4th International Conference of Legal Regulators

Toronto, Ontario, Canada July 27-28, 2015

Doris C. Gundersen MD Medical Director,

Colorado Physician Health Program President,

Federation of State Physician Health Programs

Lawyers on the Edge: Licensure and the Impaired Professional

Objectives • Understand addiction as an

illness

• Become familiar with other potentially impairing conditions

• Barriers to Care: Character traits and fear of punishment

Substance-Related and

Addictive Disorders

Addiction Defined

• A primary, indiscriminate, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations.

• Incurable but manageable, like diabetes or hypertension

• Characterized by one or more behaviors

– Impaired control over use

– Compulsive use

– Continued use despite harm

– Craving

Mark Twain: Smoking

- Mark Twain (1835-1910)

“Stopping smoking is the easiest thing I have ever done – I have done it hundreds of times.”

DSM V Criteria

• Taking the substance in larger amounts or for longer

than intended

• Wanting to cut down or stop using the substance but

unsuccessful in doing so

• Spending a lot of time procuring, using, or recovering

from use of the substance

• Cravings and urges to use the substance

• Not managing to do what you should at work, home

or school, because of substance use

DSM V Criteria (cont)

• Continuing to use, even when it causes problems in relationships

• Giving up important social, occupational or recreational activities because of substance use

• Using substances again and again, even when it puts

you in danger

• Continuing to use, even when the you know you have

a physical or psychological problem that could have

been caused or made worse by the substance

DSM V (cont)

• Needing more of the substance to get the effect you want (tolerance)

• Development of withdrawal symptoms, which can be relieved by taking more of the substance (dependence)

The Brain: A Chemical Messaging System

• Serotonin regulates mood, appetite and sleep

• Adrenalin protects us in danger

• Endorphins protect us from pain

• Dopamine provides rewards:

– Food

– Sex

– Drugs

Dopamine Neurotransmission

Dopamine Neurotransmission: Motivation, Drive, Pleasure, Addiction

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Di Chiara et al.

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Risk Factors - Personal Factors

Genetics

Gender: male > female

Co occuring, untreated mental illness

Co occuring undertreated medical illness

The accidental addict

Risk Factors - External Factors

l Family of Origin

l Culture

l Peer Group

l External Stressors: poverty, job stress, single parenting, unemployment, divorce (isolation)

l Exposure to Trauma: childhood abuse, natural disaster, combat, sexual assault, international conflict

l Access

Addiction Among Attorneys

• It is estimated that 18-20% of attorneys have a drinking problem – Alcohol Abuse – Alcohol Dependence

• This is two times what is observed in the general population • This is higher than what is observed in physicians (10-15%)

• Liquor cabinets in law offices – time to rethink?

• Alcoholism accounts for 95% of addiction among attorneys

– Alcohol is legal and therefore acceptable – Slow progression to dependence – Highly treatable disorder

Addiction Among Attorneys

• Onset of alcohol dependence is gradual and insidious

• Ages 40 to 55 years is period of greatest

risk, usually after 20 years of alcohol

consumption

Law Students

• Law students experience more anxiety than the general population

• Psychiatric distress (OCD symptoms and paranoia)

• 40% meet criteria for clinical depression

Andy Benjamin 1986 study

• Students frequently turn to alcohol and other drugs to cope

• May establish a habit that ultimately leads to substance abuse and/or dependence in later years

• Law students are universally resistant to reaching out for help

• Social isolation is the norm when under stress

American Association of Law Schools Study – 1994

Effects of Marijuana Intoxication and Pilot Performance Am J Psychiatry 1985;142:1325-1329

• Ten experienced licensed private pilots trained for 8 hours on a flight simulator landing task

• Each smoked a THC cigarette (19 mg)

• 24 hours later their mean performance on the flight task showed trends toward impairment in all variables, some tasks showed significant impairment

• Despite the deficits, the pilots reported no awareness of impaired performance

How will LAPs Evaluate and Monitor?

Social Media

Facebook

MySpace

LinkedIn

Twitter

U Tube

Web Logs

Tinder

Process Addictions

• Compulsive viewing of pornography

• Gambling

• Sexual addiction (texting and “sexting”)

• Shopping

• Binge eating

• Workaholism

Professionalism

Workaholism is very much like substance abuse

• Disrupts sleep

• Creates multiple family problems & destroys marriages.

• Decreases your efficiency and your ability to concentrate

• Makes you irritable and fatigued.

• Increases your risk of back problems, gastro-

intestinal disorders, heart disease and stroke.

Detection of Substance Abuse

• Vocational

– Late for work

– Looks disheveled

– Absent (not returning calls)

– Absent (emotionally/psychologically)

– Delinquent with deadlines/filings

– Client complaints

– Regulatory complaints

Types of Drug Tests

• Urine;

• Oral-Fluid;

• Blood;

• Sweat

• Hair

• Nail

Loss of Function Hierarchy for Addicted Attorneys

• Community

• Spiritual life

• Recreation and avocation

• Friends

• Peers

• Family

• Work** **A Medical Emergency

after Talbott

Outpatient Treatment

• Early in course of illness – Binge drinking vs dependence

• Adequate (sober) sources of support

• Family is not enabling

• High functioning

• Acceptance of Illness

• High motivation/compliance

• Absence of serious co morbid disorders

Inpatient Treatment

Specialized Residential Treatment for Professionals

– Professionals listen to other professionals (like addicts listen to addicts) – Therapeutic confrontation of denial – Stage of Illness and lethality of drug of choice considered – Efficacy observed w/ residential treatment – Removed from:

• Access to drugs • Stressful environment • Enabling environment • Temptation/urgency to return to work

Relapse Study: Years in Program

• 90% Recovery rates observed

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Addiction Among Attorneys: In Summary

• Alcoholism is correlated with both malpractice and discipline (60% of cases)

• Punishing ill attorneys does not make them well

• Complaint driven processes identify end stage illness

• Confidentiality leads to more attorneys seeking treatment voluntarily

• Confidentiality and Lawyers Assistance Programs afford early intervention, before impairment sets in and public safety is jeopardized