Child Family Investigator Colorado Substance Abuse Substance Abuse

Child & Family Investigator Colorado Substance Abuse

Substance Abuse • CJD 04 -08 Standard 13 • CFIs no longer “routinely” conduct testing • Make recommendations to court for testing and/or evaluation if appropriate • Done by CFI only if sole issue of appointment, and if qualified

Substance Abuse An enormous problem • • More than one in 10 in US live with dependent or abusing parents • Profound effects on the children

Effects on Parenting The effects of Substance Abuse on Parenting • • Parent unavailable to child • Parent disappears • Parent wastes the resources of the family • Unstable housing, community and schools • Criminal activity, child endangerment • Child more likely to abuse

What the Child experiences • Broken promises • Inconsistency and unpredictability • Shame and humiliation • Tension and fear • Paralyzing guilt and an unwarranted sense of responsibility • Anger and hurt • Loneliness and isolation • Lying as a way of life • Feeling Responsible and obligated

CHARACTERISTICS OF AN ADDICTION n n n n DENIAL IMPULSIVITY-SENSE OF IMMEDIACY COMPULSION TO USE LOSS OF CONTROL TOLERANCE WITHDRAWAL OF USE (OR BEHAVIOR) LEADS TO DISCOMFORT PROGRESSION OVER TIME

OTHER ADDICTIONS: It’s not just about drugs n n n Internet Pornography Sexual Gambling Shopping “Positive” Addictions (i. e. exercise)

UNDERSTANDING SUBSTANCE ABUSE AND DEPENDENCE: n n DSM IV DIAGNOSIS CONTINUUM OF USE MODEL -NO USE/NON-PROBLEM, SOCIAL/RECREATIONAL USE, MISUSE, EPISODIC ABUSE, DEPENDENCE n n n CO-OCCURRING M. H. DISORDERS AND S. A. DISORDERS DEFENSE MECHANISMS IMPACT ON COGNITIVE, PSYCH. & SOCIAL SYSTEMS

CONTINUUM OF USE MODEL n n n n Social/Recreational Heavy Drinking/Problem Drinker Misuse Sustained vs. Periodic Use Abuse (Heavy Episodic Binging-5+ drinks) Dependence (Psychological/Physiological) Addiction/Addictive Behaviors

ADDICTION AS AN ATTACHMENT DISORDER n A DISORDER IN SELF-REGULATION n DYSFUNCTIONAL ATTACHMENT STYLES n n PADS VS. DAPS (PEOPLE ARE DRUG SUBSTITUTES vs. DRUGS ARE PEOPLE SUBSTITUTES) THOSE DEPENDENT ON ADDICTIVE SUBSTANCES n CANNOT REGULATE THEIR EMOTIONS, HAVE PROBLEMS WITH SELF-CARE, SELF-ESTEEM AND INTERPERSONAL RELATIONSHIPS

THE POPULATION n n n PRE/POST DIVORCE – USUALLY HIGH CONFLICT OVERREACTION AROUND SUBSTANCE ABUSE/ DEPENDENCE TENDENCY FOR ONE PARTY TO EMBELLISH AND THE OTHER TO MINIMIZE OFTEN DUAL-DIAGNOSIS ISSUES, TRAUMA… THERE MAY BE CRIMINAL AND CIVIL LEGAL ISSUES AT STAKE GENERALLY, THIS IS A RESISTIVE POPULATION

GOALS OF A SUBSTANCE USE EVALUATION n n To understand the role that a substance plays in a person’s life/level of involvement with the substance To determine how the substance use impacts the person’s functioning n n n Cognitive: executive functioning, judgment, decisionmaking, tracking/monitoring, problem solving, memory, Psychological: mood, feelings, emotional regulation Social/Legal/Occupational Medical/Physical To offer recommendations that can be implemented into a parenting plan To provide a piece of the puzzle for a larger evaluation

THE TRUTH IS RARELY PURE AND NEVER SIMPLE OSCAR WILDE

COMPONENTS OF A GOOD EVALUATION n n n Overview of the Assessment Process Developing rapport during the evaluation to reduce defensiveness and anxiety Use of Assessment Tools n n Brief Mental Status/Cognitive Screening Instruments (AUI, SASSI-3, SUDDS-IV) Drug Testing/Monitoring History n n n Family of Origin: Hx of M. H. , S. A. , Trauma, Abuse. . Relationship History Substance Use: Current and Past

COMPONENTS OF A GOOD EVALUATION n n Use of Collateral Sources: spouse, family members, custody evaluator, psychotherapists, treatment programs, family doctors, criminal records/motor vehicle records/COPDMP Assessment of Motivation n Presentation/Demeanor n Stages of Change Interpretation/Integration - Cross-checking data - Preponderance/concurrence of evidence Report/Recommendations

WHAT GETS US INTO TROUBLE IS NOT WHAT WE DON’T KNOW, IT’S WHAT WE KNOW FOR SURE THAT JUST AINT SO! MARK TWAIN

KEY CONSIDERATIONS n n Is the concern a current problem (within the past 12 months)? How much of a factor is the stress of the divorce? Has use occurred during parenting time/Does use impact parenting? Documented history vs. “He said, She said”?

KEY CONSIDERATIONS n n Past substance use and mental health treatment history/records? Is concern based on single or multiple episodes? Meaning of allegations in the context of the divorce dynamics. Are there concerns about the credibility of the accuser/allegations?

IMPLICATIONS FOR PARENTING PLANS n n Overall concern is keeping children safe Do there need to be restrictions on parenting time? Do the parents need treatment? Do children and/or other family members need treatment or support?

IMPLICATIONS FOR PARENTING PLANS n n n Is limited substance use OK? What defines relapse/How to respond? Is monitoring necessary?

IMPLICATIONS FOR PARENTING PLANS: n n MONITORING STRATEGIES What Tests to Use: n n n n Breath/Saliva testing Urine testing Blood testing Hair testing Transdermal (Sweat) Frequency of Testing: Random or Fixed Duration of Testing Response to Missed, Dilute or Positive Tests

Recommendations and Treatment Resources n n n Self-management (no use at times prior to parenting time) Drug Testing/Monitored Antabuse AA, CA, NA, Life. Ring Individual, family or group counseling Intensive Outpatient Program or Inpatient Tx Psychiatric Referral for consultation/medication

DSM-IV criteria Substance dependence • • Tolerance of the substance • Withdrawal • More amounts, no efforts to control • Time and resources spent obtaining substance • Outside activities fall away • Continued use in spite of significant problems

DSM-IV criteria Substance abuse • • • Failure to fulfill major obligations • Physically dangerous situations • Related legal problems • Persistent or recurrent social or interpersonal problems A person is either dependent or abusing a particular substance, not both at the same time

American Psychiatric Association DSM-5 Development Proposed Revision Substance-Use Disorder: n n A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12 -month period: recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e. g. , repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) recurrent substance use in situations in which it is physically hazardous (e. g. , driving an automobile or operating a machine when impaired by substance use) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e. g. , arguments with spouse about consequences of intoxication, physical fights)

American Psychiatric Association DSM-5 Development Proposed Revision n tolerance, as defined by either of the following: a. a need for markedly increased amounts of the substance to achieve intoxication or desired effect b. markedly diminished effect with continued use of the same amount of the substance (Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers. ) n n n withdrawal, as manifested by either of the following: a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances) b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms (Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers. )

American Psychiatric Association DSM-5 Development Proposed Revision • amounts or over a longer period than was intended • a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects • important social, occupational, or recreational activities are given up or reduced because of substance use • the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance • Craving or a strong desire or urge to use a specific substance

American Psychiatric Association DSM-5 Development Proposed Revision Severity specifiers: n n n Moderate: 2 -3 criteria positive Severe: 4 or more criteria positive Specify if: With Physiological Dependence: evidence of tolerance or withdrawal (i. e. , either Item 4 or 5 is present) Without Physiological Dependence: no evidence of tolerance or withdrawal (i. e. , neither Item 4 nor 5 is present)

Relapse • Now recognized to be standard piece of the road to recovery • How will this affect your recommendations? • How can safety be provided for the child?

A Brain Disorder Mesolimbic dopamine system • • • Pleasure pathway • Creates attachment • Drug use is self-medication Behavioral extremes

DBT: Dialectical Behavior Therapy

OVERVIEW: • DRUG AND ALCOHOL CATEGORIES AND TOXICOLOGY • BASICS OF AVAILABLE DRUG TESTING, SCREENS AND CONFIRMATION TESTS • NEW TECHNOLOGIES • MONITORING STRATEGIES - daily, fixed, periodic or random oral/saliva/breath/blood/urine/hair/patc h

Substances of Abuse • • Alcohol • Amphetamines/Meth/Ecstasy Barbiturates • Benzodiazepines Cannabis • Cocaine Hallucinogens • Opiates Prescription Medications Anabolic Steroids Designer Drugs (incense, synthetic THC)

TOXICOLOGY: n n n Oral Fluids/Saliva (Strips, Swabs) Breath (Balloons, Tubes, Breathalyzers, Sobrietor, In. Home, Soberlink, Smart Start) Blood (MD authorized lab. procedures) Urine (Screens/Chemical or IA, GC/MS, LC/MS/MS) Hair (Head, Axillary, Body) Transdermal (Patch, SCRAM)

Parent Drug vs Metabolites Alcohol (Ethanol) -Ethyl Glucuronide (Et. G) -Ethyl Sulfate (Et. S) • Cocaine -Benzoylecgonine -Cocaethylene -Norcocaine • Marijuana (THC) -Cannabinoids 50 n

Testing Limitations/Problems: n Chain of Custody/Forensic Collection Process n Time Limitations & Elimination Rates n n Errors and Fallibilities (Immunoassay/Chemical assay vs Gas Chromatography/Liquid Chromatography/Mass Spectometry) Analysis/Interpretation of Tests (Negatives, False Negatives, Detection Levels)

Chain of Custody and Forensic Collection Process: Is the testing site licensed, with certified staff (CLIA) that follow Federally Mandated SAMHSA Guidelines, Procedures and Detection/Cutoff Levels? • Do they follow Federal DOT Chain of Custody Guidelines: -Driver License Identification -Same gender observation for UA’s -Labelling/Sealing of Specimen -Transportation and Testing Procedures n

Elimination Rates n Alcohol- 0. 6 -1. 0 drinks per hour n n n Metabolites Et. G and Et. S up to 80 -84 hours Amphetamines-1 to 3 days Methamphetamines-3 to 5 days Methylenedioxy-methamphetamine (MDMAEcstasy)-3 to 4 days Barbiturates-1 to 3 days (Phenobarbitol L. A. up to 2 -3 weeks) Benzodiazepines-range from 2 to 7 days and with long term use up to 4 -6 weeks

Elimination Rates • Cocaine (metabolite-Benzoylecgonine)-1 to 2 days and up to 5 days with serious abuse • Opiates (Heroin, Codeine, Morphine, Oxycodone, Oxycontin, Hydromorphone)-1 to 3 days Methadone-1 to 3 days • Marijuana/Cannabis (THC)-varies significantly with quality, amount/frequency of use, activity level (and stores in lipid tissue): -Occasional User-3 to 10 days -Recreational/Social User- 5 to 10 days -Daily/Chronic User-30 to 45 days • Phencyclidine (PCP)-usually 1 to 2 days (up to 7 to 14 days)

Errors, Screening and Confirmation Tests n Immunoassay or Chemical Assay Screens n n False positive error rate of 1/200 to 1/400 Large cross reactivity with other substances and other drugs • Gas Chromatography/Mass Spectometry (GC/MS) Confirmation Test (to identify and quantify at a higher level) • Liquid Chromatography/Mass Spectometry (LC/MS/MS) is the platinum standard in testing

Analysis and Interpretation of Tests n Negative Result does not equal no use! -the use can be under the detection or cutoff level (for IA, GC/MS, or LC/MS/MS) for screens or confirmation tests (for saliva, breath, urine, blood, hair, transdermal, etc. ) • If Positive Result for GC/MS or LC/MS/MS for UA or Hair tests it’s Positive

Oral Fluids/Saliva Toxicology Screens n Alcohol and Drug Screens are available Rapid Screening Devices that are inexpensive and can screen for most substances n More sensitive to recent oral/nasal use of substances and is present before showing up in the urine n More false negatives (can dilute/cleanse oral cavity) - False positives from alcohol in mouthwash, Nyquil, cold medicines, etc. n

Saliva Toxicology (Cont. ) Alcohol Qtip Swab Saliva Screens n can screen up to. 15 BAL; thermometer like (expensive- 10 for $130. 00) n Alcohol Screen Saliva Test Strips-at. 02 BAL; change color (inexpensive-24 for $66. 00) n Breath. Scan Alcohol Screening Test-at. 02 BAL; squeeze and break center and then blow into tube and then changes color (inexpensive-25 for $68. 75) • Oral Fluid Drug Screen Device-tests for Alcohol, THC, Cocaine, Opiates, Meth & Amphetamines, Benzodiazepines (inexpensive-25 tests for $375. 00) n

Breath Toxicology n Breath Sensors/Breathalyzers for Alcohol blow into straw or tube n can read BAL that is time/date stamped and can be scrolled up and down and store 500 -600 readings n easy to use and portable n reliable and inexpensive to purchase or lease • Sobrietor for Alcohol; telephone modem based breathalyzer through BI, Inc. - reliable and inexpensive also n

Urine Toxicology Screens and Confirmation Tests for most substances of abuse n n n Usually 5 or 7 panel tests (7 panel adds Benzodiazepines and Barbs) + Creatinine Level for dilution Can include Et. G and Et. S tests Can include Anabolic Steroids testing (as in hair & blood testing) Can request to test for other substances GC/MS and LC/MS/MS very reliable Negative results can mean under detection or cutoff level

Urine Toxicology (Cont. ) • Specimen Validity Tests n Creatinine Level n Basic Adulteration Tests n for odor, color, physical characteristics like temperature and or abnormal instrument response • Masking Attempts with Detox Teas, Golden Seal Tea, Lavage, and other agents (bleach, drano, etc. ) • Substitution with clean urine, Wizonators, plastic bags and tubes Whizzinator (Priceless!) comes complete with fake penis, dried synthetic or clean urine, chemical heater packs, thermometer)

Urine Toxicology (Cont. ) • False Positives related to Diabetes for alcohol testing and urinary tract and bacterial infections for Et. G testing • Et. S testing not effected by Diabetes, urinary tract and bacterial infections n 5 or 7 panel-lab test from $15 -30. 00 n Et. G and/or Et. S tests from $35 -65. 00 n LC/MS/MS tests slightly higher than GC/MS n (www. etg. weebly. com for Dr. Skipper’s informationn Replaces www. ethylglucuronide. com site)

Hair Tests Very reliable-if positive, no false positives n Increased window of detection to 90 days n Deterrent to drug use n Cocaine metabolites detected up to 3 months n False Negatives for Et. G/Alcohol-bleaching/dyeing hair/shampoo kits n Does not capture recent drug use of last 1 1/2 to 2 weeks n Suggest periodic tests every 10 weeks to not have lacunae or gaps in testing • Urine Toxicology Screens and Tests for two weeks prior to initial hair test if possible • Usually head hair sample will be 1 1/2 inches long and pencil diameter in thickness (150 -200 strands) n

Hair Testing (Cont. ) Axillary (armpit) or Body hair testing can detect prior drug use up to 1 year n Usually 5 or 7 panel test n Cost from $70 -150. 00 • Limitations: n Cannot test for Alcohol n Cutoff levels may not capture occasional or infrequent use n Darker hair more susceptible to picking up drug use n

Transdermal Toxicology-Patch Screening n Fairly Reliable Increased window of detection to 7 days Deterrent to drug use No sample dilution or substitution Parent drug and metabolites-no alcohol testing n Unknown sensitivity and specificity to environmental n n exposure or pre-existing drug contaminants on skin • Cost approximately $36. 00 (Alco. Pro or Pharm. Chek or pharmchem. com at 817. 590. 2537(or 0571)

SCRAM-SECURE CONTINUOUS RANDOM ALCOHOL MONITORING n n n Transdermal alcohol detection via ankle monitor that is downloaded by landline telephone modem for readout to service center or downloaded twice weekly at service center. Positives lead to Et. G testing for confirmation. 24/7 detection window-Cost is approximately $13 -14. 00 daily (Rocky Mountain Offenders Management, 8787 Turnpike Dr. , Westminster, 303. 443. 4277) Sleep. Time Monitoring • • • 24/7 Alcohol and Other Drug Abuse Monitoring System Wrist actigraphy monitor, FDA cleared medical device used for sleep studies, detects erratic sleep patterns that are reliable indicators of alcohol and drug abuse and recommends Et. G and other urine testing to verify episodes of apparent substance abuse Downloaded on Monday and Thursdays; Cost $3. 50/day + $39. 00 per + drug test (ICCS, 1651 Kendall, Lakewood, 303. 232. 4002)

IMPLICATIONS FOR PARENTING PLANS n n Overall concern is keeping children safe Do there need to be restrictions on parenting time? Do the parents need treatment? Do children and/or other family members need treatment or support?

What Tests to Use: - Oral Fluids/Saliva testing Breath testing n Urine testing n Blood testing (Prescription Drugs) and Alcohol. Phosphatidylethanol-Peth) n Hair testing n Transdermal (Sweat)Patch n SCRAM (Secure Continuous Random Alcohol Monitoring) n Sleep. Time Frequency of Testing: Daily, Fixed, Periodic, Random Duration of Testing Response to Missed, Dilute or Positive Tests n

Recommendations and Treatment Resources Self-management (no use at times prior to parenting time) Drug and Alcohol Screens, Testing and Monitoring Use of Medications ( Monitored Antabuse (Disulfiram) and Acomprosate (Campral), Vivitrol and Naltrexone, Suboxone AA, CA, NA, Life. Ring Individual, family or group counseling Intensive Outpatient Program or Inpatient Tx Psychiatric Referral for consultation/psych. medications

QUESTIONS AND DISCUSSION: Toxicology Web Links: www. norchemlab. com www. omegalabs. net www. questdiagnostics. com www. redwoodtoxicology. com www. usdrugtestinglab. com

MEDICAL MARIJUANA ISSUES n n n Marijuana is illegal under federal law Regulation of the industry is on-going and evolving Medical marijuana is a political, legal, health and moral issue Do people really qualify or do they just want to get high? Should drug abuse be treated as a health issue, a legal issue, a moral issue or all?

MEDICAL MARIJUANA ISSUES • What or has anything changed in assessing cannabis use with medical marijuana recommendations? • Right to use in Colorado but not a Right to be Impaired when parenting children! n n Dosing Issues (Smoking, Vaporizers, Edibles, Tinctures, Oils) Right to Use vs. Impact on Personality Functioning (Impact on Parenting Capacity) n Research-What we know about impact on Executive Functioning/Motor Skills n Marijuana and Tolerance and Adaptation to use?

MEDICAL MARIJUANA ISSUES • Previous History of Cannabis Use/Abuse/Dependence? Prior to Card? • Environmental Concerns, Exposure of Children to smoke (clothes/backpacks), cannabis and edibles unlocked at home (infants/toddlers/pre-schoolers) • Impact on Emotional and Behavioral Attunement of Parents with children (Ability of Parent to regulate emotions and reflect on child? ) • Aspirational aspects of having parents not use 12 hours or longer or during parenting time; Window of Detection Issues (Can this be enforced or monitored? ) • Can we regulate prescriptions? (No control over their dosing)

MEDICAL MARIJUANA ISSUES n Is there a documented history of debilitating disorders? n Is using medicinal cannabis the best practices for the medical issue? n How is assessment the same or different for pain medications and medical marijuana? • When should a pain specialist be used for pain assessment or when to use an IME (Independent Medical Evaluation)? • Medical Marijuana and CPS (neglect and abuse? ) • Medical Marijuana Use and DUID’s (Children in vehicle) How do we safeguard children from parents that use cannabis regularly? Can we? •