04/22/2023 1

Project Blue Print CAPTASA Conf.

By

Gary D. Carr, MD, FAAFPDiplomate ABAMPast President FSPHP

04/22/2023 2

Why Study PHPs

• PHPs claim an amazing success rate. Is it true?

• If it is true, why?• Are their implications for

society in general?• We have high profile

detractors• A sensation-driven News

Media does not consider a success story newsworthy

04/22/2023 3

The Investigators

• Tom McLellan, PhD• Bob DuPont, MD• Greg Skipper, MD• FSPHP Steering

Committee

Grant from Robert Wood Johnson Foundation

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Study Design

• Physicians Only• Questionnaires • Retrospective Study: Phase I &

II• Tested by 5 PHPs• F/U Calls• Steering Committee

Adjustments.

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Phase I

• Structure and Function of PHPs

• Survey 49 states• 42 (86%) Responded• Physicians entering before

9/01• Cases taken sequentially

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PHP Affiliation

• 54% Independent 501c3 Corp

• 35% Component of Med. Assoc.

• 10% Board Run

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Physician Health Issues Addressed

• Substance Use Disorders -100%

• Psychiatric Illness - 85%

• Distressed Behavior - 79%

• Physical Illness - 62%

• Other - 18%

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Professions Served

• Physicians Only 36%• Physicians and Others 64% Dentists 51% Veterinarians 33% Podiatrists 23% Pharmacists 21% Others 18%

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PHP Referral Sources

State PHPs Board 21% Self 26% Colleagues 22% Med Staff 14% Other 17%

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Authority

• All claim some agreement or memorandum of understanding with their state board

71% formal 29% informal• Legal authority – 76% 59% - specific state laws 20% - peer review laws 21% - other (Contract)

Independent Non-Profit FoundationMedical

Association or Society

Regulatory Licensing

Board

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Funding The Avg PHP Funding

Sources Boards 50% Participants 16% Medical Assoc. 10% Hospitals 9% Malpractice Carriers 6% Other 10%

i.e. The average PHP receives 50% of its funding from the state Board

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Other PHP Characteristics

• Paid PHP Staff 1 – 19 c average = 5 • Budget - $21,000 – 1.5 million c Avg =

$538,000 • Avg no. of New A & D Cases/PHP/Yr Avg 34 / yr (range 0 – 150) • Avg caseload – 138 physicians Range – 9 – 541 Total 5,091 monitored by 37 state PHPs

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0%

5%10%15%20%25%30%

35%

Mandated Informal < Formal self Ref

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Drugs of Abuse• 49% - Alcohol • 35% - Opioids • 8% - Stimulants • 5% - Sedatives • 3% - Marijuana • 2% - Other

• Alcohol Only – 37%• Drugs Only - 27%• Both - 31%

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Co-occurring Psychiatric Illness

• 37.4% Average• 40% Median• Range 16% - 65%

• Probably skewed. More reasonably 40 – 50 %

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Specific PHP Activities/Requirements

State PHPs Interventions 100% Evals by Referral 71% Eval by PHP 18% Caduceus Groups 95% Outside Psychotherapy 97% 12 Step Programs 94% Drug Testing 100% Outside TPA 66% In House 34% Approved Eval/TX Centers76% Require Progress reports 95% Worksite Monitors 71%

04/22/2023 17

Types of Material Drug Tested*

* N = 36 Programs Responding

0.1%

0%

4%

1%

3%

3%

0%

18%

21%

50%

100%96%

0% 20% 40% 60% 80% 100%

Other

Sweat

Saliva

Breath

Hair

Urine

Physicians Tested Programs Testing Material

04/22/2023 18

Types of Drug Test Panels Used*

* N = 36 Programs Responding

2%

2%

7%

20%

66%

14%

19%

36%

36%

61%

0% 20% 40% 60% 80% 100%

Drug of Abuse Only

5- or 10- Panel

40+ Panel

Flex Testing

20+ Panel

Physicians Tested Programs Using Panel

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Frequency of Drug Tests• Compared the first and last years of

contract– Physicians are tested for drugs an average

of 4 times per month in the first year of their contract for a total of about 48 tests in initial year• Range = 12 to 120 tests per physician

– By the final year of the contract, the average frequency of testing is about 20 tests per year• Range = 4 to 72 tests per physician

– In general, PHPs tend to increase the frequency of testing if there has been a positive test * N = 40 Programs Responding

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Randomization of Drug Tests

• All PHPs conduct random drug testing– 22 of 39 (56%) test only

during the week – 16 of 39 (44%) test randomly

including weekends.

* N = 39 Programs Responding

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EtG Testing

• 41% of physicians routinely receive EtG testing

• 43% receive it on an as needed basis

• Cutoff level used for EtG testing varies from 100 to 500 ng/ml with the average being approximately 250 ng/ml

* N = 36 Programs Responding

04/22/2023 22

Board Reporting Requirements

* N = 35 Programs Responding

Percent of PHPs Required to Report to Board

69%

49%

51%

37%

29%

71%

47%

56%

53%

50%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Danger to Patients

Repeated + Test

Repetitive Relapse

Any Use + Test

Any Use

Non-Mandated Mandated

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Phase II

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Programs Participating• All programs invited• 16 PHPs agreed to

participate• Western – 3, Central - 2,

SW - 1, SE - 6 and NE – 4 • Chart review instrument

developed• < 120 physician chart

reviews per program • PHP Staff paid $20 per

chart

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Inclusion Criteria• Physicians only• Must have signed a contract

including DOA testing before 9/1/01

• Chart must be taken sequentially in order proceeding to next previous

• 908 chart reviews submitted• 4 excluded – did not meet

inclusion criteria• Average 7.2 year Follow-up• 904 total included in study

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Characteristics %Sex Women 14 Men 86Age, Mean (44.1 years) <40 y 18 40-60 y 68 >60 y 14Marital status at contract signing Married 63 Divorced 14 Single 16 Separated 4 Other 4

Characteristics – 904 Physician Charts

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Prior History with PHP?

• 77% - No

• 23% - Yes 61% - 1 prior contract 18% - 2 prior contracts 13% - 3 prior contracts 5% - 4 prior contracts 3% - 5 or more

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Prior History of Substance Use Disorder Treatment?• Yes – 39% • No - 61%

Of the 39% with prior treatment…

In Your PHP During prior Treatment?

• Yes - 42% • No - 58%

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Specialties• Overrepresented

– Anesthesiology, Emergency Medicine, Psychiatry, and Family Practice

• Underrepresented– Pediatrics, Surgery,

Pathology

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Type of Substance Abuse Treatment

N 899 Percen

tMean Days of Treatment

Successfully Completed

Residential treatment 575 63% 72Range 1 – 393

SD = 44.9Mdn = 71

98.6%

Intensive Outpatient –not allowed to work

80 9% 194Range 7 –

2132SD = 381.2Mdn = 73

94.3%

Intensive Outpatient - allowed to work

162 18% 90.1%

d. Other Outpatient, Explain: _96 docs did not receive treatment (renewals, transfers, etc)________________________

82 9% 92.9%

Level of Treatment Received

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Use of Medication to Treat Addiction• Only one individual, of the

entire 906 physician cohort, was placed on methadone (no other agonist therapy used).

• Naltrexone was used in 46 (5%) of individuals as an adjunct to treatment,

• 32% were placed on antidepressants.

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Relapse (N=904)

• Level I Behavior w/out use 15%

• Level II Outside of practice 16%

• Level III In context of practice 6%

• Substance Relapse (Level II/III) in PHPs-22% over an average of 7.2 years monitoring !!!

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Relapse• A total of 73,942 drug tests were

performed 162 (18%) participants had at least one positive drug test.

• 199 participants were reported as having relapsed, (Relapses of 37 (19% of relapses) participants were diagnosed by other means than a positive drug test.

• Relapse rate of 22% for participants over the entire monitoring period of 7.2 years (avg).

• Same relapse rate (22%) as previous ten year study of Washington State PHP (Domino et al).

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Components of monitoring program

% Yes(n=908)

% Requi

red(n=908)

a. Health professionals aftercare group facilitated by a paid mental health professional (WAS THIS CADUCEUS?)

61 55

b. Health professionals aftercare group - Non-facilitated 33 31

c. Non-health professional aftercare group facilitated by a paid mental health professional 2 2

d. AA/NA or other 12-step groups 92 86

e. 12-step “Alternative” Groups (RR, SOS, or other) 7 4

g. Psychiatric care 31 27

h. Individual therapy 38 32

i. Identified physician medication monitor 43 41

j. PHP follow-up visits to office or committee 53 48

k. Worksite monitors 34 31

l. Sponsor 76 64

m. Annual retreat or other addiction/recovery-related CME______________ 30 23

n. Other Antabuse -1, Caduceus 26, halfway house, family therapy – 3, Meeting logs - 25, Recovery progress report 36 (these are number of cases and not percents) 11 10

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Outcomes

• 78% - Maintained sobriety over avg

7.2 years• 22% - Relapse (n = 199) 102 (55%) reported to

Board • 11% - Report to Board w/out

relapse

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Outcomes: Relapse and Report to Board• N = 102 physicians relapsed and

reported to Board• 66% had action taken 18% - Practice Limitations 18% - Public Probation

Agreements 23% - License Suspension 8% - License Revocation 9% - Loss of DEA 18% - Managed by PHP 16% - Non-public probation

04/22/2023 37

Actions Against Physicians Who Did Not Experience Relapse• 40% of Physicians w/out

relapse had adverse action 14% - Public Probation 13% - Non-public

Probation 7% - Suspension 6% - Practice

limitations 2% - Revocation

04/22/2023 38

0%10%20%30%40%50%60%70%80%90%

PHPs DrugCourt

Standard AllEntering

General Population Relapse Rate at One Year

5 yr

04/22/2023 39

License Status

At Date of Signing

%(n=908)

Most Recently

%(n=908)

a – Active 75 72 b – Inactive 2 3c – Retired 0.2 2 d – Unlicensed 8 5 e – Probation or other

action able to practice 8 5 f - Suspended 7 5 g – Revoked (no license) 0.2 4h – Reported to NPDB ref

monitored condition ??? ???

04/22/2023 40

Most Recent Status of Medical Practice

FSPHP

• Full Time Practice 74% • Part Time Practice 2% • Licensed. No Practice 5% • Not Licensed 11%

• Other 11% (May exceed 100%)

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Outcomes of Study Participants (N = 904)

FSPHP • Successfully Completed 66% • Continued Monitoring 11% • Appropriate Transfer 8% • Died 2% • Moved. Lost to F/U 5% • D/Ced by PHP 6% • Suicide 1% (May exceed 100%)

04/22/2023 42

Patient Safety?

• One (1) Report of Patient Harm – Overprescribing

• Consistent with earlier study of 259 physicians monitored over 11 years that failed to document even one case of patient harm. (Domino)

04/22/2023 43

Some Important Findings

• 78% Total abstinence x 7.2 yrs• 6% Relapse in context of medical practice• Only 1 report of pt harm

(overprescribing)• PHPs are not utilizing

medications proven helpful (i.e. Naltrexone, Antabuse, Vivitrol, etc)

• More punitive states do not have better outcomes.

04/22/2023 44

Conclusions

• PHPs are effective• Addiction is highly

treatable• Recovering Doctors can

practice safely

04/22/2023 45

Conclusions

• Many possible reasons physicians do well:– Wealth, position, family

supports– Higher quality care– Most Important:

Monitoring with support & contingency plan

04/22/2023 46

Conclusion• Long-term monitoring with

support & contingency plan: May be the missing component to improve addiction treatment outcomes!– May be the key for PHPs– May be the key for Drug

Courts– May be the key for public at

large?

04/22/2023 47

Contact MeGary D. Carr, MD, FAAFPDiplomate ABAMMedical Director Emeritus PHNPast President FSPHPBRI II

Office: Southern Neuro and Spine Institute 1 Lincoln Parkwaqy Suite 303 Hattiesburg, MS 39402

Cell No. 601-297-6777Email – Docgcarr@aol.com