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Responsibility for Addiction among Physicians with Addictive Disorders FSPHP Annual Meeting, Ft. Worth, Texas, April 25

Responsibility for Addiction among Physicians with Addictive Disorders FSPHP Annual Meeting, Ft. Worth, Texas, April 25, 2012 . Michael H. Gendel MD Medical Director Emeritus Colorado Physician Health Program. © Colorado Physician Health Program 2012 All Rights Reserved

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Responsibility for Addiction among Physicians with Addictive Disorders FSPHP Annual Meeting, Ft. Worth, Texas, April 25

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  1. Responsibility for Addiction among Physicians with Addictive DisordersFSPHP Annual Meeting, Ft. Worth, Texas, April 25, 2012 Michael H. Gendel MD Medical Director Emeritus Colorado Physician Health Program © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  2. FSPHP Presenter Disclosure Slide “Responsibility for Addiction among Physicians with Addictive Disorders” Michael H. Gendel MD has Nothing To Disclose FSPHP Annual Conference and Meeting Fort Worth, Texas April 23-26, 2012 © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  3. Inquiry • The relationship between neuroscience of behavior and volition and the responsibility persons have for their addictive illness and behavior related to it • The differences in language regarding responsibility: neuroscience/neuroscientists, the law, 12-step concepts, and those who treat addiction – and resulting confusion © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  4. Areas of Law to be Considered • Criminal law • Civil/disability law • Regulatory law © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  5. “Brain Disease” • Current emphasis on addiction as a brain disease • Alan Leshner: “That addiction is tied to changes in brain structure and function is what makes it, fundamentally, a brain disease. A metaphorical switch in the brain seems to be thrown as a result of prolonged drug use. Initially, drug use is a voluntary behavior, but when that switch is thrown, the individual moves into the state of addiction, characterized by compulsive drugs seeking and use.” [Science 278:45-7, 1997] © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  6. “Brain Disease” • O’Brian and McLellan: At some point after continued repetition of voluntary drug-taking, the drug ‘user’ loses the voluntary ability to control its use. At that point, the ‘drug misuser’ becomes ‘drug addicted’ and there is a compulsive, often overwhelming involuntary aspect to continuing drug use and to relapse after a period of abstinence [Lancet 347:237, 1996] © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  7. Volition - Voluntariness • Notice the choice of words. Drug use begins as “voluntary” but after the addictive process is initiated drug use becomes something else – Compulsive? Involuntary? • What is the difference between a behavior that is voluntary versus compulsive? • What does “voluntariness” have to do with responsibility? © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  8. Pathology of Motivation and Choice • “A primary behavioral pathology in drug addictionis the overpowering motivational strength and decreased abilityto control the desire to obtain drugs.” • “Pathophysiological plasticity in excitatory transmission reducesthe capacity of the prefrontal cortex to initiate behaviorsin response to biological rewards and to provide executive controlover drug seeking. Simultaneously, the prefrontal cortex ishyper responsive to stimuli predicting drug availability, resultingin supraphysiologicalglutamatergic drive in the nucleus accumbens,where excitatory synapses have a reduced capacity to regulateneurotransmission.” [Kalivas, Volkow, Am J Psychiatry 162:1403-1413, August 2005] © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  9. Pathology of Motivation and Choice • Cellular adaptations in prefrontalglutaminergic innervation of the accumbens promote the compulsivecharacter of drug seeking in addicts by decreasing the valueof natural rewards, diminishing cognitive control (choice),and enhancing glutaminergic drive in response to drug-associatedstimuli.[Kalivas, Volkow. Am J Psychiatry 162:1403-1413, August 2005] © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  10. Addiction Neurobiology Amygdala PFC Glut NA DA VTA © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  11. Addiction Neurobiology • Ventral tegmental area (VTA) and nucleus accumbens (NA): Dopaminergic connections to other brain regions alerting the organism to novel emotionally relevant events (salient stimuli) and to the pending appearance of them. • Reward pathways: “Rewarding” – but sense of pleasure not necessary © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  12. Addiction Neurobiology • Prefrontal cortex (PFC), especially the anterior cingulate gyrus (AC) and orbital prefrontal cortex (OPC): Areas of the brain recruited by emotionally relevant events (ERE) and predictors of them (dopamine mediated) • Involved in the evaluation of salience of the stimuli and the choice of behavioral response and it’s intensity (glutamate mediated). © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  13. Addiction Neurobiology • Amygdala: Associates emotionally relevant events to otherwise neutral stimuli that predict the event (largely gluatamate mediated) and involved in fear-mediated behavior © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  14. Addiction Neurobiology • “Extended amygdala” – Koob[Neuropsycholopharmacology 24(2): 97-129, 2001] central nucleus of the amygdala, bed nucleus of the striaterminalis, posterior shell of the nucleus accumbens. Core circuitry in state of allostasis. • Koob also describes the recruitment of brain and hormonal stress systems in the allostasis • Not addressed here because of its complexity and my focus on issues that relate to voluntariness

  15. Addiction Neurobiology[Am J Psychiatry 162:1403-1413, August 2005] “Theglutamatergic projection from the prefrontal cortex to the accumbensis a final common pathway for eliciting drug seeking. This anatomicallocus of pathology is consistent with behavioral dysregulationin addiction, since the prefrontal-accumbens projection is creditedwith providing the properties of motivational salience and directionto normal goal-directed behavior.” © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  16. Craving and Neurobiology • Complex concept and measurement • Confused with concept of “desire” and “avoidance of temptation“ in literature on voluntariness and responsibility for addiction © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  17. Personality • Lack of empirical data for “addictive personality”. • E.g., Vaillant’s prospective work • Novelty seeking and risk taking – generally consistent findings of personality dimension in those with addictions • These personality traits are heritable © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  18. Addiction Neurobiology[Am J Psychiatry 162:1403-1413, August 2005] “End-stage addiction, which is characterized by an overwhelmingdesire to obtain the drug, a diminished ability to control drugseeking, and reduced pleasure from biological rewards.” © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  19. Addiction Neurobiology • Thesefindings combined with functional imaging studies in addictsreveal a situation whereby prefrontal regulation of behavioris reduced in basal conditions, thereby contributing to thereduced salience of nondrug motivational stimuli and reduceddecision-making ability. [Kalivas, Volkow. Am J Psychiatry 162:1403-1413, August 2005] © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  20. Addiction Neurobiology • “The behavioral sequencesinvolved in obtaining desired rewards (e.g., sequences involvedin hunting or foraging) become overlearned. As a result, complexaction sequences can be performed smoothly and efficiently,much as an athlete learns routines to the point that they areautomatic but still flexible enough to respond to many contingencies.Such prepotent, automatized behavioral repertoires can alsobe activated by cues predictive of reward.” [Hyman - Am J Psychiatry 162:1414-1422, August 2005] © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  21. Addiction Neurobiology • “The drug-seeking/foraging repertoiresactivated by drug-associated cues must be flexible enough tosucceed in the real world, but at the same time, they must havea significantly overlearned and automatic quality if they areto be efficient. Indeed the cue-dependent activationof automatized drug seeking has been hypothesized to play amajor role in relapse…” [Hyman - Am J Psychiatry 162:1414-1422, August 2005] © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  22. Addiction Neurobiology • “The upshot of such a scenario would be a biased representationof the world, powerfully overweighted toward drug-related cuesand away from other choices, thus contributing to the loss ofcontrol over drug use that characterizes addiction.” [Hyman - Am J Psychiatry 162:1414-1422, August 2005] © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  23. Addiction Neurobiology • In Hyman’s view: [American Journal of Bioethics, 7(1): 8-11, 2007] • Brain mechanisms of learning and memory, specific to the pursuit of “natural rewards”, • rewards which are represented in the prefrontal cortex which assigns “value” to the stimulus, • mechanisms initiating automatic sequences of behavior dependent on the dorsal striatum, • all of these dopamine mediated, • are usurped by drugs because they activate this circuitry more powerfully than natural reinforcers. © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  24. Addiction Neurobiology • Damasio[American Journal of Bioethics, 7(1):3-7, 2007] points out that lesions of the ventral and medial prefrontal cortices (VMPFC) impact decision making, including social and moral decisions • Those patients favor solutions that are less wise, less emotional, less acceptable • Social emotions are impacted – empathy, justice, compassion • VMPFC monitors connection between decision options and actions, and outcomes • Learning is likely cumulative • Anterior cingulate may modulate conflictamong decision options © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  25. Addiction Neurobiology • Thus: apparently complex and “voluntary” drug seeking behaviors…may not be as freely planned and executed as they first appear.” • “Such cognitive views have not yet penetrated folk psychology, and it is premature for these views to have any place in the courtroom. Nonetheless, these cognitive views deserve a place in current ethical discussions of personal responsibility.” © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  26. Analysis of Legal Issues • In the following, note that the law emphasizes behavior despite (generally) acknowledging that addiction is an illness © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  27. Landmark Rulings • Robinson v. California[1962] held that it was unconstitutional to convict a person for being an addict because to do so would be to punish him for having a disease, in violation of the Eighth Amendment which prohibits cruel and unusual punishment. © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  28. Landmark Rulings • From Robinson: • “Even one day in prison would be a cruel and unusual punishment for the ‘crime’ of having a common cold…I do not see how under our system being an addict can be punished as a crime. If addicts can be punished for their addiction, then the insane can also be punished for their insanity. Each has a disease and must be treated as a sick person.” © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  29. Landmark Rulings • Powell v. Texas [1968]: Powell was an alcoholic convicted of public drunkenness, and argued that drunkenness was a symptom of a disease and that he was therefore powerless to control it. The court ruled that Powell could not be found criminally responsible for being an alcoholic, but he could for being drunk in public. The majority of the U.S. Supreme Court found that though Powell was alcoholic, he did not suffer from an “irresistible compulsion” which he was “utterly unable to control”.[Gendel – Psych Clin N. Am, 29: 619-673 2006] © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  30. Landmark Cases • Bonnie [J Am Acad Psychiatry Law 30:405-13, 2002] points out that in Powell, the justices were reluctant to imply that conditions which impair volition could be used to excuse criminal behavior, such as pyromania and kleptomania, which would “unsettle the law of criminal responsibility.” • Interestingly, this case was Powell’s 100th conviction for public drunkenness. © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  31. Landmark Cases • Generally, in the criminal law, voluntary intoxication is not exculpatory and does not admit of insanity defense • One possible exception is in specific intent crimes, as opposed to general intent crimes: Diminished Capacity (also called Diminished Responsibility) • e.g. 1st degree murder in which conviction may only result from the determination that the defendant had the specific intent to kill rather than the general intent to harm • Requires that the defendant have the mental capacity to form specific intent • Intoxication may impair the capacity to form intent © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  32. Landmark Cases • Montana v. Egelhoff[1996] U.S. Supreme Court upheld a Montana lower court which, acting on the basis of the Montana criminal code which excluded consideration of voluntary intoxication in determining the mental state of a defendant, convicted Egelhoff for murder though he argued that his BAL of 0.36 percent rendered him incapable of the mental state required. • Montana Supreme Court had overturned the conviction, arguing that “all relevant evidence” should be considered when evaluation whether Egelhoff acted “knowingly and purposefully” (definition of intent). • U.S. Supreme Court noted that four-fifths of the states allowed information about intoxication to be used in considering whether a defendant had the mental capacity to form the specific intent to commit a given crime. The Court also noted that it was well-established in common law that voluntary intoxication did not provide an excuse for committing a crime. The Court held that though consideration of intoxication in determining mental state was generally accepted, they did not find it to be fundamental. [Gendel – Psych Clin N. Am, 29: 619-673 2006] © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  33. Disability Law[Bonnie - J Am Acad Psychiatry Law 30:405-13, 2002] • Americans with Disability Act “embodies the distinction between disease and conduct.” • Employer may establish rules of conduct that apply even when an employee is disabled. • Rules of conduct trump non-discrimination • Use of illegal drugs even away from work are grounds for firing • May institute drug screens and fire for positive illegal drugs even if worker suffers addiction • Enrolling in treatment provides a safe harbor if following program recommendations © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  34. Disability Law[Bonnie - J Am Acad Psychiatry Law 30:405-13, 2002] • Under ADA, employee may sign an agreement in which his job is hostage to compliance with the terms • Should employers have the authority to prescribe conditions of treatment? • Emphasizes responsibility rather than excuse • Other ADA cases involving diabetes, bipolar disorder and asthma suggest that it is emerging that under this law people have the responsibility of managing their illnesses © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  35. Regulatory Law • It is common among professions regulated by the states for addicted professionals to be: • Disciplined for having and addictive disorder (progress is being made in some states) • Disciplined for behavior caused by such illness • Disciplined in the form of probationary agreements that allow continued practice if meeting conditions of treatment and monitoring • Clearly under the theory that people are capable of preventing addiction, managing behavior, and avoiding relapse © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  36. Regulatory Law • Recent study [McClellan – Brit J Med. Nov 2008] demonstrates that monitored addicted physicians have high rates of sobriety and long term preservation of the ability to work • 2-3 times that of the general population • This success attributed to monitoring: • Oversight and support • Accountability • Network therapy (after Galanter) • Implicit or explicit contingency contract © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  37. Regulatory Law • Makes incorrect attributions regarding the ability to prevent addiction, but… • Underscores the salutary effect of taking responsibility for addictive disorder, especially relapse • Even if volition is impaired • Even if behaviors downstream to addictive illness may not be as voluntary as they seem © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  38. AA/12-Step • Big Book: fundamental early document addressing both medical and moral aspects of addiction • Addresses issues of responsibility in radical and profound manner – as a (stepwise) process • Steps 1-3: Powerlessness as the foundation of responsibility, spirituality as a tool for becoming responsible • Steps 4-9 are about taking responsibility • Steps 10-12 are about maintaining it © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  39. AA/12-Step • The process of becoming responsible should be part of the dialogue regarding responsibility for • Behavior caused by addiction • Managing “defects of character” • Relapse • Effective treatment, promoted by PHP monitoring, as in the AA tradition, must be about the dynamic process of assuming responsibility © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  40. Summary • Injury caused by addiction, or allostasis to the condition of addiction, involves changes in the pre-frontal cortex (and other neurobiological changes) that impact the process of rational, emotional, and social decision-making • Therefore, the addict’s ability to choose, and to choose abstinence, is to some degree impaired and diminished © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  41. Summary • Damage to the mechanisms of decision making and choosing, or volitional impairment (evaluating behavioral options and shaping behavior) suggests that the addict be afforded: • Better access to care and protections caused by their need (e.g. medical care, disability contexts) • Mitigation (rather than excuse) to varying extent in criminal and regulatory contexts • Understanding of loved ones © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  42. Summary • There is a fundamental difference between having no choice and a hard choice (despite the language of neuroscientists who speak of involuntary and compulsive behavior) • e.g. literal or figurative involuntariness (seizure, muscle fatigue) and impairment of volition (compulsion or “automatic” behavior) are fundamentally different • Responsibility for aspects ofaddiction is codified in many aspects of law and ordinary social mores, and in the 12-step tradition • Responsibility is a dynamic concept, not static © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  43. SUMMARY • The diminished ability to choose wisely (choose not to use) is core disability in addiction • That disability is a burden, because choosing to remain sober is hard • Becoming increasingly responsible for maintaining sobriety = becoming less disabled = more effectively treated illness © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  44. Suggestions for Educating PHP Participants • Explain that damage to the decision making apparatus is a core disability, characteristic of their illness • Learning to manage this disability is a hard task but is their responsibility – their mission should they choose to accept it • The disability does not resolve, but improves to the degree that they learn to be responsible • The activities that we all know to be central to successful recovery are aimed at this lesion © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  45. Suggestions for Educating PHP Participants • One cannot do it alone – one’s own thinking isn’t good enough, ever • The scaffolding afforded by the 12-step fellowships facilitates the assuming of responsibility and diminishes the disability • Assuming responsibility for addiction is an active process © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  46. Given the following illness, how responsible is the person for becoming ill? (1 - lowest; 6 - greatest) © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  47. Given the following illness, how responsible is the person for relapse/recurrence/worsening of their condition? © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

  48. Selected Readings • Bonnie RJ. Responsibility for addiction. J Am Acad Psychiatry Law 30:405-13, 2002 • Gendel, MH. Substance misuse and substance related disorders in forensic psychiatry. Psychiatric Clin N Am. 2006 29: 619-673 • Hyman SE. The neurobiology of addiction: implications for voluntary control of behavior. American Journal of Bioethics 7(1): 8-11, 2007 • Hyman SE. Addiction: A disease of learning and memory. Am J Psychiatry 2005;162:1414-1422. • Kalivas, PW, Volkow ND. The neural basis of addiction: A pathology of motivation and choice. Am J Psychiat 2005;162(8):1403-1413 • Koob GF, Le Moal M. Drug addiction, dysregulation of reward, and allostasis. Neuropsycholopharmacology 24(2): 97-129, 2001 © Colorado Physician Health Program 2012 All Rights Reserved Please do not reproduce or use without written permission of CPHP

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