Substance Abuse Issues in Health Professionals Shannon V Chavez, MD Chair, UCSD Physician Well-Being Committee Director, UCSD Health Professional Program.

Substance Abuse Substance Abuse IssuesIssues

in in Health ProfessionalsHealth Professionals

Shannon V Chavez, MDShannon V Chavez, MD

Chair, UCSD Physician Well-Being CommitteeChair, UCSD Physician Well-Being Committee

Director, UCSD Health Professional ProgramDirector, UCSD Health Professional Program

Medical Director, UCSD Outpatient Psychiatric ServicesMedical Director, UCSD Outpatient Psychiatric Services

UC San Diego School of MedicineUC San Diego School of Medicine

Defining Substance AbuseDefining Substance Abuse

Use of legal substances (alcohol, Use of legal substances (alcohol, prescribed medications eg opiates) in an prescribed medications eg opiates) in an uncontrolled fashion, oruncontrolled fashion, or

Use of illegal substancesUse of illegal substances

Common Denominators:Common Denominators: Impairment at workImpairment at work Negative life impact – family, legal, healthNegative life impact – family, legal, health

Definition of DisordersDefinition of Disorders

Substance Use Disorders:Substance Use Disorders: AbuseAbuse DependenceDependence

Substance Induced DisordersSubstance Induced Disorders

Substance AbuseSubstance Abuse

OVER A 12 MONTH PERIOD ONE OR MORE HAS OVER A 12 MONTH PERIOD ONE OR MORE HAS OCCURED:OCCURED:

Failure to fulfill major role obligationsFailure to fulfill major role obligations

Use of drugs in hazardous situationsUse of drugs in hazardous situations

Recurrent legal problems secondary to drug useRecurrent legal problems secondary to drug use

Continued drug use despite persistent Continued drug use despite persistent social/interpersonal problems BECAUSE of usesocial/interpersonal problems BECAUSE of use

Substance DependenceSubstance DependenceToleranceTolerance WithdrawalWithdrawal Drug is taken in larger amounts than intended, or over longer time than Drug is taken in larger amounts than intended, or over longer time than

intendedintended Efforts to cut down or control use are unsuccessfulEfforts to cut down or control use are unsuccessful Excessive time is spent obtaining, using and recovering from drug effectsExcessive time is spent obtaining, using and recovering from drug effects Important activities – social, professional, recreational are reduced or given up Important activities – social, professional, recreational are reduced or given up

completelycompletely Continued use DESPITE knowledge these problemsContinued use DESPITE knowledge these problems likely caused by the substance/drug likely caused by the substance/drug

Substance Induced Substance Induced DisordersDisorders

Depression – suicidal thoughtsDepression – suicidal thoughts

AnxietyAnxiety

Psychotic symptoms – hallucinations, Psychotic symptoms – hallucinations, paranoiaparanoia

Mood swingsMood swings

Health Care ProfessionalsHealth Care Professionals

We have a unique relationship with other We have a unique relationship with other human beingshuman beings

Trust and faith in a health care professional is Trust and faith in a health care professional is inherent in any relationship whether patient, inherent in any relationship whether patient, client or employerclient or employer

ANY healthcare professional with ANY type of ANY healthcare professional with ANY type of contact (talk, touching, interpreting data etc) contact (talk, touching, interpreting data etc) has the potential to harm a patienthas the potential to harm a patient

Examples of Impairment:Examples of Impairment: A physician can ignore pages and miss important diagnosesA physician can ignore pages and miss important diagnoses

A nurse can give substandard bedside care, divert prescriptions, A nurse can give substandard bedside care, divert prescriptions, forge prescriptionsforge prescriptions

A pharmacist can make errors in filling prescriptionsA pharmacist can make errors in filling prescriptions

A therapist can give ineffective or inappropriate therapy with A therapist can give ineffective or inappropriate therapy with boundary violations or patient abandonmentboundary violations or patient abandonment

A dentist can give substandard care, fail to give appropriate A dentist can give substandard care, fail to give appropriate treatment, divert drugstreatment, divert drugs

A CNA or Home Health Assistant can fail to give care to patients A CNA or Home Health Assistant can fail to give care to patients who cannot perform their own ADL’s, abuse patients, divert drugs who cannot perform their own ADL’s, abuse patients, divert drugs

More Examples for Health More Examples for Health Care ProfessionalsCare Professionals

Missed calls and pagesMissed calls and pages Late and increased sick daysLate and increased sick days Disheveled appearance/change in appearanceDisheveled appearance/change in appearance Erratic performance/moodErratic performance/mood Slurred speechSlurred speech TremorsTremors Unusual medication prescribing/missing Unusual medication prescribing/missing

medicationmedication Arrests – DUI, DV, shopliftingArrests – DUI, DV, shoplifting

Does Treatment Work?Does Treatment Work?Federation of State Physician Federation of State Physician

Health ProgramsHealth Programs 80% of participants had successful 80% of participants had successful

completion of treatment programs with completion of treatment programs with return to work under monitoringreturn to work under monitoring

Almost 80% of physicians were working Almost 80% of physicians were working successfully as physicians at 5 yearssuccessfully as physicians at 5 years

Does Treatment Work?Does Treatment Work?

There is not a lot of data in addiction as to the There is not a lot of data in addiction as to the effectiveness of treatmenteffectiveness of treatment

HOWEVER:HOWEVER:

HEALTH CARE PROFESSIONALS ARE HEALTH CARE PROFESSIONALS ARE HUMAN BEINGS WITH THE SAME HUMAN BEINGS WITH THE SAME PERCENTAGE OF SUBSTANCE ABUSE AS PERCENTAGE OF SUBSTANCE ABUSE AS THE GENERAL POPULATION. THE GENERAL POPULATION.

Does Treatment Work?Does Treatment Work?

Health Care Professionals are subject to medical diseases, Health Care Professionals are subject to medical diseases, other than addiction that can also impair performance. other than addiction that can also impair performance.

Q: HOW DO WE ADDRESS THE HEALTH OF OUR Q: HOW DO WE ADDRESS THE HEALTH OF OUR HEALTH CARE PROFESSIONALS? HEALTH CARE PROFESSIONALS?

Q: Do we throw all of these practitioners out? Take their Q: Do we throw all of these practitioners out? Take their licenses? licenses?

And if not, how would we go about monitoring their other And if not, how would we go about monitoring their other potentially impairing illnesses - diabetes, high blood potentially impairing illnesses - diabetes, high blood pressure, seizure disorders? pressure, seizure disorders?

Q: Can these practitioners be of service to the public if they Q: Can these practitioners be of service to the public if they are treated and monitored?are treated and monitored?

Does Treatment Work?Does Treatment Work?

A: So – although data is sparse and many A: So – although data is sparse and many health professionals seek and receive health professionals seek and receive successful care on their own without successful care on their own without DCA/Board involvementDCA/Board involvement

Data does show that treatment PLUS Data does show that treatment PLUS monitoring can work to create safe health monitoring can work to create safe health practices in all the healing artspractices in all the healing arts

Monitoring ProgramsMonitoring Programs

Monitoring Programs do work, with the following Monitoring Programs do work, with the following caveats:caveats:

Monitoring should be CONFIDENTIAL to maintain Monitoring should be CONFIDENTIAL to maintain patient protected rights (when the patient IS the health patient protected rights (when the patient IS the health care provider) care provider)

Monitoring should be STANDARDIZED across all the Monitoring should be STANDARDIZED across all the health care professions to ensure all providers meet health care professions to ensure all providers meet the criteria of reporting, abstinence and compliance the criteria of reporting, abstinence and compliance

Substance Abuse/Dependence is a chronic, lifelong Substance Abuse/Dependence is a chronic, lifelong illness that may require LIFELONG MONITORINGillness that may require LIFELONG MONITORING

Treatment plus Treatment plus MonitoringMonitoring

ONE MODEL: ONE MODEL:

Health Care Provider is evaluated and Health Care Provider is evaluated and referred to appropriate level of treatment referred to appropriate level of treatment per evidence based standardized per evidence based standardized placement criteria (may be voluntary or placement criteria (may be voluntary or ordered by DCA)ordered by DCA)

Treatment plus Treatment plus MonitoringMonitoring Provider agrees to participate in a formal Provider agrees to participate in a formal

program that will maintain confidentiality if 100% program that will maintain confidentiality if 100% compliant; if not, reporting laws are enforcedcompliant; if not, reporting laws are enforced

Random body fluid testing (appears to be the Random body fluid testing (appears to be the single most effective monitoring tool) to detect single most effective monitoring tool) to detect any relapse following treatmentany relapse following treatment

Worksite monitor reports and open Worksite monitor reports and open communication with monitoring staff to ensure communication with monitoring staff to ensure timely reporting of any concerning behaviortimely reporting of any concerning behavior

Participation in an abstinence based self help Participation in an abstinence based self help programprogram

Treatment plus Treatment plus MonitoringMonitoring

Multi-system checks in place to ensure Multi-system checks in place to ensure practitioner is quickly taken from practice practitioner is quickly taken from practice if not 100% compliantif not 100% compliant

Strict and enforceable rules across all Strict and enforceable rules across all specialties to conform to safe practice specialties to conform to safe practice standardsstandards

Voluntary vs Forced Voluntary vs Forced TreatmentTreatment

Very few enter treatment voluntarily – pressure from Very few enter treatment voluntarily – pressure from family, work, judicial system, not just professional family, work, judicial system, not just professional boardsboards

Change occurs when addictive behavior is Change occurs when addictive behavior is interrupted and tools are given to change lifestyle interrupted and tools are given to change lifestyle and attitudeand attitude

Change does not happen quickly, most programs Change does not happen quickly, most programs are 5 yearsare 5 years

If provider is unable to be compliant for 5 years, or If provider is unable to be compliant for 5 years, or is chronically relapsing and unable to follow is chronically relapsing and unable to follow direction, then loss of licensure may be only answerdirection, then loss of licensure may be only answer

Addiction, Treatment, Addiction, Treatment, Punishment, RecoveryPunishment, Recovery

Addiction WILL happen – at rate of regular Addiction WILL happen – at rate of regular population (10 – 13%)population (10 – 13%)

Impairment MAY happen if addiction not Impairment MAY happen if addiction not detected and treateddetected and treated

Recovery and productive return to work CAN Recovery and productive return to work CAN happen in monitored and standardized settings happen in monitored and standardized settings that allow Boards to communicate effectively that allow Boards to communicate effectively with participants and monitoring programswith participants and monitoring programs