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

2. 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

3. The Investigators Tom McLellan, PhD Bob DuPont, MD Greg Skipper, MD
FSPHP Steering Committee
Grant from Robert Wood Johnson Foundation
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4. Study Design Physicians Only Questionnaires
Retrospective Study: Phase I & II
Tested by 5 PHPs
F/U Calls
Steering Committee Adjustments.
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5. 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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6. PHP Affiliation 54% Independent 501c3 Corp
35% Component of Med. Assoc.
10% Board Run
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7. Physician Health Issues Addressed
Substance Use Disorders -100%
Psychiatric Illness %
Distressed Behavior %
Physical Illness %
Other %
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8. Professions Served Physicians Only 36% Physicians and Others 64%
Dentists %
Veterinarians 33%
Podiatrists %
Pharmacists %
Others %
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9. PHP Referral Sources State PHPs Board 21% Self 26% Colleagues 22%
Med Staff %
Other %
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10. 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)
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11. Funding The Avg PHP Funding Sources Boards 50% Participants 16%
Medical Assoc %
Hospitals %
Malpractice Carriers 6%
Other %
i.e. The average PHP receives 50% of its funding from the state Board
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12. 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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13. 11/30/2018

14. Drugs of Abuse 49% - Alcohol 35% - Opioids 8% - Stimulants
5% - Sedatives
3% - Marijuana
2% - Other
Alcohol Only – 37%
Drugs Only %
Both %
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15. Co-occurring Psychiatric Illness
37.4% Average
40% Median
Range 16% - 65%
Probably skewed. More reasonably 40 – 50 %
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16. Specific PHP Activities/Requirements
State PHPs
Interventions %
Evals by Referral %
Eval by PHP %
Caduceus Groups %
Outside Psychotherapy 97%
12 Step Programs %
Drug Testing %
Outside TPA %
In House %
Approved Eval/TX Centers76%
Require Progress reports 95%
Worksite Monitors %
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17. Types of Material Drug Tested*
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* N = 36 Programs Responding

18. Types of Drug Test Panels Used*
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* N = 36 Programs Responding

19. 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

20. 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

21. 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

22. Board Reporting Requirements
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* N = 35 Programs Responding

23. Phase II
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24. 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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25. 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

26. 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
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27. 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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28. Prior History of Substance Use Disorder Treatment?
Yes – 39%
No %
Of the 39% with prior treatment…
In Your PHP During prior Treatment?
Yes - 42%
No %
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29. Specialties Overrepresented
Anesthesiology, Emergency Medicine, Psychiatry, and Family Practice
Underrepresented
Pediatrics, Surgery, Pathology
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30. 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

31. 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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32. Relapse (N=904)
Level I Behavior w/out use %
Level II Outside of practice %
Level III In context of practice %
Substance Relapse (Level II/III) in PHPs-22% over an average of 7.2 years monitoring !!!
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33. 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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34. 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
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35. 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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36. 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

37. 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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38. General Population Relapse Rate at One Year
5 yr
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39. 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
???
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40. Most Recent Status of Medical Practice
FSPHP
Full Time Practice 74%
Part Time Practice %
Licensed. No Practice 5%
Not Licensed %
Other %
(May exceed 100%)
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41. Outcomes of Study Participants (N = 904)
FSPHP
Successfully Completed %
Continued Monitoring %
Appropriate Transfer %
Died %
Moved. Lost to F/U %
D/Ced by PHP %
Suicide %
(May exceed 100%)
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42. 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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43. 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.
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44. Conclusions PHPs are effective Addiction is highly treatable
Recovering Doctors can practice safely
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45. 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
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46. 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

47. 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 –
11/30/2018