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,
Promises Treatment Centers
– Medical Review Officer,
Affinity Ehealth
Copy of Slides at:
www.gregskippermd.com
Overview
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Epidemiology
Professional Health Programs in USA
National Study of Physician Health Programs
Outcomes
Intervention
Evaluation
Treatment
Monitoring
Epidemiology
Substance Disorders - Physicians
• 10% - 15% Lifetime prevalence (similar to
population at large)
45
40
44
35
30
33
25
20
15
10
11
5
0
Alcohol
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•
Opiates
Sedatives
7
4
Stimulants
Other
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.
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.
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
Data Regarding Physicians
Why Physicians Use Drugs
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Curiosity
Recreation
Therapeutic
Relaxation
Easy access
Peer pressure
Other
Symptoms of Substance
Abuse among Physicians
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AOB
Cognitive Impairment
DUI
Disruptive
Withdrawn
Unavailable
Missing drug inventory
“Where there’s smoke there’s fire”
M.D.
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D.V.M.
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D.M.D.
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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
Physicians As Patients
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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.
Source of Initial Referral
Physician/Colleague
461
Self Referral
126
BME
107
BME Licensure
105
Hospital Administration
65
Family
26
Nurse
15
Patient
12
Other
127
This is your Medical License…
This is your Medical License…on drugs!
Physician Health Programs
Physician Health Programs
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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
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
How it Works!
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Confidential reports
Discrete inquiry, confidentiality!!!!
Intervention
Referral for thorough evaluation
(physician oriented programs)
Secondary Intervention (if needed)
Treatment
Monitoring
Advocacy and Expert Testimony
Terminology
• Illness
• Disability
• Impairment
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
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.” )
Why Hospital Wellness Committees
Are Not Enough
• Codependence
• Most importantly, over 50% of
physicians are not associated with a
hospital medical staff
Key Ingredients:
What Helps a PHP Be Effective
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Immunity - liability
Confidentiality – records/participants
Trust – w licensing board
Standards – policies and procedures
Leadership – committee oversight
Education
Early intervention emphasizing pt safety
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:
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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
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
Total physicians practicing in-state*
Total Board disciplinary actions (2009)
Total new substance abuse cases
New substance abuse cases per 1,000
licensees**
Total number of physicians in active
monitoring
Physicians in active monitoring per
1,000 licensees
Alabama
Georgia
10,518
64
52
4.95
18,422
132
30
1.63
270
182
25.7
9.9
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
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
Study of
Physician Health Programs
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
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
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=2b230eaeedbb-4b38-951f-75529f5cb2c5)
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
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.
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
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
Phase I - What are PHPs ?
• Most PHPs do not provide treatment
services
• How PHPs described their function
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Manage physician rehabilitation
Oversee treatment and monitoring
Case management
Treatment supervision
• Care management
• Contingency management
What PHPs Are Named
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Physician Health Program
Physician Assistance Program
Health Professionals Program
Diversion Program – California only
Alternative Program
Phase I - Results
• PHP Structure/Affiliation
– 54% - independent non-profit
foundations
– 35% - state medical associations
– 8% - regulatory licensing boards
themselves
– 3% - for profit
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
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
Phase I - Results
PHP 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
Phase I - Results
Budgets
Average Percentage of Funding from Each Source
50%
50%
40%
30%
16%
20%
10%
9%
10%
6%
10%
0%
State Board
Participant
Fees
Medical Assn
Hospitals
Malpractice
Companies
Other includes: grants, donations, labs, universities, etc
Other
Phase I - Results
Type of
Referral
2005
Type of Referral in 2005
35%
31%
31%
30%
25%
21%
20%
16%
15%
10%
5%
0%
Mandated
Informal
Less Formal
Self Referred
Phase I - Results
Types of Substance Abuse Treatment
Percentage of Participants Receiving
Various Types of Care in 2005
Inpatient
49%
Detoxification
39%
Outpatient
23%
Day Treatment
22%
Intensive
Outpatient
18%
Halfway House
4%
0%
10%
20%
30%
40%
50%
Services provided by PHPs
– Authorizing and monitoring evaluation
and treatment programs
• 28 of 37 programs (76%) maintain list of
authorized providers
• 48% maintain criteria for authorizing them
• All but one program (95%) require
treatment programs to send regular
progress reports during treatment of a
physician
Services provided by PHPs
• Contracts (Agreements) – 100% of programs
required - most for duration of 5 years (one
program 3 years)
• Therapy groups – 95% utilized outside
counselors and required 1-2 years of weekly
groups
• AA/NA – 12 step support groups – 94% referred
and encouraged 5 years of participation
• Worksite monitor – 71% required for 5 years
• Psychiatrist
• Therapist
Services provided by PHPs
Drug Testing
• 100% – random – usually 5 years
(1 program 3 years)
• 25 programs (66%) exclusively
used outside agencies (TPAs) to
conduct drug testing
• 13 programs (34%) managed their
own drug testing programs
Phase I - Results
Licensing board reporting
• 92% of PHPs indicated they had
reported at least one doctor to their
licensing board in the past year
• Number of doctors reported from
PHPs in 2005 = average 5.3, median 3,
range 1-25 reported
Drug Testing - Matrix Tested*
100%
96%
Urine
Hair
Breath
50%
3%
21%
1%
Saliva
4%
18%
Sweat 0%
0%
3%
Other 0.1%
0%
20%
40%
Physicians Tested
60%
80%
Programs Testing Material
100%
Drug Testing - Types of Panels Used*
61%
66%
20+ Panel
36%
Flex Testing
20%
36%
40+ Panel
7%
19%
5- or 10- Panel
2%
14%
Drug of Abuse Only
2%
0%
20%
40%
Physicians Tested
60%
80%
100%
Programs Using Panel
Frequency of Drug Tests*
• Compared the first and last years of
contracts
– 4 times per month in the first year of contract
(about 48 tests in initial year)
• Range = 12 to 120 tests per physician
– final year of contract, the average about 20 tests
per year
• Range = 4 to 72 tests per physician
– PHPs increase frequency of testing
substantially if problems appear
EtG Testing*
• 61% of physicians routinely receive EtG
testing
• 83% receive it on an as needed basis
• Cutoff level used for EtG testing varied
from 100 to 500 ng/ml with the median
being 250 ng/ml
Board Reporting Requirements*
Percent of PHPs Required to Report to Board
50%
Any Use
29%
53%
Any Use + Test
37%
56%
51%
Repetitive Relapse
47%
49%
Repeated + Test
71%
69%
Danger to Patients
0%
10%
20%
30%
40%
Non-Mandated
* N = 35 Programs Responding
50%
60%
70%
Mandated
80%
Phase II
Outcomes
Method
• All programs invited
• 16 PHPs agreed to
participate
• Western – 3, Central
- 2, SW - 1, SE - 6
and NE – 4
• Record review
instrument
developed
• Programs paid $20
per record reviewed
STATE
Valid
AL
CO
DC
FL
IL
IN
KY
MA
MS
MT
NC
NJ
NY
SC
WA
WY
Total
Frequency
119
78
16
76
80
58
100
30
94
51
23
15
58
61
34
11
904
Percent
13.2
8.6
1.8
8.4
8.8
6.4
11.1
3.3
10.4
5.6
2.5
1.7
6.4
6.7
3.8
1.2
100.0
Valid Percent
13.2
8.6
1.8
8.4
8.8
6.4
11.1
3.3
10.4
5.6
2.5
1.7
6.4
6.7
3.8
1.2
100.0
Cumulative
Percent
13.2
21.8
23.6
32.0
40.8
47.2
58.3
61.6
72.0
77.7
80.2
81.9
88.3
95.0
98.8
100.0
Inclusion Criteria
• Physicians only
• Signed monitoring contract
involving regular drug
testing on or before
September 1, 2001
• Records taken sequentially
• 904 records reviewed &
included in study
• Data collected between
11/2006-1/2007
Year signed monitoring contract
Year
Enrolled in
PHP
N
%
2001
228
25.2%
2000
296
32.7%
1999
135
14.9%
1998
116
12.8%
1997
66
7.3%
1996
50
5.5%
1995
14
1.5%
Total
904
100.0%
Types of Contracts/Agreements
Type of Contract
N
%
Avg. Duration
Alcohol or substance
797 88.2%
Dependence
Alcohol or substance
86 9.5%
Abuse/Diagnostic
Monitoring
Other (e.g., no type, etc.) 18 2.0%
4.7 years
Continued Monitoring
1.5 years
3
0.3%
2.9 years
3.1 years
Characteristics – 904 physician records
Primary drug of
choice
Alcohol
Opioids
Stimulants
Other
Injection Drug Use
Arrest related to
alcohol or drugs
Conviction(s)?
%
50
36
8
6
14
17
9
General
Population
9%
13%
Specialties
• Overrepresented
– Anesthesiology (2.5 to 1)
– Emergency Medicine, Psychiatry, and
Family Practice
• Underrepresented
– Pediatrics, Surgery, Pathology
Other Findings
Referred to PHP by
Regulatory Board
Hospital (Admin or Med Staff)
Self (w/ coercion)
Colleague or Partner outside Hospital
Self (w/o apparent coercion)
Treatment centers
Other
%
22
18
14
14
11
7
9
Use of medication to treat
addiction
• Only one individual, of the entire 904 physician
cohort, was placed on methadone (no other
agonist therapy used).
• Naltrexone was used in 46 (6%) of individuals as
an adjunct to treatment,
• 32% were placed on antidepressants.
Overall Outcomes - Completions
Physicians consecutively enrolled into 16 state
physician health programs (n=904)
Transferred or moved and lost to follow-up (n=102):
•Transferred in good standing (n=78) and
•Left care with no apparent referral (n=24)
Followed 5 or more years (n=802)
64% Completed
contract (n=515):
16% Extended
contract (n=132):
•Not monitoring (n=448)
•Voluntarily continued
monitoring (n=67)
•Relapse(s) resulted in
further treatment and
monitoring
19% Failed to
complete contract
(n-155):
•Retired (n=85)
•License revoked (n=48) or
•Died (n=22; 6 suicides)
Outcomes - Licensure Status
License Status
Active
Inactive
Retired
Probation or other action but
licensed with restrictions and
able to practice
Revoked (no license)
At Date of
Signing
%
(n=802)
Most
Recently
%
(n=802)
75
2
0.2
72
3
2
8
5
0.2
4
Outcomes – relapses, patient harm
Relapses
Relapse “behavior” without illicit drug or alcohol use
(i.e., dishonesty, failing to attend meetings, angry
outbursts, etc.
b. Relapse with illicit drug or alcohol use outside the
context of active medical practice, on call duties, etc.
c. Relapse with illicit drug or alcohol use directly
affecting or potentially affecting medical practice (i.e.,
at work, on call, and/or unable to report to work)
(n=904)
%
15
16
5
d. Specific identified harm done to a patient because of
relapse (noted in record)
0.1
Long-Term PHP Drug Test
Results
Conclusions
• This form of care management (contingency
contracts, and intensive monitoring) in this
population is highly successful – 19% failed to
complete, 96% retained license, 79% total
abstinence at 7.2 years average follow-up
• Most relapses (80%) were outside the context of
practice and most were detected early
• Anesthesiologists, ER docs, psychiatrists, and
family practitioners at higher risk
• No significant evidence of patient harm associated
with relapses noted in physician records
Anesthesiologists with Substance
Use Disorders: A 5-Year Outcome
Study from 16 State Physician
Health Programs
• 102 anesthesiologists within 904 physician
sample (11%)
• Primary outcomes examined
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–
–
–
–
Relapse
Return to anesthesiology practice
Disciplinary actions
Death
Patient harm
Results
• Anesthesiologists were significantly more
likely
– (p<.001) to enroll in PHP secondary to opioids
than alcohol
– (p<.001) to use intravenously
– (p<.0017) to receive more drug tests (101 vs 82)
• Anesthesiologists were significantly less
likely
– (p<.0017) to fail at least one drug test (11% vs
23%)
Results
• No statistically significant differences
between anesthesiologists and other
physicians regarding
–
–
–
–
Program completion
Disciplinary actions
Return to practice
Deaths
• No documented incident of patient harm
Physician Health Program
Component Parts
- Intervention
- Evaluation
- Treatment
- Monitoring
Intervention
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•
•
•
•
Most important
Boundaries, boundaries, boundaries!
Careful use of leverage - key
Less may be better
Intervene “to evaluation” rather than to
treatment
• Set a time limit
• Specify re work
Evaluation
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•
•
•
Most difficult component to do well
Progressive evaluation not good
Criteria for authorized providers - good
Best to do most thorough evaluation at first
opportunity
• Multidisciplinary assessment is best
• Evaluation based on established diagnostic
criteria – best if specifically detailed
• Only use programs with high integrity
Evaluation Components
• Addiction Medicine
• Psychological evaluation
• Psych testing – cognitive testing,
personality testing, etc.
• Psychiatric assessment
• Group assessment
• Treatment milieu
• Referent
• Sex, Pain, Gambling, etc.
Treatment
•
•
•
•
Best if individualized
Variable length of stay
Goal oriented
Mix of professional and nonprofessional groups, AA, educational,
family, aftercare
• Long-term monitoring
Monitoring
• Contingency contract/agreement
• Duration – health professionals usually
5+ years
• Opportunity to continue voluntarily
• 3rd party monitoring – TPA, etc.
• Drug testing, worksite monitoring,
groups, individual therapy, etc
Reporting or Assisting a
Troubled Peer?
These doctors can’t help
themselves…
Greg Skipper, MD
Director Professional Health Services
Promises Treatment Centers
www.professionalstreatment.com
www.professionalsevaluations.com
gskipper@promises.com
310-633-4595