Project Blue Print CAPTASA Conf. By Gary D. Carr, MD, FAAFP Diplomate ABAM Past President FSPHP 11/30/2018

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 11/30/2018

The Investigators Tom McLellan, PhD Bob DuPont, MD Greg Skipper, MD FSPHP Steering Committee Grant from Robert Wood Johnson Foundation 11/30/2018

Study Design Physicians Only Questionnaires Retrospective Study: Phase I & II Tested by 5 PHPs F/U Calls Steering Committee Adjustments. 11/30/2018

Phase I Structure and Function of PHPs Survey 49 states 42 (86%) Responded Physicians entering before 9/01 Cases taken sequentially 11/30/2018

PHP Affiliation 54% Independent 501c3 Corp 35% Component of Med. Assoc. 10% Board Run 11/30/2018

Physician Health Issues Addressed Substance Use Disorders -100% Psychiatric Illness - 85% Distressed Behavior - 79% Physical Illness - 62% Other - 18% 11/30/2018

Professions Served Physicians Only 36% Physicians and Others 64% Dentists 51% Veterinarians 33% Podiatrists 23% Pharmacists 21% Others 18% 11/30/2018

PHP Referral Sources State PHPs Board 21% Self 26% Colleagues 22% Med Staff 14% Other 17% 11/30/2018

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) 11/30/2018

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 11/30/2018

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 11/30/2018

11/30/2018

Drugs of Abuse 49% - Alcohol 35% - Opioids 8% - Stimulants 5% - Sedatives 3% - Marijuana 2% - Other Alcohol Only – 37% Drugs Only - 27% Both - 31% 11/30/2018

Co-occurring Psychiatric Illness 37.4% Average 40% Median Range 16% - 65% Probably skewed. More reasonably 40 – 50 % 11/30/2018

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% 11/30/2018

Types of Material Drug Tested* 11/30/2018 * N = 36 Programs Responding

Types of Drug Test Panels Used* 11/30/2018 * 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 11/30/2018 * 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. 11/30/2018 * 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 11/30/2018 * N = 36 Programs Responding

Board Reporting Requirements 11/30/2018 * N = 35 Programs Responding

Phase II 11/30/2018

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 11/30/2018

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 11/30/2018

Characteristics – 904 Physician Charts % Sex Women 14 Men 86 Age, Mean (44.1 years) <40 y 18 40-60 y 68 >60 y Marital status at contract signing Married 63 Divorced Single 16 Separated 4 Other 11/30/2018

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 11/30/2018

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% 11/30/2018

Specialties Overrepresented Anesthesiology, Emergency Medicine, Psychiatry, and Family Practice Underrepresented Pediatrics, Surgery, Pathology 11/30/2018

Level of Treatment Received Type of Substance Abuse Treatment N 899 Percent Mean Days of Treatment Successfully Completed Residential treatment 575 63% 72 Range 1 – 393 SD = 44.9 Mdn = 71 98.6% Intensive Outpatient – not allowed to work 80 9% 194 Range 7 – 2132 SD = 381.2 Mdn = 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 92.9% 11/30/2018

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. 11/30/2018

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 !!! 11/30/2018

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). 11/30/2018

Components of monitoring program % Yes (n=908) % Required 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 d. AA/NA or other 12-step groups 92 86 e. 12-step “Alternative” Groups (RR, SOS, or other) 7 4 g. Psychiatric care 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 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 11/30/2018

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 11/30/2018

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 11/30/2018

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 11/30/2018

General Population Relapse Rate at One Year 5 yr 11/30/2018

License Status 75 72 2 3 0.2 8 5 7 4 ??? a – Active b – Inactive At Date of Signing % (n=908) Most Recently a – Active 75 72 b – Inactive 2 3 c – Retired 0.2 d – Unlicensed 8 5 e – Probation or other action able to practice f - Suspended 7 g – Revoked (no license) 4 h – Reported to NPDB ref monitored condition ??? 11/30/2018

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%) 11/30/2018

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%) 11/30/2018

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) 11/30/2018

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. 11/30/2018

Conclusions PHPs are effective Addiction is highly treatable Recovering Doctors can practice safely 11/30/2018

Many possible reasons physicians do well: Conclusions Many possible reasons physicians do well: Wealth, position, family supports Higher quality care Most Important: Monitoring with support & contingency plan 11/30/2018

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? 11/30/2018

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 – Docgcarr@aol.com 11/30/2018