Substance Use Disorders
Mason Turner, MD
Assistant Director
Regional Mental Health and Chemical Dependency Services
Chief, Department of Psychiatry, San Francisco Medical Center
Kaiser Permanente Northern California
No Financial Disclosures
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Alcohol and Drugs: Use or Abuse?
Objectives
 Delineate the scope of the problem of drug and
alcohol misuse
 Understand how personality type affects
propensity to abuse substances
 Present the spectrum of problem substance use
 Describe ways of detecting problematic
substance use in others
 Discuss what to do when you suspect a friend,
family member, colleague or yourself, is
misusing substances
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“This is a disease that tells you that you
don’t have it. It’s the only disease I know
that argues with you and says, ‘Look,
despite all the evidence, you don’t have
a problem’”
JD, age 64
from Coombs, R. Drug-Impaired Professionals. 1997.
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“I didn’t think it could happen to me because
I’m too smart and I have all this knowledge.
I’m unique, a doctor, a cut or two above the
average citizen. When I found out I was
addicted, I was devastated. It sneaked up
on me and had me by the throat before I
even had an inkling.”
MD, age 50
from Coombs, R. Drug-Impaired Professionals. 1997.
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The Scope of the Problem
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The Scope of the Problem: Alcohol
 140 million individuals in the United States use alcohol
each year.
 In 2009, the alcohol beverage sales economy topped
almost $400 billion (includes liquor sales, wages, and
other economic contributors). Direct sales of spirits
account for $20 billion per year. Both grow by about 4%
per year. (Distilled Spirits Council of the United States)
 Premium spirits are among the fastest growing segments
of the alcohol beverage economy.
 Spending on alcohol actually goes up during times of
economic distress. The “Liquor, Cigarette and Prostitute”
hypothesis.
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The Scope of the Problem: Alcohol
 Although estimates vary, about 10% of
people who use alcohol will develop
“problem” drinking at some point in their
lives.
 While ethnic variation in ability to
metabolize alcohol exists, rates of alcohol
dependence do not vary by ethnicity.
 Men are over five times as likely as
women to develop problematic drinking
behaviors.
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The Scope of the Problem: Alcohol
 Alcohol is a ubiquitous aspect of the social and
occupational environment.
 Binge drinking is also problematic, with recent
data demonstrating that almost 15% of
individuals in the U.S. report having had 5+
drinks in one sitting in the last month.
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The Scope of the Problem: Drugs
 Reliable statistics for drug use
are not available; however,
some studies demonstrate that
as many as 30-40% of
individuals in the U.S. have used
an illicit substance at least once.
Up to 80% of 12th graders in
some studies report one time
use, so this number is set to
increase dramatically.
 Rates of abuse and dependence
are high, ranging from 10-25%
of all individuals who use,
depending on the substance
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The Scope of the Problem: Nicotine
 Nicotine remains a significant drug of abuse,
with reports of as many as 60 million individuals
in the U.S. who smoke regularly.
 Except among certain populations (mentally ill
among them), rates of smoking are decreasing.
 Nicotine is thought to be nearly twice as
addictive as heroin. Almost half of all individuals
who ever try just one cigarette will become
dependent on nicotine.
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The Scope of the Problem:
The Workplace
Acute effects of alcohol and drug use include:
 Euphoria and feeling of invincibility
 Delayed reaction time
 Decreased memory function
 Diminishing social “filters” and poor
interpersonal functioning (direct frontal lobe
effect)
 Unreliability
 Activity in the areas of the brain that control
reasoning and judgment is reduced. Rational
thought is limited.
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The Scope of the Problem:
The Workplace
Service professionals,
such as attorneys and
physicians, use and
abuse substances
and experience
mental illness at
greater rates than the
general population.
WHY???
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The Scope of the Problem:
The Workplace
 Almost 20% of attorneys will develop a
substance use disorder in their lifetimes, twice
as high as the general population
 Approximately one-third of attorneys are
dissatisfied with their career and would choose
another profession if they could;
 Suicide is the third leading cause of death for
attorneys after cancer and heart disease;
 Over half of lawyers experience stress at higher
levels than the population
Lauren Thibodeaux, personal communication 12/12/2011
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The Scope of the Problem:
The Workplace
 Financial pressure: Personal and institutional
 High expectations
 Competitive work environments
 Need for constant “performance” to clients, judges, other
attorneys
 Long work hours
All of which leads to….
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STRESS!!!
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The Spectrum of Substance Use
Diagnostic and functional terms exist across all
substances, including nicotine and caffeine:
– Use
– Misuse
– Abuse
– Dependence
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The Spectrum: Substance Use
 “Casual” or “Social” use
 Frequency not important
 Consequences do not occur
 May progress to abuse
 Can occur for alcohol as well as drugs
 Misuse involves using substances for inappropriate reasons
(i.e., drinking to relieve tension).
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The Spectrum: Substance Abuse
As a direct result of substance use, one or more serious
consequences occur:
– Legal
– Occupational/Educational
– Social
– Relational
Substance use continues in spite of these
consequences.
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The Spectrum: Substance Abuse
 No signs of physical tolerance or withdrawal
present
 Insight is usually impaired
 Frequently progresses to dependence
 Controlled use is possible, frequently outside of
the context of a treatment program
 Difficult for clinicians to address
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The Spectrum:
Substance Dependence
Features of abuse are present and are
combined with the following:
 Uncontrolled use, in spite of frequent
efforts to stop
 Physical tolerance or withdrawal are
frequently, but not necessarily, present
 Use continues in spite of insight that
substances are causing the problems.
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The Spectrum:
Substance Dependence
 Abstinence is widely recognized as the most
appropriate goal, but is it?
 Most treatment programs target the dependent
population, rather than substance abusing
individuals.
 Harm reduction remains a viable treatment
recommendation.
 All treatment options have proven efficacy
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Warning Signs: Recognizing Problem
Substance Use
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Warning Signs:
Safe Alcohol Use
How much can one drink over his or her lifetime
and have no greater chance of developing
medical, psychological, or legal problems that
are related to alcohol use than the baseline
population who doesn’t drink?
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Warning Signs:
Safe Alcohol Use
Safe Drinking Guidelines: Men
 2 alcohol equivalents per day OR
 4 alcohol equivalents, once per week, in one
sitting
 Approximately 10-14 drinks per week
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Warning Signs:
Safe Alcohol Use
Safe Drinking Guidelines: Women
 1 alcohol equivalent per day OR
 2 alcohol equivalents, once per week, in one sitting
 Approximately 7 drinks per week
Women do not metabolize alcohol as efficiently as men,
and cannot safely drink as much.
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Warning Signs:
Safe Alcohol Use
Alcohol Equivalents
 1.5 ounces of spirits (10 drinks
per pint)
 12 ounces of beer
 6 ounces of wine (4-5 glasses
per bottle)
REMEMBER TO MEASURE!!
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Warning Signs:
Safe Drug Use
 Prescription drugs only (and only according to
doctor’s orders)
 A great deal of controversy exists regarding “safe”
use of illicit substances, but in reality, this probably
can (and does) occur in limited situations
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Warning Signs: Recognizing Problem
Substance Use
Spheres of Influence:
 Individual/Personal
 Family/Families of Choice
 Friends/Community
 Workplace/Professional
These are guidelines only, and should be taken in
the total context. Seek professional advice early
and often!
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Warning Signs: Individual/Personal
 Deteriorating personal hygiene and grooming
 Multiple physical complaints
 Frequent emergency room visits
 Frequent accidents and hospitalizations
 Personality and behavioral changes
 Inappropriate physical symptoms, such as tremors and /
or sweating
 Emotional crises
 Irritable and short-tempered behavior
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Warning Signs
Family/Families of Choice
 Problem behavior is
excused, rather than
challenged and corrected
 Drinking activities are a
priority
 Fights, arguments and
violent outbursts are
frequent.
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Warning Signs
Family/Families of Choice
 Fragmentation of family systems
 Abnormal, illegal, and antisocial actions,
including child neglect and abuse
 Financial crises
 Sexual problems: Impotence and low
libido
 Extramarital affairs
 Separation or divorce
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Warning Signs: Friends/Community
 Personal isolation
 Embarrassing and inappropriate behavior
 Legal problems and criminal behavior
 Neglect of social commitments
 Unpredictable and erratic behavior, such as
inappropriate spending
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Warning Signs: Workplace/Professional
Work Environment and Comportment
 Excessive work habits (i.e., a Type A Workaholic),
a frequent cause of problem substance use
 Disorganized schedule
 Prolonged lunch breaks
 Decreased workload and tolerance
 Frequent office absences, including frequent use
of sick leave , i.e., “Monday morning flu”
 Frequent tardiness to client appointments and staff
meetings
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Warning Signs: Workplace/Professional
Interpersonal Interactions
 Unreasonable expectations of others
 Unpredictable, changing or inappropriate
behavior.
 Inaccessibility to clients and staff
 Frequent complaints by clients and staff
regarding behavior or work performance
 Heavy drinking and intoxication at staff
functions
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Warning Signs: Workplace/Professional
Other Professional Warning Signs
 Frequent job changes or relocation
 Unusual medical history
 Vague letters of reference
 Frequent lying
 Misrepresentation of qualifications to clients or staff
 Increasing or excessive malpractice incidence or
disciplinary actions
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Help Is Available!
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Responding to a Problem
Developmental Perspectives:
Stages of Change
 Pre-contemplative
 Contemplative
 Preparation
 Action
 Recovery
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Responding to a Problem
Recognition of your Role
 Spouse/Partner
 Friend
 Colleague
 Supervisor/Manager
 Patient
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Responding to a Problem: General
 Express concern and empathy
 Use concrete observations
 “I feel” is better than “You make me feel.”
 Confrontation is rarely useful, but
occasionally necessary
 For substance abuse, insight-oriented
discussions are important
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Responding to a Problem:
Spouse/Partner
 Avoid enabling behavior and co-dependency.
 A pound of prevention is worth an ounce of cure.
Know your limits and address issues before you
reach them.
 Al-Anon and CODA are important acronyms.
 Protect your family and yourself above all
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Responding to a Problem: Friend
 Use honest and open
communication
 Enlist support from
spouses and
partners, i.e.,
interventions
 Discuss personal
experiences with
addiction if relevant
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Responding to a Problem: Colleague
 To the extent possible, respond as a friend and not a
colleague, using personal, not professional, influence
 Performance issues should be directed to the individual’s
supervisor or manager, and not to that person directly
(with some caveats)
 Respond only with factual information or concerns.
 Avoid gossip
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Responding to a Problem:
Supervisor/Manager
 Use concrete, specific performance issues to guide
discussions.
 Limit identification of specific employees who have
expressed concerns, if applicable
 Utilize the Employee Assistance Program
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Responding to a Problem:
Supervisor/Manager
 Resist overextension of your role. Details of medical
treatment are not appropriate for discussion.
 Create an action plan for performance improvement and
hold the individual to it.
 Utilize human resources and legal resources for
consultation and for legal protection/information.
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Responding to a Problem: Patient
 Don’t be afraid! Help is available!
 Listen to those who express their concerns
(professional treatment groups are a must).
 Seek professional advice and consultation ASAP.
 Realize that alcohol and drug use can progress.
Today’s use is tomorrow’s dependence
 Respond to the concerns of others, while realizing
that your health and well being is your responsibility
and your primary goal.
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Responding to a Problem:
Resources
 Self assessment tests
 Alcoholics Anonymous www.aa.org
 Life Ring www.lifering.com
 Al-Anon www.alanon.alateen.org
 Substance Abuse and Mental Health
Services Administration www.samhsa.gov
 Your personal care providers
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