Victorian Doctors Victorian Doctors Health ProgramHealth Program

Dr Naham (Jack) WarhaftDr Naham (Jack) WarhaftM.B.,B.S., F.A.N.Z.C.AM.B.,B.S., F.A.N.Z.C.A., F.A.Ch.A.M.., F.A.Ch.A.M.

Medical DirectorMedical Director

VICTORIAN DOCTORS

ICPH Ottawa, Nov 2006

An Alternative Approach to 12-step Participation in the Management of

Addicted Physicians

HEALTH PROGRAM

VICTORIAN DOCTORS

Victoria is the second largest state by population in Australia. It has about

•5 million people;

•17 000 doctors and

•2000 medical students

It covers an area about the size of North Carolina. Approximately 3 million live in Melbourne and a further 1 ½ million within 90 minutes drive

VICTORIA

VDHP - Principal Aims

• To assist doctors and medical students whose condition will, or is likely to, impact adversely on their ability to continue to practice medicine.

• An independent legal entity• Confidential professional service

MODEL

• US and Canadian PHPs– The original intention was to use the North

American model. – It became apparent that it would have to be

• Modified to suit Australian conditions

• Commenced May 2001

VDHP Services

• Intervention• Assessment and referral• Case management• Aftercare and monitoring• Assistance with re-entry to work• Caduceus (support and monitoring) groups• Family support• Advocacy – Work, MPBV, Courts

Administrative Structure

• Independent Board of Management: – 3 doctors appointed by the AMA– 3 doctors appointed by the Medical Board (but not

on the Medical Board)– Chairperson jointly appointed by AMA and

MPBV• Fully funded by the Medical Board

Main differences between Australia and North America

CULTURAL

LEGAL

Some Cultural DifferencesSome Cultural Differences

• Concept of ‘cross addiction’ is poorly recognised• More Secular Society

– Religion is considered a more ‘private’ matter– Low level of religious observance (monthly attendance is approximately

10% in Australia compared with over 40% in the US). – This has implications for 12-step programs, but AA / NA are well

established all over the country

• Anti-authoritarian attitude• ‘Drink til you drop’ attitude. Moderate inebriation is

tolerated. • ‘Wowsers’ are thin on the ground.

In Australia:

Legal DifferencesLegal Differences

• Much lower level of litigation in Australia (but we’re learning, and catching up fast!)

• As a consequence, some of the North American programs appear to us to be more rigid (less capacity to tailor to individual needs)

• We have never had a lawyer represent a doctor at the VDHP or at a back-to-work conference

• Our MPBV is more interested in impairment than drug use

Recovery PathwaysRecovery Pathways

12-Step Non-12-Step

Preferred Pathway • 12-Step not desired by all participants

• 12-Step may be counter-productive for some participants

Comprehensive program More tailored approach required

Total abstinence Allows for alcohol consumption in some cases

Selection criteria include

• Narrow repertoire of drug use

• Past history of treatment and relapse

• Family history

• Consideration of comorbid disorders

• Enthusiasm for or resistance to 12-Step program

• Total or limited abstinence requirement

Program Requisites

• High quality

• Intense

• Enduring

Program components - TherapyProgram components - Therapy

12-Step Other

AA / NA Mutual Support Group

Caduceus Caduceus

1:1 AOD Counselling 1:1 AOD Counselling

Other Counselling Other Counselling

Medical / Psychiatric Medical / Psychiatric

Reservations about these Results

• No differentiation between dependency or abuse

• Outcome measures are imperfect

• Difficulty in labelling participants as 12-Step or Non-12-Step

ResultsResultsComparison of 12-Step and Other Pathways

(71 participants in Case Management, Aftercare and Monitoring Program – ‘CAMP’)

12-Step (38)

Other (33)

Alcohol

Other Drugs

18

20

9

24

Successful 32 (84%) 28 (85%)

Unsuccessful - Unable to practice

6 5

- In treatment

- Unchanged or Deteriorated

- Dead

1

3

2

1

2

2

Relapses

12-Step (38)

Other (33)

No Relapse in the last 12 months

29

(16 > 3 years)

25

(13 > 3 years)

Some examples of Non-12-StepAlcoholics

• ‘Saltbush Bill’ – 40’s radiologist – now sober 3 years

• ‘Waltzing Matilda’ – 36 yr ENT surgeon – now sober 1 year

• ‘Ben Bowyang’ - 40’s pathologist, DD, 3 years sober

• ‘Crocodile Dundee’ – 50’s physician/academic, DD, 1 year sober

Some examples of ‘Other’Other drugs

• ‘Ginger Mick’ – 65 yrs anaesthetist, narcotics relapsed after 8 years. Now 5 years clean

• ‘Ned Kelly’ – 60 yrs anaesthetist, narcotics, now 10 years clean, but passed on to us due to personality disorder

• ‘Snowy River’ – 35 yrs GP, narcotics. Now 2 years clean

• ‘Midnight Grease’ – 26 yrs, cocaine, speed, alcohol etc. came as student. 3 years clean (1 lapse)

Conclusions

• The VDHP data over 5 years shows no significant difference between the outcomes of the 2 groups

• The wider use of alternatives to AA/NA may assist in the retention in ongoing treatment of some participants

• Further studies are required to help clarify the situation

Conclusions

Our results suggest that there are effective alternatives to 12-Step participation in the management of SUDs in physicians

The experience of the VDHP is that high quality, intense and enduring alternative programs have a significant place in their management.

Further Studies

• It is hoped that in 2007, every VDHP participant with SUDs will be independently reassessed. Outcomes will be analysed in relation to:– Diagnosis (dependency or abuse)– 12-Step or Alternate Program– “Drinking” or “Total Abstinence”

• Outcome measures will also be reviewed.

Victorian Doctors Health Program

Tel. 9495 6011Level 8, Aikenhead Building27 Victoria ParadeFitzroy 3065

vdhp

HEALTH PROGRAM

VICTORIAN DOCTORS