Workshop: Conceptualizing Addiction in Clinical Practice: Choice, Compulsion, and Responsibility-Conceptualizing Addiction in Clinical Practice: Choice, Compulsion, and Responsibility

Conceptualizing Addiction in Clinical Practice: Choice, Compulsion, and Responsibility
Video Transcription
Thank you very much for coming. Thank you. Thank you. My name is Jungjin Kim, and I'm the chairperson for today's workshop.  Here today, together with me, are my distinguished colleagues from McLean Hospital.  On the far right is Dr. Reuben Hendler, who is an attending psychiatrist at McLean Hospital's Inpatient Detoxification and Stabilization Unit.  Together with us is also Dr. Karavolis, Zoe Karavolis, who is a clinical pharmacist, whose presence on the unit has been indispensable for all the work that we do.  And at the far left is Dr. Sedgwick, a good colleague of mine whose special interest is in treating patients with addiction and trauma, and especially women's mental health.  In today's talk, I brought my colleagues together with me to talk about conceptualization of addiction in clinical practice,  and our subtitle is Choice, Compulsion, and Responsibility. With that, I'm just going to do a brief intro to frame our discussion,  which is that there is a lot of considerable debate about what addiction really is, even among addiction psychiatrists.  On one side stand those who see addiction as a chronic and relapsing brain disease,  characterized by intense cravings and compulsion to which the individual has no choice but to relinquish control.  On the other side stand those who see addictive behavior as a choice, a constrained one perhaps, but fundamentally an intentional and conscious act subject to self-control.  Now, both views may have intuitive appeal, but they conflict with one another and raise a lot of challenging questions.  So, for example, if addiction is a brain disease, how can we hold people responsible for addictive behavior, especially if the addictive behavior is unlawful?  If addictive behavior reflects choice, how can we explain recurrent akrasia, that is, acting against one's best judgment in the face of self-destruction?  The practice of addiction psychiatry and medicine more broadly often benefit from educating the patients  and the public about addiction, and treatment decisions and public health policies are often implicitly and explicitly informed by our beliefs about the nature of addiction.  So reflecting on how to conceptualize addiction is a practical use to all of us clinicians.  So in this interactive workshop we will use a series of clinical vignettes drawn from psychopharmacology,  psychotherapy, trauma-informed treatment, and the Anglo-American law to examine and challenge our understanding of the nature of addiction.  And we hope that you will draw from your clinical experience, your neuroscience and behavioral psychology knowledge,  philosophical ethical reasoning to work through these cases and engage in a dialogue with your peers.  And we hope that you will engage with each other to obtain a deeper and more sophisticated appreciation for what addiction really is.  So with that, I'm going to go through our disclosures. We don't have any sense to atone for.  And here are our learning objectives. Consider two different ways of conceptualizing addiction, the advantages and disadvantages of each and how to reconcile them.  Clarify our own beliefs about the nature of addiction and reflect on how these beliefs influence our clinical care of patients.  And practice applying different ways of conceptualizing addiction to optimize clinical care through a case discussion  that brings together psychopharmacology, psychotherapy, trauma-informed treatment, and the law. Now with that, let's start with a survey.  Thanks very much. Thanks very much, Dr. Kim. Is this on? Slide it up. All right. How's this? Better? Now we're. Thank you. Excellent.  Great. So where we'd like to start, the fact that you're in this room and pick this, among other competing workshops,  suggests that many of you probably have thought about what the nature of addiction is.  And that's sort of where we want to start is by inviting everyone to reflect on our beliefs that we already have about this topic.  And to do that, we're going to use a tool called Menti. And so I'll invite everyone to take out your phones and your cameras  and zoom in on this QR code here. It's the same ones also on your handout that was on your chair.  Or if it's easier for you, just pull up a web browser on your phone and go to Menti.com.  That's M-E-N-T-I dot com. And then put in this code that's on the top right of our screen here.  And please raise your hand if you're having trouble with the tech and we can help troubleshoot. You're in just the right place. And I will explain what your points mean.  Are folks still logging on? Folks are there. All right. Excellent. So we're going to switch over here to our poll. We're going to have a few questions for you.  All right. People are already diving in. So the idea of this question here, we've laid out a couple of different ways that people sometimes describe addiction.  And what we're interested in is between these, which of these resonate most with how you think about addiction?  So if you believe that chronic brain disease is the only way to describe addiction that makes any sense,  you could get that all 100 points. If you feel like all of these are about equal,  you could give them each about 16 or 17 of your 100 points. And let's kind of see what we as a group think.  Looks like chronic brain disease is in the lead here, but the plurality, not the majority. Then we've got really the psychological ones, psychological compulsion, self-medication,  which together add to about the same amount. And then the social, spiritual pieces lower. And then last, really moral failing, almost no ratings there. All right.  Our next one here. Let's see. How strongly do you agree or disagree with these statements? People have control over behavior to which they're addicted.  And then the second question, the different flavor of that, people have a choice about engaging in behavior to which they're addicted.  We've got some ratings coming in, and you can see both kind of the average and also these shapes show you about where the different ratings are going.  People are sort of in the middle on these.  And we do have, it looks like some real variation. It looks like some folks are more on the strongly agree, some folks more on the strongly disagree side.  Would anyone mind sharing who is more on the strongly agree side for one or both of these, kind of what was going through their mind? You could just throw a hand up.  Yeah, thanks.  Great. So the fact that some of our interventions work might be able to tell us about, you know, that people must have some control or the capacity to generate some control. Great.  And what about someone who's more on the disagree side? Would anyone mind sharing a thought there? Yeah.  Great. Thanks for sharing. So that's why we're kind of in the middle there.  So this is like part of the nature of addiction, right, is that it sort of becomes a very uphill battle. Yeah, another thought?  I really appreciate that point. I'm just gonna amplify it in case folks couldn't hear. It sounds like you're saying it depends on the person, right? It depends  on the addiction. Some folks may actually be able to stop cold turkey. Other folks, no matter what, it seems to be really difficult. So addiction, we talk about  addiction. Addiction might be one thing. It might actually be, there might be heterogeneity there as well, yeah, which might account for some of the different  views. So let's go to another question here. Again, how strongly do you agree or disagree? People are responsible for their addictive behavior. People should  be held legally responsible when they violate the law in service of addictive behavior or to facilitate addictive behavior, like stealing to afford drugs.  And then people addicted to drugs should be held legally responsible when they violate the law while intoxicated or under the influence, right? So these are,  the last question was really about choice and control. Now it's more about responsibility. So it's a different side of that coin. So folks are about in the  middle again and kind of on both sides here, but it looks like more towards the kind of agree side about responsibility. That's a little bit further to that side  than when it came to the control or choice, which is interesting. I'm curious, is anyone, you know, these, if you drew a straight line down, it would be pretty  consistent between these three answers. Anyone answer really differently, you know, between these three different questions? I appreciate that. So there's,  responsibility might be, it might be useful for us to help patients feel responsible for their behavior and agentic in that way. And, but that might  be different than fault or punishment. Yeah, great. So we've got one more question for you, and this is the toughest one, probably. This is more  open-ended. How would you actually put words to this, right? When we say addiction, right, what do we mean by that, right? So very curious to see a pathology  of choice. Disease of choice, pathology of choice. Okay, and then we have more, you know, behavioral ideas. We have some here that sort of match the, some of the DSM  features. Okay, and then we have some that are more neurobiologically oriented. Reward pathway, reward system. Okay, let me see if I can scroll down. Great. And  then we have more psychological ones, right? So an attempt to cope. And the cognitive aspect, thought disorder. Mm-hmm. And we have some etiological ideas,  genetics, environment, both. Oops.  All right, a few more still coming in here.  A physiological aspect, so more of the biological. I'm impressed that everyone is taking a stab at this. Thank you. It's a tough one. But we really wanted to  encourage that. We wanted to start here with thinking, kind of get you thinking about your prior ideas about this, which you'll be able to then use in our case  discussion. And with that, I'm going to turn it over to Dr. Kim to give us a little bit more background when it comes to some of the ways that addiction is  commonly understood. Thank you. So clearly there is a diversity of our attitude and our understanding of addiction. So I thought the first task would be to review our current  conceptualization of addiction briefly to frame the discussion. So let's start with the DSM-5. So DSM-5 does not use the term addiction explicitly. Instead, the  DSM lists individual substance use disorders, depending on the involved problematic substances. The DSM definition, though, is somewhat elastic. It  is a set of 11 criteria combined and accumulated in different permutations to meet the diagnostic threshold on a continuum of severity. But nonetheless,  most of us understand and describe addiction as persistent substance seeking and using, often compulsively or with cravings in the face of negative  consequences. On the other hand, the National Institute on Drug Abuse, NIDA, explicitly embraces a brain disorder model. So it defines addiction as a  chronic relapsing disorder characterized by compulsive drug seeking and use despite hazardous consequences, and it is considered a brain disorder involving  functional changes to the brain circuits. Note that throughout all of these descriptions, at its core, addiction is behaviorally defined. So the essence  of today's discussion is whether and to what extent addiction-driven behaviors are compelled beyond one's control. So intuitively, we know that addictive  behaviors are not pure reflexes or mechanisms. For example, injecting or inhaling fentanyl is not entirely analogous to automatisms in epilepsy or  spiking a fever in response to a viral infection. Or are they? Put another way, are addiction-driven behaviors intentional human actions that can be  subjected to conscious, effortful control, even if it's formidably difficult, that in turn can be subjected to evaluation for responsibility. Those asserting that  addiction as choice model point to high rates of spontaneous cessation of substance use, often with good enough reason. So for example, desire for a better life,  desire for when the livelihood is at stake, and with adequate support such as family, friends, and AA community. And also consider the observation that  individuals with addiction respond rather powerfully to incentives. Look at efficacy of contingency management, probation and parole programs, there's some controversy  there, and physician and airline pilot health services, all suggesting that individuals with addiction indeed may have substantial or at least some control  over their addiction-driven behaviors. However, people on the other side would argue that such control is essentially minuscule, sufficiently small enough to  warrant different expectations and accordance of responsibility. So consider the view that the neuroscientific evidence that persistent use of substances, we know,  changes neural circuitry and physiology, and consequently primes the pleasure-seeking motor systems and dramatically weakens our mental resources needed to exert  effortful control over our behavior. These changes remarkably undermine our cognitive, that is our capacity for rational thinking, and our behavioral,  emotional control over our actions. So much so that they often lead rather directly to actions that disproportionately prefer small, immediate  rewards over later, larger ones, despite devastating consequences. So the question is, should our existing clinical, legal, social institutions then redraw  the line of responsibility to better conform to the contours of human capacity articulated by the neuroscientific evidence? Now let us explore and discuss.  All right, I'm going to introduce you to a patient case. So you are caring for M, a 30-year-old woman with opioid use disorder. M has been using opioids since  being introduced to them at age 15 by her mother, who also has an opioid use disorder. M was abused growing up by her mother's boyfriend, and M now lives with  an abusive boyfriend. M experienced opioid withdrawal during a brief recent period of incarceration for shoplifting, and she describes motivation to stop  using illicit opioids. This is the patient case that we will use throughout the remainder of the workshop, so you can also find it at the beginning of your  handout if you would like to reference it. So there are a variety of medications that we use to treat various substance use disorders. Pictured here may be some  that you are most familiar with. There are, of course, other medications that we use for things like tobacco use disorder, stimulant use disorder, so this list is  certainly not all-inclusive. The pharmacology of these agents differ significantly. Some, like disulfiram, are designed to be a deterrent from the very  substance that someone is using. Other agents, like methadone and buprenorphine, are meant to supplement the same receptors of the drug that someone is  using. And yet, a medication like naltrexone that works exactly opposite something like methadone, but is approved for the same indication. Additionally,  something like naltrexone is approved for multiple substance use disorders, opioid, alcohol, also used for stimulant use disorders, kind of highlighting the  complex pharmacological approaches that we have for treating substance use disorders. We know that medications to treat substance use disorders,  particularly our opioid agonists for OUD, have significant mortality and morbidity benefits, thus most clinicians routinely offer these to their patients.  However, the way we think about these medications may shift based on how we are conceptualizing addiction. Regarding pharmacology, why is it important whether  or not to know whether addiction is a disease? From a public health standpoint, to ensure that the limited health care resources we have are appropriately  distributed, we must be reasonably clear what, first, is a disease, and second, which diseases are most worth investing our time and money. Today's medicine has an  unprecedented ability to actually do things, and it matters a great deal on what we decide to tackle. The ability to make powerful, effective interventions  into people's health brings with it new ethical responsibilities. In the U.S., proponents of the brain disease model have argued that it will help deliver  more effective medical treatments for addiction, with the cost of these pharmacological agents being covered by health insurance, making treatment more  accessible for people with addiction. However, it also begs the question, are new disease entities being created to match drug development? Was addiction as  a disease concept created to further the buprenorphine and methadone industries? The promised treatment benefits associated with the brain disease model  have not been materialized. Most of us know, but few new drugs have been approved for the treatment of addiction over the past few decades. The most  widely used drugs for addiction, things like methadone or nicotine replacement therapy, preceded the brain disease model by more than 30 years. Special challenges  do exist for the development of new drugs to treat addiction. Pharmaceutical companies may be reluctant to invest in drugs for addiction because they doubt  the new treatment will produce profit. In view of the limited capacity of people with addiction to pay for treatment, the absence or limited availability of  health insurance coverage for addiction treatments, and regulations that prevent the clinical use of drugs with similar effects of recreational drugs. To answer  these questions about the concepts of addiction in relation to pharmacotherapy, I find it helpful to consider goals of therapy. For example, commonly cited goals  of therapy for buprenorphine are to suppress opioid withdrawal symptoms and cravings that can lead to continued opioid use, so eliminating negative  reinforcement. To block the euphoric and motivational effects of opioid use, eliminating positive reinforcement. And to eliminate toxicity of opioid use by  blocking its respiratory depression and associated overdose harms. The goals of therapy can shift based on how we are viewing addiction. Are we merely trying  to reduce craving with these agents? Are we trying to reduce the dysfunction that is caused by drug use? Pharmaceutical agents are highly leveraged in all  spectrums of diseases. Therefore, is it better for us to call addiction a disease? Because then people are more likely to get the drugs that can thus  reduce the morbidity and mortality. Medications are also sometimes the only treatment people are receiving for their substance use disorder. According to the  SAMHSA tip 63, medication management can be used independently of other treatment like psychotherapy and still be successful. Laws and regulations about  pharmacotherapy can also signal how substance use disorders can be conceptualized. Since there are very few other disease states that have a  stringent restrictions on their treatment as does methadone. And lastly, a patient's concept of addiction can also have major implications for  pharmacotherapy. Does something like buprenorphine or methadone therapy give control back to a patient or take it away? This is a question I consider you  think about as we go through the next few discussion questions. So at this point, we're going to ask you to break into some small groups as you work  together through these two questions here. You recommend buprenorphine to treat M's opioid use disorder and reduce risk of overdose death. M expresses  hesitation telling you, I don't want to trade one substance for another and asks, won't I then just be addicted to Suboxone? How would you explain the  difference between opioid agonist therapy and opioid addiction? And what strategies would you use to convey the rationale for opioid agonist therapy in a way that is compelling for  M. These two questions are also listed on the first page of your handout if you would like to continue referencing them, but at this point we're going to ask you  to speak with some of the people next to you in small groups. We'll give you about five minutes, and if you do also want to select someone in your group at that  point to be a spokesperson, we'll come back together for a group discussion in about five minutes. So it seemed like there's some lively discussion. There's  two questions that we were talking about here. First was about explaining the difference between opioid agonist therapy and opioid addiction. I think  we've all probably heard this in our practice about patients not wanting to be on things like Spoxone and methadone because they don't want to switch one  addiction for another. So if anyone would like to share something that was discussed about in their group? Any volunteers? Yeah.  Yeah, so adding an element of control, emphasizing safety, I hear.  Yeah, so I hear kind of emphasizing what the patient's goals are, trying to identify what their goals of the therapy are, and using that  kind of as leverage. Great. Any other points? Yeah.  Yeah, that's a fantastic point. So thinking about like stages of change, the mindset of where the patient is, even thinking maybe about experience I have  in the past with pharmacotherapy or treatment in general. Any other groups like to share? Yeah.  Yeah, yeah, absolutely. So also hearing more about like addressing patient goals, and I think an important part of that also is keeping in mind that patient's  goals may not be the same as your goals, right? Do you have something else to share?  What do you think happens? And to talk about that, I'm going to scare people a little bit. Scare tactics. Nice.  I tend to go, most of my folks are like a lean metastatic antifetanil, so like a dopamine, XY graph that describes like how high your dopamine levels are getting, and why you get so depressed and anxious afterwards.  And then I like to draw out the little receptors, and show like the D-delta-kappa, but I think it's like the gradient withdrawal, and then the high.  And then I like to show it feeling part of it, like this is 30 minutes long.  That's a lot of fantastic information. Yeah, awesome. Yeah, I also as a pharmacist love receptors, so yes, thank you.  Great, anyone else like to share? Okay, cool. So I heard a lot of really emphasizing like patient goals and safety are kind of overarching themes.  At this point, I'm going to hand it off to our next section. Thank you so much.  So we have talked about medication, and now I'm going to invite us to consider the next part of our case, which will be about psychotherapy.  Because these issues of how we define addiction, and how it relates to self-control and choice, come up all the time in psychotherapy.  And so to prepare you for the next part of the case, I'm going to share briefly an overview of how some of the different evidence-based psychotherapies for addiction,  consider some of these questions about definition, and how to think about self-control, because there are some commonalities, but there are also some real differences.  So I'm hoping that will help jumpstart your brain for the next part of the case.  So I want to start with 12 steps and AA. We don't have to look far in the AA literature before we get to some of these issues.  Step one begins with accepting a powerlessness over alcohol. So very clearly up front, this idea that people with addiction do not have control over their addictive behavior.  And the therapeutic corollary to that is that it can kind of cut through denial. And also it sort of implies that someone really needs to seek support from outside themselves.  Seek support from a higher power, give over to the 12-step model, to the group, and the wisdom of the group. Psychodynamic approaches also center this idea of powerlessness.  But not necessarily powerlessness in relation to the substance. So some of the psychodynamic understandings of addiction talk about powerlessness over strong affect,  some other situation in one's life, and see addictive behavior as an attempt to regain a sense of control over one's affect.  And so there the corollary has less to do with the relationship to the particular substance,  but more to do with trying to increase the patient's self-efficacy for emotion regulation and managing their life.  That idea of people liking to be in control, and hating being out of control, gets picked up in motivational enhancement and MI.  Which was developed in part as a response to the fact that people generally hate being told what to do.  Especially when it comes to behavior like addictive behavior. And so it's a way of sort of bypassing that when we're talking to patients.  And MI really comes from a person-centered Rogerian psychotherapy perspective,  which takes as an axiom that given the right circumstance, people will naturally do what will support their own well-being and success in life.  But that's something that all people kind of want and will strive for.  So how do they understand addictive behavior that seems to be self-sabotaging? So they point to this idea of ambivalence.  That people don't just have one motivation, people have multiple different conflicting motivations.  And so the therapeutic corollary there is to try to help people to resolve their ambivalence in favor of change.  And to do that, we have to actually help patients to build up their confidence, in their ability to control themselves, in their ability to make a change.  Making change is hard, so that's a lot of what MI is all about, building people up. That idea of ambivalence comes up as well in contingency management.  Where there's this notion that people are often making a choice about which they're conflicted,  between shorter and sooner rewards, like those that people get from addictive behavior, and larger but later rewards that come with abstinence and sobriety.  It adds to that notion of ambivalence, the principle of delay discounting. So this is a psychological feature that we all have,  where all things being equal, rather have something we want now than have it later. But this gets accentuated in people with addiction, who may feel hopeless about their future,  and their potential to engage in enough constructive behaviors to build towards those larger and later rewards.  And so the therapeutic corollary there is to increase people's ability to make choices, that ultimately will be in their best interest in the long term.  We need to help them out with some more modifications to the contingencies in their environment. So add in artificially some sooner, smaller rewards along the way.  Last slide before we get into the case. CBT, cognitive behavioral therapy, builds on that idea of operant conditioning and contingency management,  and also talks about classical conditioning, and understands behavior in terms of antecedents and consequences.  And so if you want to gain some more control over your addictive behavior, that may be difficult directly, but perhaps you can modify the antecedents.  Perhaps you can modify some of the consequences to influence behavior that way,  or you can increase your affect regulation skills, or you can change the way you're thinking about addiction when it comes, for example, to the abstinence violation effect.  So these are some of the ways that CBT tries to restore control indirectly over addictive behavior.  And DBT, dialectical behavior therapy, also looks at how people need skills to be able to engage in self-control.  And it supposes that oftentimes in the context of addictive behavior, people are reaching a breakdown in their ability to regulate themselves.  And so the therapeutic corollary is to actually try to teach people more skills for emotion regulation,  distress tolerance, so that they can do a better job of being in control of their behavior. And DBT adds to CBT the idea of mindfulness.  So as one of the skills, the skill of being present to something that's going on without being reactive, being able to tolerate something without reacting right away,  which creates the opportunity for bringing consciousness online and kind of top-down prefrontal cortical regulation,  system two processes to try to kind of control the bottom-up impulses, limbic drive that often prompts addictive behavior.  And when it comes to the idea of to what extent people should feel powerless or in control of addictive behavior, DBT unsurprisingly takes kind of a dialectical approach.  It tries to find a middle ground with the skill of clear mind. And clear mind really says, if you feel like you have no control over your addictive behavior,  you may be in trouble, right? Because if you're engaging in addictive behavior, you feel like you have no control, why even try to stop, right?  On the other hand, if you believe that you got this and there's no way you could ever go back to addictive behavior,  you may do things like take a lot of risks and you may do things like not engage in treatment. And that in and of itself sets up a vulnerability to return to addictive behavior.  So it suggests this clear mind where you're not engaged in addictive behavior,  but you are ever mindful and vigilant about the fact that addiction connotes a chronic vulnerability to return to that behavior.  And you're actively engaged in ways to prevent yourself from falling back into that.  So with that, I hope that will help prepare us, give us some things to think about when it comes to the next part of our case.  And because I have the mic, I will read it aloud for us. You diagnose M with complex PTSD and recommend psychotherapy.  M presents tearfully to a therapy session and reports having briefly returned to fentanyl use  after arguing with her boyfriend and then encountering someone who has provided her fentanyl in the past. She says, I don't know what came over me.  I saw my dealer and the next thing I knew I was using. When I feel a certain way, I don't have a choice, I just use.  And our questions for you to discuss in your groups are, what are the advantages and disadvantages of M seeing herself as without control over addictive behavior?  And then how would you explore with M the role of choice in addictive behavior in the therapy context?  So we'll give you another five minutes and then we'll come back as a large group.  Would anyone be game to share something that came up in their discussion?  Go ahead.  Thank you. Yeah. We were thinking about the internalization of addiction. So this idea that you're a permanent agent of M, and M is up and down the room and you're a real agent,  and that's how you have to think both on that.  The advantage of feeling an addiction is that you're not responsible for anything that happens in your life.  And then the disadvantage of that is that you're not in control of everything that's going on in your life. So the problem of wanting to approach the substance,  and we were talking about trying to level those two realities.  internalizing and realizing that we shouldn't think that we should or we should not think that we should or we should not and maybe there's a conflict of interest.  So I think that's why... What a sophisticated discussion. If you're not doing DBT, I think maybe you should be with finding ways to integrate these different things.  And I... Oh, that always helps. That always helps. So there's that idea that that external locus of control, we didn't use those words,  internal-external locus of control, but I think that applies here. There may actually be a real affective meaning to that.  And if we're trying to get our patients gradually to feel more control, we also have to respect the fact that the external locus of control  may be doing something important for them, which is helping to stave off some of the shame and guilt, but also be problematic and perpetuate  addictive behavior as negative reinforcement. Thanks for that. Yeah?  It seems like the case is kind of broken in chain analysis. If you go back and you look at all the stems from not having a relatively complete scale,  that is something that you can point to having some more control over in that setting. And that is the whole idea about substance use in that sense. Great. I really appreciate that.  So if we think of addictive behavior as this one act of using a substance, that's one thing, but if we look at sort of the whole temporal chain,  we might identify where the person last felt like they did have control. And that may be a place that we can intervene. Oh, we've got two. Okay, go ahead.  Yeah.  Sensitive to where the patient is, meeting them where they are. Did you have the last?  Yeah.  We did have that in mind writing the case. And we do see it a lot. I was on a slide, but I didn't say anything about it, the learned helplessness idea.  So we know from psychological research, sometimes people feel they have no control when circumstances change, and they do. So that's one thing we can be sensitive to.  And maybe last comment.  Right. As someone who loves MI, I really appreciate your pointing to, what can we affirm here? What can we do to help build back somebody's sense of control  without necessarily it being confronting the idea that they are just subject to the whims of seeing their dealer or something like that. Wonderful.  So with that, I'm going to turn it over to Dr. Sedgwick. Pass the baton.  So this discussion is a pretty perfect segue to the third portion of our case.  Which is focusing on co-occurring trauma.  So why is trauma-informed approach so important in treatment of patients with substance use disorders? It is important because most of our patients have trauma.  There are many studies citing high numbers of patients with substance use disorders who also have co-occurring trauma exposure and PTSD, among other mental health concerns.  And at every level of care, we hear patients recounting traumatizing experiences  prior to or woven throughout their use of substances. A 2009 study found that 95% of participants with substance use disorders and mental health problems reported having experienced  one or more childhood traumatic events. A 2023 study of women with substance use disorders who were homeless or near homeless found that 100% reported having at least one type  of traumatic experience in their life. And the majority, 75%, having five to seven types of trauma. So we need trauma-informed approaches to be integrated into our treatment  as a rule and not the exception. In 1998, the CDC and Kaiser Hospital released the landmark Adverse Childhood Experience, or the ACE study,  documenting a link between adverse childhood experiences and subsequent adult health outcomes. This was the largest study of its kind to examine the health, social,  and economic effects of ACEs over the lifespan and included over 17,000 participants. Adverse childhood experiences are categorized into three groups,  abuse, neglect, and household challenges. Each category is then further divided into multiple subcategories listed below.  Not only were the findings common, but they also found that they were cumulative. As the ACE score or childhood stress increases,  so does the risk of these health problems later in life. They also noted that many subpopulations were disproportionately affected,  so females and several racial or ethnic minority groups were at greater risk for experiencing four or more ACEs.  The LGBTQ populations also experienced higher rates of an increased number of ACEs. So having four or more ACEs puts you at much greater risk of these outcomes  compared to people with no ACEs. So the odds ratio represents the odds that an outcome will occur given a particular exposure compared to the odds of the outcome occurring  in the absence of that exposure. In this case, the number next to each outcome is the odds of developing that outcome  for patients with four or more ACEs when compared to those with none. As you can see, these patients with extensive trauma exposure  are, for example, three times more likely to smoke, seven times more likely to have an alcohol use disorder, 10 times more likely to use IV drugs,  and 30 times more likely to have had at least one suicide attempt, and so on. So when treating patients with these conditions, training people to treat these conditions,  and developing treatment programs for our patients, we need to prioritize a trauma-informed approach. Some of these things come naturally to many of us  or are integrated into certain therapeutic approaches, whereas others need to be more intentionally implemented.  The major components of trauma-informed care are relationship building, so creating safety for patients in any way possible and establishing rapport,  forming connections both in individual and group settings, fostering environments where these connections can be formed with safe boundaries, self-care.  This applies to clinicians and to patients. It's a widely used term, but the way I think about it  is the practice of taking action to preserve our own emotional and physical well-being. We need to both promote this among patients by providing opportunities  and teaching them, as well as modeling this behavior in our own lives so that we can be calm and present to foster these connections.  Peer-to-peer interactions are incredibly powerful when they happen in a safe environment. Our patients often need guidance and, again, modeling,  which sometimes means taking a strong stance on negative or unsafe behaviors when we observe them. This can often lead to difficult decisions in group treatment models  where one patient's behavior is compromising the safety of the milieu and or other patients. Handling this with skill and predictable boundaries is incredibly important  for fostering a trauma-informed approach. Teaching coping and emotional self-regulation, so often our patients do not have the skills they need  or do not believe that skills are effective. Treatments such as DBT, grounding, mindfulness, just to name a few, are incredibly useful as a primary or adjunct treatment approach.  Psychoeducation on the link between trauma, mental health, substance use disorders is incredibly important  and can help immensely to reduce the burden of shame and negative self-talk that is often present among patients with substance use disorders.  Motivational interviewing, as Ruben mentioned, can be very useful trauma-informed intervention as it helps patients to feel more empowered  and in control of their behavior and choices. So the next part of our case, you and M come to understand that M used opioids as a teenager  as a way to soothe distress related to abuse by her mother's boyfriend and recurrent opioid use now tends to follow conflict with or abuse by M's boyfriend.  M suggests, I think my real problem is PTSD. I'm self-medicating. If I can get out of this relationship and process all the awful things that have happened to me,  I won't have any problem staying sober. So the first question is how would you help M conceptualize the relationship between opioid use disorder and PTSD?  And a little additional information, M relays that she needs to discharge urgently. She does not disclose details,  but you suspect that her abusive relationship is influencing her decision to leave and impacting her ability to follow through with treatment recommendations.  How would you utilize a trauma-informed approach to best support M considering the key components? So if you guys want to discuss in your small groups for about five minutes  and we'll come back. Does anybody want to share their thoughts on responses to these two questions?  Go ahead, yeah.  Absolutely. That's a great point. Yes, absolutely. And it often happens, I think, with people with trauma where they get sober and things get a little worse, right?  They have actually more symptoms, which can be surprising for them. Yeah. Go ahead.  Your own distress as in the patient or yours? Yes, absolutely. I think both apply, though. That's what I was trying to get at. Yeah, so trying not to over-identify with control,  like swing all the way to the other end of the pendulum and identify this as the only problem. Anyone else have any thoughts? Yeah.  So getting her to recognize exactly what the distress is and applying some skills or education around that. Perfect, yeah. Anyone else? Go ahead.  Yeah, so often we have to have them come to a place of accepting that now they have this, too, right? It might have been started by something, but now this is there.  They have to deal with this as well. That's a really great point, yeah.  I like to describe trauma as like a wound, like you can't see it. So I kind of like act out like, okay, you have like a huge gap in your leg, and then it heals very poorly.  Like have you ever had a pain in your leg?  So over time, it's like all the time. But you have to be ready. Like your coping mechanism right now is heal me up. You have to give yourself some time to develop in other ways  because you're going to keep having arguments with your boyfriend and things are going to keep happening. You just take time to learn some other skills  because when you're ready to open up,  you're going to have to be ready to take the head on in terms of something else, not be able to deal with that. So you have to come across, but again,  take some time for us to be able to get to a point where we heal that. Yeah, so slowing people down from maybe from this over-identification of  this is the problem, this is going to be fixed, but then really setting expectations for reality of what that's going to be like. That's incredibly important, yes.  Anyone have anything else?  It's incredibly challenging. Yes, I  Think sometimes people need to grab on to something to get them started, but it is important to  Kind of be with them in the nonlinear journey because it's definitely ups and downs  Mm-hmm Great anyone have any last comment  You know, yes, let's do that  Absolutely That's a really important point because I think that is a huge step for her and oftentimes people are not at that step yet  Right, they're not like ready to leave or they haven't they're not even at the place to acknowledge it  That's something that we know and and we're watching them work through but yes, you're right This is that is a very big step getting to that's important  All right, I will turn it over to dr. Kim  All right, so final stretch the last case  So  Determining whether and when  individuals with addiction may be held criminally responsible for conduct that may be symptomatic of addiction is  Timely and relevant so this vignette explores whether an act considered symptomatic of addiction may be deemed involuntary and therefore  Exculpatory in the criminal law So before we dive in to the vignette I wanted to kind of go over the Anglo-American law and the general conceptual framework in a legal sense  so the Anglo-American criminal law presumes what's called a folk psychological view of  person and behavior and folk psychological view is also known as  commonsensical psychology in philosophy of mind Folk psychological theory states that mental states that form the intent  most fundamentally and causally explain human behavior  so for example of folk psychological  Explanation of why you may be here today is perhaps you desire to appreciate addiction more richly You believe that coming to this workshop  Would satisfy that desire and you form the intent to attend So consistent with that framework the US criminal laws criteria for  criminal responsibility are based on two things acts and mental states of the defendant both a  culpable mens rea guilty mind and actus reus the prohibited act are required both of them are required to establish criminal liability and the job of the  Prosecutor is to prove these two elements beyond the reasonable doubt to establish  criminal responsibility in a proceeding  So even if the prosecution succeeded however in proving the elements of a crime the criminal law  Provides for what's called affirmative defense to negate  responsibility in two important ways  justification and excuse  Justification is when a behavior that is otherwise unlawful is permissible under specific circumstances  So an example is if you're fighting back on assailant that is called self-defense  On the other hand excuses are when defendant has acted wrongly but is not held responsible for the conduct most commonly because the defendant lacked the  ability to appreciate the wrongfulness of their conduct and the legal term of art for such an excuse is called insanity and And  Addiction is commonly raised as basis for excusing or mitigating conditions So the question in criminal law context then becomes to what extent does addiction undermines one's  Cognitive capacity for appreciation of wrongfulness of one's behavior and one's volitional  Control over one's conduct now. I want to want to briefly go over the US Supreme Court guideposts They decided two important cases back in the 1960s about the issue of addiction  The one is called Robinson v. California. It's which is a 1960 case and the other ones probably Texas anybody familiar with these two cases  Okay, so out for the rest of us who has not heard of these cases I'll briefly go over what they decided so  In Robinson v. California the court was asked to decide then Whether there so there at the time the California statute had a law that criminalized someone for being an addict and  The court there was a man. Mr. Robinson who was stopped by the police and  He was arrested because he had needle marks and he was punished. He was basically prosecuted for having  addiction and he litigated and  The court was asked to decide whether that California law that criminalized someone for being an addict was corollary unusual punishment according to the constitutional law and  the court the Supreme Court held that the statute was indeed unconstitutional by six to three and  The majority opinion at the time reasoned that punishing someone for the status of having an addiction  Much like punishing someone for having a common cold or schizophrenia would be unconstitutional because no harmful act or actus reus was involved and  Then several years later court was then asked to decide on the case of mr.  Powell he's he was someone who we would consider in these days to have a severe alcohol use disorder and a track record of  repeatedly and chronically being drunk in the public and being disorderly and And  He was tried yet again for that same charge and he introduced expert witness testimony to assert that  citing the earlier Robins ruling That being drunk and disorderly in public was compulsive symptom flowing from his addiction that he had no control over  So in effect Powell was asking the court to create a constitutional defense  To for using addiction to negate criminal responsibility and for this case court was heavily divided ultimately the plurality of rejected  Powell's arguments narrowly by five to four and  they noted among other things that medical science at that time was insufficient to establish Powell's conduct as  compulsion symptomatic of disease and ever since no state or federal court has been willing to conclusively establish a Quote compulsion or  involuntariness defense by reason of addiction But is it time to change?  Given the explosion of neuroscientific evidence suggesting impaired voluntariness in individuals with addiction. Let's dive in to our vignette  So the case discussion  During a follow-up appointment and reports anxiety about an upcoming court date related to shoplifting charges  She says I've been thinking about how you said addiction is when you keep doing something and have trouble stopping  Even though you know, it's bad if my actions are because of my brain disease. Why am I being punished for something? I have no control  Can you write a letter to help me out with a judge? so the first question is how would you respond to a request to educate the court that addiction is a psychiatric illness and  Her implicit request to help mount an affirmative defense to negate her criminal responsibility  and Then there's a second piece After the hearing the judge places her on probation for which the condition is remaining drug-free. Now you guys know  Probably heard about the Eldred case. So this is loosely based on the Eldred v Commonwealth case  and Submitting to random drug screens 12 days after being placed on probation She tests positive for fentanyl same judge revokes her probation and sends her to prison  M challenges the constitutionality over incarceration for probation violation. She argues that  relapsing is a natural course of her addiction a  Brain disease and that it is cruel and unusual punishment to be blamed for a disease that rendered her incapable of remaining drug-free  Should a constitutional challenge to having probationary requirement of being drug-free Considering our conceptualization of self-control and addiction prevail  Why don't we take five minutes to discuss  All right, anybody want to volunteer any thoughts opinions  So, how about the first question  Anybody have thoughts? Yeah, sure. Sure  Oh, yes, I was preaching to the choir  Maximum felony  In other states it is a bill that creates a diversion supposition for mentally ill clients. Now drug abuse is, if the issue, drug abuse and PTSD, that's bread and butter.  That, you know, you can get people into diversion. But PTSD is specified in the statute in California.  So the key point is be realistic when you're taking a plea about what you are capable of. When you're talking with the patient, you know, like, don't set up a guarantee. Yes, sure.  And then for the second issue, there's no constitutional right to get by. You know, there probably should be, but...  This is America.  We don't know where it is, what state it is in. Yeah, I just kind of, yeah, I mean, the standard can be different for each state.  But let's just say based on the McNaughton state, say, yeah. Yes, exactly, exactly.  Let's just say it's the kind of common standard where the legal standard for insanity is cognitive ability to appreciate the wrongfulness.  But every state excludes due to intoxication. Yes.  Do you think that mandating an inpatient detox or residential partnership is a fair amount of shock? Ultimately, I like, you know, of course. I mean, this is a... This is a...  Yes. Yes. All right, so we are almost at the end, so I'm just going to conclude with a conclusory survey. Should we do it, or I feel like we should stick to time?  All right, we're going to skip that because it's time, and we want to respect your time. But we really appreciate all of your participation.  We kind of reviewed today how there are really, even among us, different ways of thinking about addiction. It really does matter.  It matters to whether patients accept life-saving medication. It matters to whether and how patients feel like they can overcome addictive behavior.  It matters to how we as a society treat people with addiction and to what extent we respond with punishment or care.  So we hope that you've, through the workshop, had a chance to reflect on your own beliefs  and can go into your roles caring for patients with sort of an intentional sense for kind of how all this fits together.  So we really appreciate it and hope you have a good rest of the conference.
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