Many of us working in the field of addiction medicine intuitively identify someone who has a substance use disorder (SUD) just like you might identify a duck because it waddles. It has feathers and quacks, right? But what if someone has three herniated discs and prescriptions for multiple sedatives and painkillers? Suppose they have anxiety, maybe even PTSD, and a medical marijuana card. Maybe they only drink alcohol on Fridays and always Uber home. How can you tell who has, or doesn’t have, SUD?
Truth be told, it doesn’t matter. If the person is being irresponsible—not fulfilling their normal family, school, or work obligations; missing parent time-sharing exchanges; showing up late for video-court hearings—and/or is prone to seizures and falls a lot, they may have a problem. Not everyone will provide definitive evidence as occurred during a family case management hearing when at 10 am the mother was seen on camera drinking a beer. For many, the evidence is more insidious. But, like the proverbial duck, people with SUDs have definitive patterns of behavior, and, consequently, definitively impact their family members.
In 2013, the American Psychiatric Association published in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) revised criteria to identify SUDs. The criteria are essentially the same for any substance of addiction: two to three symptoms indicate a mild disorder, four to five symptoms indicate a moderate disorder, and six or more symptoms indicate a severe disorder. Each symptom has a negative impact on the person and their family. Here is a summary of the 11 SUD symptoms and how they may present in your clients.
11 SUD Symptoms
- There is a loss of control, and more of the substance is taken for longer than intended. Longer periods of use are likely to include parenting time and limit a parent’s ability to engage with the child(ren). Sedatives typically cause problems with alertness and time management. Stimulants can trigger anxiety and forgetfulness. THC may cause paranoia, hallucinations, and other perceptual disturbances; it may trigger an underlying psychiatric disorder. It does not matter if these drugs are prescribed and/or legal; what matters is if the person is impaired as a result of ingestion.
- Repeated efforts to control use fail. This is a simple one to identify. If a parent tests positive while being monitored through family court, they most likely have SUD and may have a co-occurring mental health disturbance.
- Time is wasted obtaining, using, or hung over from a substance. While harder to prove perhaps, a quick check of credit card usage, prescription quantities and refills, or no-shows for parenting time often reveals the primacy of SUD in a person’s life.
- The person has a craving to use. The person claims to just like the taste of a substance, or their doctor prescribed it “as needed” and they “need” it daily, even when being accused or monitored. This sounds like a craving to me. When someone doesn’t have a problem and is accused of abusing a substance, they simply stop using it.
- Obligations at work, school, and/or home are ignored due to use. Your client seldom responds to requests, doesn’t answer their co-parent’s emails as agreed, and isn’t keeping up with the children’s schoolwork. While these examples may not be considered major in the grand scheme of things, they certainly can become major issues when parental responsibility and time-sharing is being determined.
- The person continues to use when it is causing social and interpersonal problems. This one is a no-brainer. A parent argues that they have a right to use a substance despite the above symptoms and the other parent’s allegations of abuse. It’s a duck!
- Life revolves around “getting high,” and other activities are ignored. It may be hard to prove it’s because of substance abuse, but if the person’s world has gotten smaller and smaller, it’s a good hint a substance or its effects is distracting from other life activities.
- There is recurrent use when it is physically hazardous. Anyone with a co-occurring medical condition or who is taking more than one psychoactive medication yet continues to use a mood-altering substance meets this criteria. Add a safety-sensitive career or a few DUIs and it’s clear the person has an urge to use that overwhelms their concern for safety.
- The person continues using knowing it will exacerbate a physical or psychological problem. In addition to the above factors, consider these scenarios: A mother suffers from anxiety and regularly consumes large quantities of stimulants (prescribed or illicit). A father has a history of bipolar disorder with several hospitalizations, yet he continues to use cannabis. A parent with type 2 diabetes regularly consumes alcohol.
- The person has developed a tolerance, i.e., it takes more to get the same effect. So, you think your client is taking a large amount of a substance, yet they seem to be functioning normally. What if their blood alcohol level was .25 when they were stopped for a broken headlight? These are quite likely indicators of tolerance.
- The person experiences withdrawal symptoms when use is discontinued. It’s embarrassing to admit, but early in my practice, I noticed a dad had a pattern of “catching the flu” each time he changed jobs. I interpreted it as a function of anxiety lowering his immune system. Wrong! His job changes were frequent and each time he applied for a new job, he had to be drug tested. Withdrawal from opioid pain medications present as flu-like symptoms. And make sure any drug screening looks for gabapentin, kava, and kratom. These are touted as substances to help with the withdrawal from sedative drugs, but they are also drugs that are often abused.
When should you recommend someone get tested for drug use? Any time there is an allegation or a suspicion. Someone with a substance use disorder may escape undetected for a period of time, but, in the long run, if random testing is used, they will always get caught. And, if they don’t get “caught,” they may actually not have an SUD, as it will be evident that they can control their use.
Cannabis use is a special case because there is no reliable test (as of July 2023) for active intoxication from cannabis. Cannabis remains illegal at the federal level, and, therefore, the major organizations funding research to identify levels of intoxication rarely fund research on cannabis. The good news is the symptoms of cannabis use disorder are based on the 11 criteria above and not on one’s urine level of THC.
The most failsafe toxicology screening is based on analysis of blood drawn directly from the individual. This is both invasive and costly to obtain a history of drug use that only goes back 72 hours. Most drugs tested using blood, saliva, or urine have a three-day window of detection. Blood draws and blood spots for Phosphatidylethanol (PEth) have a three-week window for alcohol use. Hair and nail samples have a 90+-day window of detection.
What if someone is prescribed the substance? Can they also abuse it? Of course! Can you tell definitively by a drug test? No. Your best bet is to send a body fluid (blood, urine, saliva) sample to a lab for quantification and follow up with a consult with the toxicologist. If the quantities are way out of line from the prescribed dose, they can let you know. But everyone metabolizes drugs differently, so they may not be able to confirm nor deny the individual is abusing a substance. Remember, SUD is based on 11 observable behavior patterns, not tox screens.
Chutes and Ladders: A Model for Recovery and Relapse
This childhood game is a great visual for a step-up/step-down parenting plan for those in recovery. SUD is a medical condition. When in remission, the parent is perfectly capable of functioning totally normally with no substance-related risk to the child(ren). When in relapse, the parent cannot be trusted to be with the child(ren) unsupervised. I recommend incentivizing recovery with progressive time-sharing (going up the ladder for more time with the child(ren) as the parent is abstinent for longer periods. If a relapse occurs, the recovering parent automatically goes “down the chute” to supervised time-sharing. Three- to six-month steps can be identified. Generally, four to five steps of increasing time-sharing are adequate to protect the child(ren) and assure the parent is continuing their recovery from the debilitating illness of SUD. If alcohol is the primary concern, a handheld breathalyzer with facial recognition may be used to monitor the parent. If other drugs are a concern, random testing and collateral reports from a GAL or other concerned party will verify recovery or relapse.
Alcohol and other drugs highjack the brain. The reward system is retrained to prefer drugs over virtually everything, except air. The frontal lobe (executive functioning part of the brain) is offline during addiction. It takes roughly 100 days for the brain to heal sufficiently enough for an individual to reliably control impulses. For this reason, it is best to have supervised time-sharing with a parent during their first three months of recovery. Depending on the severity of the addictive behaviors, the vulnerability of the child(ren), and evidence of recovery, subsequent time-sharing schedules can be expanded. If a child is very young, err on the side of caution. The first supervised level may need to extend for six months. Next, build trust (and establish safety) with unsupervised, public time-sharing. Frequency and duration of visits during Levels 1 and 2 can vary (two to six hours, one to three times a week). Level 3 time-sharing can move into the recovering person’s home environment with similar frequencies and time durations. Level 4 should allow for a gradual increase of overnights in anticipation of Level 5, allowing a return to the family’s time-sharing goal. Levels can vary in number, parameters, and duration contingent on the recovery of the person with SUD. Testing should occur weekly during Levels 1 and 2 (daily if monitoring for alcohol). Random testing is recommended until the recovering person has been abstinent for a minimum of 12 months. Confirmation of relapse results in a return to Level 1. Thus, the children are protected, and the recovering parent is assured a return to full time-sharing provided they remain abstinent.
Once monitoring is completed, I recommend a stipulation that allows either parent to request a random 16+ panel urine drug screen any time there is concern a parent is impaired by a substance. If the test is negative, the parent making the request pays the fees. If the test is positive, the parent testing absorbs the cost and unsupervised timesharing is discontinued immediately.
SUDs are chronic medical conditions. When the individual is in remission, there are no negative consequences or disturbances. When the disease is active, there are many disturbances. A parent in long-term recovery is no different than any other parent, but a parent with unstable abstinence must be monitored to protect the children. If a parent is quacking, there might be a duck around!