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Article for CLE Credit: Addiction, Substance Abuse and the Legal Profession

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ONE HOuR CLE CREDIT
ADDICTION, SUBSTANCE
ABUSE AND THE LEGAL PROFESSION
BY MICHAEL S. LEVY, D.O.
since my first clinical exposure to addictive disease as a medical intern in 1979, i have been increasingly fascinated, and at times astounded, by the effects of addictive substances on my patients and society in general. the primary substances of abuse during those early years were alcohol and barbiturates. Heroin and cocaine have been part of the drug scene for hundreds of years and were initially considered medicinal. in fact, cocaine continues to be used as a local anesthetic and as an eye medication to cause constriction of the pupil. prescription pain medications are now epidemic agents of abuse and dependence worldwide, with respiratory depression being the primary cause of death. the following information is clinical in nature, yet illustrates the significant medical, personal, professional and social problems associated with the disease of addiction.
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What is Addiction?
The following excerpts come from the website of the American Society of Addiction Medicine:1 Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic 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 often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. Genetic factors account for about half of the likelihood that an individual will develop addiction. Environmental factors interact with the person’s biology and affect the extent to which genetic factors exert their influence. Culture also plays a role in how addiction becomes actualized in persons with biologic vulnerabilities to the development of addiction. It is frequently stated that addiction is a disease of mind, body and spirit.
Cognitive changes in addiction can include: a) Preoccupation with substance use; b) Altered evaluations of the relative benefits and detriments associated with drugs or rewarding behaviors; and c) The inaccurate belief that problems experienced in one’s life are attributable to causes other than being a predictable consequence of addiction. Emotional changes in addiction can include: a) Increased anxiety, dysphoria and emotional pain; b) Increased sensitivity to stressors associated with the recruitment of brain stress systems, such that “things seem more stressful” as a result; and c) Difficulty in identifying feelings, distinguishing between feelings and the bodily sensations of emotional arousal, and describing feelings to other people. Behavioral manifestations and complications of addiction, primarily due to impaired control, can include:
For example, acute opioid (any synthetic narcotic that has opiate-like activities but is not derived from opium) withdrawal symptoms may include nausea, vomiting, diarrhea, abdominal bowel spasms, sweats and hot/cold chills to name a few. This is clearly not a desired condition. While a person develops a tolerance to the “high,” no tolerance develops to the emotional and physical “low” associated with the cycle of intoxication and withdrawal. As addiction is a chronic disease, periods of relapse, which may interrupt spans of remission, are a common feature of the disease. It is also important to recognize that relapse is not inevitable. Clinical interventions can be effective in altering the course of the disease; however it is a certainty that addiction can cause disability or premature death, especially when left untreated or treated inadequately. Dr. Elliot Gardner, Chief of the Neuropsychology Section at the National Institute on Drug Abuse, noted “Addiction is as old as humankind,” and used this biblical reference as an example: And Noah planted a vineyard. And he drank of the wine, and became drunken. And he was naked and dirty in his tent. And Ham saw the nakedness and filthy condition of his father, and told his two brothers. And Shem and Japheth took a garment ... and covered the nakedness of their father: and they turned their faces away, so as to avert their eyes from their father’s nakedness and shame. Genesis 9:20-23.
a) Excessive use and/or engagement in addictive behaviors, at higher frequencies and/or quantities than the person intended, often associated with a persistent desire for and unsuccessful attempts at behavioral control; b) Excessive time lost in substance use or recovering from the effects of the substance use and/or engagement in addictive behaviors, with significant adverse impact on continued on page 18 social and occupational functioning; c) Continued use and/or engagement in addictive behaviors, despite the presence of persistent or recurrent physical or psychological problems that may have been caused or exacerbated by substance use; d) A narrowing of the behavioral If not...you will repertoire focusing on rewards that are part of addiction; and e) An apparent lack of ability and/or readiness to take consistent, ameliorative action despite recognition of problems. f) Addiction is not a disease of choice. Over time, repeated substance use experiences or addictive behaviors are not associated with increasing reward activity within the brain and are not as subjectively rewarding. Withdrawal from drug use results in anxious, agitated, unhappy emotional experiences, as well as All Communications Confidential. physical symptoms that may be debilitating. January 2013 Nevada Lawyer 17
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ONE HOuR CLE CREDIT
ADDICTION, SUBSTANCE ABUSE AND THE LEGAL PROFESSION
continued from page 17
Dr. Gardner also notes that of the known 30,000,000 chemical compounds, approximately 100 are addictive. The common properties of these addictive substances are: a) b) c) d) They are rewarding, reinforcing and pleasurable; Animals self-administer them, just as humans do; They activate the reward circuitry in the brain; and The degree of activation of reward circuitry in the brain correlates with addictiveness.
5) Significant time devoted to obtaining the substance, use the substance, or recover from the effects of the substance; 6) Important social, occupational or recreational activities are given up or reduced because of substance use; and 7) Continuation of substance use despite knowledge of physical or psychological problems caused by the substance use. Does this brain disease that significantly impacts the legal profession make intellectual sense? The answer, initially, is no – until the competitive, overachieving driven nature of attorneys and the drive to self-medicate, with whatever means are necessary to maintain at least a status-quo of competence and effectiveness, are considered. In fact, “addiction is a chronic, relapsing disease that results from the prolonged effects of drugs on the brain.”4 Whether or not there is a genetic predisposition, whether or not advanced education is a factor, whatever the sex, color or ethnicity of the involved individual, most individuals underestimate the effect of alcohol and drugs on the brain. An old mantra from an unnamed reference is, “the only difference between a drug and a poison is the dose.” The State Bar of Nevada offers a confidential service, Lawyers Concerned for Lawyers (LCL), to attorneys in need of assistance with alcohol and drug problems, mental health, personal and gambling issues. The organization has existed in Nevada since 1985 and its primary mission is to provide assistance, support, referral and assessment to attorneys suffering from addiction. LCL also offers a network of recovering attorneys who carry the message of sobriety to members of the profession. Addiction medicine physicians, inpatient and outpatient treatment programs, Alcoholics Anonymous and spiritual resources through every organized religion are just a few of the many approaches to sobriety that are effective. “There is a way.”
1 http://www.asam.org/research-treatment/definition-of-addiction. 2 Wisconsin Lawyer, Vol. 80, No. 80, August 2007. 3 Diagnostic and Statistical Manual, Text Revision, IV of the American Psychiatric Assn. 4 Addiction Is a Brain Disease, and It Matters, Alan Leshner, Science Magazine, Vol. 278, Oct. 1997.
The Legal Profession
While some estimates of chemical dependency in the general population are as high as 10 to 12 percent, the corresponding estimate for the legal profession is 15 to 18 percent. A 1990 study by Johns Hopkins Medical School concluded that lawyers have the highest rate of clinical depression of all professions surveyed. In the Sept./Oct. 2011 issue of The Bencher, the author states that among male lawyers, the suicide rate is approximately twice that of men in the general population. Female attorneys have an even higher rate of depression. Substance abuse often develops as an attempt to self-medicate the mental health issues. In approximately 50 to 70 percent of cases in which lawyers face disciplinary charges, alcohol dependence and/or other addictions are involved. The prevailing view that addictive disease is a sign of weakness is outdated and unsupported. There continues to be a wide gap between the scientific facts and perception of substance dependence/addiction. A 2007 article in Wisconsin Lawyer identifies that attorneys are held to a higher standard of conduct, therefore it is important to maintain an image of being in control. “Fear of loss of respect from colleagues, loss of clients and loss of job dominates a cognitive defense system in the addicted attorney. This selfdefense is manifested by denial, blame, and rationalization, ultimately to the point where the lie becomes the truth in the addict’s mind.”2 It is important to recognize that initial use of a legal or illegal drug for a recreational purpose may not strictly constitute abuse. Rather, the spectrum of use and subsequent abuse becomes recurrent in situations that may be physically hazardous, resulting in legal or social consequences, or failure to fulfill role obligations at work and at home. Despite the knowledge of these adverse consequences, the substance use is continued. Logic is lost in a sea of distorted thinking and decision-making. This behavior is contrary to the intellectual and advocacy pursuits of the legal profession. The progressive deleterious effects of substance use and dependence are manifested by the following:3 1) 2) 3) 4) Tolerance; Withdrawal; Increased consumption over a longer period than was intended; Persistent desire or unsuccessful efforts to cut down or control substance use;
MIChAEL S. LEvy is the founder and medical director of the Center for Addiction Medicine in Las Vegas, Nevada. Levy is board certified in family medicine and addiction medicine. He has been an active member of the Moral, Character and Fitness Committee of the State Bar of Nevada since 1996, and serves as an expert consultant in civil, criminal, and family law cases. He can be reached at mslevy@addictionhelp.com.
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Nevada Lawyer
January 2013

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