Convention registrants may access all convention materials online at
http://www.ohiobar.org.
Session # 405
Legal Ethics and Professional Conduct
Committee Annual Program
Legal Ethics and Professional Conduct Committee
2.5 CLE Hours (1 Ethics, 1 Professionalism, .5
Substance Abuse)
May 1214, 2004
♦
Cleveland
CONTRIBUTORS
Jonathan E. Coughlan
Disciplinary Counsel,
The Supreme Court of Ohio
Columbus, Ohio
B.A., Hobart College; J.D., Case Western Reserve University School of Law. Professional Memberships:
National Organization of Bar Counsel; Columbus Bar Association; Ohio State Bar Association; American
Bar Association; Erie County Bar Association. Mr. Coughlan is Disciplinary Counsel for the Supreme
Court of Ohio. He is a frequent speaker for the OSBA CLE Institute and teaches at the National District
Attorneys Association National Advocacy Center in South Carolina.
Scott R. Mote
Executive Director
Ohio Lawyers Assistance Program, Inc.
Columbus, Ohio
B.A., Wright State University; M.A., University of Dayton; J.D., Capital University Law School.
Professional Memberships: Ohio State Bar Association (Council of Delegates, District 7; Estate Planning,
Trust and Probate Law Section; Lawyers Assistance Committee); Columbus Bar Association (Admissions
Committee; Family Law Committee; Professionalism Committee; Probate Committee); The Florida Bar
(OutofState Practitioners Division); Ohio State Bar Foundation; Columbus Bar Foundation; Franklin
County Trial Lawyers Association; Collaborative Family Law Council of Ohio; Central Ohio Association
of Criminal Defense Lawyers. Mr. Mote is Executive Director of the Ohio Lawyers Assistance Program,
Inc., which was formed by the Lawyers Assistance Committee of the Ohio State Bar Association. In
addition, he is a partner at Harris, McClellan, Binau & Cox with a general civil practice. Mr. Mote can be
contacted via phone at 8003484343 or 6144642572; fax at 6144642245; or email at
smote@hmbc.com or smote@ohiolap.org.
Professor John “Jack” P. Sahl
The University of Akron School of Law
Akron, Ohio
B.A., Boston College; J.D., University of Vermont College of Law; LL.M., Yale University School of
Law. Professional Memberships: Ohio State Bar Association (Legal Ethics and Professional Conduct
Committee); Cleveland Bar Association (Legal Ethics and Professional Conduct Committee). Professor
Sahl is the Deputy Director of the Miller Institute of Professional Responsibility and a Research Fellow of
the Constitutional Law Center at The University of Akron School of Law. He is an expert on lawyer and
judicial ethics and discipline and currently serves on the Publications Board of the ABA Center for
Professional Responsibility. Professor Sahl has served as an expert witness in lawyer malpractice and other
cases and has provided advisory opinions and preventive consultations to lawyers regarding professional
responsibility and litigation. He has authored articles on a variety of legal topics in such publications as
The Encyclopedia of Law and Religion,
and is a frequent lecturer on lawyer and judicial ethics and
discipline for CLE programs.
Geoffrey Stern
Kegler Brown Hill & Ritter
Columbus, Ohio
B.A., The Ohio State University; J.D., The Ohio State University Michael E. Moritz College of Law.
Professional Memberships: Columbus Bar Association (Professional Ethics Committee); Ohio State Bar
Association (Past Chair, Legal Ethics and Professional Conduct Committee); Columbus Bar Foundation
(Fellow); Ohio State Bar Foundation (Fellow); American Bar Foundation (Fellow). Mr. Stern practices in
the areas of legal ethics, professional responsibility, professionalism and appellate practice. He is a Special
Investigator for the Ohio Supreme Court Board of Commissioners on Character and Fitness. Mr. Stern
recently received the Columbus Bar Association’s Liberty Bell Award for community and professional
service. He is a frequent lecturer on legal ethics and substance abuse issues.
Laurence A. Turbow
Laurence A. Turbow LPA, Inc.
Cleveland, Ohio
B.S.E.D., The Ohio State University; J.D., Cleveland State University ClevelandMarshall College of Law.
Professional Memberships: Ohio State Bar Association (Family Law Committee; Legal Ethics and
Professional Conduct Committee); Cuyahoga County Bar Association (Family Law Section; Grievance
Committee; Joint Bar Admissions Committee). Mr. Turbow is also a member of the Guardian
ad Litem
Advisory Committee of the Cuyahoga County Court of Common Pleas. Mr. Turbow specializes in family
law. He is a frequent contributor to continuing legal education programs.
Ann K. Zimmerman
General Counsel,
Cleveland Bar Association
Cleveland, Ohio
Legal Ethics and Professional Conduct Committee Annual
Program
Session # 405
chapter 1
Substance Abuse, Chemical Dependency and Mental Health Concerns in the Legal Profession
Scott R. Mote
The Three Components .......................................................................................................................................1.1
The Organizations ...............................................................................................................................................1.1
Key Rules and Statutes........................................................................................................................................1.1
Funding and Other Support.................................................................................................................................1.2
Introduction .........................................................................................................................................................1.3
Disclaimer/Publication Notice.............................................................................................................................1.4
Substance Abuse, Chemical Dependency and Mental Health Concerns in the Legal Profession.......................1.5
What Are Some Functional Definitions of Addiction?.........................................................................1.5
What Are the Primary Classifications of Substance?............................................................................1.5
What Do We Mean When We Say It’s a Disease? ...............................................................................1.8
What Kind of a Disease Is It? .............................................................................................................1.10
How Will the Disease Manifest Itself? ...............................................................................................1.12
What Are the Ultimate “Personal Costs” of Doing Nothing?.............................................................1.14
What Are the Ultimate Professional Costs?........................................................................................1.15
Why Would Someone Generally Want to Avoid Treatment?.............................................................1.16
What Other Mechanisms Are Active That Help the Individual Avoid Treatment?............................1.16
What Can Be Done to Promote Recovery?.........................................................................................1.18
What Must Be Accomplished as Part of Any Recovery Program Regardless of the
Technique or Treatment Modality Selected? ........................................................................1.19
What Is the “Lawyers Support System” Aftercare Program? .............................................................1.19
What Is the Role of Alcoholics Anonymous (A.A.) and Other Programs Such as
Narcotics Anonymous (N.A.), Cocaine Anonymous (C.A.), and Allied Programs
Like Alateen and AlAnon?..................................................................................................1.21
What Are the Steps of Alcoholics Anonymous?.................................................................................1.21
What Can I Do? ..................................................................................................................................1.23
What Is the Lawyers Assistance Committee of the Ohio State Bar Association and
Its Companion Organization the Ohio Lawyers Assistance Program, Inc.? ........................1.23
How Do I Actually Contact OLAP? ...................................................................................................1.24
Conclusion ..........................................................................................................................................1.25
Are You an Alcoholic?......................................................................................................................................1.27
Test Yourself for Addiction ..............................................................................................................................1.31
Facing the Facts.................................................................................................................................................1.39
Part I....................................................................................................................................................1.39
Part II ..................................................................................................................................................1.39
Substance Abuse Linked to Attorney Misconduct..............................................................................1.39
The Facts of Addiction .........................................................................................................1.40
The Disease of Alcoholism...................................................................................................1.41
What Can You Do?...............................................................................................................1.42
The Intervention Team..........................................................................................................1.44
The Answer Is…...................................................................................................................1.45
Mental Health Concerns in the Legal Profession ..............................................................................................1.47
What Is Mental Illness?.......................................................................................................................1.47
Know the Facts from the Fiction.........................................................................................................1.47
Mental Illnesses Are Treatable! ..........................................................................................................1.48
Types of Mental Illnesses..................................................................................................................................1.51
Anxiety Disorders ...............................................................................................................................1.51
Treatments That Will Help—Not Make Things Worse ......................................................................1.55
Diagnostic Criteria for Generalized Anxiety Disorder (DSMIVTR, P. 476) ...................................1.57
ObsessiveCompulsive Disorder (OCD).............................................................................................1.58
Ask Yourself .......................................................................................................................................1.60
A Screening Test of ObsessiveCompulsive Disorder ........................................................................1.61
Prevalence ...........................................................................................................................................1.65
Diagnostic Criteria for ObsessiveCompulsive Disorder (DSMIVTR, P. 462463) ........................1.65
Help Is Available.................................................................................................................................1.66
Depression .........................................................................................................................................................1.69
What Is Depression? ...........................................................................................................................1.69
Depression...........................................................................................................................................1.69
What Causes Depression? ...................................................................................................................1.70
There Is Help.......................................................................................................................................1.70
Facts on Depression...........................................................................................................................................1.71
What Is Depression? ...........................................................................................................................1.71
Types of Depression............................................................................................................................1.71
What Are the Symptoms of Depression? ............................................................................................1.71
Treatment of Depression .....................................................................................................................1.72
Economic and Social Costs of Depression..........................................................................................1.72
Depression and Seniors .......................................................................................................................1.72
Adolescent and Child Depression .......................................................................................................1.73
Depression and Women ......................................................................................................................1.73
Depression and Suicide .......................................................................................................................1.73
Verbal and Behavioral Clues Someone May Be Contemplating Suicide..........................................................1.74
Verbal Clues........................................................................................................................................1.74
Behavioral Clues .................................................................................................................................1.74
Depression .........................................................................................................................................................1.75
Major Depressive Episode ..................................................................................................................1.75
Dysthymic Disorder (DSMIVTR, PGS. 380381) ...........................................................................1.77
Criteria for Manic Episode (DSMIVTR, P. 362) .............................................................................1.78
Bipolar Disorder ................................................................................................................................................1.79
What Is Bipolar Disorder? ..................................................................................................................1.79
Facts About Bipolar Illness.................................................................................................................1.79
Symptoms............................................................................................................................................1.80
Bipolar Illness Is Often Unrecognized ................................................................................................1.81
Treatment Is Effective (National Institute of Mental Health, 1995) ...................................................1.82
Getting Treatment ...............................................................................................................................1.82
Bipolar Disorder Not Otherwise Specified (DSMIVTR, P. 400401)..............................................1.82
Adult Attention Deficit Disorder.......................................................................................................................1.83
Characteristics of Adults with AD/HD ...............................................................................................1.83
Attention Deficit/Hyperactivity Disorder—Diagnostic Features ........................................................1.84
Diagnostic Criteria for Attention Deficit/Hyperactivity Disorder.......................................................1.85
Which Conditions Most Commonly CoExist with AD/HD?.............................................................1.87
The Prognosis......................................................................................................................................1.87
After Diagnosis, What Then?..............................................................................................................1.87
Dual Diagnosis ..................................................................................................................................................1.89
What Is Dual Diagnosis?.....................................................................................................................1.89
Mental Illness ......................................................................................................................................1.89
Disorder/Drugs of Abuse ....................................................................................................................1.89
Both Problems Can Be Successfully Treated!.....................................................................................1.90
Why Learn About Dual Diagnosis? ....................................................................................................1.90
Why Do Some People Have a Dual Diagnosis? .................................................................................1.90
No Matter What the Cause, the Problem Can Be Treated...................................................................1.91
Look for Warning Signs......................................................................................................................1.91
Getting Help Makes Sense ..................................................................................................................1.91
chapter 2
Legal Ethics
Geoffrey Stern
Why Is Legal Ethics So Hot a Topic? .................................................................................................................2.1
Relation of Legal Ethics and Legal Malpractice .................................................................................................2.1
Resource Materials—Rely on More Than Your Buddy......................................................................................2.2
Selected Code Provisions That May Be Crucial to Practitioners ........................................................................2.4
Nature of Ethical Enforcement............................................................................................................................2.6
Ohio Disciplinary Procedure for Attorneys—
See
Guttenberg and Snyder,
The Law of Professional
Responsibility in Ohio
(Anderson’s 1992), Chapter 13 ........................................................................2.7
Recent Developments
in Ohio, as Regularly Reported in the
Ohio State Bar Association Report
,
Are Contained in the Attached Summary of “Ohio Cases” ................................................................2.11
Ohio Cases.........................................................................................................................................................2.13
chapter 1
Substance Abuse, Chemical Dependency
and Mental Health Concerns in the Legal
Profession
Scott R. Mote
Executive Director, Ohio Lawyers Assistance Program, Inc.
Harris, McClellan, Binau & Cox PLL
Columbus, Ohio
Stephanie S. Krznarich
Associate Director, Ohio Lawyers Assistance Program, Inc.
Columbus, Ohio
Paul A. Caimi
Associate Director, Ohio Lawyers Assistance Program, Inc.
Paul A. Caimi Co., LPA
Cleveland, Ohio
Substance Abuse • 1.1
chapter 1
Substance Abuse, Chemical Dependency
and Mental Health Concerns in the Legal
Profession
Scott R. Mote
1
Executive Director, Ohio Lawyers Assistance Program, Inc.
Harris, McClellan, Binau & Cox PLL
Columbus, Ohio
Stephanie S. Krznarich
2
Associate Director, Ohio Lawyers Assistance Program, Inc.
Columbus, Ohio
Paul A. Caimi
3
Associate Director, Ohio Lawyers Assistance Program, Inc.
Paul A. Caimi Co., LPA
Cleveland, Ohio
Ohio’s integrated program:
The legal professions response to substance abuse, chemical dependency and mental health
concerns in Ohio
I. THE THREE COMPONENTS
A. Education.
B. Advice and intervention assistance.
C. Treatment and aftercare support.
II. THE ORGANIZATIONS
A. The Lawyers Assistance Committee of the Ohio State Bar Association.
B. The Ohio Lawyers Assistance Program, Inc. (OLAP).
C. The Lawyers Support System.
III. KEY RULES AND STATUTES
A. Gov. Rule I, § 3(E)(2).
One hour of instruction to sit for bar examination.
1.2 • Legal Ethics and Professional Conduct
B. Gov. Rule X, § 3(A).
CLE requirements.
C. DR 1103(C).
Confidentiality.
D. Ohio Rev. Code § 2305.28.
Qualified immunity for intervention participant.
E. Gov. Rule V, § 9(B).
Monitoring.
IV. FUNDING AND OTHER SUPPORT
A. The Supreme Court of Ohio.
B. The Ohio State Bar Association.
C. Ohio Bar Liability Insurance Company (OBLIC).
D. Local bar associations.
Substance Abuse • 1.3
INTRODUCTION
Since 1990 OLAP has assisted Ohio’s judges, lawyers and law students obtain
appropriate treatment for substance abuse and chemical dependency. Over 700 men
and women have been helped. Recognizing that an impaired lawyer negatively affects
nine other people each day, over 6300 men, women and children have somehow been
touched by OLAP.
OLAP and the profession in recent years have observed an increasing number of
attorneys who not only have substance abuse problems, but also mental health
problems. In addition, OLAP recognized that there are a growing number of attorneys
who are suffering from untreated mental health illnesses, and who do not have a
substance abuse problem, but need someone to intervene and help them seek
appropriate treatment. Such untreated problems not only affect them and their
families, but may also affect their clients.
The American Bar Association surveyed attorneys in 1990. Among the startling
statistics at that time were that
A. Onethird of practicing lawyers suffer from depression, making lawyers 510
times more likely than other professionals to suffer from a major depressive
disorder;
B. Eighteen to twenty percent of lawyers suffer from alcoholism, compared with
10% of the rest of Americans. After 20 years of practice, the rate rises to 25%.
Alcohol and drug problems cause half the disciplinary cases involving lawyers
(
Wall Street Journal
, 11/30/90); and
C. Lawyers are twice as likely as other professionals to commit suicide.
Florida Coastal School of Law Professor Susan Daicoff (formerly at Capital
University Law School), who is also a psychologist, has studied this issue. In an
article she wrote, which was published in
The Georgetown Journal of Legal Ethics
in
Spring. 1998, she states the following
D. Incidence of Substance Abuse and Depression Among Lawyers.
A serious influence complicating and compounding the...crisis is the
incidence in substance abuse and depression among lawyers.
Estimates of the frequency of substance abuse problems, including
alcoholism, among lawyers range from three to thirty times that of
the general population. About nine to ten percent of the general
population in the United States is alcoholic, while empirical studies
consistently show that about eighteen percent of lawyers and law
students are alcoholic. Similarly, while three to nine percent in the
general population in the United States is clinically depressed, as
much as nineteen to twenty percent of practicing attorneys is
depressed. A 1986 study found that only about ten percent of
entering law students exhibited significant symptoms of
psychological problems including depression, anxiety, hostility,
paranoia, and obsessivecompulsive symptoms, but this percentage
jumped dramatically to 32% by the end of the first year of law
1.4 • Legal Ethics and Professional Conduct
school. By the end of the third year of law school it was 40%, and
two years after graduation it was 17.9%. A 1995 study replicated
these findings and found that problems did not significantly abate
after the individuals entered the practice of law. Depression, anxiety,
social isolation and alienation, hostility, paranoid ideation, and
obsessivecompulsive symptoms were more frequent in attorneys
than in the general population. Thus, a greater than average
percentage of attorneys (as a group) is psychologically impaired in
some way. Further, it appears that while the problems often do not
appear until the first year of law school, lawyers do not return to
their prelaw school level of psychological health after graduation.
(Pages 555557.)
In one of Professor Daicoff’s footnotes, she cites a study by Connie A. Beck which
was published in 19951996. Ms. Beck’s findings are as follows.
Base Rate
Among Lawyers
Male Female Male Female
Depression 8.5% 14.1 % 21% 16%
Anxiety 4% 4% 30% 20%
ObsessiveCompulsive 1.4%2% 1.4%2% 21% 15%
Based upon the Ohio State Bar’s experience and the empirical information cited
above, OLAP sought and received additional support from The Supreme Court of
Ohio to assist those in the profession with mental illness. Professional staff has been
added, and additional professional assistance across the state is being secured. The
purpose of this publication is to provide you with information, education and
resources if you or someone else in the profession is in need of assistance.
DISCLAIMER/PUBLICATION NOTICE
This publication was funded by The Supreme Court of Ohio. However, the opinions
expressed in this publication do not necessarily reflect the position of the Court, and
no endorsement of the Court should be inferred.
These materials are published as part of the Ohio Lawyers Assistance Program, Inc.’s
(OLAP) educational services. The purpose of this publication is to provide Ohio’s
legal profession with information, education and resources. This publication is not to
be used to selfdiagnose or to diagnose others. Contact OLAP for further assistance.
This publication does not reflect the position of the Ohio State Bar Association or
Ohio Bar Liability Insurance Company.
Substance Abuse • 1.5
SUBSTANCE ABUSE, CHEMICAL DEPENDENCY AND MENTAL HEALTH
CONCERNS IN THE LEGAL PROFESSION
I. WHAT ARE SOME FUNCTIONAL DEFINITIONS OF ADDICTION?
A. The inability to stop the use of the substance or behavior in question; the
perceived inability to stay stopped.
B. Behavior characterized by
1. Compulsion: an internal demand beyond intellectual resource or
understanding;
2. Loss of control over amount consumed; and
3. Continued use or activity despite adverse consequences.
C. Another way of saying it.
Psychoactive Substance Dependence (Addiction).
The essential feature of this disorder is a cluster of cognitive, behavioral, and
physiological symptoms that indicate that the person has impaired control of
psychoactive substances and continues to use the substance(s) despite adverse
consequences.
D. A related term.
Psychoactive Substance Abuse.
Psychoactive Substance Abuse is a residual category for noting maladaptive
patterns of substance use that have never met the criteria for dependence.
II. WHAT ARE THE PRIMARY CLASSIFICATIONS OF SUBSTANCE?
The Diagnostic and Statistical Manual of Mental Disorders (DSMIVTR) (American
Psychiatric Association, 2000) has divided substances into 11 categories.
A. Alcohol—drug in liquid form;
B. Sedatives, hypnotics and
antianxiety
drugs—sleeping pills and “nerve
medication”;
Barbituates
Benzodiazepines
Date Rape Drugs
Seconal Zolpidem (Ambien) GHB (Georgia Homeboy, Grievous
Bodily Harm)
Pentobarbital
(Nembutal)
Flurazepam (Dalmane) Flunitrazepam (Rohypnol) (“Roofies,”
“Roffirs,” “Rophirs,” “Roche,” “Forget
Me Pill”)
1.6 • Legal Ethics and Professional Conduct
Tuinal Lorazepam (Ativan) (
See
Ecstacy under amphetamines and
hallucinogens since it has both properties.
It is not classified as a sedative hypnotic.
Phenobarbital
(Luminal)
Clorazepate (Tranzene)
Secobarbital (Amytal) Chlordiazepoxide
(Librium)
Anembutal Oxazepam (Serax)
Butalbital (Fiorinal,
Fioricet)
Alprazolam (Xanax)
Meprobamate (Equanil,
Miltown)
Butabarbital (Butisol) Diazepam (Valium)
Talbutal (Lotusate) Triaxolam (Halcion)
Mephobarbital
(Mebaral)
Estazolam (ProSam)
Methohexital
(Brevital)
Quazepam (Doral)
Thiamylal (Surital) Temazepam (Restoril)
Thiopental (Pentothal) Halazepam (Paxipam)
Prazepam (Centrax)
Midazolam (Versed)
Clonazepam (Klonopin)
Older sedative hypnotics (not readily available).
Golutethimide (Doriden)
Noludar
Methaqualone (Quaalude, Soper)
Placidyl
C. Cannabis/marijuana/hashish/hash oil;
D. Cocaine/Crack;
Substance Abuse • 1.7
E. Amphetamines (stimulants and sympathomimetics);
Methamphetamine/”Crank”/”Ice”(smokable)/”Crystal”/”Chalk”/
“Fire”/”Glass”
Ritalin (Metadate, Methylini)
Preludin (“Ecstacy”)
Aderol
Cylert
F. Hallucinogens;
LSD
Psilocybin and Psilocyn
Mescaline and Peyote
DMT
MDMA (“Ecstacy,” “XTC,” “Adam,” “Essence,” “Clarity,” “Lover’s Speed”)
G. Inhalants;
Gasoline, glue, paint thinners, spray paint, cleaners, typewriter correction
fluid, spraycan propellants, nitrous oxide (“whipits”), amyl and butyl nitrate
(“poppers,” “locker room”).
H. Caffeine;
I. Nicotine;
J. Opiates; and
Thebaine Loret Tussionex
Anexsia Hycodan Hycomine
Hydrocodone Oxymorphene Nalbuphine
Nalonone Naltrexone Tylos
Lortab Hydromorphone Morphine (Roxanol)
Heroin Darvon Codeine
Dilaudid Demerol Oxycodone
Meperidine Percodan Methadone
Pentazocine Buprenorphine Fentanyl
Oxycontin Duragesic patch (Fentanyl)
Codeine Vicoden Percocet
Lomotil Paragoric MSIR
MSContin
K. Phencyclidine (PCP, Hog, Tranq, Angel Dust and PeaCe Pill), Sernyl
Arylcyclohexylamine.
Ketamine (Ketalar, Ketaject, “Special K,” “K,” “Vitamin K,” “Cut Valiums”)
Cyclohexamine
Dizocilpine
1.8 • Legal Ethics and Professional Conduct
III. WHAT DO WE MEAN WHEN WE SAY IT’S A DISEASE?
A. Since 1956, the American Medical Association has considered alcoholism (or
chemical dependency) to be a disease, and the American Bar Association’s
Commission on Lawyers Assistance Programs has adopted this model as well.
B. Alcoholism is a primary, chronic, disease with genetic, psychosocial and
environmental factors influencing its development and manifestations. The
disease is often progressive and fatal. It is characterized by continuous or
periodic impaired control over drinking, preoccupation with the drug alcohol,
use of alcohol despite adverse consequences and distortions in thinking, most
notably denial. (American Society of Addiction Medicine (ASAM), National
Council on Alcoholism and Drug Dependency (NCADD), 1990.)
C. What are the principal characteristics of the disease?
1. Primary disease.
The disease itself causes the drinking or drug use. It is not secondary
to some other disease of mental illness,
etc.
2. Chronic.
There is no cure for the disease, but it can be treated and controlled.
3. Progressive.
The disease always gets worse, it does not get better and there is no
turning back and beginning all over again as if one never drank or
used.
4. Fatal.
This is a fatal disease if not controlled. It always leads to premature
death and serious health problems even if the death certificate
indicates the cause of death to be one of the complications of the
disease,
e.g
., heart problems, liver failure, bleeding ulcers, cancers,
etc.
5. Treatable.
The disease can be controlled if the drinking or drug use is stopped. It
is much like diabetes in the sense that if body chemistry is stabilized
by not drinking or using, then the alcoholic may lead a normal life.
Recovery rate among the general population who have undergone
appropriate treatment is around 70% and among some professional
groups (including lawyers) as high as 90%.
Substance Abuse • 1.9
D. What are the diagnostic criteria for substance abuse according to the DSM
IVTR (page 199)?
1. A maladaptive pattern of substance abuse leading to clinically
significant impairment or distress, as manifested by one (or more) of
the following within a 12month period.
a. Recurrent substance use resulting in a failure to fulfill major
role obligations at work, school, or home (
e.g
., repeated
absences, poor performance, suspensions from school, neglect
of children);
b. Recurrent substance use in situations in which it is physically
hazardous (
e.g
., driving, operating a machine, hunting,
boating);
c. Recurrent substancerelated legal problems (
e.g
., arrests); and
d. Continued use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of
the substance (arguments with spouse, physical fights).
2. The symptoms have never met the criteria for substance
dependence/addiction for this class of substance.
E. What are the diagnostic criteria for substance dependence (addiction)
according to the DSM IVTR (page 197)?
A maladaptive pattern of substance use, leading to clinically significant
impairment or distress, as manifested by three (or more) of the following,
occurring at any time in the same 12month period.
1. Marked tolerance: need for markedly increased amounts of the
substance in order to achieve intoxication or desired effect, or
markedly diminished effect with continued use of the same amount;
2. Characteristic withdrawal symptoms (increased pulse, respirations,
blood pressure, tremors, nausea, vomiting, diarrhea, constipation,
sweats). Use of substance to relieve or avoid withdrawal symptoms;
3. Substance is often taken in larger amounts or over a longer period than
the person intended;
4. Persistent desire or one or more unsuccessful efforts to cut down or
control substance use;
5. A great deal of time spent in activities necessary to get the substance,
take the substance, or recover from its effects;
6. Important social, occupational, or recreational activities given up or
reduced because of substance use; and
1.10 • Legal Ethics and Professional Conduct
7. 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 (
e.g
., current
cocaine use despite recognition of cocaineinduced depression, or
continued drinking despite recognition that an ulcer was made worse
by alcohol consumption).
F. Substance abuse versus substance dependence.
1. Unlike the criteria for substance dependence, the criteria for substance
abuse do not include tolerance, withdrawal or a pattern of compulsive
use and only include the harmful consequences of repeated use. DSM
IVTR, p. 198.
2. Substance abuse is more likely in individuals who have begun to use
substances recently. DSM IVTR, p. 206.
3. Treatment, education and abstinence are critical for one diagnosed
with substance abuse for at least three primary reasons.
a. To ensure the safety of the individual, the individual’s family
and the public;
b. Because the diagnosis of substance abuse indicates that the
abuser is, for practical purposes, “out of control” due to
“repeated” use in situations where use is inappropriate, harmful
and even life threatening. Such “repeated” use may be
tantamount to and easily confused with “compulsive” use
which indicates dependence; and
c. Because substance abuse often evolves into substance
dependence. DSM IVTR, p. 206.
IV. WHAT KIND OF A DISEASE IS IT?
A. It is a genetic and biochemical disease.
Just since 1980, there have been hundreds of studies and scholarly papers
(including the discovery of perhaps one of the actual genes) corroborating a
genetic or familial predisposition to the disease.
B. Two genetic varieties of the disease.
1. Highly heritable.
a. More likely in the male line.
b. Person can be alcoholic from first use or first drink.
c. Children as young as eight years of age or younger can be
alcoholic or drug dependent.
Substance Abuse • 1.11
d. If you have one parent who is an alcoholic/addict, you have a
50% chance of being chemically dependent. If you have two
parents who are chemically dependent, you have an 80%
chance of becoming an alcoholic and/or an addict.
2. Milieu limited.
a. More likely to come on in 30s or 40s after a more prolonged
period of use (average period being seven years).
b. Can be associated with crisis events in life and inability to
control amount used.
C. Biochemistry issues.
1. Brain chemistry affects how one feels.
How do the alcoholics or drug dependents feel that they want to drink
for relief? Alcoholics are stimulus augmenters and live in a world that
is too loud.
2. Brain wave studies.
Low amplitude “Pd” brain waves are too low or are missing. These
waves affects cognitive ability to tolerate, interpret, and utilize stress.
“Alpha” waves are also deficient or absent.
3. Brain chemistry.
a. Neurotransmitter and opioid deficiencies.
Is there something else missing that normally affects feeling
good? In alcohol craving rats, there is a serotonin deficiency.
Serotonin is a major “feel good” compound in the brain.
The brain has morphine receptor sites because it makes some
form of endogenous morphine—these are the endorphines we
produce,
e.g
., “runner’s high.” Spinal fluid of an alcoholic is
deficient in “feel good” endorphines.
Alcoholic rats are deficient in enkephalines as well—these are
other “feel good” chemicals in the brain.
Some research shows deficiencies in still others like
noradrenaline.
b. At first, alcohol makes the alcoholic feel normal.
The alcoholic therefore begins to feel good or normal, like
normal people, after he or she has begun to drink and the
alcohol has begun to affect the amount of these feel good
chemicals in the brain.
1.12 • Legal Ethics and Professional Conduct
But this is also the point at which the alcohol becomes a double
bind because other chemical reactions going on in the
alcoholic’s chemical system begin to set up the craving process
for more and more alcohol.
c. Then the craving process begins. This craving is the alcoholic’s
allergic response.
When the alcohol is enough to overcome the normal
metabolism of acetaldehyde there is production of dopamine
(new gene research involves dopamine receptors) resulting in
THIQ which when given to rats will cause them to drink
