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
Presented by
Amanda Buhl, MPH Mick Oreskovich, MD
Research Coordinator, Washington
Physicians Health Program
Psychiatric Medicine Associates
Gary Carr, MD
Charles Meredith, MD
Medical Director, Washington
Physicians Health Program
Associate Medical Director, Washington
Physicians Health Program
Washington Physicians Health Program
Risk Factors for Relapse Among
Healthcare Practitioners with a
Substance Use Disorder:
A Follow-up Study
Background: Domino, et al.1
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 cooccurring 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)
Background: McLellan, et al.2
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.
Background: Skipper, et al.3
• N=83 Anesthesiologists compared to
697 Nonanesthesiologists from Blue
Print Study
Anesthesiologists Nonanesthesiologists P Value
Positive Drug
Tests
11%
23%
0.02
Reported to
Board
18%
20%
0.77
Completed
Contract
71%
64%
0.09
Licensed and
Practicing
Medicine
76%
73%
0.21
Background: Buhl, et al.4
• N= 144 Surgeons compared to 636
Nonsurgeons from Blue Print Study
Surgeons
Nonsurgeons
P Value
Positive Drug
Tests
22%
21%
0.91
Reported to
Board
19%
20%
0.70
Completed
Contract
62.5%
65%
0.68
Licensed and
Practicing
Medicine
67%
75%
0.10
Did Not Return to
Medicine
26%
17%
0.02
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
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.
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.
New data: 2002 - 2008
Results: Descriptive Characteristics
N
Age (years)
MeanSD
Range
Age
< 40
>= 40
Gender
Female
Male
Specialty
Anesthesiology
Dentistry
Emergency Medicine
Family Medicine
Internal Medicine/Sub-Specialty
Psychiatry
Physician Assistant
Surgery/Sub-Specialty
Access to IV Drugs
No access to IV drugs
Access to IV drugs
%
4710
27-70
38
133
22%
78%
30
142
17%
83%
11
28
20
25
26
11
18
16
6%
16%
12%
15%
15%
6%
10%
9%
106
66
62%
38%
New data: 2002 - 2008
Results: Descriptive Characteristics
Drug of choice
Alcohol
Fentanyl
Minor opioids
Major opioids
Other
Smoker
No
Yes
Family history
No
Yes
Co-occurring disorders
No
Yes
N
%
103
4
32
16
17
60%
2%
19%
9%
10%
107
63
63%
37%
68
102
40%
60%
45
127
26%
74%
New data: 2002 - 2008
Results: Descriptive Characteristics
Co-occurring disorders
Both axis 1 and axis 2
Axis 1 but not Axis 2
Axis 2 but not Axis 1
Neither axis 1 nor axis 2
Past Psych. Treatment
None
Outpatient only
Inpatient
Psych. Meds at enrollment
No
Yes
Past lethal behaviors
None
Ideation
Attempt
N
%
35
82
10
45
20%
48%
6%
26%
80
71
21
47%
42%
12%
82
86
49%
51%
118
40
12
69%
24%
7%
New data: 2002 - 2008
Results: Relapse Rates
Estimated 1-, 3- and 5-year cumulative
relapse-free rate (%) for all subjects
1-year rate
(95% CI)
All
subjects
3-year rate
(95% CI)
86% (81%-92%) 82% (76%-88%)
5-year rate
(95% CI)
79% (72%-87%)
New data: Frequency of Relapse
Frequency of Relapse*
2% 2% 1%
12%
No Relapse
1 Relapse
2 Relapse
83%
3 Relapse
4 Relapse
*For clients admitted
1/1/2002 – 12/31/2008
n=172
Domino & Buhl Data
Buhl et al (only WPHP)
Not yet 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
New data: 2002 - 2008
Results: Cox regression summary - all subjects
Risk Factor
Age
<40
>=40
Gender
Male
Female
Specialty
Anesthesiology
Dentistry
Emergency Medicine
Family Medicine
Internal Medicine
Psychiatry
Physician Assistant
Surgery Sub-Specialty
Access to IV Drugs
No access to IV Drugs
Access to IV drugs
N
HR (95% CI)
38
133
ref.
1.75 (0.61-5.01)
142
30
ref.
0.72 (0.31-1.67)
11
28
20
25
26
11
18
16
0.42 (0.05-3.61)
1.26 (0.38-4.15)
0.79 (0.19-3.33)
1.50 (0.45-4.94)
ref.
0.55 (0.06-4.74)
1.61 (0.47-5.56)
0.38 (0.04-3.31)
106
66
ref.
0.98 (0.47-2.03)
p*
0.3
0.4
0.4
0.4
0.7
0.8
0.5
0.6
0.5
0.4
1
New data: 2002 - 2008
Results: Cox regression summary - all subjects
Risk Factor
Smoker
No
Yes
Family history
No
Yes
Co-occurring disorders
No
Yes
Co-occurring disorders
Not Axis 1
Axis 1
Co-occurring disorders
Not Axis 2
Axis 2
Number of axis 2
diagnoses
Co-occurring disorders
Total number of diagnoses
N
HR (95% CI)
p*
107
63
ref.
2.17 (1.06-4.46)
0.03
68
102
ref.
1.06 (0.51-2.21)
0.9
45
127
ref.
1.62 (0.62-4.25)
0.3
55
117
ref.
1.15 (0.51-2.59)
0.7
127
45
ref.
1.94 (0.93-4.03)
0.08
1.42 (1.04-1.93)
0.03
1.25 (0.97-1.60)
0.08
New data: 2002 - 2008
Results: Cox regression summary - all subjects
Risk Factor
Drug of Choice , Fentanyl and major
opioids combined
Alcohol
Minor opioids
Major opioids & fentanyl
Other
Drug of Choice: Fentanyl
No
Yes
Drug of Choice:
Fentanyl or major opioids
No
Yes
Drug of Choice: Alcohol
No
Yes
Any alcohol: Any use
No
Yes
N
HR (95% CI)
p*
0.2
103
32
ref.
0.64 (0.24-1.69)
0.4
20
17
0.55 (0.16-1.85)
0.21 (0.03-1.59)
0.3
0.13
168
4
ref.
0.00 (0.00-Inf)
1
152
20
ref.
0.69 (0.21-2.27)
0.5
69
103
ref.
2.00 (0.91-4.38)
0.08
39
ref.
133
3.36 (1.02-11.12) 0.047
Next steps...
• Examine relapse DOC
• Increase N
• Why alcohol? – legal gateway
drug?
• Importance of ETG?
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)?
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)
Future Questions
• Increased sample size
– (independent effects of specialty)
• Recovery planning
• Other factors (stress/burnout) that
contribute to relapse
• Patient harm/malpractice incidents
Special thanks...
• Mick Oreskovich, MD
• Charles Meredith, MD
• Gary Carr, MD
• Nayak Polissar, PhD
• Moni Blazej Neradilek, MS
References
1.
2.
3.
4.
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 5year 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.