encouraging note: people in recovery are amazing. Through life s challenges, which never stop. they are able to maintain a sense of gratitude, humor, humility, and grounding that serve themselves, their

5 family and friends, their careers, their colleagues and communities, in ways they could never have imagined. If you or someone you know is in the downward spiral of alcohol or drug addiction, do not, out of false pride or some sense of privacy or propriety, avoid dealing with it. Seek help. Offer hope. Contact TLAP.