1. Substance Abuse Issues in Health Professionals Shannon V Chavez, MD Chair, UCSD Physician Well-Being Committee Director, UCSD Health Professional Program Medical Director, UCSD Outpatient Psychiatric Services UC San Diego School of Medicine

2. Defining Substance Abuse Use of legal substances (alcohol, prescribed medications eg opiates) in an uncontrolled fashion, or Use of illegal substances Common Denominators: Impairment at work Impairment at work Negative life impact – family, legal, health Negative life impact – family, legal, health

3. Definition of Disorders  Substance Use Disorders:  Abuse  Dependence  Substance Induced Disorders

4. Substance Abuse  OVER A 12 MONTH PERIOD ONE OR MORE HAS OCCURED:  Failure to fulfill major role obligations  Use of drugs in hazardous situations  Recurrent legal problems secondary to drug use  Continued drug use despite persistent social/interpersonal problems BECAUSE of use

5. Substance Dependence Tolerance Withdrawal Drug is taken in larger amounts than intended, or over longer time than intended Efforts to cut down or control use are unsuccessful Efforts to cut down or control use are unsuccessful Excessive time is spent obtaining, using and recovering from drug effects Important activities – social, professional, recreational are reduced or given up completely Continued use DESPITE knowledge these problems Continued use DESPITE knowledge these problems likely caused by the substance/drug likely caused by the substance/drug

6. Substance Induced Disorders  Depression – suicidal thoughts  Anxiety  Psychotic symptoms – hallucinations, paranoia  Mood swings

7. Health Care Professionals  We have a unique relationship with other human beings  Trust and faith in a health care professional is inherent in any relationship whether patient, client or employer  ANY healthcare professional with ANY type of contact (talk, touching, interpreting data etc) has the potential to harm a patient

8. Examples of Impairment:  A physician can ignore pages and miss important diagnoses  A nurse can give substandard bedside care, divert prescriptions, forge prescriptions  A pharmacist can make errors in filling prescriptions  A therapist can give ineffective or inappropriate therapy with boundary violations or patient abandonment  A dentist can give substandard care, fail to give appropriate treatment, divert drugs  A CNA or Home Health Assistant can fail to give care to patients who cannot perform their own ADL’s, abuse patients, divert drugs

9. More Examples for Health Care Professionals  Missed calls and pages  Late and increased sick days  Disheveled appearance/change in appearance  Erratic performance/mood  Slurred speech  Tremors  Unusual medication prescribing/missing medication  Arrests – DUI, DV, shoplifting

10. Does Treatment Work? Federation of State Physician Health Programs  80% of participants had successful completion of treatment programs with return to work under monitoring  Almost 80% of physicians were working successfully as physicians at 5 years

11. Does Treatment Work?  There is not a lot of data in addiction as to the effectiveness of treatment  HOWEVER:  HEALTH CARE PROFESSIONALS ARE HUMAN BEINGS WITH THE SAME PERCENTAGE OF SUBSTANCE ABUSE AS THE GENERAL POPULATION.

12. Does Treatment Work?  Health Care Professionals are subject to medical diseases, other than addiction that can also impair performance.  Q: HOW DO WE ADDRESS THE HEALTH OF OUR HEALTH CARE PROFESSIONALS?  Q: Do we throw all of these practitioners out? Take their licenses?  And if not, how would we go about monitoring their other potentially impairing illnesses - diabetes, high blood pressure, seizure disorders?  Q: Can these practitioners be of service to the public if they are treated and monitored?

13. Does Treatment Work?  A: So – although data is sparse and many health professionals seek and receive successful care on their own without DCA/Board involvement  Data does show that treatment PLUS monitoring can work to create safe health practices in all the healing arts

14. Monitoring Programs  Monitoring Programs do work, with the following caveats:  Monitoring should be CONFIDENTIAL to maintain patient protected rights (when the patient IS the health care provider)  Monitoring should be STANDARDIZED across all the health care professions to ensure all providers meet the criteria of reporting, abstinence and compliance  Substance Abuse/Dependence is a chronic, lifelong illness that may require LIFELONG MONITORING

15. Treatment plus Monitoring  ONE MODEL:  Health Care Provider is evaluated and referred to appropriate level of treatment per evidence based standardized placement criteria (may be voluntary or ordered by DCA)

16. Treatment plus Monitoring  Provider agrees to participate in a formal program that will maintain confidentiality if 100% compliant; if not, reporting laws are enforced  Random body fluid testing (appears to be the single most effective monitoring tool) to detect any relapse following treatment  Worksite monitor reports and open communication with monitoring staff to ensure timely reporting of any concerning behavior  Participation in an abstinence based self help program

17. Treatment plus Monitoring  Multi-system checks in place to ensure practitioner is quickly taken from practice if not 100% compliant  Strict and enforceable rules across all specialties to conform to safe practice standards

18. Voluntary vs Forced Treatment  Very few enter treatment voluntarily – pressure from family, work, judicial system, not just professional boards  Change occurs when addictive behavior is interrupted and tools are given to change lifestyle and attitude  Change does not happen quickly, most programs are 5 years  If provider is unable to be compliant for 5 years, or is chronically relapsing and unable to follow direction, then loss of licensure may be only answer

19. Addiction, Treatment, Punishment, Recovery  Addiction WILL happen – at rate of regular population (10 – 13%)  Impairment MAY happen if addiction not detected and treated  Recovery and productive return to work CAN happen in monitored and standardized settings that allow Boards to communicate effectively with participants and monitoring programs