Child & Family Investigator Colorado Substance Use Disorders Armand Lebovits, LCSW, CAC III [email protected].

Child & FamilyInvestigatorColorado

Substance Use Disorders

Armand Lebovits, LCSW, CAC III

[email protected]

Substance Abuse

• CJD 04-08 Standard 13

• CFIs no longer “routinely” conduct testing

• Make recommendations to court for testing

and/or evaluation if appropriate

• Done by CFI only if sole issue of appointment,

and if qualified

Substance Abuse

• An enormous problem

• More than one in 10 in US live with

dependent or abusing parents

• Profound effects on the children

Effects on Parenting

• The effects of Substance Abuse on Parenting

• Parent unavailable to child

• Parent disappears

• Parent wastes the resources of the family

• Unstable housing, community and schools

• Criminal activity, child endangerment

• Child more likely to abuse

What the Child experiences

• Broken promises

• Inconsistency and unpredictability

• Shame and humiliation

• Tension and fear

• Paralyzing guilt and an unwarranted sense of responsibility

• Anger and hurt

• Loneliness and isolation

• Lying as a way of life

• Feeling Responsible and obligated

CHARACTERISTICS OF AN ADDICTIONCHARACTERISTICS OF AN ADDICTION

DENIALDENIAL IMPULSIVITY-SENSE OF IMMEDIACYIMPULSIVITY-SENSE OF IMMEDIACY COMPULSION TO USECOMPULSION TO USE LOSS OF CONTROLLOSS OF CONTROL TOLERANCETOLERANCE WITHDRAWAL OF USE (OR WITHDRAWAL OF USE (OR

BEHAVIOR) LEADS TO DISCOMFORTBEHAVIOR) LEADS TO DISCOMFORT PROGRESSION OVER TIMEPROGRESSION OVER TIME

UNDERSTANDING SUBSTANCE UNDERSTANDING SUBSTANCE USE AND DISORDERS:USE AND DISORDERS:

DSM V DIAGNOSTIC CRITERIA (Slides 21-27)DSM V DIAGNOSTIC CRITERIA (Slides 21-27) CONTINUUM OF USE MODELCONTINUUM OF USE MODEL

-NO USE/NON-PROBLEM, -NO USE/NON-PROBLEM, SOCIAL/RECREATIONAL USE, MISUSE,SOCIAL/RECREATIONAL USE, MISUSE,BINGE USE, ABUSE, DEPENDENCEBINGE USE, ABUSE, DEPENDENCE

CO-OCCURRING M.H. DISORDERS ANDCO-OCCURRING M.H. DISORDERS ANDS.A. DISORDERSS.A. DISORDERS

DEFENSE MECHANISMSDEFENSE MECHANISMS IMPACT ON COGNITIVE, PSYCH. & SOCIAL IMPACT ON COGNITIVE, PSYCH. & SOCIAL

SYSTEMS SYSTEMS

CONTINUUM OF USE MODELCONTINUUM OF USE MODEL

Social/RecreationalSocial/Recreational Heavy Drinking/Problem Drinker Heavy Drinking/Problem Drinker MisuseMisuse Sustained vs. Periodic UseSustained vs. Periodic Use Abuse (Heavy Episodic Binging-5+ Abuse (Heavy Episodic Binging-5+

drinks)drinks) Dependence Dependence

(Psychological/Physiological)(Psychological/Physiological) Addiction/Addictive Behaviors Addiction/Addictive Behaviors

ADDICTION AS AN ATTACHMENT ADDICTION AS AN ATTACHMENT DISORDERDISORDER

A DISORDER IN SELF-REGULATIONA DISORDER IN SELF-REGULATION

DYSFUNCTIONAL ATTACHMENT STYLESDYSFUNCTIONAL ATTACHMENT STYLES

PADS VS. DAPS (PEOPLE ARE DRUG PADS VS. DAPS (PEOPLE ARE DRUG SUBSTITUTES vs. DRUGS ARE PEOPLE SUBSTITUTES vs. DRUGS ARE PEOPLE SUBSTITUTES)SUBSTITUTES)

THOSE DEPENDENT ON ADDICTIVE SUBSTANCESTHOSE DEPENDENT ON ADDICTIVE SUBSTANCES CANNOT REGULATE THEIR EMOTIONS, HAVE PROBLEMSCANNOT REGULATE THEIR EMOTIONS, HAVE PROBLEMS

WITH SELF-CARE, SELF-ESTEEM AND INTERPERSONALWITH SELF-CARE, SELF-ESTEEM AND INTERPERSONALRELATIONSHIPSRELATIONSHIPS

THE POPULATIONTHE POPULATION

PRE/POST DIVORCE – USUALLY HIGH CONFLICTPRE/POST DIVORCE – USUALLY HIGH CONFLICT OVERREACTION AROUND SUBSTANCE ABUSE/ OVERREACTION AROUND SUBSTANCE ABUSE/

DEPENDENCEDEPENDENCE TENDENCY FOR ONE OR BOTH PARTIES TO TENDENCY FOR ONE OR BOTH PARTIES TO

EMBELLISH OR MINIMIZE USE OF SELF/OTHEREMBELLISH OR MINIMIZE USE OF SELF/OTHER OFTEN DUAL-DIAGNOSIS ISSUES, TRAUMA…OFTEN DUAL-DIAGNOSIS ISSUES, TRAUMA… THERE MAY BE CRIMINAL AND CIVIL LEGAL THERE MAY BE CRIMINAL AND CIVIL LEGAL

ISSUES AT STAKEISSUES AT STAKE GENERALLY, THIS IS A RESISTIVE POPULATIONGENERALLY, THIS IS A RESISTIVE POPULATION

GOALS OF A SUBSTANCE USE GOALS OF A SUBSTANCE USE EVALUATIONEVALUATION

To understand theTo understand the role that a substance plays role that a substance plays in a personin a person’’s life/level of involvement with s life/level of involvement with the substancethe substance

To determineTo determine how the substance use impacts how the substance use impacts the personthe person’’s functionings functioning Cognitive: executive functioning, judgment, Cognitive: executive functioning, judgment,

decision-decision- making, tracking/monitoring, problem making, tracking/monitoring, problem solving, memory,solving, memory,

Psychological: mood, feelings, emotional regulation Psychological: mood, feelings, emotional regulation Social/Legal/OccupationalSocial/Legal/Occupational Medical/PhysicalMedical/Physical

To offerTo offer recommendations that can be recommendations that can be implemented into a parenting planimplemented into a parenting plan

To provide aTo provide a piece of the puzzlepiece of the puzzle for a larger for a larger evaluationevaluation

THE TRUTH IS RARELY PURETHE TRUTH IS RARELY PURE

AND NEVER SIMPLEAND NEVER SIMPLE

OSCAR WILDEOSCAR WILDE

WHAT GETS US INTO TROUBLEWHAT GETS US INTO TROUBLE

IS NOT WHAT WE DONIS NOT WHAT WE DON’’T KNOW,T KNOW,

ITIT’’S WHAT WE KNOW FOR SURES WHAT WE KNOW FOR SURE

THAT JUST AINT SO!THAT JUST AINT SO!

MARK TWAINMARK TWAIN

KEY CONSIDERATIONSKEY CONSIDERATIONS

Is the concern a current problem Is the concern a current problem (within the past 12 months)?(within the past 12 months)?

How much of a factor is the stress How much of a factor is the stress of the divorce?of the divorce?

Has use occurred during Has use occurred during parenting time/Does use impact parenting time/Does use impact parenting?parenting?

Documented history vs. Documented history vs. ““He said, He said, She saidShe said””??

KEY CONSIDERATIONSKEY CONSIDERATIONS

Past substance use and mental Past substance use and mental health treatment history/records?health treatment history/records?

Is concern based on single or Is concern based on single or multiple episodes?multiple episodes?

Meaning of allegations in the Meaning of allegations in the context of the divorce dynamics.context of the divorce dynamics.

Are there concerns about the Are there concerns about the credibility of the credibility of the accuser/allegations?accuser/allegations?

IMPLICATIONS FOR PARENTING PLANSIMPLICATIONS FOR PARENTING PLANS

Overall concern is keeping children safeOverall concern is keeping children safe

Do there need to be restrictions on Do there need to be restrictions on parenting time?parenting time?

Do the parents need treatment?Do the parents need treatment?

Do children and/or other family members Do children and/or other family members need treatment or support?need treatment or support?


Overall concern is keeping children safeOverall concern is keeping children safe

Do there need to be restrictions on Do there need to be restrictions on parenting time?parenting time?

Do the parents need treatment?Do the parents need treatment?

Do children and/or other family members Do children and/or other family members need treatment or support?need treatment or support?


Is limited substance use OK?Is limited substance use OK?

What defines relapse/How to What defines relapse/How to respond?respond?

Is monitoring necessary?Is monitoring necessary?

IMPLICATIONS FOR PARENTING IMPLICATIONS FOR PARENTING

PLANSPLANS:: MONITORING STRATEGIESMONITORING STRATEGIES What Tests to Use:What Tests to Use:

Breath/Saliva testingBreath/Saliva testing Urine testingUrine testing Blood testingBlood testing Hair testingHair testing Transdermal (Sweat)Transdermal (Sweat)

Frequency of Testing: Random or FixedFrequency of Testing: Random or Fixed Duration of TestingDuration of Testing Response to Missed, Dilute or Positive Response to Missed, Dilute or Positive

TestsTests

Recommendations and Treatment Recommendations and Treatment ResourcesResources

Self-management (no use at times prior to Self-management (no use at times prior to parenting time)parenting time)

Drug Testing/Monitored AntabuseDrug Testing/Monitored Antabuse AA, CA, NA, LifeRingAA, CA, NA, LifeRing Individual, family or group counselingIndividual, family or group counseling Intensive Outpatient Program or Inpatient Intensive Outpatient Program or Inpatient

TxTx Psychiatric Referral for Psychiatric Referral for

consultation/medicationconsultation/medication

DSM-IV criteria

• Substance dependence

• Tolerance of the substance

• Withdrawal

• More amounts, no efforts to control

• Time and resources spent obtaining substance

• Outside activities fall away

• Continued use in spite of significant problems

DSM-IV criteria

• Substance abuse

• Failure to fulfill major obligations

• Physically dangerous situations

• Related legal problems

• Persistent or recurrent social or interpersonal problems

• A person is either dependent or abusing a particular substance, not both at the same time

American Psychiatric Association DSM-V American Psychiatric Association DSM-V

Substance-Use DisorderSubstance-Use Disorder:: A. A maladaptive pattern of substance use leading to A. A maladaptive pattern of substance use leading to

clinically significant impairment or distress, as manifested by clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month 2 (or more) of the following, occurring within a 12-month period: period:

recurrent substance use resulting in a failure to fulfill major recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from substance-related absences, suspensions, or expulsions from school; neglect of children or household) school; neglect of children or household)

recurrent substance use in situations in which it is physically recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) machine when impaired by substance use)

continued substance use despite having persistent or continued substance use despite having persistent or recurrent social or interpersonal problems caused or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical with spouse about consequences of intoxication, physical fights)fights)


tolerance, as defined by either of the following: tolerance, as defined by either of the following: a. a need for markedly increased amounts of the a. a need for markedly increased amounts of the

substance to achieve intoxication or desired effect substance to achieve intoxication or desired effect b. markedly diminished effect with continued use of the b. markedly diminished effect with continued use of the

same amount of the substancesame amount of the substance(Note: Tolerance is not counted for those taking (Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)antidepressants, ant-anxiety medications or beta-blockers.)

withdrawal, as manifested by either of the following: withdrawal, as manifested by either of the following: a. the characteristic withdrawal syndrome for the a. the characteristic withdrawal syndrome for the

substance (refer to Criteria A and B of the criteria sets for substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances) Withdrawal from the specific substances)

b. the same (or a closely related) substance is taken to b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptomsrelieve or avoid withdrawal symptoms(Note: Withdrawal is not counted for those taking (Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)antidepressants, anti-anxiety medications or beta-blockers.)


• amounts over a longer period than was intended

• a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects

• important social, occupational, or recreational activities are given up or reduced because of substance use

• the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

• Craving or a strong desire or urge to use a specific substance


Severity specifiersSeverity specifiers::

•• Mild: Presence of 2-3 symptomsMild: Presence of 2-3 symptoms Moderate: Presence of 4-5 symptomsModerate: Presence of 4-5 symptoms Severe: Presence of 6 or more symptomsSevere: Presence of 6 or more symptoms SpecifySpecify if: if: With Physiological Dependence: evidence of With Physiological Dependence: evidence of

tolerance or withdrawal (i.e., either Item 10 or 11 is tolerance or withdrawal (i.e., either Item 10 or 11 is present)present)

Without Physiological Dependence: no evidence of Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 10 nor 11 tolerance or withdrawal (i.e., neither Item 10 nor 11 is present)is present)

27

DSM-V CONTINUED

• Specify if:In early remissionIn sustained remission

Relapse

• Now recognized to be standard piece of the road to recovery

• How will this affect your recommendations?

• How can safety be provided for the child?

MEDICAL MARIJUANA ISSUESMEDICAL MARIJUANA ISSUES

Marijuana is illegal under federal lawMarijuana is illegal under federal law Regulation of the industry is on-going and Regulation of the industry is on-going and

evolvingevolving Medical marijuana is a political, legal, Medical marijuana is a political, legal,

health and moral issuehealth and moral issue Do people really qualify or do they just Do people really qualify or do they just

want to get high?want to get high? Should drug abuse be treated as a health Should drug abuse be treated as a health

issue, a legal issue, a moral issue or all?issue, a legal issue, a moral issue or all?


•• What or has anything changed in assessing cannabis use with What or has anything changed in assessing cannabis use with medical marijuana recommendations?medical marijuana recommendations?

•• Right to use in Colorado but not a Right to be Impaired when Right to use in Colorado but not a Right to be Impaired when parenting children!parenting children!

Dosing Issues (Smoking, Vaporizers, Edibles, Tinctures, Oils)Dosing Issues (Smoking, Vaporizers, Edibles, Tinctures, Oils)

Right to Use vs. Impact on Personality Functioning (Impact on Right to Use vs. Impact on Personality Functioning (Impact on Parenting Capacity)Parenting Capacity)

Research-What we know about impact on Executive Research-What we know about impact on Executive

Functioning/Motor SkillsFunctioning/Motor Skills

Marijuana and Tolerance and Adaptation to use?Marijuana and Tolerance and Adaptation to use?


• Previous History of Cannabis Use/Abuse/Dependence? Prior to Card?

• Environmental Concerns, Exposure of Children to smoke (clothes/backpacks), cannabis and edibles unlocked at home (infants/toddlers/pre-schoolers)

• Impact on Emotional and Behavioral Attunement of Parents

with children (Ability of Parent to regulate emotions and reflect on child?)

• Aspirational aspects of having parents not use 12 hours or longer or during

parenting time; Window of Detection Issues (Can this be enforced or monitored?)

• Can we regulate prescriptions? (No control over their dosing)

MEDICAL MARIJUANA ISSUESMEDICAL MARIJUANA ISSUES Is there a documented history of debilitating disorders?Is there a documented history of debilitating disorders?

Is using medicinal cannabis the best practices for the medical issue? Is using medicinal cannabis the best practices for the medical issue?

How is assessment the same or different for pain medications and medical How is assessment the same or different for pain medications and medical marijuana?marijuana?

•• When should a pain specialist be used for pain assessment or when to use an IME When should a pain specialist be used for pain assessment or when to use an IME (Independent Medical Evaluation)? (Independent Medical Evaluation)?

•• Medical Marijuana and CPS (neglect and abuse?)Medical Marijuana and CPS (neglect and abuse?)

•• Medical Marijuana Use and DUIDMedical Marijuana Use and DUID’’s (Children in vehicle)s (Children in vehicle)

•• How do we safeguard children from parents that use cannabis regularly? Can we?How do we safeguard children from parents that use cannabis regularly? Can we?

•• Each case is ideographic and unique, case by case basis for MM & Amendment Each case is ideographic and unique, case by case basis for MM & Amendment 64 Recreational Use64 Recreational Use

Child & Family Investigator Colorado Substance Use Disorders Armand Lebovits, LCSW, CAC III [email protected].

Documents

socialrecreational use

binge use

understanding substance

discomfort withdrawal

use of selfother tendency

effects of substance

time slide

substance abuse cjd