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Treating Substance Use Disorders in Healthcare Professionals

Penelope P. Ziegler, MD Professionals Resource Network (PRN)

Fernandina Beach, FL

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Penelope P. Ziegler, Disclosures

• Conflicts or potential conflicts of interest: None

• Off-label use of pharmacological agents: Use of topiramate as an anti-craving agent is discussed

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Planning Committee, Disclosures

AAAP aims to provide educational information that is balanced, independent, objective and free of bias and based on evidence. In order to resolve any identified Conflicts of Interest, disclosure information from all planners, faculty and anyone in the position to control content is provided during the planning process to ensure resolution of any identified conflicts. This disclosure information is listed below:

The following developers and planning committee members have reported that they have no commercial relationships relevant to the content of this webinar to disclose: AAAP CME/CPD Committee Members Dean Krahn, MD, Kevin Sevarino, MD, PhD, Tim Fong, MD, Tom Kosten, MD, Joji Suzuki, MD and AAAP Staff Kathryn Cates-Wessel, Miriam Giles, Sharon Joubert Frezza, and Justina Andonian.

All faculty have been advised that any recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported, or used in the presentation must conform to the generally accepted standards of experimental design, data collection, and analysis. Speakers must inform the learners if their presentation will include discussion of unlabeled/investigational use of commercial products.

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Target Audience

• The overarching goal of PCSS-O is to offer evidence-based trainings on the safe and effective prescribing of opioid medications in the treatment of pain and/or opioid addiction.

• Our focus is to reach providers and/or providers-in-training from diverse healthcare professions including physicians, nurses, dentists, physician assistants, pharmacists, and program administrators.

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Educational Objectives

• At the conclusion of this activity participants should be able to:

− List three common psychiatric disorders in healthcare

professionals that can lead to professional impairment.

− Cite three or more advantages of participation in a monitoring program for a professional identified as having a substance use disorder.

− Employ specific resources for assisting professionals with substance use disorders.

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Case Study

• 25 year old single male medical student arrested for DUI with BAL of 0.91 is referred to Professionals Health Program by his school for evaluation.

• At time of evaluation his UDS is positive for EtG/ EtS and THC, and PETH is 170.

• No prior history of treatment for SUD or psychiatric illness

• He denies drinking since his arrest 2 months ago, admits to smoking marijuana at a party the previous weekend but denies regular use.

• He is scheduled to begin third year clinical rotation in internal medicine later this week.

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Epidemiology

• Alcohol abuse and dependence − No difference in incidence or prevalence from general population − Most common SUD in physicians and dentists − Usually has later onset, less antisocial behavior

• Illicit drug abuse and dependence

− Lower than in general population − Marijuana is most common drug of choice

• Prescription drug abuse and dependence

− Higher than in general population − Oral opioids are most common drug of choice − Opioid dependence is most common chemical addiction in

nurses and pharmacists

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Outcomes and Prognosis

• Factors indicating high relapse risk − Presence of co-occurring psychiatric illness − Injection opioids as drug of choice

• Factors associated with low risk of relapse

− Longer period of professional treatment (whether residential or outpatient)

− Longer period of monitoring − Active involvement in 12-Step programs

• Factors not shown to influence relapse risk

− Specialty − Precipitating event for entering program

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Outcomes and Prognosis (cont.)

Incidence of relapse in physicians • 25% experience one or more episodes of return to use of drug of choice

or other chemical(s) • 50% + of these relapsers receive additional intensive treatment • 90% of total return to practice • Approximately 10% of total are unable to complete monitoring due to

relapse and/or death

Incidence of long-term outcomes in physicians • A relapse is the best indicator of more relapses • Timing of relapse provides valuable indicators of need for further

treatment and type of treatment • Continued monitoring improves long-term prognosis • Addressing return to work issues is critical

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Outcomes for Other Professionals

• No large-scale studies

• Outcomes for dentists appear to be similar to outcomes for physicians

• Nurses have poorer outcomes – Higher relapse rates – Higher incidence of license suspension/revocation – Lower rates of successful re-entry – Probably related to fewer resources for treatment

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Initial Treatment of Addictive Disorders

• Reduction of denial and acceptance of diagnosis and need for treatment

• Understanding of chronicity of disease, need for ongoing treatment and monitoring

• Training in relapse prevention

• Identification and treatment planning for complicating co-morbidities

− Psychiatric − Medical

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Why Are Professionals Different?

• Maybe detected and referred for treatment at an earlier stage of disease

− Increases strength of denial − Ultimately improves prognosis if professional is able to accept

diagnosis and need for treatment

• Patient safety and regulatory issues − Demand for assurance of adequate treatment − Ongoing monitoring required to insure compliance and

continued stable functioning

• Personality traits (perfectionism, emotional detachment, need for control) and enabling systems in medical workplace protect disease and support denial

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Risk Factors for Physicians

• Old familiar stress themes − Long hours, lack of privacy − Responsible for life and death decisions − Disrupted family life

• New challenges that cause increased stress

− Managed care, less autonomy − Litigation stress, increasing malpractice rates

• Access to controlled drugs

• Internal issues (personality traits)

− Perfectionism, compulsivity − Difficulties with intimacy, detached from feelings

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Risk Factors for Nurses

• Genetics- high incidence of alcohol/drug dependence in family

• Co-dependent, caretaking traits

• Access to controlled drugs

• Attitude – “Knowledge is power”- knowing how drugs work and what they

are prescribed for will somehow lower my risk – “Waste not, want not”- taking home left over or discarded

medication because I might find a use for it later

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Assessment and Treatment Planning

• When addiction is suspected, medical professional requires careful evaluation. – Is substance use disorder a primary diagnosis? – Are other psychiatric disorders present which also require

immediate treatment? – Are there medical conditions which will complicate the

treatment and recovery?

• Once diagnosis is established, treatment planning is the next step. – What type of treatment is needed? – What level of care is indicated for initial treatment?

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Essentials Elements of Treatment for Addicted Healthcare Professionals

• Effective confrontation of denial, intellectualization

• Acceptance of chronic nature of disease and need for ongoing treatment

• Relapse prevention which addresses issues specific to the professional’s practice or student’s circumstances – Plan for continuing treatment of all identified disorders – Re-entry stresses – Access to drugs – Need for workplace, school monitoring – Dealing with Board issues, legal issues

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Other Important Elements

• Identifying psychiatric co-morbidity

• Addressing complex family dynamics

• Planning for treatment of symptoms which initiated self-prescribing – Chronic pain – Insomnia

• Exploring career issues

• Developing individualized continuing care and relapse prevention plan

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Experience and Training of Treatment Providers

• Familiarity with special needs of professionals

• Familiarity with system with which the professional is involved and ability to provide effective care while remaining responsive to system

• Ability to deal with sophisticated defenses − Intellectualization − Defocusing and redirecting − Caretaking − Devaluing

• Ability to recognize, explore and utilize transference and

counter-transference

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Boundaries in Treating Professionals

• Maintaining clear therapist-patient relationship with persons with whom one identifies and who may be colleagues or co-workers

• Keeping focus on the disease, not the system

• If therapist is recovering, coping with interacting with patient encountered in recovery meetings

• If therapist is not recovering, coping with devaluation of his/her lack of personal experience

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Level of Care

• Outpatient − Individual therapy in early stages of recovery is generally not

effective in reducing denial and increasing honesty. − Group therapy is more effective, but may also fail due to

professional’s tendency to dominate group or engage in caretaking behaviors with other group members.

− Specialized intensive outpatient programs knowledgeable about needs of professionals are hard to find.

• Residential or Partial Hospital − Standard short-term rehabilitation program − Specialized short-term rehabilitation program − Specialized extended care residential or partial hospital program

(60-90 days or more)

• Inpatient- reserved for brief stabilization of acute medical and/or psychiatric concerns

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Medication-Assisted Recovery

• Disulfuram (Antabuse®)- widely accepted and utilized for alcohol dependence by peer-assistance and monitoring programs, but generally ineffective unless witnessed

• Anti-craving drugs (acamprosate, naltrexone, topiramate* and others) for alcohol dependence- accepted

• Antagonist (naltrexone) therapy for opioid dependence)- accepted and encouraged but must be long-acting injectable or witnessed

• Agonist therapy for opioid dependence- controversial

*Off-label

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Agonist Therapy for Opioid Dependence

• Methadone – Majority of physician monitoring programs do not permit doctors to practice

on methadone – Monitoring programs for nurses are more diverse – A few programs have no restrictions – Increasingly, programs are considering case by case requests and requiring

cognitive screening

• Buprenorphine – Increasing number of programs are permitting physicians and other

professionals to practice on buprenorphine if individual is stable and working a comprehensive recovery program

– Some programs require cognitive testing

• Other Issues – Malpractice insurance companies usually will not underwrite a professional on

agonist or partial agonist treatment – Employer/group practice/managed care concerns – Some licensure Boards are opposed to medication assisted treatment

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What About Professionals with Chronic Pain?

• If a professional has a chronic pain condition for which s/he is taking opioids, is that person impaired?

• Should that person be required to be monitored?

• Should that person be required to disclose their medications to their patients?

• If that person is involved in a medical malpractice suit, is her/his personal medical history/medications/etc. discoverable? If s/he has not disclosed the medications to the malpractice carrier, can the carrier refuse to indemnify her/him?

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Monitoring

• Advantages – Improves outcomes – Documents abstinence for needed advocacy – Addresses demand for protection of patients – Rebuilds trust in professional relationships

• Elements of a monitoring contract

– Documentation of treatment compliance and continuing progress – Urine drug screens and other toxicology testing – Compliance with prescribed medications – Hair, nail and blood testing if indicated – Communication with treatment providers, employers, licensure

boards, etc. as indicated

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Re-entry Issues

• Returning to practice – When is the professional ready to re-enter? – What preparations and/or restrictions are needed prior to re-entry?

• Modifications of practice needed

– Changing circumstances in work setting – Access to drugs – Availability of support at work – Work site monitoring – Changing to different work setting – Changing focus of practice – Re-training in a new specialty or profession

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Central Role of Twelve-Step Program Participation for Recovering Professionals

• Specialized treatment programs for physicians and physician monitoring programs document that non-attendance at AA/NA or alternative mutual help programs is single most common factor in relapse.

• Research data support this finding.

• Progression toward relapse often begins with decrease in frequency, then cessation of Twelve-Step meeting attendance.

• Most monitoring programs will accept alternative mutual help programs such as Smart Recovery, Women for Sobriety, etc. that are abstinence based, but availability is limited and no research has been done.

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What Are A Professional’s Reporting Requirements?

• Legally this varies from state to state, and many state statutes that mandate reporting are in conflict with federal confidentiality law 42CFR, Part 2.

• Legal statutes rarely define impairment.

• Your state’s physician health program can usually provide information about laws in the state.

• Where conflict exists, many professionals elect to go with ethical directives and try to get help for colleagues who are experiencing progressive illness.

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Case Study (cont.)

• Initial evaluation recommended a residential 3-4 day evaluation in hopes of providing reassurance and encouragement to be open about chemical use.

• Once his initial fear and shame were decreased, he was able to share more honestly about his increasing tolerance for alcohol and marijuana, episodes of binge drinking, frequent marijuana use, and fears about his future as a physician.

• He did well in an intensive outpatient program experienced in working with medical professionals, monitoring through the PHP, attending specialized 12-Step meetings for medical professionals and regular AA meetings.

• He was able to graduate with his class and matched in a psychiatry residency with advocacy from the PHP for both his residency and his training license. Eventually he hopes to complete an addiction psychiatry fellowship.

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References: Recent Studies Related to Physicians with

Impairing Illness • Buhl A, Oreskovich MR, Meredith CW, Campbell MD, DuPont RL. Prognosis for the recovery of

surgeons from chemical dependency. Arch Surg 2011, 146(11): 1286-1291.

• Domino K, Hornbein T, Polissar N, Renner G, Johnson J, Alberti S, Hankes L. Risk factors for relapse in health care professionals with substance use disorders. JAMA 2005; 293 (12): 1453- 1460.

• DuPont RL, McLellan AT, Carr G, Gendel M, Skipper G. How are addicted physicians treated? A national survey of physician health programs. J. Sub Abuse Treatment 2009, 37: 1-7.

• Galanter M, Dermatis H, Mansky P, McIntyre J, Perez-Fuentes G. Substance-abusing physicians: monitoring and Twelve-Step-based treatment. Am J Addictions 2007; 16: 117-123.

• McLellan AT, Skipper G, Campbell M, DuPont R. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ 2008, 337(41): a2038.

• Merlo LJ, Greene WM, Pomm R. Mandatory naltrexone treatment prevents relapse among opiate-dependent anesthesiologists returning to practice. J Addict Med 2011, 5(4):279-283.

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References: Studies Related to Other Healthcare Professionals with Impairing Illness

• Katsavdakis KA, Gabbard GO, Athey GI. Profiles of impaired health professionals. Bull Menninger Clin 2004, 68:60-72.

• Kenna GA, Lewis DC. Risk factors for alcohol and other drug use by healthcare professionals. Subst Abuse Treat Prev Policy 2008, 29;3:3.

• Kenna GA, Wood MD. The prevalence of alcohol, cigarette and illicit drug use and problems among dentists. J Am Dent Assoc. 2005, 136(7):1023-32.

• Maher-Brisen P. Addiction: An Occupational Hazard in Nursing. AJN 2007, 107(8):78–79.

• Monroe T, Kenaga H. Don't ask don't tell: substance abuse and addiction among nurses. J Clin Nurse 2011, 20(3-4):504-509.

• Pooler D, Sheheen F, Davidson J. Professional impairment: a history and one state’s response. J Addict Diseases 2009. 28: 113-123.

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Resources for Assisting Professionals with Impairing Conditions

• Federation of State Physician Health Programs www.fsphp.org

• American Dental Association Dentist Health and Wellness siweka@ada.org

• National Organization for Alternative Programs (NOAP) www.alternativeprograms.org

• Several recent articles on Medscape, one of which includes state-by-state information http://www.medscape.com/viewarticle/840112_3

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PCSS-O Colleague Support Program and Listserv

• PCSS-O Colleague Support Program is designed to offer general information to health professionals seeking guidance in their clinical practice in prescribing opioid medications.

• PCSS-O Mentors comprise a national network of trained providers with expertise in addiction medicine/psychiatry and pain management.

• Our mentoring approach allows every mentor/mentee relationship to be unique and catered to the specific needs of both parties.

• The mentoring program is available at no cost to providers.

• Listserv: A resource that provides an “Expert of the Month” who will answer questions about educational content that has been presented through PCSS-O project. To join email: pcss-o@aaap.org.

For more information on requesting or becoming a mentor visit: www.pcss-o.org/colleague-support

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PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership with: American Dental Association (ADA), American Medical Association (AMA),

American Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA), American Society for Pain Management Nursing (ASPMN),and

International Nurses Society on Addictions (IntNSA).

For more information visit: www.pcss-o.org For questions email: pcss-o@aaap.org

Twitter: @PCSSProjects

Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Opioid Therapies (grant no. H79TI023439) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the

official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.