Substance Use and the Medical Professional

1. Substance Use and the Medical Professional September 2014 Presented by Amy Tardy, PhD

2. Medical Professionals Health Program Amy Tardy PhD • Case Manger MPHP Maine Medical Association • Medical Professionals Monitor and Advocate • Certified Trainer for CPI Non-Violent Crisis Intervention • Educator & Instructor, University of Phoenix • Human Resources educator, trainer and presenter • Program Director numerous Non-Profit Maine agencies *Dr. Tardy is not connected with any commercial interests nor received financial gain or compensation for the development, production and distribution for this educational power point presentation.

3. Objectives • Gain an understanding of addiction and its prevalence in the medical professional population • Understand signs and symptoms of impairment • Understand the law related to substance use by the medical professional and related board actions • Gain an understanding of MPHP’s relationship with the licensing boards, including protocols and consent agreements • Learn about replacement medications and their role in treating addiction

4. Short Definition of Addiction: Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

5. Average Annual U.S. Substance Drug Use Patterns- General Population • Approximately 45% of Americans know someone with a substance use problem • In 2011, 6.3% of adults ages 26 and older used illicit drugs- with the majority of this represented by adults who used prescription-pain psychotherapies for nonmedical purposes • 54.2% of these people report they got it “for free” from friends or family, and 18.1% reported they got it from their doctor. The remaining population got it from a friend/dealer or off the internet. • Males had a higher tendency to use illicit drugs; females more likely to abuse prescription medications. • The U.S. is the worlds largest consumer of painkillers.

6. Average Annual U.S. Substance Use Patterns- General Population 2011 • Use of opioids is the #2 cause of accidental death in the United States. In 2009, there were 15,500 deaths that resulted • More then 50% of the US population was considered “regular drinkers” • 22.6% were considered “binge drinkers” at 5 or more drinks at a time, during at least 1 day of the past 30 days. This translates to 58.3 million people ages 12 and older • Relapse rates from addiction (40 to 60%) can be compared to those suffering from other chronic illnesses such as Type I diabetes (30 - 50%), Hypertension (50-70%) and asthma (50 to 70%). Drug addiction should be treated like any other chronic illness, with relapse indicating the need for renewed intervention.

7. Statistics and the Medical Professions • The Lifetime prevalence of physicians who will develop a substance use disorder during their careers is unknown, but estimates range from 5-15%. Best estimate is about 8% • Alcohol remains a drug of choice for the majority of physicians. Up to 18% of 2nd year medical students in one study met criteria for alcohol abuse • It appears that heavy drinking decreases with age in the general population, but increases with age in physicians

8. The Statistics in Medical Professionals • It is estimated that approximately 11-15% of pharmacists are confronted with alcohol/drug dependency problems at some time in their career • It is estimated that 46% of pharmacists have used drugs off prescription. 62% of pharmacy students have done the same • In contrast, between 10-20% of nurses in the United States have substance abuse, misuse, and/or dependency problems. • It is estimated that approximately 14% of veterinarians and vet techs are confronted with alcohol/drug dependency problems at some time in their career

9. The Statistics • The drug of choice for veterinarians: analgesics (painkillers), sedatives/tranquilizers • The drug of choice for pharmacists: seems to be narcotics such as Vicodin, oxycodone, and hydrocodone. Very high rates of alcohol use. • Drug of choice for nurses: opiates such as fentanyl, morphine, Percocet; narcotics such as Vicodin and hydrocodone. • Anesthesiologists or CRNA’s: major opioids, IV morphine, fentanyl, meperidine • Psychiatrists: benzodiazepines • Family Practice Physicians: opioids—codeine, oxycodone, hydrocodone and other oral medications

10. Why so many Medical Professionals? • The level of importance that is placed on work by those in the health professions is often very high. • High Stress, busy practice • Maintaining access to the drug of choice may provide an incentive to stay on the job • As a result, social, financial and interpersonal decay often occur before the addiction interferes with the job. • Families, partners, and friends are much more likely to have been impacted by the effects of addiction long before it is noticed at work and they are more likely to be reluctant to confront

11. Some Signs and Symptoms of Chemical Use, Abuse, Misuse, and Dependency- general • Uncontrollable craving • Secrecy • Excessive amount of money spend on obtaining a particular substance • Weight loss • Nausea • Headache • Paranoia • Confusion • Glazed/ red eyes

12. Signs and Symptoms, cont • Persistent cough • Excessive energy/ fast speech • Anxiety • Mood swings • Social isolation • Poor work performance • Neglect of family responsibilities • Neglect of personal hygiene • Insomnia • Personality changes

13. Possible Complications due to Chemical Use • The list of complications that have been mentioned in various sources for Chemical addiction includes: • Depression • Excessive Anger • Relationship and Social problems • Workproblems • Physical health concerns (Drug abuse can put people at risk for high blood pressure, diabetes, heart disease, liver disease, cancer, depression, cardiovascular disease and other health problems. Premature aging) • Permanent impairment to neurological functioning • Potential for overdose • Death

14. Components of a Strong Treatment Program • Therapy • Identification of trigger mechanisms • Development of non-chemical coping mechanisms • Achieving balance by changing priorities • Psychiatry and/or addictionology • Attendance in 12-step meetings (AA/NA/Al Anon) • Participation in Caduceus • Strong support system in the workplace • Professional Monitoring • medication management and pain management contracts (if applicable) • Understanding and acceptance of disease concept • Family involvement • A full professional evaluation with a treatment plan

15. Replacement Meds • Replacement therapy may be used in the treatment of drug or alcohol addiction. • Those commonly used: Methadone (for opiate addiction), Suboxone (for opiate addiction), Naltrexone (for opiate and alcohol addictions) Vivitrol (once a month injectable for opiate and alcohol addictions), • Problems with replacement drugs? Highly successful but also addictive. Therefore, use must be carefully monitored • Use of replacement medications should not be life-long. Instead, they should be used for immediate assistance with cravings, combined with therapy, and tapered as soon as clinically indicated.

16. What should you do if you suspect someone of using? • Talk to them or a supervisor- depends how well you know/how closely you work with the person • Report to the Medical Professionals Health Program • Report to the Board of Licensure

17. What can happen next?? • It is much more difficult to quit without professional help. The majority of individuals who try, fail. • relapse usually occurs within the first 3 years • Make the appropriate connections and have a treatment team surrounding the person and offering guidance to reduce risk of relapse

18. The Medical Professionals Health Program • The Medical Professionals Health Program assists medical professionals in developing strategies for treatment, helping them return to successful professional careers. The MPHP does not make diagnoses or provide treatment. The MPHP clinical staff and committee members act as advocates for their impaired colleagues, providing compassionate, comprehensive and confidential assistance.

19. Medical Professionals Health Program • Who can make a referral? • Self- usually occurs earlier in illness so treatment is more effective • Friends and family • Colleague or practice partner • Employer • Board or licensing agency- occurs later in disease after it has affected social and/or work life

20. Why be in the program? • Nationally recognized PHPs are 75-90% successful in preventing relapse • Demonstrate to employers that you are safe to practice (comfort) • Establish a record to get back a suspended license • Required by a Board as a condition of licensure • Advocate with the licensing board

21. Medical Professionals Health Program • What happens after referral? • Initial intake interview, screening and initial contract development. • When indicated, a comprehensive psychological evaluation will be conducted • Determination of treatment needs and/or eligibility to be part of the program

22. Medical Professionals Health Program • What does monitoring entail? The MPHP generally offers a 5 year monitoring contract (case manager will consider many factors of the illness- such as symptomology and years in recovery- before setting contract length) • Monthly Self Reports • AA and Caduceus (or approved alternative such as SMART recovery) self-help group attendance • Worksite monitor reports • Treatment provider reports - therapist, addictionist, psychiatrist, chronic pain specialist, primary care physician • Medication reports • Daily call-ins for selections • Random toxicology testing

23. Other MPHP initiatives • April 5, 2013- MPHP held the first annual Health and Wellness conference for physicians; conference coming up on April 17, 2015 in Portland • Developed a web-based mentorship training curriculum • Mentorship program • Community education and outreach

24. Voices of Recovery • “I reflected on what gifts MPHP has brought to me: Caduceus and the friendships I have built there; integration of my identity as a physician and as a person in recovery; recognition that I had shame about having addiction, and the ability to transform shame into neutral acceptance of having the disease of addiction” • “Sobriety has let me forgive and go easier on myself. Now I can be easier on others. I am grateful to be asked to work rather then asked not to work. My sobriety isn’t just about me, it has affected everyone around me”

25. The Law • Law: Diagnosable substance use may be grounds to deny a pharmacy license, refuse to renew a license, or impose other disciplinary conditions • Example of Unprofessional Conduct (Pharmacy rule): “Being unable to practice pharmacy with reasonable skill and safety by reason of illness, use of drugs, narcotics, chemicals, or any other type of material, or as a result of any mental or physical condition. A pharmacist affected under this subsection shall at reasonable intervals be afforded an opportunity to demonstrate that the pharmacist can resume the competent practice of pharmacy with reasonable skill and safety to patients.” • Applies even when patient harm has not occurred

26. Consent Agreements: What they are and directives in them • Consent agreements are documents that may be issued to a professional who the board would not otherwise license. • Consent agreements impose restrictions upon the professional license. Each licensing board has different “standards” for their consent agreements.

27. Consent Agreements: Examples from Pharmacy • Example 1: • ____________shall completely abstain from the ingestion of alcohol. • ____________shall comply with the terms of her January 6,2012 contract with the Maine Medical Professional Health Program which she shall forward forthwith to the Board with any future amendments. • ____________shall work as a pharmacist no more than 40 hours per week. She shall immediately inform Kelly McLaughlin, Senior Consumer Assistant Specialist of any employment as a pharmacist during the duration of the MMPHP contract. Ms. Davis may petition the Board in person to change this restriction which shall remain in effect until at least January 1,2014. • ___________and her employer shall both report any misfills in writing to the Board. Ms. Davis and/or her employer may petition the Board in person to change this restriction which shall remain in effect until at least January 1, 2014.

28. Consent Agreements: Examples from Pharmacy • Example 2: • ______________admits that she should have disclosed the convictions and acknowledges that her conduct could be found by the Board to constitute grounds for disciplining her pursuant to 10 M.R.S. § 8003(5-A)(A)(I). In re: __________ Consent Agreement • 2011·PHA~7823 • As discipline for the conduct in paragraph 3, __________agrees to pay a fine in the amount of five hundred dollars ($500.00). • The Board grants ________ her Certification of Administration of Drugs and Immunizations and the renewal of her license to practice pharmacy. As conditions of licensure, _______, agrees to the following, which shall remain in effect for a period of five (5) years unless otherwise an1ended by the Board: • Maintain her contract with the MMPHP; however, after two years, ________ may request that the Board amend this Consent Agreement. The Board, acting in good faith, shall have sole discretion to amend the Consent Agreement to reduce the length of the Agreement. • Follow all recommendations of the MMPHP. • This Consent Agreement shall resolve finally any complaints or matters for failure to disclose information to the Board. • Violation of any of the terms or conditions of this Consent Agreement by _______ shall constitute grounds for discipline, including but not limited to modification, suspension, or revocation of licensure or the denial of licensure or re-licensure. • This Consent Agreement is ~10t appealable and is effective until modified or rescinded by the parties hereto. • The Board and the Office of the Attorney General may communicate and cooperate regarding any matter related to this Consent Agreement. • This Consent Agreement is a public record within the meaning of 1 M,RS. § 402 and will be available for inspection and copying by the public pursuant to 1 M.R.S. § 408.

29. Employer Reactions: A New Direction • Employers are starting to take a different perspective as those with substance use disorders. This is evidenced by our caseload of pharmacists… on 9/10/13 we had 10 pharmacists and pharmacy techs in the MPHP program. 7 are actively employed in their professional field. At this time last year, only 3 of them were employed. • Starting to view substance use as a chronic disease, but treatable. • Witnessed some strong structure and mentoring in the workplace that has aided professionals returning to the field.

30. Online resources • Al-Anon and Alateen (www.al-anon.alateen.org) • Alcoholics Anonymous (www.aa.org) • American Society of Addiction Medicine (www.asam.org) • International Doctors in AA (www.idaa.org) • National Institute on drug Abuse (www.nida.nih.gov)

31. Caduceus Groups (open only to medical professionals) • Bangor Regional CaduceusOsprey Room at Acadia Hospital, BangorMondays at 7:00 p.m.George (603)781-3088 • Central Maine Caduceus (L/A)Lobby Conference Room, St. Mary's Hospital New wing, Campus Avenue, Lewiston, Maine. Tuesdays at 7:00 p.m. Julie (207)784-2985 • Central Maine Caduceus (Manchester)Manchester Community Church, Manchester Corner of Rte. 17 and 202, enter church through door that faces the parking lot that has 3 steps. Meeting is held upstairs. Thursdays at 7:00 p.m.Jack (207) 578-0232 • Eastern Maine Caduceus15 Palmer Street, Calais Thursdays at 7:15 p.m.Bob (207) 595-0512 • Northern Maine CaduceusThe Aroostook Medical Center, Presque IsleThursdays at 7:30 p.m.Nat (207)551-2171 • Southern Maine CaduceusMercy Hospital, Portland Meeting is on B2 the upper auditorium-which is actually in the basementWednesdays at 7:00 p.m.Bill (207) 653-4729 • Portsmouth, New HampshirePortsmouth Ballroom, Portsmouth, NHMondays at 7:30 p.m.Laura (603) 534-2372

32. Medical Professionals Health ProgramStaff Lani Graham, MD, MPH, Director Heidi LaMonica, Administrative Assistant Margaret Palmer, PhD, Senior Clinical Associate Amy Tardy, PhD, Case Manager Cathryn Stratton, Systems Manager Andrew MacLean, Esq., Legal Counsel

33. Medical Professionals Health ProgramAdvisory Committee Ibra “Chip”Ridley, CRNA, MSNA JerrRoberts, DDS Paul Rouleau, RN Michael Sloan, DDS Gordon Smith, Esq. Jenie Smith, MD William Sullivan, MD Robert W. Chagrasulis, MD, Chair Crissa Evans, RN Earl Freeman, DO Christopher Guido, RPh Patricia Kelley, Associate Dean, UNE Bill Nugent, Esq.,Ex-Officio John Murray, RPh, co-chair Mark Publicker, MD

34. Post Test • True or False: Substance use is a problem that affects the medical professional population • True or False: One possible reason for abuse is the perception from society of the level of importance placed on the medical professional’s job • True or False: We believe that the medical professional can easily quit use on their own without a treatment team and strategy • True or False: The professional licensing boards don’t care about substance use history as long as it has not resulted in patient harm.