Federation of State Physician Health Programs 2012 Annual Meeting & Conference

1. Risk Factors for Relapse Among Healthcare Practitioners with a Substance Use Disorder: A Follow-up Study of Washington Physicians Health Program Clients Federation of State Physician Health Programs 2012 Annual Meeting & Conference

2. Presented by Amanda Buhl, MPH Research Coordinator, Washington Physicians Health Program Gary Carr, MD Medical Director, Washington Physicians Health Program Mick Oreskovich, MD Psychiatric Medicine Associates Charles Meredith, MD Associate Medical Director, Washington Physicians Health Program

3. Washington Physicians Health Program Risk Factors for Relapse Among Healthcare Practitioners with a Substance Use Disorder: A Follow-up Study

4. Background: Domino, et al.1

5. Background: Domino, et al.1 • N= 292 • 11 year follow-up period • 25% had at least 1 relapse • Family history increased risk (HR 2.29) • Use of major opioid in presence of co-occurring psychiatric disorder increased risk (HR 5.79) • Presence of all three markedly increased risk (HR 13.25) • First relapse increased risk of subsequent relapse (HR 1.69)

6. Background: McLellan, et al.2

7. Background: McLellan, et al.2 • N=904 • 5 years of data • 72% completed or extended contract • 81% had no incident of drug or alcohol misuse • 78% were licensed and working at the end of the monitoring period • 95% of contract completers were licensed at the end of the monitoring period.

8. Background: Skipper, et al.3 • N=83 Anesthesiologists compared to 697 Nonanesthesiologists from Blue Print Study

9. Background: Buhl, et al.4 • N= 144 Surgeons compared to 636 Nonsurgeons from Blue Print Study

10. New WPHP data: 2002 - 2008 AIMS: • Examine relationships between previously demonstrated risk factors for relapse and relapse rates • Examine rates of relapse following program modifications

11. New data: 2002 - 2008 Methods • N = 173 • Retrospective cohort design, 7 years of data • Excluded: • History of prior treatment • Previous clients • Those for whom outcome was not known • MD, DO, PA-C, DDS, DVM, DPM • Personal data collected including: demographics, drug use, health and psychiatric history, and professional information. • All components of study approved by the University of Washington IRB.

12. New data: 2002 - 2008 Statistics • Survival Analysis methods: Cox proportional hazards regression model and log-rank test. • Relapse rate per 1000 person years in each program period: Phase I (0-2 years), Phase II (2-5 years), Phase 3: (5+ years) • Cross-tabulation with X2 test, t tests, or Mann-Whitney test were used to detect co-variates associated with risk factors for relapse.

13. New data: 2002 - 2008 Results: Descriptive Characteristics

14. New data: 2002 - 2008 Results: Descriptive Characteristics

15. New data: 2002 - 2008 Results: Descriptive Characteristics

16. New data: 2002 - 2008 Results: Relapse Rates Estimated 1-, 3- and 5-year cumulative relapse-free rate (%) for all subjects

17. New data: Frequency of Relapse

18. Domino & Buhl Data • Buhl et al (only WPHP) • Notyet published • Domino et al (only WPHP) • JAMA 2005 • N= 292 over 11 years • No Relapse = 75% • Single Relapse = 17% • Two or more = 8% • Death = .6% • Return to practice = 100% NR 61% One or more • Completion of 5 year contract = 86% • Chg of specialty = NA • N=173 over next 7 years • No Relapse = 82% • Single Relapse = 13% • Two or more = 5% • Death = 1% (in remission) • Return to practice = 100% NR 68% One or more • Completion of 5 year contract or still being monitored successfully = 95% • Chg of specialty = NA

19. New data: 2002 - 2008 Results: Cox regression summary - all subjects

20. New data: 2002 - 2008 Results: Cox regression summary - all subjects

21. New data: 2002 - 2008 Results: Cox regression summary - all subjects

22. Next steps... • Examine relapse DOC • Increase N • Why alcohol? – legal gateway drug? • Importance of ETG?

23. What we have learned • Remarkably low relapse rates: importance of tri-modal monitoring (unique PHP care model) • Smoking • Co-occurring disorders (Axis 2) • Alcohol (any use)?

24. Study Limitations • Retrospective cohort design, observational • Sample size! • Small numbers within individual groups • Pooling Domino/Buhl data • Aggregating data from other PHPs • Multivariate models • Incidence of relapse underestimated because of loss of follow up (after 5 years)

25. Future Questions • Increased sample size • (independent effects of specialty) • Recovery planning • Other factors (stress/burnout) that contribute to relapse • Patient harm/malpractice incidents

26. Special thanks... • Mick Oreskovich, MD • Charles Meredith, MD • Gary Carr, MD • Nayak Polissar, PhD • Moni Blazej Neradilek, MS

27. References • Domino, K B, Hornbein TF, Polissar NL, et al. Risk factors for relapse in health care professionals with substance use disorders. JAMA. 2005;293(12):1453-1460. • McLellan T, Skipper GE, Campbell M, DuPont R. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. British Medical Journal 2008;337:a2038 doi:10.1136/bmj.a2038. • Skipper GE, Campbell MD, DuPont RL. Anesthesiologists with substance use disorders: A 5-year outcome study from 16 state physician health programs. Anesthesia and Analgesia. 2009;109:891-896. • Buhl A, Oreskovich MR, Meredith CM, et al. Prognosis for the recovery of surgeons from Chemical Dependency. Archives of Surgery. 2011;146(11):1286-1291.