Transcript Project Blue Print

Project Blue Print
CAPTASA Conf.
By
Gary D. Carr, MD, FAAFP
Diplomate ABAM
Past President FSPHP
7/20/2015
1
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
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The Investigators
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•
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Tom McLellan, PhD
Bob DuPont, MD
Greg Skipper, MD
FSPHP Steering Committee
Grant from Robert Wood
Johnson Foundation
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Study Design
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•
•
•
•
•
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Physicians Only
Questionnaires
Retrospective Study: Phase I & II
Tested by 5 PHPs
F/U Calls
Steering Committee Adjustments.
4
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
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•
•
•
•
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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
Regulatory
71% formal
Licensing
Board
29% informal
• Legal authority – 76%
59% - specific state laws
Medical
Association
or
20% - peer review laws
Society
21% - other (Contract)
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Independent
Non-Profit
Foundation
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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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35%
30%
25%
20%
15%
10%
5%
0%
7/20/2015Mandated
Informal
< Formal
self Ref
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Drugs of Abuse
•
•
•
•
•
•
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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
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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%
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Types of Material Drug
Tested*
Urine
Hair
50%
3%
21%
Breath 1%
Saliva
100%
96%
4%
18%
Sweat 0%
0%
3%
Other 0.1%
0%
20%
40%
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60%
80%
100%
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Physicians Tested
* N = 36 Programs
Responding
Programs Testing
Material
20+ Panel
Types of Drug Test61%
Panels
66%
Used*
36%
Flex Testing
20%
36%
40+ Panel
7%
19%
5- or 10- Panel
2%
14%
Drug of Abuse Only
2%
0%
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20%
40%
Physicians Tested
60%
80%
100%
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Programs Using Panel
* N = 36 Programs Responding
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
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* N = 40 Programs Responding
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.
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* N = 39 Programs Responding
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
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* N = 36 Programs Responding
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%
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10%
20%
30%
40%
Non-Mandated
50%
60%
70%
80%
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Mandated
* N = 35 Programs Responding
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 – 904 Physician Charts
Characteristics
%
Sex
Women
Men
14
86
Age, Mean (44.1 years)
<40 y
40-60 y
>60 y
18
68
14
Marital status at contract signing
Married
Divorced
Single
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Separated
Other
63
14
16
4
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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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Level of Treatment Received
Type of Substance Abuse
Treatment
Residential treatment
N 899
575
Percent
63%
Mean Days of
Treatment
72
Range 1 – 393
SD = 44.9
Mdn = 71
194
Range 7 – 2132
SD = 381.2
Mdn = 73
Successfully
Completed
98.6%
Intensive Outpatient –
not allowed to work
80
9%
94.3%
Intensive Outpatient allowed to work
d. Other Outpatient,
Explain: _96 docs did not
receive treatment
(renewals, transfers,
etc)_____________________
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___
162
18%
90.1%
82
9%
92.9%
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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
• Level II Outside of practice
• Level III In context of practice
15%
16%
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
a. Health professionals aftercare group facilitated by a paid mental health
professional
(WAS THIS CADUCEUS?)
% Yes % Required
(n=908)
(n=908)
61
55
33
31
2
2
92
86
7
4
g. Psychiatric care
31
27
h. Individual therapy
38
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i. Identified physician medication monitor
43
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j. PHP follow-up visits to office or committee
53
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k. Worksite monitors
34
31
l. Sponsor
76
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m. Annual retreat or other addiction/recovery-related CME______________
30
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b. Health professionals aftercare group - Non-facilitated
c. Non-health professional aftercare group facilitated by a paid mental health
professional
d. AA/NA or other 12-step groups
e. 12-step “Alternative” Groups (RR, SOS, or other)
n. Other
Antabuse -1, Caduceus 26, halfway house, family therapy – 3,
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Meeting logs - 25, Recovery progress report 36 (these are number of cases
and not percents)
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10
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
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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
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General Population Relapse Rate at One Year
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
5 yr
PHPs
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Drug
Court
Standard
All
Entering
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License Status
a – Active
b – Inactive
c – Retired
d – Unlicensed
e – Probation or other action
able to practice
f - Suspended
g – Revoked (no license)
h – Reported to NPDB ref
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monitored condition
At Date of
Signing
%
(n=908)
75
2
0.2
8
Most Recently
%
(n=908)
72
3
2
5
8
5
7
0.2
5
4
???
???
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Most Recent Status of Medical Practice
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•
•
•
•
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)
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•
•
•
•
•
•
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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%)
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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)
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Some Important Findings
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• 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.
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Conclusions
• PHPs are effective
• Addiction is highly treatable
• Recovering Doctors can
practice safely
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Conclusions
• Many possible reasons
physicians do well:
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– Wealth, position, family
supports
– Higher quality care
– Most Important:
Monitoring with support
& contingency plan
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Conclusion
•
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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?
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Contact Me
Gary D. Carr, MD, FAAFP
Diplomate ABAM
Medical Director Emeritus PHN
Past President FSPHP
BRI II
Office: Southern Neuro and Spine Institute
1 Lincoln Parkwaqy
Suite 303
Hattiesburg, MS 39402
Cell No. 601-297-6777
Email – [email protected]
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