Substance Use Disorder
by Judge Jeri Beth Cohen, Ret.
Presently in the United States, nearly 9 million children live with at least one parent who suffers from a Substance Use Disorder, including alcohol (SUD). This constitutes no less than 12% of all children in the United States. Fifty percent of those suffering from a SUD, also suffer from a co-occurring mental health issue such as depression, anxiety or bipolar disorder. If you practice in any division of the Court, except the Civil Division, you are likely to frequently encounter clients who are suffering from SUD, untreated Mental Health issues (MH) or both conditions. Moreover, it is likely that a majority of these clients have a genetic or familial history of SUD and or MH, have experienced unresolved childhood and/or adult trauma, and have never had access to or received targeted treatment for either their MH issues or SUD. The negative effects on children living with parental SUD are well documented and will be addressed separately in this issue of Kidside. The goal of this article is to provide you with a simple roadmap for helping your adult clients.
When working with clients suffering from SUD, it is important that you treat the SUD as a medical problem or disease of the brain and not a moral choice or shortcoming. No one wakes up in the morning and says, “gee, I’d like to become addicted to drugs”. Rather, as stated above, biopsychosocial factors, including genetics, trauma and untreated mental health issues, all contribute to addiction. Addiction alters brain chemistry and causes uncontrollable cravings and compulsive drug seeking behaviors that persist despite devastating consequences, guilt and shame. Cravings can persist for years and be exacerbated by life circumstances such as stress, contact with old drug using friends, visiting places where drug usage occurred or engaging in things that are reminiscent of a drug using lifestyle (commonly referred to in treatment jargon as “people, places and things”).
Given the complex nature of addiction, treatment is not simple and relapse is common. While this is not always the case, addiction is often referred to as a chronically relapsing disease that requires multiple episodes of treatment and a life- long commitment to recovery. Therefore, it is crucial to obtain a good evidence- based SUD/MH assessment for your client, such as a strength based multidimensional assessment using the American Society of Addiction Medicine Criteria, so that your client can obtain targeted services at the right dosage and duration, and in an integrated manner designed to address all co-occurring issues. There should never be a “one size fits all” approach to treatment. While treatment plans and treatment duration vary based on the chronicity of the SUD and other co-occurring factors, the longer the treatment, and the more comprehensive and holistic, the better the outcomes. Treatment that lasts less than three months is generally deemed subtherapeutic so be wary of 30 day programs, the duration of treatment generally funded by insurance companies. And, be aware, some of your clients may meet criteria for residential or inpatient treatment that should also last no less than 90 days. Whether your client engages in residential or outpatient treatment there should always be a “step-down” plan and/or a plan for a continuum of care. https://www.ncbi.nlm.nih.gov/books/NBK64088/.
To be effective, treatment should be gender specific, culturally sensitive and address all of an individual’s co-occurring issues, including trauma, mental illness and other medical problems. There are many evidence-based interventions for SUD. It is beyond the scope of this article to discuss the behavioral therapies available, but treatment interventions can be accessed, inter alia, on the websites of the Substance Abuse and Mental Health Administration( SAMHSA), the National Institute of Health (NIH), and National Institute on Drug Abuse (NIDA) websites. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3725219/; https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment/behavioral-therapies. Keep in mind, SUD and MH are family problems. Treatment should occur in the context of the entire family and close relatives and friends. You often hear, “he/she has a drug problem but there is nothing wrong with me, it’s his/her problem”. Unfortunately, it’s just not that simple. When one individual in a family suffers from SUD or untreated MH, the entire family structure suffers. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3725219/ . Even in situations of divorce, the nonimpaired parent should become educated on issues related to MH and SUD. Children, as well, should receive counseling if necessary and be educated about the diseases of SUD and Mental Illness, and especially about genetic predisposition. Individuals should never be treated in a vacuum, but in the context of their family and community.
In cases of Opioid Use Disorder (OUD) and Alcohol Use Disorder (AUD), it is crucial to explore the use of Medication Assisted Treatment with a medical doctor not just for humane detoxification and stabilization, but as a long-term component of any treatment plan. These life-saving and life changing medications are most effective when coupled with counseling and other behavioral SUD therapies. Such medications include Subutex or Suboxone (Buprenorphine), Methadone, and short or long acting Naltrexone. Naltrexone can be used both for OUD and AUD. These medications have a plethora of science to support their efficacy and should never be considered as replacing one drug for another. https://www.fda.gov/drugs/information-drug-class/information-about-medication-assisted-treatment-mat#section-nav. Never advise your clients to just go “ cold turkey”, especially when dealing with addiction to alcohol, opioids or benzodiazepines (e.g. Xanax). This can cause extreme symptoms or death and should be done under the supervision of a medical professional. If your client is addicted to opioids, always make sure that the client has naloxone in his/her possession and/or in the possession of a family member in case of overdose. Naloxone, purchased without a prescription at a drug store, is easy to administer and saves lives. https://www.drugabuse.gov/publications/drugfacts/naloxone.
Peer support in the form of 12 Step AA/NA/Smart Recovery is highly recommended for most individuals. Keep in mind, peer support is not treatment but a complementary intervention that provides long term community support. Remember, people live in communities not courts, and any assistance provided by the Court or by you should always focus on strengthening healthy community and family supports so that your clients can live productive independent lives as nurturing parents. Finally, If your client is eligible for a Drug Court take advantage of the opportunity. Drug courts cut through a lot of the bureaucracy of finding and accessing treatment and are presided over and administered by knowledgeable and compassionate judges and case managers. Dade County has several Drug Courts (and Mental Health courts) in the Criminal, Dependency, Delinquency and Domestic Violence Divisions. In addition, Dade County has a knowledgeable Magistrate presiding over civil Marchman Act (SUD) and Baker Act (MH) petitions. For information regarding treatment availability for clients who are uninsured or do not have government benefits, contact Thriving Minds d/b/a The South Florida Behavioral Health Network. www.thrivingmind.org.
There is a misperception that treatment needs to be voluntary to be effective. While many individuals are in denial about their SUD, feel shame and disappointment in themselves and are afraid of losing their children, compassion coupled with sanctions (supervised visitation) and enticements (unsupervised visits) from family, employers or the court can increase treatment entry and retention. Once an individual engages in treatment, he/she will gradually internalize and utilize recovery tools learned in treatment. This doesn’t mean that relapse will not occur or that one treatment intervention will be enough to lead to long term recovery. Since recovery is, for most individuals, a life- long process, you should always recommend that your clients, in coordination with family members and close friends, develop a safety plan for themselves and their children in the event of relapse. I can’t emphasis enough that relapse is the expectation rather than the exception and should be used as a learning tool to prevent subsequent relapses rather than as a means to gain punitive advantage in court. This by no mean is meant to suggest that relapse should not be taken into account when determining conditions of visitation and custody.
One of the hardest problems in all of this is assessing when someone is truly maintaining sobriety and internalizing treatment. To ask it differently, when is an individual in recovery? Of course, the best way to determine sobriety is to conduct truly random drug tests on a frequent basis using a 12 panel screen designed to detect adulteration or dilution. Most substances only remain detectable in the body with urine sampling for 72 hours, with THC remaining detectable longer and alcohol detectable for only about 8 hours. Therefore, if alcohol, still the most widely abused drug along with tobacco, is the drug being tested then an individual should be fitted with a SCRAM bracelet that is designed to monitor any alcohol intake, https://www.scramsystems.com/scram-blog/alcohol-testing-scram-cam-vs-etg/, or perform urine testing with a special ETG urine screen. Another popular alternative utilized by the Court in the family divison is Soberlink (www.soberlink.com) which is a remote, real-time alcohol monitoring solution. There are many “designer drugs” and synthetic fentanyl that simply avoid detection. Drug tests, after an adequate period of time in treatment, provide an effective deterrent to drug usage and an indication of whether treatment is effective or needs to be modified. Remember, over treating an individual may be just as dangerous as under treating and treatment protocols should be continuously monitored to assess their effectiveness. For more information on drug testing, you can go to the National Association of Drug Court Professionals website. www.nadcp.org. Finally, the best indicator of recovery is behavioral change, i.e., improved parenting and problem solving skills, better interpersonal relationships, decreased anger and reactive behaviors and better compliance with the demands of employment or school.
People can and do recover. I experienced this on a daily basis presiding for nearly 28 years in DUI court, Criminal Drug Court, the Juvenile Delinquency and Dependency divisions of Juvenile Court, and Unified Family Court. All judges and lawyers practicing in these divisions (including the Probate Division), have an obligation to educate themselves about SUD/MH and the literature surrounding these diseases. For many coming into our courts, this is the first time that they have ever had the opportunity to access treatment for themselves and their children. It may be the first time anyone will have asked them about their trauma in a compassionate and nonjudgmental way. For many, it will present their first real opportunity to break the cycle of familial SUD, untreated mental illness and domestic abuse. We, in our role as judges and lawyers, have a unique opportunity to serve as motivational change agents for these families.