Federation of State Physician Health Programs 2012 Annual Meeting & Conference Risk Factors for Relapse Among Healthcare Practitioners with a Substance Use Disorder: A Follow-up Study of Washington Physicians Health Program Clients

Presented by Amanda Buhl, MPH Research Coordinator, Washington Physicians Health Program Gary Carr, MD Medical Director, Washington Physicians Health Program Mick Oreskovich, MD Psychiatric Medicine Associates Charles Meredith, MD Associate Medical Director, Washington Physicians Health Program

Washington Physicians Health Program Risk Factors for Relapse Among Healthcare Practitioners with a Substance Use Disorder: A Follow-up Study

Background: Domino, et al. 1

N= year follow-up period 25% had at least 1 relapse Family history increased risk (HR 2.29) Use of major opioid in presence of co- occurring psychiatric disorder increased risk (HR 5.79) Presence of all three markedly increased risk (HR 13.25) First relapse increased risk of subsequent relapse (HR 1.69)

Background: McLellan, et al. 2

N=904 5 years of data 72% completed or extended contract 81% had no incident of drug or alcohol misuse 78% were licensed and working at the end of the monitoring period 95% of contract completers were licensed at the end of the monitoring period.

Background: Skipper, et al. 3 N=83 Anesthesiologists compared to 697 Nonanesthesiologists from Blue Print Study AnesthesiologistsNonanesthesiologistsP Value Positive Drug Tests 11%23%0.02 Reported to Board 18%20%0.77 Completed Contract 71%64%0.09 Licensed and Practicing Medicine 76%73%0.21

Background: Buhl, et al. 4 N= 144 Surgeons compared to 636 Nonsurgeons from Blue Print Study SurgeonsNonsurgeonsP Value Positive Drug Tests 22%21%0.91 Reported to Board 19%20%0.70 Completed Contract 62.5%65%0.68 Licensed and Practicing Medicine 67%75%0.10 Did Not Return to Medicine 26%17%0.02

New WPHP data: AIMS: Examine relationships between previously demonstrated risk factors for relapse and relapse rates Examine rates of relapse following program modifications

New data: Methods N = 173 Retrospective cohort design, 7 years of data Excluded: –History of prior treatment –Previous clients –Those for whom outcome was not known MD, DO, PA-C, DDS, DVM, DPM Personal data collected including: demographics, drug use, health and psychiatric history, and professional information. All components of study approved by the University of Washington IRB.

New data: Statistics Survival Analysis methods: Cox proportional hazards regression model and log-rank test. Relapse rate per 1000 person years in each program period: Phase I (0-2 years), Phase II (2-5 years), Phase 3: (5+ years) Cross-tabulation with X 2 test, t tests, or Mann-Whitney test were used to detect co-variates associated with risk factors for relapse.

New data: Results : Descriptive Characteristics N% Age (years) Mean  SD47  10 Range27-70 Age < % >= % Gender Female3017% Male14283% Specialty Anesthesiology116% Dentistry2816% Emergency Medicine2012% Family Medicine2515% Internal Medicine/Sub-Specialty2615% Psychiatry116% Physician Assistant1810% Surgery/Sub-Specialty169% Access to IV Drugs No access to IV drugs10662% Access to IV drugs6638%

New data: Results : Descriptive Characteristics N% Drug of choice Alcohol10360% Fentanyl42% Minor opioids3219% Major opioids169% Other1710% Smoker No10763% Yes6337% Family history No6840% Yes10260% Co-occurring disorders No4526% Yes12774%

New data: Results : Descriptive Characteristics N% Co-occurring disorders Both axis 1 and axis 23520% Axis 1 but not Axis 28248% Axis 2 but not Axis 1106% Neither axis 1 nor axis 24526% Past Psych. Treatment None8047% Outpatient only7142% Inpatient2112% Psych. Meds at enrollment No8249% Yes8651% Past lethal behaviors None11869% Ideation4024% Attempt127%

New data: Results: Relapse Rates Estimated 1-, 3- and 5-year cumulative relapse-free rate (%) for all subjects 1-year rate (95% CI) 3-year rate (95% CI) 5-year rate (95% CI) All subjects86% (81%-92%)82% (76%-88%)79% (72%-87%)

New data: Frequency of Relapse

Domino & Buhl Data N= 292 over 11 years No Relapse = 75% Single Relapse = 17% Two or more = 8% Death =.6% Return to practice = 100% NR 61% One or more Completion of 5 year contract = 86% Chg of specialty = NA N=173 over next 7 years No Relapse = 82% Single Relapse = 13% Two or more = 5% Death = 1% (in remission) Return to practice = 100% NR 68% One or more Completion of 5 year contract or still being monitored successfully = 95% Chg of specialty = NA Domino et al (only WPHP) JAMA 2005 Buhl et al (only WPHP) Not yet published

New data: Results: Cox regression summary - all subjects Risk FactorNHR (95% CI)p* Age <4038ref. >= ( )0.3 Gender Male142ref. Female ( )0.4 Specialty 0.4 Anesthesiology ( )0.4 Dentistry ( )0.7 Emergency Medicine ( )0.8 Family Medicine ( )0.5 Internal Medicine26ref. Psychiatry ( )0.6 Physician Assistant ( )0.5 Surgery Sub-Specialty ( )0.4 Access to IV Drugs No access to IV Drugs106ref. Access to IV drugs ( )1

New data: Results: Cox regression summary - all subjects Risk FactorNHR (95% CI)p* Smoker No107ref. Yes ( )0.03 Family history No68ref. Yes ( )0.9 Co-occurring disorders No45ref. Yes ( )0.3 Co-occurring disorders Not Axis 155ref. Axis ( )0.7 Co-occurring disorders Not Axis 2127ref. Axis ( )0.08 Number of axis 2 diagnoses 1.42 ( )0.03 Co-occurring disorders Total number of diagnoses 1.25 ( )0.08

New data: Results: Cox regression summary - all subjects Risk FactorNHR (95% CI)p* Drug of Choice, Fentanyl and major opioids combined0.2 Alcohol103ref. Minor opioids ( )0.4 Major opioids & fentanyl ( )0.3 Other ( )0.13 Drug of Choice: Fentanyl No168ref. Yes40.00 (0.00-Inf)1 Drug of Choice: Fentanyl or major opioids No152ref. Yes ( )0.5 Drug of Choice: Alcohol No69ref. Yes ( )0.08 Any alcohol: Any use No39ref. Yes ( )0.047

Next steps... Examine relapse DOC Increase N Why alcohol? – legal gateway drug? Importance of ETG?

What we have learned Remarkably low relapse rates: importance of tri-modal monitoring (unique PHP care model) Smoking Co-occurring disorders (Axis 2) Alcohol (any use)?

Study Limitations Retrospective cohort design, observational Sample size! –Small numbers within individual groups –Pooling Domino/Buhl data –Aggregating data from other PHPs Multivariate models Incidence of relapse underestimated because of loss of follow up (after 5 years)

Future Questions Increased sample size –(independent effects of specialty) Recovery planning Other factors (stress/burnout) that contribute to relapse Patient harm/malpractice incidents

Special thanks... Mick Oreskovich, MD Charles Meredith, MD Gary Carr, MD Nayak Polissar, PhD Moni Blazej Neradilek, MS

References 1.Domino, K B, Hornbein TF, Polissar NL, et al. Risk factors for relapse in health care professionals with substance use disorders. JAMA. 2005;293(12): McLellan T, Skipper GE, Campbell M, DuPont R. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. British Medical Journal 2008;337:a2038 doi: /bmj.a Skipper GE, Campbell MD, DuPont RL. Anesthesiologists with substance use disorders: A 5- year outcome study from 16 state physician health programs. Anesthesia and Analgesia. 2009;109: Buhl A, Oreskovich MR, Meredith CM, et al. Prognosis for the recovery of surgeons from Chemical Dependency. Archives of Surgery. 2011;146(11):