Effectiveness of a Unique Support Group for Physicians in a Physician Health Program.

The prevalence rate of addiction among physicians is similar to the general population, with approximately 10% to 12% of U.S.-based physicians developing substance use disorders (SUDs) during their lifetimes. To address this public health concern, physician health programs (PHPs) have been created to facilitate the early identification, evaluation, treatment, and monitoring of physicians. Although a number of published studies provide outcome information from PHPs, there has been no comprehensive review of the related literature. The objective of this narrative review is to summarize the treatment outcomes, including treatment types, rates of relapse, rates of contract completion or extension, as well as licensure and work status rates of a nationally representative physician cohort and related subpopulations from a single dataset. Based on the studies included in this review, our findings reveal that physicians who completed their PHP contracts have more favorable treatment outcomes than members of the general population who receive mainstream treatment. In addition, our review describes unique features of physician rehabilitation facilitated by PHPs. However, further prospective research is needed to ensure a standardized and comparable dataset and facilitate performance improvement.

Overall their lifetimes, 10-12% of physicians will develop a substance use disorder [1]. This rate is comparable to that of the general public. Physicians who are suspected of having substance use disorders or other mental health issues are often referred to their state physician health program (PHP) for evaluation. These referrals might come from chief medical officers, boards of medicine, or colleagues in a group practice. PHPs meet with, assess, and monitor physicians who have been referred to them for substance use or other mental and behavioral health problems. Once referred, physicians often have little choice but to comply with any and all recommendations by the PHP in order to continue practicing medicine, because they have often been told by the referral source that failure to comply with any and all recommendations of the PHP will result in termination of their ability to practice medicine. In most states, for example, boards of medicine rely completely on the PHPs for guidance about how to deal with impaired physicians. So even though PHPs don’t directly have the ability to prevent physicians from practicing medicine, since PHPs can’t themselves revoke medical licenses or hospital privileges, their determinations of physician compliance with their recommendations often result in exactly those actions. PHPs are therefore extremely powerful.

Many physicians are referred to state physician health programs (PHPs) for evaluation, monitoring, and treatment of mental health and substance use disorders. If the physician agrees to cooperate with the PHP and adhere to any recommendations it might make, the physician often can avoid disciplinary action and remain in practice. Despite their considerable power, many PHPs operate with little oversight. I review recommendations that a co-author and I previously made regarding oversight of PHPs and then review some of the findings from a recent performance audit of the North Carolina Physicians Health Program by the North Carolina Auditor's Office. Physicians who might object to the conclusions and recommendations of PHPs in many states do not have the ability to appeal and lack due process. Additionally, given that many of the evaluation and treatment centers to which PHPs refer their clients also sponsor meetings of PHPs, there is significant potential for conflict of interest in the standard operations of PHPs. National standards should be put in place for the day-to-day operation of PHPs and include avenues for appealing decisions and recommendations by them. Also, PHPs should be routinely audited to ensure the soundness and fairness of their practice.

The objective of this study was to compare outcomes of psychiatrists and nonpsychiatrist physicians enrolled in state physician health programs for substance use disorders. The study used the data set from a five-year, longitudinal cohort study of 904 physicians, including 55 psychiatrists, with diagnoses of substance abuse or dependence consecutively admitted to one of 16 state physician health programs between 1995 and 2001. There was a higher proportion of women among psychiatrists than among other physicians, but there were no other significant differences between the cohorts. Five-year outcomes were similar between psychiatrists and the other physicians, with at least 75% of psychiatrists continuing their medical practice after five years of monitoring and treatment. Psychiatrists were not overrepresented compared with other physician groups and had similar clinical outcomes at the five-year follow-up. Physician health programs appeared to be effective treatment programs for psychiatrists with substance use disorders.

A Comparative Analysis of Substance Use Disorder Programs Between Three Safety Sensitive Professions.

Physician Health Committee of the Medical Society of the District of Columbia and Georgetown University Law Center, Washington, DC. ccohenp@aol.comThe recent editorial by Berge and colleagues1sends an extremely important message to the anesthesia community, and I agree with many of its thoughtful and incisive points. However, I must take issue with the authors’ proposed new default position of “one strike, you’re out.” I believe that the question of return to work is far too complex to be approached in a monolithic fashion that lumps all anesthesiologists who have manifested drug dependence into a single group that “should be directed toward lower-risk occupational environments, either within medicine or in a different field entirely.”A uniform prognosis cannot be assigned to every drug-dependent anesthesiologist. For example, Domino et al. 2suggest that dual diagnosis and family history are among the major factors that must be taken into account when predicting the risk of relapse in opioid-addicted physicians. My own experience supports an additional and extremely important variable that must be considered when deciding whether or not a drug-dependent anesthesiologist should return to his or her profession: The availability of long-term supervision, support, and monitoring. The Medical Society of the District of Columbia’s Physician Health Committee (PHC) intervenes on physicians whose colleagues (and sometimes themselves) believe them to be suffering from the disease of drug dependence. The PHC refers this physician to a specialist in addiction medicine and, if recommended, facilitates admission to treatment (usually residential). Immediately after discharge the physician, now in early recovery, enters into a five-year contract with the PHC. This contract mandates random drug testing (a daily phone call determines whether or not an observed urine sample must be furnished within the next 12 h), monitoring by a member of the PHC, participation in 12-step programs, and continuing aftercare under the supervision of an addictionologist. Some of our clients also submit hair samples for drug testing every two to three months. Our recommendation for a graduated return to work is made only after we receive a recommendation from the treating specialist that this would be appropriate. Aftercare of opioid-addicted anesthesiologists in recovery may include the use of depot naltrexone. At least one supervisory member of the department is made aware of the individual’s history at the time of return and is informed that the PHC will be responsible for monitoring.Approximately 90% of physicians (including anesthesiologists) enrolled in the Washington, DC Medical Society’s Physician Health Program have successfully completed their 5-yr contracts.3The PHC has monitored sufficient numbers of anesthesiologists in recovery whose return to work has been recommended to support my stance that “one strike” need not preclude reentry into anesthesiology. At the present time, although some of our clients do indeed voluntarily leave anesthesiology for another medical specialty, those who have returned to the practice of anesthesiology have been successful in their recovery. While the group of anesthesiologists with whom we have experience is small in comparison with the entire national cohort, our observations support my view that individual consideration, long-term close surveillance, and aftercare by specialists in addiction medicine may provide an alternative to the editorial’s default position.In contrast, the editorial1appears to base at least some of its argument on a “pragmatic review of our personal experience with our Mayo Clinic nurse anesthetists,” leading to the observation that “there has been nearly a 100% relapse rate” (relapse is not defined and could represent anything from a single “slip” to a full-fledged resumption of frequent drug use). It is significant that the authors do not provide evidence of long-term monitoring of these nurse anesthetists. Indeed, they state that “it is difficult to exactly quantify the relapse rate, because far too often affected individuals are simply lost to formal follow-up.”Finally, the editorial refers to Gastfriend’s statement that addiction is “a brain disease that subverts self-preservation”4to support its contention that “decision-making is damaged by addiction so that abstinence is not simply a choice.” However, Gastfriend also clearly emphasizes—quoting reports from several other Physician Health Programs—that “the vast majority of physicians who have substance use disorders seem to do surprisingly well in recovery.” While I certainly do not disregard the unmistakable threat that addiction poses to anesthesiologists and patients, my own personal experience, and that of other PHC chairs, suggests that the editorial’s pessimism is not justified. Documented sobriety is possible within the operating room environment. When complemented with vigilance,*including supportive and careful long-term monitoring, return to work can be successful for both the physician and society.Physician Health Committee of the Medical Society of the District of Columbia and Georgetown University Law Center, Washington, DC. ccohenp@aol.com

Tremendous strides have been made in the identification, treatment and monitoring of physicians who abuse alcohol or other drugs. Nevertheless, balancing the desire to help such physicians against the need to protect the public remains a perennial challenge for medical boards. This article offers suggestions for medical boards on establishing a positive working relationship with their state physician health programs (PHPs). Boards and PHPs have distinct yet complementary missions, and the facilitation of trust and communication between these two entities is critical. The article also reviews current trends in treatment and aftercare, including more individualized treatment planning and more extensive and sophisticated drug testing.

Substance use disorders (SUDs) are highly prevalent and associated with a substantial public health burden. Although evidence-based interventions exist for treating SUDs, many individuals remain symptomatic despite treatment, and relapse is common.Mindfulness-based interventions (MBIs) have been examined for the treatment of SUDs, but available evidence is mixed. To determine the effects of MBIs for SUDs in terms of substance use outcomes, craving and adverse events compared to standard care, further psychotherapeutic, psychosocial or pharmacological interventions, or instructions, waiting list and no treatment. We searched the following databases up to April 2021: Cochrane Drugs and Alcohol Specialised Register, CENTRAL, PubMed, Embase, Web of Science, CINAHL and PsycINFO. We searched two trial registries and checked the reference lists of included studies for relevant randomized controlled trials (RCTs). RCTs testing a MBI versus no treatment or another treatment in individuals with SUDs. SUDs included alcohol and/or drug use disorders but excluded tobacco use disorders. MBIs were defined as interventions including training in mindfulness meditation with repeated meditation practice. Studies in which SUDs were formally diagnosed as well as those merely demonstrating elevated SUD risk were eligible. We used standard methodological procedures expected by Cochrane. Forty RCTs met our inclusion criteria, with 35 RCTs involving 2825 participants eligible for meta-analysis. All studies were at high risk of performance bias and most were at high risk of detection bias. Mindfulness-based interventions (MBIs) versus no treatment Twenty-four RCTs included a comparison between MBI and no treatment. The evidence was uncertain about the effects of MBIs relative to no treatment on all primary outcomes: continuous abstinence rate (post: risk ratio (RR) = 0.96, 95% CI 0.44 to 2.14, 1 RCT, 112 participants; follow-up: RR = 1.04, 95% CI 0.54 to 2.01, 1 RCT, 112 participants); percentage of days with substance use (post-treatment: standardized mean difference (SMD) = 0.05, 95% CI -0.37 to 0.47, 4 RCTs, 248 participants; follow-up: SMD = 0.21, 95% CI -0.12 to 0.54, 3 RCTs, 167 participants); and consumed amount (post-treatment: SMD = 0.10, 95% CI -0.31 to 0.52, 3 RCTs, 221 participants; follow-up: SMD = 0.33, 95% CI 0.00 to 0.66, 2 RCTs, 142 participants). Evidence was uncertain for craving intensity and serious adverse events. Analysis of treatment acceptability indicated MBIs result in little to no increase in study attrition relative to no treatment (RR = 1.04, 95% CI 0.77 to 1.40, 21 RCTs, 1087 participants). Certainty of evidence for all other outcomes was very low due to imprecision, risk of bias, and/or inconsistency. Data were unavailable to evaluate adverse events. Mindfulness-based interventions (MBIs) versus other treatments (standard of care, cognitive behavioral therapy, psychoeducation, support group, physical exercise, medication) Nineteen RCTs included a comparison between MBI and another treatment. The evidence was very uncertain about the effects of MBIs relative to other treatments on continuous abstinence rate at post-treatment (RR = 0.80, 95% CI 0.45 to 1.44, 1 RCT, 286 participants) and follow-up (RR = 0.57, 95% CI 0.28 to 1.16, 1 RCT, 286 participants), and on consumed amount at post-treatment (SMD = -0.42, 95% CI -1.23 to 0.39, 1 RCT, 25 participants) due to imprecision and risk of bias. The evidence suggests that MBIs reduce percentage of days with substance use slightly relative to other treatments at post-treatment (SMD = -0.21, 95% CI -0.45 to 0.03, 5 RCTs, 523 participants) and follow-up (SMD = -0.39, 95% CI -0.96 to 0.17, 3 RCTs, 409 participants). The evidence was very uncertain about the effects of MBIs relative to other treatments on craving intensity due to imprecision and inconsistency. Analysis of treatment acceptability indicated MBIs result in little to no increase in attrition relative to other treatments (RR = 1.06, 95% CI 0.89 to 1.26, 14 RCTs, 1531 participants). Data were unavailable to evaluate adverse events. In comparison with no treatment, the evidence is uncertain regarding the impact of MBIs on SUD-related outcomes. MBIs result in little to no higher attrition than no treatment. In comparison with other treatments, MBIs may slightly reduce days with substance use at post-treatment and follow-up (4 to 10 months). The evidence is uncertain regarding the impact of MBIs relative to other treatments on abstinence, consumed substance amount, or craving. MBIs result in little to no higher attrition than other treatments. Few studies reported adverse events.

AMA to Work With APA, Other Groups on Integrated Care

Back to table of contents Previous article Next article Education & TrainingFull AccessResource Document Calls for Improved Residency Training on SUDsMark MoranMark MoranSearch for more papers by this authorPublished Online:26 Apr 2021https://doi.org/10.1176/appi.pn.2021.5.23AbstractTrainees need to see patients in a wide variety of settings, over time, with supervisory training that focuses on a patient’s addiction.When trainees are exposed to patients who recover from a substance use disorder, it is humanizing, destigmatizing, and unforgettable, said Shelly F. Greenfield, M.D., M.P.H., a member of APA’s Council on Addiction Psychiatry, at the virtual meeting of the American Association of Directors of Psychiatric Residency Training (AADPRT).“When trainees have that opportunity to work with a patient with a substance use disorder over time and see the patient get better in a real-world setting, it is incredibly gratifying,” says Shelly F. Greenfield, M.D., M.P.H.Residents and fellows need more of those experiences. Greenfield cited data from surveys of program directors and from an October 2020 APA Resource Document on Education and Training for Substance Use Disorders (see section below) indicating that trainees generally do not receive sufficient training in the treatment of substance use disorders (SUDs), including faculty supervision focused specifically on treatment of SUD patients over time. Additionally, too few residents receive training in prescribing buprenorphine and other medications approved for treating SUDs.“When trainees graduate as early career psychiatrists—no matter where they practice—they will see a very high proportion of patients with an SUD either alone or co-occurring with another psychiatric disorder,” Greenfield said. “Yet they have very little training in their four years overall. There have been some positive changes in addiction training in residency, but most studies and the APA resource document demonstrate that training for diagnosing and treating patients with substance use disorders is inadequate for graduating residents in 2021.”She noted that the requirement of the Accreditation Council for Graduate Medical Education for just four weeks of dedicated training in addiction has not been changed since 2001. A 2012 survey of 104 program directors supported by the APA Council on Addiction Psychiatry found that only 19% of program directors reported that trainees were paired with supervisors for addiction, and 68% said patients with SUDs were sent elsewhere for treatment. Most did not provide opportunity for long-term treatment for patients with SUDs.In comments to Psychiatric News after the meeting, Greenfield emphasized four areas in which training in addiction falls short:Lack of supervision that is specifically focused on treatment of patients with SUD. Greenfield cited a 2018 survey of 84 program directors by the Addiction Task Force of AADPRT that found that in many programs addiction training takes place only on general psychiatry units in which co-occurring disorders are evaluated and treated, but the extent to which addiction-trained supervisors are available or addiction is the focus of the training is unclear. In that survey, 41.6% of program directors indicated there was a limited number of faculty with expertise in co-occurring conditions to provide trainee supervision.Greenfield said one approach for programs that lack faculty expertise in addiction is collaboration with other programs, an opportunity made possible by the widespread use of video technology in medicine and psychiatry during the pandemic.Failure to see patients over time. Trainees need to see the progress and recovery of patients with SUD over time. “Longitudinal experience with patients having SUD usually happens in outpatient settings where the trainee can treat patients with SUD, receive supervision, and be able to follow them beyond just a four-week experience on an inpatient unit,” Greenfield said.Lack of training in using buprenorphine and other medications approved for addiction and SUD. “If residents have eight-hour waiver training in buprenorphine, they learn a lot about the medication and about opioid use disorder,” Greenfield said. “Data show that if you get just eight hours of training in residency, you are much more likely to prescribe this medication in your practice after residency. And yet we don’t have a requirement to complete that training.”The tendency of residents to see patients with SUD only in the emergency department. “If you mostly expose trainees to patients who present to the emergency department with SUD, this can contribute to stigma and therapeutic nihilism—the belief that this condition never gets better,” Greenfield told Psychiatric News. “Most patients with SUDs are never seen in emergency departments.”Psychiatrists should learn how to care for patients presenting in the emergency department with acute withdrawal or intoxication, she said, but most will graduate to practice in other settings—outpatient practices, community health settings, inpatient services, and residential and partial hospital settings. “Psychiatrists will routinely encounter patients in these settings who have substance use disorders including those with co-occurring psychiatric disorders, and it is imperative that they feel competent in providing that care.”In addition to the APA resource document, Greenfield cited a number of resources for trainees and training programs. They include the Opioid Response Network and the Providers Clinical Support System, of which APA is a partner. This program offers training and mentoring in evidence-based prevention and treatment of opioid use disorders and treatment of chronic pain.When trainees are expose to patients who recover from an SUD, it can be an experience the trainee will never forget.“We have an apprentice system of learning in graduate medical education—as a resident you have a supervisor, but you are treating the patient yourself,” she said. “What we know is that when trainees have that opportunity to work with a patient with a substance use disorder over time and see the patient get better in a real-world setting—it’s incredibly gratifying.” ■The APA Resource Document on Education and Training for Substance Use Disorders is posted here.APA Resource Document Offers Recommendations for Medical Students, Residents, and Lifelong Learners“Medical schools, physician training (residency) programs, and continuing education programs for physicians in practice provide limited training in the treatment of SUDs,” according to the APA Resource Document on Education and Training in Substance Use Disorders. “The scope of training on SUDs is disproportionate to the population health need to address these problems, and many with SUDs go undiagnosed and untreated.”The resource document is a product of APA’s Council on Addiction Psychiatry, the Council on Medical Education and Lifelong Learning, and the Council on Healthcare Systems and Financing. The document offers recommendations for medical schools, residencies, and continuing medical education for physicians in practice, as well as strategies for change.Recommendations for medical student rotations and residency programs include the following:Addiction and co-occurring disorders should be incorporated into all aspects of psychiatry residency training since patients with SUD are seen at all levels of care.Supervision and discussion of SUD cases should occur at inpatient and outpatient levels of care and should include an addiction psychiatrist.Programs should ensure they have access to resources to help them incorporate enhanced training in SUD with the goal of bolstering resident competencies in assessing and treating patients for these conditions.All psychiatry residents should complete the buprenorphine waiver training or its equivalent.Residents should be trained to treat patients with alcohol use disorder, stimulant use disorder, opioid use disorder, sedative/hypnotic use disorder, cannabis use disorder, tobacco use disorder, and other substances.Training experience should include various levels of patient acuity and corresponding care including outpatient and residential treatment.Residents should receive training in the use of FDA-approved medications for opioid, alcohol, and tobacco use disorder (and others as developed and approved by the FDA).Training on SUD treatments should include knowledge of the range of evidence-based behavioral therapies and competency to practice at least one. This might include, but is not limited to, the ability to integrate motivational interviewing concepts and techniques into patient assessments and sessions. ISSUES NewArchived

The link between bipolarity and substance use: A controlled clinic based study.

The Evidence for SBIRT in Adolescents

“John” was a 35-year-old white gay man who was referred to Dr. Ruiz for psychiatric care by a local family practitioner. John suffered primarily from bouts of depression and anxiety and also used cocaine quite regularly. At about age 16, John began to use pot with his high school friends during social parties. He also realized around this time that he was gay, although he kept it primarily to himself out of shame, guilt, embarrassment, and fears of rejection by family and friends. By age 18, John was occasionally using alcohol and LSD and had engaged in a few homosexual encounters. During college, he stepped up his addiction to stimulants and continued to have occasional homosexual encounters. Upon finishing college, he earned a master’s degree in education. During this period, his use of cocaine and amphetamines as well as his homosexual activities became more regular. Since earning his master’s degree, he had been working as a high school math teacher for about 10 years.

Physician Health Programs (PHPs) have been support-ing and advocating for health professionals for nearly four decades. Initially developed by state medical societies in the 1980s, PHPs recognized the need for therapeutic alterna-tives to disciplinary measures for physicians facing health issues that could impair their ability to practice safely. Originally focused on substance use disorders, PHPs have since expanded their services to encompass mental health and other co-occurring conditions.

Introduction: Substance use disorder (SUD) peers provide support and navigation through a fragmented treatment system for people who use drugs (PWUD) and those in recovery. While barriers to peers’ work are well established, from role ambiguity to stigma surrounding substance use, little research has focused on factors that facilitate peers’ work. Methods: We conducted in-depth semi-structured interviews (N=20) with peers as part of an evaluation of a larger project related to the opioid crisis in Western New York. Participants were recruited from a regional peer network via flyers, emails, and a brief presentation. Interviews were conducted in person or by phone, audio recorded, and transcribed. Transcripts were analyzed using thematic content analysis. Results: Peers emphasized two factors: healthy personal coping strategies and strong workplace supports. Coping strategies included a sense of community, setting appropriate boundaries, and self-care routines. At the workplace, peers valued mental and emotional support, as well as professional relationships and organizational policies that made their work easier and supported self-care. For a few peers, professional relationships included advocating on behalf of PWUD by sharing personal experiences of SUD. Conclusions: Peers valued peer colleagues and peer-led organizations, noting how shared experiences of substance use and recovery enabled a unique support system. For peers who lack such support at work, the authors suggest peer networks as an alternative. We also recommend organizational policies and practices to facilitate peers’ work, such as promoting peer input and feedback, but further research is needed to measure effects on peer retention and job satisfaction.