Healthcare Professionals as Walking Wounded: Saving Lives and - PDF document

Healthcare Professionals as Walking Wounded: Saving Lives and Saving Careers J. Randle Adair, DO, PhD randleadair@gmail.com New Mexico Pharmacists Association Annual Meeting January 25, 2020 1 Demographics • The prevalence of addiction in health care professionals (HCPs) is similar to that of the general population (8- 13%) – Physicians use less nicotine, but consume more opioids and sedatives (5x more likely than the general population) • Substance use is highest in psychiatrists and ER physicians – Anesthesiologists are overrepresented in treatment and are frequent users of highly potent opioids – Family physicians might also be overrepresented, but this is beginning to change with the elimination of sample closets 2 1

Demographics • The reasons for higher rates of opioid and benzodiazepine substance use disorders among physicians and other HCPs are multi-factorial: – Easier access • Prescriptive authority combined with lack of PCP or access to PCP – Frequently used in the line of work – Stressful work environment – Personality factors (perfectionism) – Feelings of omnipotence – Intellectualization 3 A Look at some Stereotypes 4 2

Alcohol Abuse or Dependency by Specialty (Oreskovich , FSPHP’14) 5 Oreskovich, MR, et al., 2012. Prevalence of alcohol use disorders among American surgeons. Arch Surg 147: 168-174. • 7,197/25,073 (28.7%) of respondents – 15.4% of respondents scored abuse or dependence – Males 13.9% vs females 25.6% – Odds Ratio with abuse or dependence • major medical error within 3 months (OR 1.45) • (+) depression screen (OR1.48) • Married/partnered (OR 2.29) • Age, for each year older (OR 0.99) • Male (OR 0.56) 6 3

What are the signs & symptoms? • There may be none! – “The job is the last to go” – Cover-ups – Enablers – Institutional denial • There may be many but…….! – WNL = “we never looked” – “I attributed it to………” • “It was prescribed for me……” – “It’s legal in Colorado!” 7 Relationship between Presence of Alcohol Abuse/Dependence and Major Medical Errors (Oreskovich , FSPHP’14) No Symptoms of alcohol abuse or Symptoms of alcohol abuse or dependence by AUDIT-C dependence by AUDIT-C (N=6109) (N=1100) • Major medical error last 3 • Major medical error last 3 months: months: • Yes = 10.9% • Yes = 7.9% • No = 89.1% • No = 92.1% p=0.0011 8 4

Ways that HCPs enter treatment: – Health Professionals Program (majority) – Licensing Board – Self-referral (the very best way!) – Family intervention – Work intervention – Provider Wellness Committee – Criminal justice system (much less likely and the least preferred) 9 FSPHP Standards for HCP Treatment • Recommended components: • “ A peer professional patient population and a staff accustomed to treating this population is highly desirable” • “ Must keep state PHP informed throughout the treatment process through calls from the therapists involved as well as written reports. Type and frequency of contact may be arranged with the state PHP but in all cases should occur no less than monthly.” • “ Length of stay must be clinically driven and justified” • “ Extended treatment options when indicated.” • http://www.fsphp.org/2005FSPHP_Guidelines.pdf 10 5

FSPHP Standards for HCP Treatment • Recommended components (continued): • “Must have the medical, psychiatric, and addictions staff necessary to fully address all health issues, obvious and otherwise” • “A multi -disciplinary team approach should be used and include psychological, psychiatric and medical stabilization ” • “Staff to patient ratio should be conducive to each patient receiving individualized attention ” • http://www.fsphp.org/2005FSPHP_Guidelines.pdf 11 FSPHP Standards for HCP Treatment • Recommended components (continued): • “A strong family program is considered mandatory. Family program component should focus on disease education, family dynamics, and supportive communities for family members. Family/SO needs must be accessed early in the process and participation with family/SO programs and individual therapy encouraged. • “Programs must use an abstinence-based model (appropriate psychoactive medication as prescribed). In rare cases that are refractory to abstinence-based treatment, alternative evidence-based approaches should be considered.” • http://www.fsphp.org/2005FSPHP_Guidelines.pdf 12 6

HCP Evaluation & Treatment Options • Residential Evaluation (3-5 days) • Direct Admission – Intensive Residential (30 days) • Extended Care – Residential (30-60 days) • Relapse Evaluation (Residential 14 days) 13 What are possible outcomes of an evaluation? • No problem! • Something other than what you suspected – Medical issues – Axis II – Workplace or domestic issues • Substance Abuse • Substance Dependence • A mixed bag – Increasingly more common 14 7

Program Specifics for HCPs • Assessments – H&P – Practice • Initial & Ongoing – Psychological – Psychiatric – Chemical Dependency – Family & Spiritual – Return-to-Work Assessment – Aftercare Planning 15 Practice (Return to Work) Assessment • Performed near end of stay by treatment center • Includes educational history, C.V. of work history, description of practice, investigation of peer and work relationships, home-life, financial stressors • Detailed look at work hours and intensity, call frequency and intensity • In-depth investigation of drug prescribing habits, availability of drugs, history of diversion • CONCRETE PLAN to provide highest likelihood of success and safety at work • Direct communication with professional referents, employers, monitoring programs 16 8

Do HCPs fare better than the average patient? • Differences in outcomes: – Success rates are disputed, but most agree that outcomes are excellent in >80% of physicians treated – 5- year sustained abstinence rates (rated as a “good outcome”) range from 75 -92% compared to <50% at 1 year in the general population • ~25% of physicians have at least one relapse • 74% of those had only one episode of alcohol or drug use – Outcomes are less impressive for lower levels of care, shorter lengths of stay, and when no monitoring program is involved 17 How much does this party cost?!?! • Residential Evaluation (3-5 days) • $7,000 • Direct Admission – Intensive Residential (30 days) • $35,000 • Extended Care – Residential (30-60 days) • $17 – 35,000 • Relapse Evaluation (Residential 14 days) • $15,000 • Post-treatment Monitoring (1-5 years) • $2,500-3000/year for drug testing 18 9

Is there any good news to report? • Colorado Physician Health Program – N = 82 participants, monitored for 5 years – # of malpractice claims • Prior to entry: 111% worse • Upon entry: 28 % worse • Upon completion: 20 % better – https://www.idaa.org/2013/cme/cme-day-1.pdf 19 SUMMARY – Prevalence of addiction in HCPs is similar to that of the general population – Drugs of choice differ, especially by specialty and access • Alcohol may underlie everything but gets lost in the mix – Treatment requires a structured program with knowledgeable staff and exposure to a cohort of other recovering HCPs – Longer treatment stays, higher levels of intensity, external and internal motivators, and continued structured support after discharge (that includes involvement of a PHP monitoring program) results in unmatched 5-year success rates 20 10

What’s the same? • Evidence of substance ≠ abuse or addiction • Abuse or addiction ≠ impairment • Impairment ≠ Abuse or addiction • Abstinence ≠ Sober • Treatment ≠ Recovery • AA/NA/Monitoring ≠ Treatment • Recovery ≠ Return to work (or prior work) • Return to work ≠ Recovery 21 What’s different? • There may be multiple “patients” – The identified patient (and family) – The Board of Medicine, Nursing, Pharmacy, et al. – The PHP – The legal system – The referring healthcare system • “Safety sensitive” may override all concerns!!!! – Patient confidentiality – Utilization review can be problematic • Post-treatment aftercare, monitoring, and advocacy 22 11

Do I have to lose my job? • No!!!! • Pharmacy Board Regulations specifically provide a pathway for confidential self- referral, professional intervention, treatment and recovery: 16.19.4.12 23 Resources • Provider Wellness Committee of Hospital – Tammy Pressnall, Medical Staff Affairs at Presbyterian for Clinical Pharmacists • New Mexico Healthcare Professional Wellness Program (formerly MTP) • Employee Assistance Programs • www.IDAA.org • New Mexico Board of Pharmacy 24 12

Thank you!! 25 13