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Addicted Professionals: Intervention, Evaluation, and Treatment

Addicted Professionals: Intervention, Evaluation, and Treatment. Greg Skipper, MD Director, Professional Health Services and Medical Director Professionals Treatment at Promises gskipper@promises.com 310-633-4595. Conflicts. None Director, Professionals Health Services,

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Addicted Professionals: Intervention, Evaluation, and Treatment

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  1. Addicted Professionals:Intervention,Evaluation, andTreatment Greg Skipper, MD Director, Professional Health Services and Medical Director Professionals Treatment at Promises gskipper@promises.com 310-633-4595

  2. Conflicts • None • Director, Professionals Health Services, Promises Treatment Centers • Medical Review Officer, Affinity Ehealth

  3. Copy of Slides at: www.gregskippermd.com

  4. Overview • Epidemiology • Professional Health Programs in USA • National Study of Physician Health Programs • Outcomes • Intervention • Evaluation • Treatment • Monitoring

  5. Epidemiology

  6. Substance Disorders - Physicians 10% - 15% Lifetime prevalence (similar to population at large) • Anthony JC. Prevalence of substance use among US physicians. JAMA 1992; 11:268(18):2518. • Brewster JM. Prevalence of alcohol and other drug problems among physicians. JAMA 1986; 255: 1913-1920. • Talbott GD. Prevalence of alcohol and other drug problems among physicians. JAMA 1987; 21:2927-2930. • Flaherty JA, Richman JA. Substance Use and Addiction Among Medical Students, Residents, and Physicians: Recent Advances in Addictive Disorders. Psychiatric Clinics of North America. 1993; 16: (1), 189-195.

  7. Substance Disorders – other professionals Nurses - Similar prevalence as physicians Griffith J. Substance abuse disorders in nurses. Nurs Forum. 1999 Oct-Dec, 34(4):19-28. Substance Use Disorder in Nursing, Resource Manual, National Council of State Boards of Nursing. https://www.ncsbn.org/SUDN_10.pdf Veterinarians – highest suicide risk of all health professionals (7x higher than age matched controls), high severity of substance use disorders Skipper GE, Williams J. Failure to Acknowledge High Suicide Risk among Veterinarians. Journal of Veterinary Medical Education, Issue 1, 2012, p.-1.

  8. Substance Disorders – other professionals Dentists, Pharmacists, Physical Therapists, and the other 31 Health Professional Boards – No research Airline Pilots – HIMS program – one study showing similar outcomes as physicians Attorneys – National COLAP Other professionals Corporate America Nuclear regulatory Other “Non-professionals” – Contingency Management

  9. Data Regarding Physicians

  10. Why Physicians Use Drugs Curiosity Recreation Therapeutic Relaxation Easy access Peer pressure Other

  11. Symptoms of Substance Abuse among Physicians AOB Cognitive Impairment DUI Disruptive Withdrawn Unavailable Missing drug inventory “Where there’s smoke there’s fire”

  12. M.D. a l i g n a n t e n i a l

  13. D.V.M. e n i a l ery a l i g n a n t

  14. D.M.D. amn a l i g n a n t e n i a l

  15. Physicians As Patients Physicians seek general medical check-ups and consultation visits less often than controls and tend to wait longer before seeking help for serious symptoms. Tendency to self diagnose and treat “Hallway” medical consultations

  16. Physicians As Patients Treatment by close personal friends Difficulty accepting the patient role Less than objective medical treatment Potential or real loss of status and authority associated with becoming a patient. Myth: Having knowledge protects them from illness.

  17. Source of Initial Referral

  18. This is your Medical License…

  19. This is your Medical License…on drugs!

  20. Physician Health Programs

  21. Physician Health Programs • Began in late 70’s • FAA began Pilots Programs around the same time • Lawyer Assistance Programs came later • Goals of Professional Assistance Programs • Safety for patients • Early intervention • Good treatment • Long-term monitoring

  22. PHPs – Value Added • Focus on education – prevention • Public Protection – FSMB – “Regulatory Boards should have a PHP” • Early intervention – prior to overt impairment and crisis • Clinical arm of regulatory board – can act on symptoms rather than evidence • Immediate results – compared to drawn out legal process • Long-term monitoring - justified

  23. How it Works! Confidential reports Discrete inquiry, confidentiality!!!! Intervention Referral for thorough evaluation (physician oriented programs) Secondary Intervention (if needed) Treatment Monitoring Advocacy and Expert Testimony

  24. Terminology Illness Disability Impairment

  25. Why Hospital Wellness Committees Are Not Enough Too often the members lack experience and training That can create obstacles and delays Motivation is not enough: the requirements for time and energy may be too much

  26. Why Hospital Wellness Committees Are Not Enough • Conflicts can make it difficult to take the actions needed • Interpersonal conflicts (“He’s my referral source.” “My wife is his cousin.”) • Organizational conflicts (“He brings in 35% of the admissions to this place.” “She is the Head of the Department.” )

  27. Why Hospital Wellness Committees Are Not Enough Codependence Most importantly, over 50% of physicians are not associated with a hospital medical staff

  28. Key Ingredients: What Helps a PHP Be Effective Immunity - liability Confidentiality – records/participants Trust – w licensing board Standards – policies and procedures Leadership – committee oversight Education Early intervention emphasizing pt safety

  29. Early detection improves safety and improves outcomes • A confidential supportive approach is the best way to encourage early detection (which protects the public) • PHPs offer regulatory boards such a clinical approach • Early referral is less likely when there is a perception that the result will be punitive Potential referents: • Are not certain there is a problem • Do not want to harm a colleague • Do not know how to intervene • Do not want to put themselves at risk

  30. PHPs increase early detection Figure 1: Comparison of two adjacent and demographically similar states, Alabama and Georgia, regarding numbers of substance abusing g physicians identified

  31. PHPs can respond rapidly • Not constrained by “due process” rules • PHP interventions are often performed the very day that symptoms are first reported • Regulatory board must usually conduct investigation, subpoena information, conduct interviews, hearings, etc. • >95% of physicians fully cooperate with PHPs (to avoid referral to regulatory board) • Safer for the public when intervention and voluntary removal from practice is rapid

  32. PHPs have a record of success • Blueprint Study – 904 physicians from 16 state PHPs who’d been under PHP care for 5+ years • 79% no relapse • Most relapses not followed by another • No patient harm • Domino Study – 735 physicians in WA state – under monitoring from 5-11 years • 80% no relapse – no patient harm

  33. Study of Physician Health Programs

  34. Why Study Physician Health Programs (PHPs) • Doctors receive a different form of addiction treatment and follow-up than that received by most other patients • To discover which states have PHPs • To document what is actually received • Outcomes are better? (~75 - 96% 5-10 year abstinence) • To verify outcomes Shore 1990, Domino 2003

  35. Researchers • Robert DuPont, MD (Washington DC) • Tom McLellan, PhD (Philadelphia, PA) • Greg Skipper, MD (Montgomery, AL) • Federation of State Physician Health Programs – steering committee • Robert Wood Johnson Foundation Grant

  36. Papers – to date • McLellan AT, Skipper GE, Campbell M, DuPont RL. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ. 2008 Nov 4;a2038, doi:10.1136.a2038 • White, W.L., DuPont, R.L., Skipper, G.E. (2008).  Physician health programs: What counselors can learn from these remarkable programs. Counselor Magazine, June 27, 2007, 44-51 • Skipper GE, DuPont RL. What About Physician Health Programs. The New Republic. January 18, 2009 (http://www.tnr.com/politics/story.html?id=2b230eae-edbb-4b38-951f-75529f5cb2c5)

  37. Papers – to date • DuPont, R. L., McLellan, A. T., Carr, G., Gendel, M & Skipper, G. E. (2008 – In Press). How are addicted physicians treated and managed: The structure and function of Physician Health Programs in the United States. Journal of Substance Abuse Treatment. • Skipper GE, Campbell M, DuPont RL. Anesthesiologists with Substance Use Disorders: A 5-Year Outcome Study from 16 State Physician Health Programs. Anesth & Analg

  38. Papers – to date - accepted • Skipper GE, DuPont RL. The Physician Health Program: A Replicable Model of Sustained Recovery Management. (Chapter 17 pgs 281-299) In: J.F. Kelly and W.L. White (eds.), Addiction Recovery Management: Theory, Research and Practice, Current Clinical Psychiatry, Springer Science & Business Media, LLC 2011 • Skipper GE, DuPont RL. US Physician Health Programs: A Model of Successful Treatment of Addictions. Counselor: The Magazine for Addiction Professionals. Dec 2010. Vol 11(6) 22-30.

  39. Papers – to date - accepted • Skipper GE, DuPont RL. Anesthesiologists Returning to Work after Substance Abuse Treatment. Anesthesiology, V110, No 6, June 2009 1426-28. • Skipper GE. Physicians and Medical Workers, Substance Abuse Among. Encyclopedia of Drugs, Alcohol & Addictive Behavior, 3rd ed., Macmillan Reference USA, 2008, Vol 3, pages 242-251

  40. Phase I • Preliminary inquiry found 49 PHPs (48 states and Washington DC) • Two states did not have PHPs • N Dakota and Nebraska • 42 programs participated (86%) • 1 program – only 3 participants and not recognized by its board – GA – omitted • 41 programs data reported

  41. Phase I - What are PHPs ? • Most PHPs do not provide treatment services • How PHPs described their function • Manage physician rehabilitation • Oversee treatment and monitoring • Case management • Treatment supervision • Care management • Contingency management

  42. What PHPs Are Named • Physician Health Program • Physician Assistance Program • Health Professionals Program • Diversion Program – California only • Alternative Program

  43. Phase I - Results • PHP Structure/Affiliation • 54% - independent non-profit foundations • 35% - state medical associations • 8% - regulatory licensing boards themselves • 3% - for profit

  44. Phase I - Results • Relationship with Regulatory Licensing Boards* • All programs (100%) claimed some type agreement or letter of understanding with their state licensing board • 71% formal • 29% informal

  45. Phase I - Results • Legal authority to operate – 76% of programs claimed legal authority* • 59% - specific state laws • 20% - peer review laws • 21% - other (memorandum of agreement, not sure, etc) • Ideally legal authority provided • Immunity from liability • Protection of records

  46. Phase I - ResultsPHP Budgets • PHP Budgets - 2005 • $409,895 per year average • $270,000 per year median • $21,250 - $1,500,000 Range • Cost per licensee (Total PHP costs only/ does not include treatment costs) • $23.04 Average • $20.53 Median • $4.33 - $71.44 Range

  47. Phase I - ResultsBudgets Other includes: grants, donations, labs, universities, etc

  48. Phase I - ResultsType ofReferral2005

  49. Phase I - ResultsTypes of Substance Abuse Treatment

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