All right. Welcome back. Once again, I wanted to congratulate Dr. Petrakis for the award. Thank you for your service to the organization. I know I've been using a lot of superlatives when introducing the sessions, but this is a really special session, partly because I'm going to be presenting with two of my mentors and my good friends, my co-authors. We're going to be talking about addictions, forensic evaluations in the addictions world. The session is called New Horizons in Addiction and the Law. As I'm typically introducing the chairs of the symposia, I'm going to be introducing Dr. Westreich, who in turn is going to be introducing me and Dr. Finals. Dr. Westreich is an associate professor of psychiatry at New York University, NYU. He is also a forensic psychiatrist, and he is a consultant for Major League Baseball, and he's the author of three textbooks on addictions. And Dr. Westreich, the floor is yours. Thank you very much, Eli. So we're going to have some fun this morning. My name is Larry Westreich. I'm delighted to chair this symposium on New Horizons in Addiction and the Law. Our not-so-hidden agenda today is to convince you to think about doing forensic work in the context of your addiction work. There are far too few addiction-trained individuals in the forensic world, and I hope you'll be piqued by some of what you hear today. If you work with people with substance use disorders, you'll notice that they get involved with the law, like a lot. DUIs, criminal acts, child endangerment, personal injury, there's work in jails and prisons, there's mandated treatment, and there's employment drug testing, among other things. How do you get involved in forensic work with people with substance use disorders? As we heard from Dr. Petrakis earlier, mentorship is enormously important at this level of your work. My own mentor, Dr. Michael Gandel, is in the room. Michael, can you raise your hand? Thank you very much for all your service. I just want to make the point that when I was a fellow, I approached Dr. Gandel somewhat shyly and said I was interested in forensics and didn't know much about it, and he took me to coffee and started me on my career. So I think that's the model for all of us, learning about how to do something that is new and perhaps unknown. More specifically, at 1245 today, there's a meeting of the Addiction and Law Committee, and everyone is welcome there, and we can have it right in this room if everyone wants to come. Today's symposium has a number of interesting subjects, obviously not everything about addiction and the law. Dr. Awoon will educate us about the philosophical underpinnings of thinking about forensic matters and legal matters within addiction. I will talk about employment and substance use, which I work in a lot, and I think that is very important if you have a patient who has a job or wants to have a job or has ever had a job. They'll need to know about those issues. Finally, Dr. Pinellas will talk with us about substance use disorders in the correctional system and educate us on those matters. So let's give a round of applause for Dr. Awoon, who will start us off. said, of addictions in the legal system. What I'm going to be focusing on is the dualism. When we're thinking about people with addictive disorders, do they have a free will to control their behaviors or are their behaviors predetermined? Is their substance using behavior predetermined or and also are the substance related behaviors that they're engaging in related? So to get us thinking about these topics, I'm going to give you, I'm going to present a case and as we're discussing the symposia at the end, I'd love your thoughts and comments on this case. So we're talking about this individual, Mr. X. He was charged criminally with dealing a small amount of heroin and he was sentenced to probation. And this is someone who has a history of an opioid use disorder after his criminal record charges, he starts to receive substance use disorder treatments and he's released on parole. While he's on parole, his parole officer requires him to do a urine drug test that comes up positive for cocaine. Now, everyone starts to get worried and thinking about, well, is this a parole violation? Should this person be reincarcerated? And the individual brings a defense expert who says, well, this is a single positive urine drug screen. It doesn't mean that he has a cocaine use disorder. Then his defense attorney says that this is not a parole violation, that it's a probation violation. He should not return to jail. He has no cocaine use disorder. This is a one-time use of cocaine and then his charges were not related to cocaine. The charges were related to heroin. And they described the urine drug test as a fishing expedition because it tests for 10 drugs rather than only testing for heroin. But the probation officer says, no, no, no, cocaine use is a problem here because the conditions of his probation would require him to be sober from all drugs and it doesn't say anything about the diagnosis. It doesn't matter whether or not this person has a cocaine use disorder or not. And then the probation officer goes on and starts to talk about, well, all addictions are interrelated. He's using an illegal substance. He's posing a danger to the public. And this is the debate that's going on back and forth between the probation and this person's attorney. Now, I'm going to start by giving you a personal anecdote. I have high blood pressure and every time I go to my doctor, he's like, Ellie, how's your diet? Your blood pressure's a little bit high and I tell him, crap. I eat a lot of things that I shouldn't eat. And he rolls his eyes at me and says, well, maybe we should talk about increasing the dose of your blood pressure medication. And the reason I'm telling you this is because if the scenario was different, imagine that it was an addiction and someone goes to the doctor and the doctor says, how are you doing with your recovery? And the patient says, well, crap, I'm using a lot of drugs. The conversation wouldn't be as simple as rolling his eyes and maybe we should talk about increasing the dose of the medication. The conversation would be a little bit more serious. The contrast here is important for our conversation because it illustrates why addictions are viewed differently from other types of illnesses. Patients with diabetes who keep eating french fries and cake, no one is looking at them and saying, you're a bad person. How could you do that? They look at them and then say, God, your illness is so severe. And they feel a lot of empathy for them. So this is where the difference happens. Doctors can be frustrated with non-addictive disorders, but that's pretty much it. But when it comes to addictive disorders, people see continued use or not being compliant with the treatment recommendation as this person is irresponsible, they're not following through, they're not compliant, they're just a bad patient. That's what we hear very often. And a lot of this has to do with the fact that addictive disorders are going through puberty. They're experiencing an identity crisis. Even though addictions are all over our society, a lot of people have addictions. We talk about addictions everywhere. You turn on the news, you're hearing stories about addictions, the legal system is, the laws are full of references about addictions. But despite all of this, there's a lot of confusion when it comes to addictions. I've already referred to addictions in five different ways. Addiction, substance use disorders, abuse, dependence, alcoholism. Looking at the terminology that used to describe addiction, this already gives us an idea of the identity crisis that we're experiencing, but also the way we approach treating addictions. Yesterday when I was interviewing Dr. Livones, I asked him about the way people in the community describe treatment, and it's very often, doesn't involve going to an addiction psychiatrist and receiving evidence-based treatment. It involves all sorts of other things. And I've heard this phrase many times, well, this person is not in treatment, even though that would be someone that I'm treating for an addiction. They're like, well, don't you think we should send him to treatment, which is part of this identity crisis that we're seeing. You're talking to certain people, and depending on the circle, sometimes people will say, well, an addiction is a brain disorder, but sometimes they'll say an addiction is a moral failure. Sometimes you'll hear, no, no, addiction is just in the genes. Addiction is a nitrogenic condition. All these patients who are going to the doctors and the doctors are over-prescribing opioids. Addiction is a criminal issue. This is why, this is part of why addictions are viewed in such a moralized way. So I like this definition of substance use disorders. It's the continued compulsive use despite the negative consequences. There's something that's unique in addictive disorders, which is the, in essence, the absurd nature of the behaviors that people engage in when they're using. Someone who continues to use, even when their spouse tells them, well, if you're going to use drugs or if you're going to drink again, I'm going to divorce you. Sometimes who continues to drink even after they're charged with a DUI. Sometimes someone who continues to drink even when they're losing custody of their children because of their alcohol use disorder. It almost sounds like the person doesn't care or that they're acting against their best interest, and that's what could explain the moralized view. Obviously, we're all here. We all understand that it's not as simple as saying the person doesn't care, but that's how it's perceived, especially by their loved ones and the justice system. So are addictive disorders related, are the behaviors that are related to addictive disorders evidence of a person's wickedness? And that's really what we have to think about. So an addiction is not just a disease of using drugs. It's a disease that affects how the person thinks about using drugs. It affects their executive functions, their cognitive abilities, their decision-making abilities. And as a part of that, it renders the individual unable to conform to the rules that they have to follow, whether it's the social rules or the laws. What happens when someone starts using drugs is that they're, well, before someone starts to use drugs, they like to do all sorts of wholesome, healthy, pro-social activities. And as they move forward with the development of their addictive disorders, they begin to enjoy and appreciate those pro-social, wholesome activities less, and their ability to enjoy those activities is reduced. And because of the changes that affect the reward pathway, they become, they struggle with appreciating anything that's outside of the drug use. So when I started, I said, we're going to be talking about the duality between free will and determinism. Free will is the concept where individuals are making their own choices and can choose the right thing to do or the wrong thing to do. And then the determinism is when we say that the person doesn't really have a lot of control. Their behaviors are predetermined and they're stuck. And this dualism is also reflected in the way the legal system views addictions. I'm mentioning these two rulings by the Supreme Court, Robinson v. California and Powell v. Texas, because they illustrate this duality. The Robinson case is the case where the Supreme Court said that substance use disorders are not a status offense, citing a violation of the due process clause of the Constitution and saying that criminalizing addictive disorders would be cruel and unusual punishment. The phrase that's often cited here is that the Supreme Court judge said, we can't criminalize an addiction in the same way that we couldn't criminalize a common cold. But then a few years later, the same court, the Supreme Court ruled in Powell that even though addiction itself is not a status offense, the behaviors that people engage in as a result of their addictive disorders are criminalized. So having a substance use disorder does not obliterate criminal responsibility. So what's the base of the deterministic argument? The argument there is that an addiction is a brain disorder that is shaped by past experiences, the behaviors that the person is engaging in, their experiences affected by genetic factors, and neurophysiological changes. And these are the types of factors that are thought to contribute to the deterministic arguments. Some of them are intrinsic to the person, their genes, sex, age, et cetera, and some extrinsic factor relating to their experiences. Another argument related to the deterministic argument is the substance use disorder mediated anhedonia that I talked about earlier. As the person is developing their addiction, their ability to experience reward from non-addictive related stimuli becomes suppressed at the expense of their, where they can only experience rewards through addictive related stimuli. Another argument that's in favor of the deterministic theory is the self-medication model where a person is experiencing suffering, and even though drug use is not going to allow the person to feel good, but at least it's going to suppress those negative feeling and in a way allow them to feel normal, quote unquote. But on the other hand, the free will argument or the volitional argument is not an illogical argument for us to think about even though we're addiction psychiatrists and we're treating people with substance use disorders, we also recognize that there is some evidence to support the volitional argument in addictive disorders. We've seen internal cognitive processes that affect a person's willingness to quit using drugs or abstain or to continue using drugs, but there are also externally driven cognitive processes that I'm going to describe, and then there's the moralistic argument. So in terms of the externally driven cognitive process, when you think about the types of behaviors that we engage in, the reasons why people drink, for example, people will say, I had a long day at work, so I'm gonna reward myself. I am feeling anxious, I'm going to reward myself. That's evidence of an externally driven cognitive process. Other evidence that points in this direction is when you observe the types of behaviors that people do when they're intoxicated, they often do things that they wouldn't do otherwise. Someone who's not necessarily aggressive uses PCP, and all of a sudden starts to assault people. Someone who uses heroin who tries to be safe, but then when they're intoxicated with heroin starts sharing needles. Someone who's engaging in responsible, low-risk sexual activity uses meth and then engages in high-risk sexual behaviors. These are some examples that support the idea that the individuals are engaging in substance-using behaviors in relationship to their cognitive processes. The moralistic argument, basically the idea here is that the person doesn't care when they're using drugs and doesn't care about the consequences. And when people are making this argument, there are a couple implicit assertions that are used to support this idea. The first one is they say, well, when I was in college, I used weed and I was able to stop. So if this person isn't able to stop, it means that they're bad. They're basically extrapolating their own experiences. My cousin works on Wall Street and uses cocaine once in a while, but is able to stop. Why is this person unable to stop? And that's obviously we know that it's not, it's incorrect to assume that an addiction is an extrapolation of excessive substance use. The other argument, the other assertion that supports the moralistic argument is that substance use and substance use disorders are a choice and a self-inflicted phenomenon. And then the third assertion is that people are engaging in activities despite understanding and being okay with the consequences. The person driving while intoxicated is okay with hitting someone and getting into a car accident. And I don't think it's a stretch to say that a lot of these assertions are driven by a stigma against substance use disorders. But it's not just stigma. Is there any data, any evidence to support the volitional argument? And I'm kind of listing a couple examples here. The anecdotal and first person reports when people have used alcohol for a long time and then after something happens in their life decide to stop using. That's not unheard of. We've seen, we've all experienced, and individuals where that was the case, that is often used as evidence to support the volitional argument. The behavioral economics model looking at the changes in drug use in society when the cost of a certain drug increases or the availability of a certain drug increases. Alternative reinforcers, the idea there is that individual, like I mentioned earlier, when the value of a substance used, when a person is unable to experience a reward from wholesome activities, introducing an alternative reinforcer that the person values more than using drugs. So for example, the fear of losing custody for a physician, the fear of losing their license for a lawyer, the fear of being disbarred, that can serve as an alternative reinforcer that increases the motivation of someone to modify or reduce their substance use. The principle of therapeutic jurisprudence, drug courts are also, when someone is involved in a drug court and they understand that if they don't participate in the drug court and if they don't move towards recovery, then they might be incarcerated for a longer period of time and their motivation increase and their likelihood of success increases. Success for achieving recovery, that's also used as evidence of volitional control. And then finally, epidemiological studies when there are some studies that demonstrate a reduction in substance use disorder frequency with age, this is also used as evidence of volitional control. There are some advantages to the volitional control. There's some studies that find that individuals with substance use disorder who ascribe to the volitional model are less likely to relapse, are more likely to do better to achieve recovery and feel like they have a sense of control and agency, but that also comes at a price, the price being that the person is internalizing their sense of blameworthiness, it increases stigma, and then it can lead people to exist in a vicious cycle. And the other argument is that free will is a major part of the rule of law and if we were to challenge the free will concept here, it would challenge the entirety of the rule of law. So with this background, I'm going to transition and talk a little bit about addictions in criminal law. For reference, President Bush Senior declared that the 90s were going to be the decade of the brain and what that really means is that there's a lot of funding for neuroscience research and it allowed us to understand addictions from the lens that we understand it today. It allowed us to develop treatments that work. To develop imaging, neuroimaging studies. So obviously we know a lot more about addictive disorders today than we did 30 years ago, but the same can't be said for an evolution of the way society understands addictive disorders or the way the legal system understands the legal addictive disorders. Now with respect to the relationship between substance use disorders and violence, this is a study that basically looked at the publications examining the nexus between addictions and violence over the years and as you can see in the past two decades, the number of studies looking at this relationship has increased tremendously. We love to have good evidence and this topic, the relationship between addiction and violence is so important that not only do we have meta-analyses looking at this, we have meta-analyses of meta-analyses. And basically the findings are pretty consistent. Substance use disorders are associated with increased risk of violence and especially if the person is a male, especially if there's co-occurring psychotic disorder. What's interesting here is that with drug use, drug use is associated with an increased risk of violence perpetration, but when it comes to alcohol use, it's a bidirectional relationship. It increases the risk of violence perpetration but also of violence victimization. Now, as you might expect, the relationship between addictions and criminal behaviors go hand in hand with addictions and violence. So in the US, roughly you have a little bit less than a million crimes committed every year when the person is intoxicated with drugs or alcohol and this is true also internationally. The second study is a study that looks at international homicide data that found that in roughly half the cases, alcohol use is involved with the homicide. Addictive disorders are associated with an increase in all criminal behaviors, but especially drug-related crimes and property offenses. But when you're looking specifically at violent crimes, alcohol use is more intimately connected with criminal behaviors than illegal drugs. So when we hear politicians talking about wanting to reduce crime rates and trying to address drug use, it would be important to address alcohol use for the same reasons. So as you might expect, there's an over-representation of substance use disorders across the criminal justice system. You see that in state facilities, in federal facilities, in prisons, in jails, for people on parole, probation, for juvenile offenders, for men, for women. Going to skip some slides. What explains this relationship? Obviously, is it the chicken or the egg? And the data looking at this question is not very decisive, but most of the data looks at methadone clinics and follows individuals in methadone clinics longitudinally to see whether having a substance use disorder increases the likelihood of engaging in criminal behaviors or vice versa. And what most of the studies found is that the relationship goes, the more common explanation is that developing a substance use disorder increases the likelihood of engaging in criminal behaviors down the line. But when you do look at those individuals who develop a substance use disorder, you're going to find that they were more likely to have committed a crime in the past. What's interesting is that these relationships are true for both men and women, but the correlation is stronger for women than it is for men. Now, we always say follow the money, and in the US, we spend roughly $200 billion per year on substance-related crimes. And the cost of alcohol-related crimes is two to four times higher than the cost of drug-related crimes. So that's also another reason why the government should be funding alcohol use interventions. And the $200 billion figure is an underestimate because it doesn't account for a lot of indirect costs. So if we were to put this relationship between criminal behaviors and addictions in models, there are two models that I'm going to present. The chronological model looks at which comes first, the chicken or the egg, and we classify the relationship as a forward causation when substance use leads to criminal behaviors, reverse causation when the criminal behavior leads to substance use, and then confounding when the criminal behavior and the substance use share a common set of causes, such as what you see in drug cartels. The other taxonomy that is most often cited is the Paul Goldstein taxonomy from 1985. People love to talk about all its limitations, but it's still the model that's cited most often. And it looks at three different categories, economic-related crimes, that's when the individual is engaging in criminal behaviors in order to fund their drug use, their stealing so that they can buy drugs or alcohol. The psychopharmacological crimes, or use-related crimes, can have a forward causation or reverse causation pathway where the individual wasn't planning to commit a crime, but then they're using a drug, they're using alcohol, they become disinhibited, they engage in a behavior that is criminal, or from the other direction, the person wants to commit a crime, but they feel like they don't have the courage to do it, they're feeling anxious, so they get intoxicated so that they can engage in the criminal behavior. And then system-related crime is the equivalent of the confounding pathway that I described earlier, where crimes result from the structure of the drug system, production, trade, et cetera. With regard to addictions in the correctional setting, Dr. Pinals is going to discuss this more extensively, I'm just going to mention a couple of points. There are a lot of barriers to access to care in the correctional system, some of it has to do with correctional policies limiting this, stigma, misconceptions. And then in the correctional system, very often when you're talking to correctional staff, they talk about addiction in the same way that we talk about infections. When you don't have the symptoms, the illness is gone, kind of like having a cold, when in fact an addiction is much more like diabetes, where even when your A1C is well-controlled, the illness is still there. But besides that, there are also security concerns, concerns for diversion, et cetera. Now, for the longest time, it was very difficult, almost impossible, to get a substance, evidence-based medication for opioid use disorder in the correctional system, but that is changing. A lot of these rules are being challenged on the basis of the Eighth Amendment and on the basis of the ADA. There are some cases from all over the country. Pesky is an interesting case to look at, where the government, where the courts ruled that the correctional facility had to provide medications for opioid use disorders. And now the most recent DOJ recommendation is that correctional facilities should provide MOUD to incarcerated individuals. It's not happening all over, but that's the most recent recommendation. The right for treatment comes from the Estelle case that's later applied to mental health, that's later applied to substance use disorders, and the Americans with Disabilities Act offers some protections for individuals with substance use disorder, prohibiting discrimination on the basis of disability. But the question is, the person has to be otherwise qualified. So why is access to MOUD restricted? Some blanket policy to detoxify anyone who comes in intoxicated. You often hear, we don't want to replace one addiction with another. The other point that's very interesting to think about is we don't want to provide treatment for substance use disorder because it's not associated with a reduction in criminal recidivism. The studies are, the findings are pretty mixed when it comes to whether or not it does reduce criminal recidivism, but the argument itself doesn't make any sense. We don't offer treatment for diabetes based on whether or not treating someone's diabetes reduces their likelihood of engaging in criminal behaviors. Well, when it comes to addiction, that's often used as an argument. And the other argument that's often presented is on parole and probation, very often the individual is not allowed to participate in MAT programs. So this is it for what I'm going to present next. Dr. Westreich is going to take over. Thank you. Thanks, Howard. Great. Thank you. Thank you. And please hold your questions for Dr. Owen. We're going to have a plenty long question and answer session at the end. And that was a perfect setup for what I'm going to be talking about now. We're about to go from the philosophical to the very, very specific. I'm going to be talking about unemployment. Dr. Pinellas is going to talk about corrections and some specific issues there. I started out today by saying that I was going to hope that you were enticed into doing forensic work within your addiction practice, which I am. But even if you don't do that, there are things about employment which you should know as a treating clinician for your patients who have substance use disorders and for yourselves, actually. And I'll get into that. The other thing I want to say is that, although I know a lot of legal words, I'm not a lawyer, and nothing that any of us say should be construed as legal advice. We might be talking about, at the end, when you might need legal advice or when your patient might need legal advice, and we can talk about that maybe during question and answer. So my educational objectives are to talk about the way that legal regulation is changing, a little bit about ADA protection for SUDs. We're going to talk about elite athletes. That's my particular workplace. We're going to talk about how cannabis issues have changed and how those might affect your patients who choose to use THC or if you choose to recommend it. So let me give you a case, and this is a couple together, but it's common enough within forensic practice. A 49-year-old male train conductor who's alleged to have alcohol on his breath at work is referred to the forensic evaluator with a phone call, and his supervisor says, is he okay to go back to work, doc? So what should you as the evaluator do first? And I'm going to be talking about that a little bit. Who should the evaluator interview? The answer to those questions is, first of all, do an assessment and certainly find as much information as you can, including records and lab testing and collateral informants. So in this matter, the conductor acknowledges that there's a lot of marital strife at home, that he's probably going to be divorced, and he's been drinking a little bit more than usual to prepare himself before he walks in the door after work. He denies drinking on the job. Eventually, the conductor does say that he's probably drinking too much, and he says, doc, can you help me out with this drinking problem I might have? And something to think about, what are the forensic evaluator's legal obligations to the conductor? What about his or her legal obligations to the employer? And how should the evaluator respond to the conductor's request for treatment after the forensic assessment is concluded? So I want to show you a few little pieces of data which tell us that, and this is workplace substance use, which tell us that oftentimes substance use occurs in the workplace. National Survey on Drug Use and Health Data found that about almost 90% of full-time workers aged 18 to 64 had used alcohol in the workplace. About 8.6% of them had used illicit drugs in the workplace. I believe that includes cannabis. And about 10% of full-time workers met criteria for substance use disorder, making the point that those of us who work in occupational functions are going to see addiction on a fairly regular basis. This is a yearly study of which industries have the most substance use. I guess, predictably, accommodation, which are hotels and food service, have about 19% of the individuals there acknowledge workplace substance use. 11% of construction workers, worrisomely, acknowledged workplace substance use. And smaller numbers in education and public administration. Again, making the point that there's plenty of substance use in our workplaces. So first is, this is sort of a philosophical question, but why test for drugs in the workplace in the first place? And if you're going to be working in the occupational sphere or if you're going to be setting up drug programs, this is something to think about. Obviously, safety, although that's not always an issue. Certainly, an employer might want to avoid liability for matters that happen in the workplace. Certainly, some employers are worried about their image if their employees are using drugs or alcohol in the workplace. Clearly, productivity is affected by substance use in the workplace. Some people might just want to avoid drug-using employees. Interestingly, many jurisdictions are now banning testing for cannabis in a pre-employment test because it's simply unfair, since in many jurisdictions it's legal, at least for recreational use. Most employers agree, because they tested all employees for cannabis, they wouldn't have a lot of employees. And then I also want to make clear that there are plenty of instances where there's mandated drug testing. Department of Transportation is the sort of gold standard for that sort of testing, but drug-free workplace testing, DOD, Nuclear Regulatory Commission, any private employer can set up whatever drug testing plan they want as long as it's not discriminatory and doesn't breach those laws that I talked about, for instance, in cannabis. Workplace drug use is expensive, enough said. So if you're thinking about doing employment drug testing, it's a little different from the drug testing we all do in our clinics and the hospitals. Most employment drug testing use what's called the control and custody form. That's that long form which says the person who's having the drug test signs it, the person who collects the specimen takes it, and the person who transports it to the lab signs it, and then the person who does the actual testing signs off. Because then when you end up in a courtroom or a hearing, when someone asks you, how do you know this is the person's urine, doctor, you can have this document and at least have some semblance of a connection between that person and the person's drug test result. And this is enormously important because a drug test result can directly affect that person's employment, like causing termination. Laboratory analysis, which we could get into in the question and answer, almost always includes a screening test, and then a confirmatory test which is much more specific and will stand up in a court. MRO review, MROs are medical review officers which is a federally licensed individual who can oversee drug testing in the laboratory and drug collection. A physician, often an addiction psychiatrist and an addiction medicine specialist. This is to weed out common problems like someone had a poppy bagel before they had their drug test, or like the drug testing in the first place wasn't lawful. It also helps us weed out people who are appropriately taking a medication which turned out positive on a drug test. And then the employer takes action on any non-negative drug test. So there's all kinds of drug testing and it's important that you understand for your patients what's happening. Are they doing pre-employment drug testing? Under the ADA, pre-employment drug testing is not considered a medical test. You can't, when you're hiring someone, you can't test someone's blood sugar and decline to hire them because they have diabetes. On the other hand, except for that specific exemption I told you about with cannabis, you can do pre-employment drug testing and deny a person employment because of that drug test, at least under the ADA. Reasonable cause testing, this is if something happens in the workplace. You have to decide what the reasonable cause is before you get to it. Is it a slip and fall? Is it driving a forklift into the wall? This has to be very clear in a policy. Random testing is just what it is. It has to be really random, like using a computer algorithm and being able to show that in a hearing after you have done the drug testing. If you don't have that in place, you'll certainly be accused of discriminating against the patient. Post-accident testing is similar to reasonable cause. Periodic testing, this is testing all employees, say Monday morning. It's often referred to as intelligence testing, not really drug testing. Rehabilitation testing, that's what we do as clinicians. I told you about medical review offers. It's an HHS certification. It looks at specifically these five agents, now six, including other opiates, using chain of custody. Dealing with negative results, which you can usually ignore. Indeterminate results, which may have been a cheat or may have been an error in the drug testing protocol. Dealing with positive results, usually MRO will notify the individual they've had a positive test. This certification is easy to get. You can get it in a weekend course. Anyone who deals with addicted people certainly has the chops to understand everything in these courses. If you're thinking about doing drug testing in your practice, anything to do with employment, I would recommend you getting this credential. In thinking about workplace drug testing, and this is important to talk about with your patients, if they're going to get tested, thinking about the differences between home versus office testing. I do a lot of office testing. It will entirely not be accepted in a courtroom because of all kinds of reasons. But it's important in my clinical practice, I think. What tissue is being tested? At baseball, we test urine. We test blood. We do breathalyzer tests. You can certainly do hair testing. But I'm gonna talk a little bit about the difficulties in all those, with all those tissues. It's important to know, as you're learning about drug testing, whether it's for a patient or for a subject in a forensic practice, what's the purpose of the test? Why are you doing it? Who gets to order the test? Is it the person's family? Is it you as a clinician? Is it their employer? Is it random testing? Who does the testing? And who gets the result? And in a legal matter where someone's employment is at risk, those questions will almost certainly be asked of a tester under oath. But the most important one is what happens because of the test, right? And any individual has the right to decline a drug test based on what's gonna happen to him or her based on the results. Now, employees may sign a contract saying that they're going to take drug tests. But of course, you should make sure that any subject you're working with knows why he or she is taking the test and what could happen. So I'm gonna get to what sorts of drug and alcohol tests employers perform. One survey of this found that about 95% of them do urine, 6% do blood. At least in my experience, and I've heard oftentimes said, subjects getting drug tested for work prefer blood testing to some extent because there's less of an invasion of privacy with giving a urine sample. Many employers do breath alcohol. Some do saliva and hair testing, although the scientific underpinnings of those two tissues are a little bit easier to attack in a courtroom than urine or blood. Who knows what Soberlink is? Okay, some people. In an employment sphere, you can use, Soberlink is one of the many drug tests or drug testing modalities that are available. It's a breathalyzer that is connected to a internet thing. So it goes off and you can take it every hour or so or every four hours, how often you set it. And that report is sent to a advisor that can be either an attorney, it can be a court, it can be a employer. And I'm mentioning Soberlink because it's the biggest one. There are several other companies out there which I think make similarly useful products. Sweat patch testing, also available. I don't think used much in the employment sphere because of some difficulties with the scientific underpinnings of this. And the reason I say that is because if you end up in a courtroom trying to defend one of these modalities, you better have a lot of peer-reviewed papers saying why they work. Hair testing. You can, general hair testing looks back about three months for a relatively substantial substance use. It's not follicle testing. Every attorney in the world calls up and asks, will you get some hair follicle testing? No one's testing follicles, you're testing hair shafts. There's point of service drug testing. That's what I told you about in the office. Either a point of service breathalyzer or a point of service dipstick test, which in an actual employment drug program, I don't think is particularly useful because it will not stand up. There are metabolites like ETG and ETS, which give you a probably 70 to 80 hour look back. Also will pick up perfume. Also will pick up mouthwash if used incorrectly. So all kinds of possibilities for doing drug testing in the employment sphere. And if you use ETG and ETS specifically and try to put those forward as a proof of someone's alcohol use in a courtroom, you'll probably get the SAMHSA warning from 2012, which said that they're highly sensitive and not particularly useful in forensic spheres. But this is what happens in hearings or courtrooms. It's adversarial system and you're gonna have to defend your drug testing. I put this slide up because every time a patient takes a drug test, sometimes forensic subjects take drug tests, they ask you, how long is that cocaine gonna stay in my urine, doc? And I wanna caution you to be very careful in answering that question. Because it depends on how much they use. It depends on what tissue's being tested. It depends on where the laboratory sets their level of detection. So my answer is usually all that stuff. It depends on a whole lot of things. And I have seen many times patients going to CVS, buying themselves one of the CVS drug tests, and then testing their own urine and going to their employer the next day, assuming they're gonna be negative because the CVS test was negative. No, no, no, don't do that. Because they're very different drug tests and some employer drug tests can go down to picogram levels on finding how much substance is in the person's urine or in a blood spot test. So that's just important information to give to your patients. I'm gonna talk about sports. This is a cartoon where the scrawny little David has just killed Goliath with a little rock. And the guy is in the Performance Enhancing Drug Test Center. Feels like this is what I do. And he says to David, David, could I have a word about that, what just happened here? Why test for drugs in sport? And most of my work outside of my clinical work has to do with drug testing for Major League Baseball. And the philosophical underpinnings are like this. First of all, health and safety of the athletes is important. Secondly, fundamental fairness for performance enhancing drugs. That if someone's competing for a position, they should be competing in a fair way in the same way everyone is competing. Thirdly, athletes are role models and are seen by many as doing what it is that they want to do. Little boys and little girls look up to athletes and think I want to do exactly what that person's doing. And I think also the business necessities of professional sport. There's no question that some sports have been tarnished by drug use. And not only did they look bad in the eyes of their fans, but they lost their advertisers also. So without going into any further depth, I think there are plenty of reasons for doing drug testing within sport. I'll talk a little bit about this specific workplace, steroids in sport. All androgenics, anabolic steroids are synthetic derivatives of testosterone. And many fewer professional athletes use them than used 10 or 15 years ago. What concerns me more than that is the continuing use of anabolic androgenic steroids by non-elite athletes. These are the Michigan data on use of steroids by 12th graders. And you can see thankfully that steroid use has gone down in the last 20 years actually. But there are still a substantial proportion of non-athlete high school and college students who are using steroids mostly for looks rather than for athletic performance. And this is deeply concerning to those of us in the field. Having treated a number of individuals in that place, I can tell you that drug testing at the high school and college level I think is important, especially for steroids. Within baseball we have a, and in every elite sport, there's a distinction between those who are illicitly using substances like amphetamines and stimulant treatments for ADD and those who are using it because they have a genuine diagnosis of ADD. And so in the sports workplace, you have to make a distinction between those two sets of people. And this is a classic example of dual agency. Those individuals making the assessment have both the obligation to be a physician and to try to get the right treatment to the right people. They also have an obligation to work as a referee or an umpire and to make sure there's a level playing field. So here's some general rules for doing therapeutic use exemptions. And a few years ago I looked at MLB rules, the other major sport rules. I looked at Olympic rules and Division I rules and they're all pretty similar. The athlete, and this is for a person who says he or she wants to use, for instance, Adderall because he or she has ADD. At the Olympic level, this is for someone who wants to use Albuterol. They say they have asthma. Different rules but same idea, therapeutic use exemption. So the athlete has a documented need for the prohibited substance and would experience serious adverse consequences if the medication was not allowed. So this is fair, right? Someone has ADD, they should be allowed to use the medication that helps them with their syndrome. And this actual sentence is in all the guidelines that I looked at. The second thing that's there, it says a therapeutic use exemption would not allow use of prohibited substance to enhance performance. Above that, if the athlete returns to normal health. I don't know what that one means. That one's a little hard to understand because it says if the person didn't have ADD, are you making her any better? Another one that comes up often, there must be no reasonable alternatives to the use of the prohibited substance. And different sports make different choices about this, about whether the clinicians are going to ask for use of a non-prohibited substance before use of Adderall. Like can someone use a non-stimulant treatment for ADD? Can someone use a psychological treatment for ADD? Must they do that before they apply for an exemption? And different sports make different choices about that. A little bit about, I'm gonna get to drug testing. Who's heard of Shy Bladder Syndrome? Okay, well most of you have, okay. And this is, I've read a number of textbooks by urologists that talk about it. If someone is unable to give a urine sample when they're being observed, which is not that uncommon actually, they recommend a full workup and clearing urinalysis. Can be due to dehydration, probably due to situational anxiety. Look for pre-existing social phobia. All of the articles very clearly say, please don't do a cystoscopes for this. Because I think there's implicit understanding that this is an anxiety syndrome rather than anything else. But that being said, it's very real and I have certainly seen in several employment spheres, someone getting an exemption from urine drug testing because of this syndrome. Simply can't urinate when being observed. Who here has seen the Whizinator? If you look online, you can see this is one of, illegal by the way, but online, ways to beat drug testing. And the Whizinator, and I'm doing you the service by not showing you the actual thing up here. So you're welcome. But what it is, is a pouch which you strap to the body, put clean urine in it, and then it's got a prosthetic penis. So, and they have different skin tones, which I'll just tell you also. And this is to try to beat observed urine testing. It wouldn't work in my particular workplace since we have people strip and you would see it immediately. But it has been used. I had a subject actually in a forensic matter who didn't understand and sent one of his employees to take the drug test for him since he, the CEO of this company, knew that he had been using drugs. The employee didn't understand what he was doing and came up positive for cocaine. So my subject had to make the point in court, that wasn't me. You have a lot of fun in forensics. But how do people beat drug tests? Put adulterants in. I mean, you know, very simplistically, can put bleach in a sample, easily found in any sophisticated drug testing. Can substitute like my subject tried to do. Can dilute out their urine. I'll be very careful with this. Any sophisticated drug testing regimen looks for a specific gravity and will reject anything which has an inappropriate specific gravity. But of course, what do people do when they have to go to the bathroom? They drink a lot, because I'm gonna give a drug test in 20 minutes. So sometimes this is not at all an attempt to beat the drug test, but simply someone trying to make the process go faster. There are pills and potions sold on the internet, which our patients certainly look for and buy. Some of them are effective in unsophisticated testing regimens. Oral fluid, adulterants, yeah, people try to beat saliva testing by doing all kinds of weird things. I would say that physicians and nurses are the most sophisticated ones in trying to beat drug tests. And there are some modalities of beating a drug test, which I don't think we can really find. Stay there. So marijuana in the workplace, what about that? I don't need to tell this audience that marijuana dependence is a real thing. A certain percentage, probably between nine and 17% of people who use marijuana will have a DSM dependence. There are neuropsychological sequelae of cannabis use. I think I'm preaching to the choir here quite literally. When I'm talking to non-clinicians, though, I do use my colleague Letitia Bader's educational slides about the obvious problems that can occur in a workplace or in any environment if someone's using THC. Is marijuana addictive? The answer is yes. These are the Quest Diagnostics Drug Testing Index, and these are not the Quest clinical numbers. These are the Quest occupational numbers, which show that workplace testing for THC has gone up since over the last five to seven years when THC has been legalized across the country. This is not surprising, nor is it proof that THC is causing workplace accidents. It simply means more people are using THC. I show you this slide about marijuana legality by state. It's as of last July. In some states, it's legalized for medical use. Some states, it's legalized for recreational use, so to speak. Some states have CBD only. Of course, federally, it's still scheduled as a Schedule I substance. Basically, it's a wild west out there. And my point to you as a clinician, as a forensic assessor, and as someone who might recommend THC, that you should be as sure as possible about the regulations in your jurisdiction before you do any of those things. And as an example, I got this chart of the way different states are acting towards employee protections. What if the employee says, yeah, I use THC, but I have a card. I have the permission to use this substance. Some examples, Arizona. There is some medical protection for anti-discrimination against employees who use cannabis as of 2014. For recreational, there isn't. In California, there is protection on both sides, although it's a little spotty, my understanding. In Maine, there's no protection for recreational marijuana use. And this becomes very important when your patient or your forensic subject comes up positive on a drug test, and the employer says, that must be why this accident happened, and the person needs to be terminated from their job. Let's think about ourselves. Of course, you can't prescribe THC, but physicians are being asked to recommend THC so people can get marijuana cards. And my friend and colleague, Doug Marla, who's a psychologist and an attorney, writes about medical malpractice for those who are recommending THC. And he writes, it's not me, physicians can be held liable to third parties who are injured in a car accident or work accident caused by a patient's use of medical marijuana. He or she may be liable in ordinary negligence for non-feasance by failing to take simple precautions that could have prevented foreseeable and serious injury. I'm not sure if that's exactly the wording that's used if you and I get sued for malpractice, but this is the sort of thing that could well happen. And these are some previous guidelines for doing an assessment of someone who you think you're going to recommend THC for, and it certainly includes everything that one would do in a psychiatric or a medical assessment. I have a few cases, and I show these, if there's any attorneys in the room, I know these don't have precedential value. I'm showing them as examples of the way cases go when drugs and employment are involved and some ways that we are asked to think about these conditions. This is Veronia V. Acton. The Supreme Court upheld suspicionless drug testing of student athletes, and the idea was that if they choose to do athletics in the school, they could be sued and they could be tested, and it wasn't an unconstitutional violation of their privacy. And the justices noted that education of the athletes had been ineffective, there was continuing drug use. Some of the student athletes were seen as drug purveyors and relied on a previous case which found that rights are different in a public school than they are elsewhere. So this is one of the supports for testing of student athletes. This is an important case about union versus a particular individual. It was seen by the Supreme Court in 1989. They were drug testing U.S. Customs officers before their promotion, without any suspicion, but simply testing everyone. The Supreme Court upheld the suspicionless drug tests with certain responsibilities. Those who were trying to themselves interdict illegal drugs, it makes sense, at least to the Supreme Court, that those persons should be free of illicit drugs. Also carrying a weapon, and again, it's sort of common sense that that person should be free of substances. And they found that the government has a compelling interest in ensuring that frontline interdiction personnel are physically fit and have unimpeachable integrity and judgment. Skinner v. Railway, and this is the way a lot of cases go. This is 1989 Supreme Court. The railroads wanted post-accident testing of certain individuals. A district court upheld the testing. Circuit court reversed. The Supreme Court found in favor of the testing. The tests were reasonable under the Fourth Amendment, even though they were undertaken without a warrant, without individualized suspicion. So they did have individualized suspicion that this particular conductor had been using drugs, but it's not unreasonable to ask a trained conductor to have a drug test. And the governmental interests outweigh the privacy concerns of the employees. Which I didn't show here, which I should have. They also made the point that some employees of the railways didn't need to have suspicionless drug testing. Like the person who's taking tickets doesn't need to necessarily be drug tested all the time since it's not a safety-sensitive position. That's what I have. I'd be happy to address questions at the end. I'd like to introduce my friend and colleague, Dr. Deb Pinals. Tough acts to follow. First of all, I want to just thank my dear friends and colleagues, Larry and Ellie, for the tremendous work that we did together. It was really fun and, well, fun and challenging, but I really appreciate how much they lifted me up through the process. So thank you guys. And also, it's fun to be here. I think I feel like a typecast psychiatrist because I spend so much time in the forensic world at the American Academy of Psychiatry and Law. So when I come to the American Academy of Addiction Psychiatry, which I've been coming to for years, people are like, really? We didn't know you do addictions work too. So I want to change that typecast immediately. So let me see if I can advance the slide. And I think I have to stand here because I realize I'm short and always am learning that over and over again. Okay, so I'm actually gonna be speaking about two subjects. He said I was only gonna talk about correctional issues. I'm also gonna be talking about family issues. So stay tuned for that at the end. So let's talk about substance use disorders and corrections. Let me get a show of hands here. How many of you have worked in correctional or carceral settings? And how many of you have worked with patients that are on parole or probation? Okay, so that gives you a flavor. You've all worked with people that are moving in and out of carceral settings, and I'm gonna talk a little bit about that. I'm gonna start with this case history to sort of get your intellectual and clinical wires, synapses connecting. So a 33-year-old male is admitted to a local jail. He has a 10-year history of opioid use disorder and a 15-year history of alcohol use disorder. He's been admitted for a charge related to stealing from family to support his drug use, very common scenario. Upon his arrest, the man becomes concerned that he will not have access to heroin in jail, and he conceals, it feels like it's echoing. Is it echoing? No, okay. And he conceals an undetected package containing the drug in a body cavity, another common scenario. On intake, he is not asked about a history of suicidal ideation or substance use, and he is not referred to a qualified mental health professional. Approximately two days into his stay, he becomes very restless, feeling very ill, likely because of withdrawal. Officers examining his cell note that he is trying to mix a powder in some fashion. They pull him out of his cell, confiscate the powder, and place him in administrative segregation for a disciplinary hearing. And this is a case that's kind of an amalgamation of cases that I've been involved with, often from a litigation perspective, when things go awry. But this is something that can happen where we have somebody with a significant addiction who, in a carceral setting, is then treated by being placed away from treatment and in administrative segregation, which is kind of antithetical to how we would wanna care for this man in a clinical place. But, you know, these are the questions that I would pose to all of you. Is there a responsibility to do a more complete assessment of this man with regard to his suicide risk and SUD history? Can a jail inmate access substance use treatment? What can happen to an inmate or a detainee found with an illegal substance? And what are trends in legal cases that could have helped him get more immediate treatment? So we're gonna talk a little bit about this. So to the hand-raising question that I asked, here's some data that I think is important to realize, is that we have in the United States, this is still somewhat old data, but, and there's been some shifts, but we have about six and a half million people under correctional supervision in the United States at any given time. And when we talk about correctional supervision, we have to think about the different places and spaces where those numbers are counted. So we, of those, only, still a lot, about two million people are in a carceral setting, okay? So when we think about correctional supervision, we also have to take into account people on probation or parole. So about four and a half million, obviously I'm rounding those numbers, are in the community on probation or parole. Why is that important to us as clinicians? Well, it's very important for us because when we think about continuity of care, anyone on probation or parole is at risk of violating their probation or parole. And very often when they violate probation or parole, including with substance use as the reason for violation, they will be moved back into a carceral setting. So if we have them on a treatment, it's very often, and unfortunately still true, and we're trying to change that from a policy perspective, that they will have a disruption in their care. Because when they get to the next setting, they may not have the care that they need and that they need for their substance use disorder. And these are very fluid places and spaces, people on probation, parole, sometimes people are on both probation and parole at the same time. And also when people move from a jail into a prison, that can be an interesting gap in care where things can go awry. Most people would move from jails to prisons, occasionally a prisoner who's released on parole will come back to the local jail before they get transferred to the prison. So there can be some movement between these systems. And care records, it's not like clinical worlds where care records follow them, there's often just that disruption. We know that the prevalence rates of substance use disorders in inmates broadly defined is very high. And I am using the word inmate because it could be a detainee, somebody who's just been arrested who hasn't been arraigned, it could be an inmate being held pretrial, it could be somebody who's sentenced, but we know that about 58% of sentenced people in prisons or 63% of sentenced jail inmates had symptoms that met criteria for a substance use disorder. Almost 20% of prisoners and sentenced jail inmates regularly used heroin and opioids, 42% of state prisoners, 37% of sentenced jail inmates were using drugs at the time of their offense. So we know substance use disorders are highly, and we heard this before, as Ellie was talking about sort of the moralistic views and how we arrest people and crime and the relationship between crime and violence and just crime itself related to substance use disorders, it all gets very complicated. So it's not a surprise to anyone working in addictions that this is a common phenomenon. Just some historical trends related to this. The war on drugs from the mid 1970s to 1990s really contributed to what we call mandatory minimum sentences to punish the manufacturer use and distribution of drugs. In the mid 1970s to 1990s, a lot of that was related to the crack cocaine epidemic, which we all know, well, you may not know, but should know that that had a lot of racial overtones. It was an issue especially for black Americans and there was a lot of criminalization related to that. So the policies that were made at those times really talked about these mandatory minimums which left people in carceral settings. Now there's a lot more discussion because we are getting better, we're not there yet, at recognizing substance use disorders as in more of a disease model. And if you look historically back, and it goes back to Ellie's talk as well, we've had, if you look back to the 1800s, lots of back and forth about whether this should be criminalized behavior or used more as a public health approach. But as we're looking at substance use disorders now more as a treatment issue, you see a couple of cases percolating up, like the case of Commonwealth versus Eldred, which was a 2018 Massachusetts case that held an individual on probation. It still held that an individual on probation could be required to remain drug free and could be penalized for a relapse as a public safety measure. There was a lot of pushback on that finding and it did result in Massachusetts of a rules change for how substance use disorders are treated for people on probation. But it is a complicated thing. If substance use was related to the prior criminal act and it is a term of your probation that you shouldn't relapse and you shouldn't use, then what does that mean for the person who uses while they're on probation? And I think many states and jurisdictions are trying to develop a sort of more nuanced stance to those decisions. Another Massachusetts case, ironically, the U.S. versus Massachusetts Parole Board involved a settlement agreement when the parole board was sued that said when parolees with opioid use disorder were required to take naltrexone, the agreement required that the parole board modify parole condition order so that people were not mandated to take certain MOUD. That was when the parole board was kind of leaning in and sort of quasi-prescribing, leaving it to the treaters to decide rather than saying that they could take naltrexone but not other forms of medication. So we're seeing movement in some of these cases that's recognizing what we think is the right way to go, which is clinicians making clinical decisions, duh, and then also maybe some balancing tests and some least restrictive alternative kind of arrangements looking at relapse as a treatment issue and trying to approach it that way more so that people aren't further, because again, what happens is these people on probation and parole can be further criminalized for their substance use disorder and it is a tough balance in society because we don't want somebody, if we're a store owner, having somebody on meth breaking our store window and it gets back to the conduct while intoxicated issues and so how do we help with that? Other cases that are important in the criminal carceral law area are some Supreme Court cases. So Estelle versus Gamble was a 1976 case having nothing to do with substance use disorders but it established that failure to provide treatment to prisoners is a constitutional violation under the Eighth Amendment. It's cruel and unusual to incarcerate people as a prisoner and then not provide them minimally adequate treatment and this gets extrapolated then in Bell versus Wolfish under a different constitutional right under the 14th Amendment that this extends to pretrial detainees so that there is a constitutional requirement to provide minimally adequate treatment akin to what the community standards would be so when you're working within jails and I do systems level work in my day-to-day practice, you're looking at what's the community standard for care and is it available to the inmate or the pretrial detainee and these are constitutionally required issues and you see the Department of Justice and others coming in and looking at investigating whether things have happened. I'll talk a little bit more about that and then this 1980 case Ruiz versus Estelle is also important as it specifically specifies elements that are required. So for example, screening and evaluation so going back to our case example, people are entitled to proper screening and evaluation, they're entitled to treatment and referral, participation by trained mental health professionals, accurate, complete and confidential medical records, safeguards against psychotropic medications and a suicide prevention program. So those are all constitutionally required. Other recent cases have come about looking at medications for opioid use disorder, this Pesky v. Coppinger case again in 2018, this was again, Massachusetts seems to be the hotbed of trying to advance the field of getting medications for opioid use disorder available to people in carceral settings although we know Rhode Island did some fantastic work in that space but essentially, this was the first case where it established it's an ADA violation to not provide treatment, medication for opioid use disorder for an individual assessment within that carceral setting so you could say, well, why isn't it available now everywhere it's moving in that direction, there are many, many barriers and hurdles but it is recognized and I don't need to go into all of the cases but there were many cases and they continue to happen across the country where jails and prisons are being sued for failure to provide appropriate medical care for people with opioid use disorder and so we're gonna see more and more movement in that direction, the barriers are fascinatingly complex, I'm not gonna get into all of those. The other thing in the carceral space that's important to recognize when I do talks to judges and sheriffs and whoever I can, really talking about re-entry as a matter of life and death that we know that people who leave carceral settings are at major risk for dying related to opioid overdose within two weeks and up to a year and beyond after their release, some of that is related to dose effect because they haven't been using, they go out, they go back into their social circles and they use and then they're not able to tolerate the dose that they're getting exposed to. There are models out there for re-entry in terms of setting up checklists, we've done a lot of work, I've had several grants working in the re-entry space to help people with substance use disorders get connected to community services and it is a big lift but part of it involves really assessing the needs and planning for those needs and getting those tight linkages to occur and one of the things we're seeing that people should be aware of is that many states are now getting Medicaid funding through what's called an 1115 waiver, demonstration waiver. So traditionally and currently the law for Medicaid does not allow for payment of treatment, meaning medications and therapy and care coordination for anyone in a carceral setting. However, with an exception which is a waiver of the Medicaid rules now, the 1115 waiver, states can opt to demonstrate effectiveness of providing certain services. So states are now applying for Medicaid waivers that will provide funding for up to 90 days pre-release and then of course kicks in post-release and so states can opt in for what they're applying for, they can apply for medications to be funded, they can apply for care coordination, they can apply for 60 days, 30 days, 90 days. So different states are applying for different waivers. Several of those state waivers have been granted. California was the first, Washington was the second, I believe Montana was the third and now there's several states and with the administration change, my understanding is that states are kind of being reviewed in clusters now with the hope that several more will get approved. I believe this is a bipartisan supported issue so I think we'll continue to see this. There may be some shifts in how it happens but this is an important area of support because it will theoretically provide more continuity of care across the re-entry space for people especially with substance use disorders which is an area of focus for all of this. Just so that you're aware, when people do have claims related to substance use disorders in carceral settings, it's not very often that it's a single malpractice case. These usually are cases, I mean that can happen but usually what happens is bigger claims under what's called Section 1983 which is a civil rights claim that there's been a constitutional violation which then involves suing not only the, it's not about suing the individual practitioners although they can get named, it's also about suing the county, the sheriffs, the state as well as the contractor that holds the contract to provide the service for failure to have policies that protect the constitutional rights of individuals. There also can be class action litigation. For example, a lawsuit that says all people under this class, like all people that are currently incarcerated with a substance use disorder are filing a claim against this county for failure to appropriately assess them, that's called a class action lawsuit and then there can be individual jurisdictional investigation by the Department of Justice under the Civil Rights of Institutionalized Persons Act where they can go in and look across institutions, across jails, prisons, juvenile justice settings and the like to say, are people getting the care that they need and those get investigated and then there can be settlements or full blown payment required. All right, so let me now totally switch gears and move into the field of addictions in pregnancy, family, and divorce. I will tell you, part of where I got involved and started to get involved in this area was when I was working in Massachusetts, gosh, now almost 20 years ago as the Assistant Commissioner for Forensic Services, one of my big jobs was overseeing our civil evaluations of people who were getting civilly committed for substance use disorders. Massachusetts is one of the states that heavily relies upon a statute that allows people to be civilly committed. And at that time, they were being civilly, the women were being civilly committed to the prison. And I was also working as an attending in the prison. It didn't quite make sense how that was happening. They would go there and they wouldn't get any treatment because there was a lawsuit saying the prison wasn't the right place for them to go for treatment, so therefore we won't provide any treatment. So they would basically go and that law got changed. It's a long story, fascinating story if anybody's interested. But all of this and our numbers of people that were getting petitioned for commitment were just skyrocketing. And so it got me very much more interested and it made me sort of have to dig into addictions more and then this whole field because people who were getting, we would have examples of women who were coming in, they were unemployed homemakers drinking alcohol, their husbands filed for their petition for commitment because they were putting their kids at risk, they may have been pregnant. And then the question would come up of should they call child welfare services to report these pregnant women? So it got very complicated. So I'm gonna give you this case example. A 32 year old woman with alcohol use disorder, opioid use disorder and PTSD discovers that she is 12 weeks pregnant. She regularly used substances before and after she conceived, now she desires to cut back her use because she's motivated to deliver a healthy baby and raise the child on her own. She has a history of taking medications for addiction treatment but did not remain in care after initial months of stability. Four years later, four years earlier, sorry, she delivered a baby with neonatal abstinence syndrome. The child has spent time in foster care but she is hoping to have the child returned to her custody. The woman is living with a friend while the child lives with the biological paternal grandmother. She has had no direct contact with the child recently and she comes to a clinician's office for treatment. Again, not an uncommon type of scenario. So questions for consideration. Given that this individual is actively using substances while pregnant, do the mandated reporting laws require the clinician to report this to Children's Services? Just by a show of hands, what do you guys think? Yes? How many people say yes? That's the right answer. What do the laws and policies support with regard to returning a child to the mother with addiction and history of custody loss? Let me just give you some background because now I spend, also in my state policy work, a lot of time working with child welfare. And it's really complicated. But we need to remember that the number of women with opioid-related diagnoses at the time of delivery has increased significantly over the years. This is somewhat old data from 2010 to 2017. Approximately 7% of women reported taking prescription opioid pain relievers during pregnancy. 20% self-reported misuse of these prescriptions. Rates of neonatal abstinence syndrome were highest in states with the highest rates of opioid prescribing. Now, what does that mean for the mother who, this context of substance use during pregnancy? There is, in law, we have very, a very, I would say, inchoate interpretation of what this means to have a fetus in utero. And this concept of what are the rights of the fetus versus the rights of the mother gets very complicated, as you'll see. So there's evolving views. Early cases showed that fetuses had no rights as it was literally part of the mother. Later case law established some individual rights. And of course, with individual rights comes other complexities. The abortion case in Dobbs, as we know, in 2022 overturned Roe v. Wade, clarifying that there is no constitutional right to abortion and that states could individually decide their abortion laws. So Dobbs didn't make abortion illegal. Dobbs basically said states should decide on their own what they wanna do. And it's not, obviously it's very politically charged and it's very controversial, but it's not untrue that there is a distinction between state and federal law. And so in many cases of complicated areas, there are distinctions between what the states can decide. Just like criminal responsibility, the states can decide that there's no constitutional right to an insanity defense. And so what we're seeing, though, is that some states are eliminating the right to abortion and making it more complicated. So that is where it gets scary when there's no constitutional right. But again, depending on your views, that's kind of how the law works. What we know in terms of pregnancy is that, and this gets complicated too, because if you have a substance using pregnant woman and they may not have access to an abortion or they may not want an abortion, federally unborn victims of violence act in 2004 to recognize an embryo or a fetus still in utero as a potentially separate entity and legal victim to certain crimes of violence. Now, this was meant to help in domestic violence situations where a woman was being abused and the unborn baby was harmed as a result so that the perpetrator would be able to be penalized for that harm, not just to the mother, but to the child. And as of May 2018, 38 states had fetal homicide laws that protect fetuses by giving them victim rights when killed by violent acts against pregnant mothers. Substance use during pregnancy, though, then becomes an issue because if somebody can be charged with murder or homicide for killing an unborn baby, what does it mean to the mother who's using substances who's then putting the baby at risk if there's a fetal right? So that can be considered child abuse with some mandated reporting in some states. The Guttmacher Institute tracks this. When reporting substance use during pregnancy to child welfare, though, it's important to realize that any number of actions and outcomes may occur. So a report to child welfare can sometimes invoke referrals to substance use treatment or other supports. That's a good outcome. But it could also fully refer as child abuse, and that means that it could go for prosecution, potentially, depending on the states. It could also lead to a documentation in the person's file so that if there's other child maltreatment reports on this mother, then this could be used later against the mother in terms of custody issues. And so this is the number of states that look at substance use during pregnancy viewed as child abuse. About half the states, health care professionals required to report suspected prenatal drug use is about half the states. Substance use during pregnancy used as grounds for civil commitment. Some states actually, just by virtue of using substances during pregnancy, you can civilly commit the woman to a confined space. Funded or created drug treatment programs for pregnant women, not as many, but some. And prohibition of publicly funded drug treatment programs from discriminating against pregnant people. Only 10 states had laws that said you can't discriminate against pregnant people. So it's hard to get pregnant people with substance use disorders even into treatment. So here's some examples of case law. This one is pretty old, 1992 here in Florida. Convicting a pregnant substance use woman for prenatal harm to her fetus. The defendant was sentenced to drug rehabilitation and probation after she was found guilty of gestational substance abuse related to the idea that the substances were passed to the fetus through the umbilical cord. The case was later overturned but had a major impact on states. Cases out of other states that have shown convictions of mothers who were using substances during pregnancy when there was fetal demise. So using cocaine and having fetal demise, for example, has been a matter of conviction in some states. We also know that the number of child removals related to substance use disorder from child welfare agencies has gone up over the years. And we know that there's a disproportionate number of black and brown youth that are removed from their homes in particular. And so there are major disparities that we see and major issues that child welfare is trying to work on related to substance use disorders. I will say there are also laws that protect from removal and require that there be what's called a plan of safe care that gets established if there can be a determination that having the child at home is safe. So there's always in child welfare this balancing test between protection of the child and removal versus reunification or maximization of a family setting. And so it is hard to make those decisions in many cases. Pregnancy in carceral settings, an area of important development. And as we know that women are one of the fastest growing populations of people in carceral settings as well as transgender individuals. 75% of women entering jails and prisons are mothers of minor children. As many as 10,000 incarcerated women may be pregnant at any given time. An estimated 2,000 babies are born annually to incarcerated women. And some states have passed legislation prohibiting the use of restraints for pregnant women in labor while they're incarcerated. But not all are followed. So in other words, a woman who delivers while they're an inmate may have to be restrained. Which is if anybody's delivering a baby, you can understand that that is just a very uncomfortable, painful, humiliating practice. But yet that is some of what's required in some states. And so just some take home points to think about is know your state laws. Child removals are increasingly related to alcohol and drug use. But there are ways to also advocate for our patients to ensure that the proper clinical information is provided. Increased need for improved access to treatment and support to help safe family preservation. And that's the ideal, is safe family preservation. And again, there are some laws that protect for that. But it has to be safe. Termination of parental rights is a permanent decision which substance use disorders can put people at risk for that. So when a mother has a termination of parental rights, same with a father too, but it is permanent. It is completely irreversible under all circumstances. Not so for foster care. That person can be returned when they're in foster placements. But once there's a court decision to terminate parental rights, they're formally terminated. Child custody decisions are based on the best interests of the child. When there are child custody cases, that is the law. And so then when we're evaluating the parents, the best interest of the child, not the best interest of the parent, are going to be what matters. Child abuse reporting laws vary regarding substance use during pregnancy, so know your law. Intentional harm caused to an unborn child separate from abortion can be criminalized. Some states have criminalized the use of substances by the pregnant mother as a result. Again, the Dobbs decision, which has major implications with regard to abortion access if states and when states start changing their laws. Women with substance use disorders may be particularly vulnerable to unwanted pregnancy, which will become another layer of challenges for them. Clinicians should stay abreast of these evolving laws and help support women in these cases. I did see a drug court once where the judge basically shamed the woman for getting pregnant and said that that was a complete violation of what she was supposed to be doing. And it was just kind of a horrible thing to watch happen. And so we really need to work with women in a way that's trauma-informed and help them get access to the care that they need. So keep these things in mind. It is a very complex area of the law, fascinating but important as we work with patients and think about these things in forensic contexts and custody work. Thank you. Thank you very much. So we have time for questions and discussion. Please come to the microphones. And if there's a particular person you'd like to answer, please let us know that. Or if you'd just like it to all try, that's fine also. Please. Dave Kundith. In response to Dr. Pinal's presentation, first, thank you. Very complicated issue, and you did a great job. Thank you. I want the group to know that the American Medical Association has policy in some of these areas. In particular, there's recent policy that a positive drug test is never an indication for a CPS investigation or removal in the absence of actual evidence of a parenting problem, that the substances themselves are not viewed as the problem. And that's now AMA policy. The other thing is that we expect the Council on Science and Public Health will present in June a report on the universal shackling of prisoners, which will, of course, have to deal with the issue of labor. My understanding is that there is also very clear AMA policy that there must be overwhelming evidence of hazard before women are shackled, before pregnant people are shackled during labor. It's an active area of work for our AMA, and I think it's going to be very important to continue Dr. Balasanova's active representation of addiction psychiatry perspectives. If you have thoughts on this, please let Dr. Balasanova know, and feel free to also copy me on some of this stuff as a member of the Council on Science and Public Health. Thank you so much. I really appreciate all that. I want to say, too, it's an active area in the National Commission on Correctional Health Care, many of these things that I sit on for the APA, as well as the APA has specific policies and pretty aligned with the AMA around these issues. And there's obviously more work to do. So thank you so much for that. AMA has worked closely with the APA. Thanks. Please. Hi, thank you so much for your talk. It was outstanding. I have a lot of experience in the forensic world, and I'm very curious to hear your thoughts on not guilty by reason of insanity laws that have the clause that eliminate substance use from being able to be considered for not guilty by reason of insanity. Thank you. You want to repeat the question? She was asking about the exclusion of substance use from not guilty by reason of insanity defenses. So it's a complicated and not so complicated issue. Basically, the thing to know about this is that substance use, per se, is not going to be a defense for the not guilty by reason of insanity. However, it can influence the substance use can lead to a defense of not guilty by reason of insanity when the substance use itself can lead to psychosis, in which case the psychosis becomes the basis for the temporary insanity. The other aspect of this to think about is the reduced mens rea, the ability to form an intent as a result of substance intoxication. And then the third aspect of this is the cases of involuntary intoxication, which are extremely rare, but are also a basis for an affirmative defense. Thank you. Please. I just have a brief question about the testing. What are some drugs which can be tested by home kits? And what home kits are available for parents, families to use? Yeah, pharmacies have a whole variety of home testing kits, including dipstick tests. I've seen some breathalyzers in pharmacies. And I think they could all be useful, especially for working with teenagers on a clinical basis. From a forensic perspective, they're worthless, not because of the tests themselves, but because of the procedure and the protocol. You can't prove to a fact finder that this is the same individual that you tested that this is the positive result for. So clinically, they're useful. I don't think they're going to have to be standing in a hearing or a courtroom. Fantastic talk. Thank you. I really enjoyed it. My question could be a whole talk in itself. But I was wondering if you could briefly discuss and talk about the intersection of behavioral addictions in the law, and what forensic and non-forensic experts can do in these types of cases. Do you want to take that and repeat it? Sure. So Tim Fong, I don't know if he's here, is the world expert in these issues. But in essence, the one thing to know is behavioral addiction, obviously, are an area that continues to evolve. Gambling disorder is recognized by the DSM. Internet gaming or gaming disorder is recognized by the ICD and not a full diagnosis by the DSM. There are other proposals for behavioral addiction diagnoses that are being investigated. The reason I'm starting from a diagnostic perspective is that is going to influence how the courts take a look at this. Now, there's been some cases where the courts have ruled that some gambling behaviors can be used for downward departures when it comes to sentencing, meaning if the person is supposed to be sentenced 20 years, the gambling can be used as a significant mitigating factor to reduce the duration of the sentence. But, and that's even happened in non-diagnosed behavioral addiction, that's even happened in shopping addiction, what's described as shopping addiction. But that's the extent. Theoretically, there could be a case for a non-guilty by reason of insanity in these cases, but it's an extremely far, far cry, and it's unlikely, I'm not aware of any cases where that's happened, and it's unlikely that it would ever pass. Yeah, to underline, I've worked on a couple of cases where the person defrauded some institution or individual and clearly had a gambling use disorder, so I was able to get, as you said, the downward departure from the sentencing by using the compulsive behavior as a mitigating circumstance. And the judges were relatively sympathetic, but certainly the person who was convicted was still punished for their crime. Michael. First of all, I'd like to thank you so much for this presentation. I was having flashbacks to the last symposium we had on this subject, which was probably 25 years ago, or so, we would call that old horizons in addictions in the law. And I have a comment, and I have two questions. So my comment is that back when we had the last symposium, Jeff Metzner, my friend, talked about corrections, and Richard Bonney, who is a professor of law at the University of Virginia, and I've lost touch with Richard, I don't know where he is right now, spoke about some of the philosophical questions. And he did make a distinction which I think is practical, in that instead of thinking about what's determinant, because if you ask the average theoretical physicist, they would just tell you there's no free will anyway, and what we know about criminal responsibility, that all is English common law from the 18th century, and I don't think they consulted Isaac Newton in that process. So instead of talking about determinism, he talked about behavior. There's involuntary behavior, like the extensor knee reflex, or the rooting reflex of an infant, which is truly involuntary, and then everything else is voluntary. And he said that when you have an addiction, you have a decision to make, but it's a much harder decision, depending on the drug, and the dose, and how long you've been addicted, and so it's a question of difficult decisions that have to be made, and that that is a real thing. And I thought that was useful. My two questions, one, the other important landmark Supreme Court case is Egelhoff, which has to do with diminished capacity, and I'm glad you didn't talk about it, because it's so confusing, but there is a neurobiology of volition, and it's getting, I don't know if it's getting clearer, but it's certainly getting more complicated, and so one, my first question is, do you anticipate that issues about diminished responsibility or diminished capacity are going to come, are going to be more problematic, or at least important in the years to come, as we do clarify the neurobiology of volition? And my second question is in the correctional area. Back in the days when I consulted to federal courts, and did monitoring of state prison systems, for Eighth Amendment violations, in terms of failure to provide treatment for health and mental health conditions, there were only two states, there were only two jurisdictions, New Mexico and Puerto Rico, in which having an addictive disorder, and having it treated was considered a constitutional right, and I never really understood how, some states said the Eighth Amendment doesn't apply, because addiction isn't an illness, and it doesn't have a treatment, it just has rehabilitation, and only two jurisdictions were these cases, considered Eighth Amendment cases, and I wonder what the current state of that is, or how it could possibly be that it was different from state to state, when it's a constitutional amendment, so thank you. Can I answer the first one, and then, you asked about Etelhoff and diminished capacity, and whether given the improving science in that sphere, whether courts are gonna react well to that, I don't know, but I can tell you how courts react now to any involuntary intoxication, they say, are you saying it's not his fault, because he was drunk, Doc, and I don't see a lot of sympathy from fact finders, either judges or juries, about diminished capacity on conviction, I think where diminished capacity can be used, is as we were talking earlier about downward departures, when someone's been sentenced, and one of us can explain to a court how this person's addiction came about, and therefore, his or her behavior, so we can talk about the trauma which led to addiction, we can talk about the person's life, we can make the person much more sympathetic to the fact finder than they would be otherwise, at least now, in my experience, that's all before sentencing, after conviction, whether that will improve, I mean, I hope it does, but I don't have a lot of personal hope for that, I haven't seen any movement in that direction. If I could just say a couple things, one is the Montana versus Egelhoff case is fascinating, but it's also a similar case where it said, we leave it to the states to decide how to deal with this, it's not a federal issue, you don't have an entitlement to say addiction caused you to not be able to have the mens rea, the guilty mind, but states can figure it out themselves, how they wanna balance that. Second of all, I would say that this is no different, in a way, from where the science is going, in terms of psychopathy, and brain development, and victim empathy, and like what we're learning more about the complexity of people who are risk takers, or should they be exonerated, and if you look historically, there was a whole period of time where the idea of hereditary moral insanity was brought up in court, which said that people had brain problems that made them not be able to distinguish right from wrong, but at the end of the day, all of these are, who do we wanna hold culpable as a society, and so I think it gets to what Larry's saying, is that it doesn't pass the sniff test, people will wanna hold some people responsible for what they've done, and we can explain science, but science will potentially make people be a little bit more sympathetic to somebody's wrongdoing, but still not let them off the hook, so to speak. I guess that's what I would say. And then in terms of the constitutional issue in the different states, I don't know the specifics of Puerto Rico, and I don't know if that was done before Estelle versus Gamble established, it was after Estelle. Well, what I would say is it wasn't, that issue wasn't litigated, and the state constitutions mandated that, and defined it differently, because state constitutions and state carceral care, like there's Title 15 in California, they can have specific standards for that jurisdiction that if it's not litigated up to a federal level, it doesn't necessarily apply to other places. That's my best explanation of that. Please. I'd like to thank you guys for this really helpful talk. I'm thinking about the free will determinism duality that you brought up, and specifically in relation to the patient's perspective on that, because we consider it a lot from the physician's perspective, and from the legal perspective, right? But the messaging that a patient gets, if we sort of embrace the neurobiological deterministic perspective, is that your relapses are foreordained, and you have no control over your illness, and obviously you presented good data that suggests otherwise, or that suggests that a belief in control over the illness is helpful for regulating the illness. So, I mean, as we're talking about this increasing, increasingly sophisticated neurobiological data around reduced capacity, how do we maintain a perspective that empowers our patients to actually exercise enough free will to not relapse? And how do we communicate with them that perspective? So, I'm going to quote Larry, quoting Sheila Bloom, that there is no form of addiction treatment that is completely voluntary. Every form of addiction treatment is compelled in some way, shape, or form. It's much more of a how voluntary is treatment? Are you, I mean, because ultimately, drugs and alcohol are fun. People are not using drugs and alcohol because it makes them feel sad. They're using to feel not sad or happy, depending on where they're at. So, for someone to want to give that up, they have to be compelled, either because of a parent, spouse telling them that you have to stop, or because of a court order telling them, well, if you don't stop, you're going to go to prison, or some stricter, compelling arguments. And the reason I'm mentioning this is because, ultimately, in the way we're communicating with patients, we have to dance with one foot in each domain. We have to recognize the patient's ability to make decisions because if the patient feels that they're unable to make their decision, they're not going to really participate in treatment. But, ultimately, recognize what we know in terms of the science and the neurobiology of the volitional aspects of addictive disorders, because we're applying those principles in the therapeutic approaches we're taking. And that kind of goes back to the issue of what's going to happen with the, the more we know about the neurobiology of volition. I think we're going to spend a lot of time recognizing the complexity of putting our head in the sand, unable to do anything about it until our knowledge evolves significantly, at which point we'll have a different conversation. Karen, please. Hi, Karen Drexler, Emory University in Atlanta. And I want to add my thanks for just an extraordinary symposium, thank you. This meeting always causes me to think, and as I was listening, I was noodling on the first symposium about contingency management, and the workshop that Ellen Edens and Wilson Compton and Will Becker and I did yesterday, where we had a little bit of conversation about the extraordinary incentive salience that addicting drugs create within our brains. And that's really probably at the heart of the illnesses that we treat. It's not that you can't make a conscious decision to override the urges, it's just that the automatic decisions become gradually more oriented towards continuing the drug use. And I was struck that in the first symposium, contingency management has an amazing ability to override those extraordinarily incentivized automatic decisions. When the consequences are brought much more proximal to the decision. And it also strikes me that in the forensic setting, drug courts really are a variation on the theme of contingency management. And I wonder, why aren't they taking off a little better than they have? And if any of you could react to that. That's a great question, because I think that drug courts, at least in my experience, have been effective. I mean, not spectacularly so, but have been effective in diverting non-violent drug offenders away from incarceration and towards treatment. And why they haven't taken off, it's almost a philosophical question. I think people are uncomfortable with therapeutic jurisprudence, with mixing those boundaries of treatment and the law and holding, and I think the best drug courts, I think, do hold consequences for people who relapse. And they're not draconian consequences, but they're consequences. The better drug courts, I've also seen, have rewards and lauding of patients who maintain their sobriety. So I find those highly effective, but I think that's based on the personality of the judge, rather than the parameters of the drug court itself. Personal opinion, but I agree with your mystification about why they haven't taken off. But I think that reflects what we also heard in the symposium yesterday. That you have to have a champion, and that these folks implementing contingency management have to be taught how to give positive reinforcement just for showing up. And as my experience is the same, that a lot of judges have this naturally, or they've learned it, and their drug courts are especially effective. And the ones who stick to the punishment-only model really don't get as good of results. And I'd love it if someone here would study that and help promulgate it. I think it's so fascinating that you're talking about the drug courts as a contingency management sort of framework. I mean, it really is, if they're doing it with more rewards than sanctions. And that, I think, is part of the problem. I think there's many challenges with having them take off, and they're costly. They're mostly grant-funded. You don't see states fully funding drug courts in every jurisdiction. You don't always have the right, the judge that wants to take this on. It's additional work for the court staff. So there's operational challenges, probably in the same way that there are for contingency management clinics, just to get them to happen. But in some ways, if we really wanna rehabilitate or correct behavior in our, quote, correctional system, we know the best way to do that is through positive reward, not punishment. But we have an entire system based on punishment, and we have to really think about that more. Thank you. The other thing about that, also, is the philosophical idea and the pushback that we're getting from people who are opposed to drug courts, saying, well, the data is pretty mixed, and it doesn't really show that participants of drug courts are less likely to recidivate criminally. And that's another example. As much as we love for treatment to have another associated outcome, the fact that it doesn't impact the criminal recidivism rate shouldn't, should be seen as a completely separate outcome, but it's not. That's a great point. I think it has to do with fidelity. Just like the symposium yesterday was talking about fidelity to the CM model, I think fidelity to the original models that showed some really amazing outcomes is the key, and I would love it if somebody with energy and funding could study that. Thank you. Thank you. Dr. Lindsey? Hi, Dr. Lindsey, Banner Health in Arizona. Thank you for the wonderful talk. Larry, thank you for your help in all the cases throughout the years. So this is gonna be a question for you, two parts. What's your 10,000-foot view of cannabis in professional sports and its impact on performance and productivity? And the other question is about the NCAA not testing for cannabis anymore for their athletes, considering many of the athletes are 18 and 19 years old. Good questions, both of them. First one was about THC in professional sports and elite sport. I think that, as in the rest of the populations, there are certain individuals who get benefit from their use of THC, whether it's a decrease in anxiety or sleep, or I think sometimes pain also. I think that the majority of individuals who I see have some problem with their use of THC, not just because they have a positive drug test, as far as impaired motivation for athletic training, as far as eye-hand coordination on the field, and as far as other issues. I think overall, it's a poor treatment for psychiatric illness, and that's the, in addition to the fact that that's my perspective as a clinician, that's the perspective of most people in leadership in elite sport. That being said, your second point, about the NCAA has stopped testing for THC, reflects broader society, right? I mean, that employers across the board are stopping testing for THC, and as you know, Major League Baseball stopped testing for THC in 2019 because we were able to start testing for cocaine and opiates, and deemed as a collective entity that that was more important than testing for THC. So that's my response to both. Thanks. Dr. Westers, have you got a recommendation, a brand name for a urine drug screen that's the most reliable for us in the office? The one I use happens to be by a company named JANT, J-A-N-T, but I don't suggest that those are any more accurate than others. I'm just using that as a thumbnail. It's effective and relatively inexpensive, but I'm not sure any of them have the standards of a clinical laboratory. I know they don't. Please. Hello. This room will be well-versed in the idea that when we're studying the intersection between criminalization and addiction, that's widely disparate by race and ethnicity, and I was wondering how the book addresses that, whether it's, or how your research has been addressing it, whether that's in the area of the principles of the intersection between criminalization and substance use or in employment law. Love to hear more discussion about that. The question was about decriminalization and drugs, and how we address it in the book, if anybody's had particular thoughts on it. What do you wanna take? Can I, sorry, can I clarify my question a little bit? I was wondering how you address that criminalization is often mediated by race and ethnicity within our judicial system. Mediated by what? Race and ethnicity. Yeah, I mean, I don't think it's a secret that there's a huge difference in how race and ethnicity affect rates of criminalization, duration of sentences. Rene Bender's done a lot of work on this. The longer someone spends incarcerated, the more likely they are to start injecting drugs. For people who've never injected before, this touches on the whole issue of social determinants of health. It's important to recognize there's a lot of movement in trying to address this, but we're still pretty far behind. There's a lot of work to be done in that area. As far as decriminalization in general, Dr. Kleinman, of blessed memory, who many of us know, was a drug policy analyst, and said that he gave his usual nuanced talk about the benefits of decriminalization and the downsides of decriminalization. Someone stood up and said, Dr. Kleinman, thank you, but could you just tell us, is decriminalization a good thing or a bad thing? And he said, I'll answer you, yes. Why don't we stop here? Thanks, everyone, for your attention today. Thank you.

addiction

legal systems

forensic arena

addiction specialists

substance use disorders

DUIs

free will

determinism

workplace substance use

drug testing

elite athletes

cannabis use

incarceration

race disparities

criminal justice system