OHSU Psychiatry Grands Rounds 6/21/16

Size: px

Start display at page:

Download "OHSU Psychiatry Grands Rounds 6/21/16"

Hester Curtis
5 years ago
Views:

1 OHSU Psychiatry Grands Rounds 6/21/16 Robbie Bahl, M.D. Monitoring Programs Medical Director Christopher Hamilton, Ph.D. Monitoring Programs Director Reliant Behavioral Health

Public Policy Statement: Definition of Addiction Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry.

2 Public Policy Statement: 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.

3 Substance Use Disorders: Key Points A pressing public health crisis Overdose deaths>>>mva deaths as leading cause of injury related deaths in the United States in 2015 Drugs of Choice change with time Demographics of patients change with time Diagnostic criteria changes with time (DSM IV/V) Underlying psychiatric conditions, poor behavioral healthcare

4 Substance Use 2016 Opioid epidemic Spans socioeconomic classes Fueled by prescription pharmaceuticals Rampantly available in high schools Poor treatment resources Social stigma Overdoses All while being a common medical treatment 4

5 5

6 6

7 7

8 8

9 9

10 Illicit drug use in the United States has been increasing In 2013, an estimated 24.6 million Americans aged 12 or older 9.4 percent of the population had used an illicit drug in the past month. Everyone knows 1 person in their lives with a substance use disorder Everyone doesn't know 10 people in their lives with a substance use use disorder

11 Re-lapse Verb /rǝ lapse/ 1. (of someone suffering from a disease) suffer deterioration after a period of improvement. Synonyms: get ill/worse again, have/suffer a relapse, deteriorate, degenerate, take a turn for the worse a few patients relapse

12 12

13 13

14 Barriers to progress. Stigma in and out of the medical world ER & PCP burden Poor education in medical schools, residencies, etc Iatrogenic opioid dependence and prescriber pride Pain as the 5th vital sign? cheap prescriptions & big pharma poor access to behavioral health care

15 Progress S. 524: Comprehensive Addiction and Recovery Act of passed 5/2016 Naloxone availability, treatment for the incarcerated, state prescription monitoring programs, FAFSA Push for better medical school/residency training for substance use disorders ABMS added Addiction Medicine in 2016 Medication Assisted Treatment (MAT) Buprenorphine, Naltrexone, Methadone Abuse deterrent opioids? Physician Monitoring Programs for State Medical Boards 15

16 Percent Using Illicit Drugs in Past Month

17 Percent Heavy Alcohol Use in Past Month

18 Healthcare Practitioner and Technical Occupations Healthcare Practitioners and Technical Occupations aged % illicit drugs 3.9% heavy alcohol Mirrors 8.2% average employed workforce use illicit drugs in the past month

19 Health Care Professionals over worked stressed surrounded by narcotics sleep deprived energy hungry This translates to a significantly increased risk of substance use disorders 19

20 20

21 The Cost of Addiction Estimated Costs: Drug abuse costs employers $81 billion annually. The National Institute on Drug Abuse (NIDA) estimates that the abuse of tobacco, alcohol, and illicit drugs costs the nation over $700 billion dollars annually due to crime, health care, and lost work productivity.

22 22

23 23

24 24

25 Treatment v Monitoring Monitoring is used as an adjunct to treatment Monitoring is not treatment State monitoring programs oversee the process of a licensed health professional through the treatment process Monitoring programs review toxicology, medications, treatment adherence and attendance The first monitoring program started in Oregon in the late 1970s as a result of an influx in physicians suicides

26 Treatment v Monitoring Monitoring programs are under medical/dental/nursing licensing boards Ensuring that a health professional enters treatment appropriately, withdraws from work appropriately, and submits normal urine toxicology The combination of treatment and monitoring has proven to result in health professionals getting the help they need at the right time, resulting in: improvements in public safety, health professional maintaining their licenses and safely returning to work

27 American Society of Addiction Medicine (ASAM) 1. All safety-sensitive workers, by definition, have a responsibility to the public. The extent of the effect on the public comes from two factors: a) The size of the population safety-sensitive workers affect and the depth of the effect from potential impairment. b) The amount of public trust that is implied in that worker s occupation. Both these factors place a burden on treatment, its efficacy, and the importance of that patient s recovery for overall public welfare.

28 American Society of Addiction Medicine During the initial diagnostic portion of the treatment experience, safely sensitive workers should discontinue work. It is the job of initial treatment providers to seek out any available monitoring program for a patient under their care, and to help the safety-sensitive worker understand that these monitoring programs are an integral part of their care.

29 American Society of Addiction Medicine Research has shown that such programs dramatically improve long-term prognoses as well. The combination of effective, managed initial treatment and long-term contingency contracting has been proposed as the gold standard for all addiction care in the United States.

30 ASAM- Treatment Completion Rates Monitored Health Professionals have significantly higher treatment completion/success rates when compared to the general public The combination of monitoring and treatment helps the professional maintain their careers/license and protects the public simultaneously

31 Recovery in the Health Care Professional chronic multifaceted treatment chronic monitoring & accountability gradual return to functionality retain professional licensing/career increasing public safety

32 32

33 Board Purpose ORS (2) All health professional regulatory boards shall operate with the primary purposes of promoting the quality of health services provided, protecting the public health, safety and welfare by ensuring that licensees practice with professional skill and safety and addressing impairment among licensees.

34 House Bill 2345 (2009) New consolidated statewide monitoring program The Oregon Health Authority, Addictions & Mental Health Division, was given responsibility to contract with an outside vendor to establish a monitoring program.

35 House Bill 2345 Program would be a diversion program, outside of discipline Program cannot diagnose or provide treatment Boards may not establish alternative programs 7/1/2010 Program Start

36 Health Professionals Services Program Mission Statement Protect public safety while assisting participants with mental health and substance use disorder problems to continue in their professional careers.

37 Health Professionals Services Program Medical Director Dr. Robbie Bahl Consulting Psychiatrist Dr. Joe Autry Program Director Agreement Monitors Masters level in behavioral health and experienced in substance use and mental health Support team

38 Health Professionals Services Program Voluntary Participation by Licensing Boards Dental Medical Nursing Pharmacy Other Health Professional Boards can only sanction licenses no alternative to discipline program.

39 Health Professionals Services Program Eligibility Requirements: Diagnosis of substance use disorder, mental health disorder or, both to be eligible for program Maintain an active state license

40 Monitoring Active case management Monitoring of adherence to treatment recommendations Weekly check-in by or voice mails Monthly check-in conversation Communication with worksite Weekly monitoring groups x 2 years (not for MH only) Quarterly check-in with periodic monitoring consultant (monthly for MH only) Random drug screens and daily IVR (not for MH only)

41 The PHP Blue Prints Blueprint Project DuPont, R.L., McLellan, A.T., White, W.L., Merlo, L.J., & Gold, M.S. Setting the standard for recovery: Physicians Health Programs. Journal of Substance Abuse Treatment March: 36(2): Five year study of 904 physicians across 16 state physician health programs.

42 Setting the standard for recovery: Physicians Health Programs Surprisingly, they are not addiction treatment programs. Instead, PHPs provide active care management for, as well as monitoring and supervision of, physicians who have signed formal, binding contracts for PHP participation (generally extending for 5 years). Five Years SUD OMB, BOP, BOD Four Years SUD OSBN

43 Setting the standard for recovery: Physicians Health Programs The PHPs offer support and, most often, a temporary safe haven for physicians who are typically in jeopardy or under pressure from others due to problems related to SUD. HPSP self referred licensees are never know to board when they remain compliant.

44 Referral Types Self referrals Board referrals Self referrals must attest that they are not (to the best of their knowledge) under investigation. Sometimes concurrent and unknown to licensee and allowed to remain self.

45 Self Referrals Must undergo a mental health and substance use evaluation by 3 rd party evaluator Must undergo a safe practice investigation Pays the cost of both the evaluation and investigation With compliance, never known to board (staff or members) No input from Board on completion

46 Current Program Stats Total enrolled in HPSP* 215 Total Board Referrals 181 Total Self Referrals 34 Board of Nursing 103 Board of Pharmacy 17 Board of Dentistry 12 Medical Board *as of 6/2/

47 Oregon Duty to Report- ORS Duty to report prohibited or unprofessional conduct, arrests and convictions; investigation; confidentiality; immunity from liability. (2) a licensee who has reasonable cause to believe that another licensee has engaged in prohibited or unprofessional conduct shall report the conduct to the board...no event later than 10 working days after... learns of the conduct. Includes licensee, workplace, and colleagues

48 Setting the standard for recovery: Physicians Health Programs Key Element 1: Contingency management aspects of PHP care management. by providing consequences for early termination of treatment or positive drug test results, strongly improve the outcome in addiction treatment. HPSP Guidelines- reinforced by statute.

49 Non-compliance Statutory outlined in ORS A. Engaged in criminal behavior; B. Engaged in conduct that caused injury, death or harm to the public, including engaging in sexual impropriety with a patient; C. Was impaired in a health care setting in the course of the licensee s employment; D. Received a positive toxicology test result as determined by federal regulations pertaining to drug testing;

50 Non-compliance Statutory outlined in ORS E. Violated a restriction on the licensee s practice imposed by the program or the licensee s board; F. Civil commitment for mental illness; G. Entered into a diversion agreement, but failed to participate in the program; H. Was referred to the program but failed to enroll in the program;

51 Setting the standard for recovery: Physicians Health Programs Key Element 2: Frequent random drug testing Maintained sobriety: 96% of study physicians who were routinely tested 64% of study physicians who were not routinely tested

52 Testing Frequency Continued HPSP: Year 1= Minimum of 36 tests Year 2= Minimum of 24 tests Year 3, 4, and beyond= minimum of 18 annual tests

53 Setting the standard for recovery: Physicians Health Programs In the study, 78% of completers had no positive tests

54 Setting the standard for recovery: Physicians Health Programs Board Total HPSP Successfully Completed July March 2016 Total Completed % and # Completed with No Positive Toxicology % and # Completed with One Positive Toxicology % and # Completed with Two or More Positive Toxicology Oregon Board of Dentistry % % 1 7.1% Oregon Board of Pharmacy % 1 6.7% 0 0.0% Oregon Medical Board % % 2 2.0% Oregon State Board of Nursing % % % All Boards % % %

55 Blue Print Study Outcomes 802 of 904 tracked to five years 515 of 802 completed monitoring contract (64%) 448 of 515 no longer monitored 67 of 515 voluntarily continued 132 of 802 contract extended (16%) 155 of 802 failed to complete

56 Do Licensees Complete HPSP? Yes, 73.6% of licensees have completed or are on target to complete HPSP. Of the 412 HPSP licensees who enrolled before July 2011, 64.8% (267) have successfully completed the program. Of the 120 OMB licensees who enrolled prior to 6/30/2011 we realize a 67.5% (81) completion rate with an additional 16.67% (20) OMB licensees still active in the program. Combined, 84.2% of Medical Board licensees have completed or are on target to complete.

57 Do self-referred licensees who become known to their boards lose their licenses? No, 80% of self-referred licensees who become known to their boards complete or are still active in the program. Of these 139 licensees, 43 (31%) have become known to their boards due to a report of non-compliance and two (1.5%) of these licensees self-reported to their boards. Of the 45 self-referred licensees who became known to their respective boards, 36 (80%) have completed or are still active.

58 Recidivism

59 Recidivism Continued As of 3/1/2016, 97 OMB licensees completed 92 of 97 have had no subsequent board orders. 3 of 5 with subsequent board orders continue to practice 98% (95 of 97) still eligible to practice Includes two retired and four who have lapsed (all of traditional retirement age)

60 Noncompliance Reports

61 Questions

62 Questions/Contact For additional information contact the HPSP at (888) Website: Christopher Hamilton, Ph.D. (503) Robbie Bahl, MD (503)

Physician Health Programs: A Model for Treating Substance Use Disorders

Physician Health Programs: A Model for Treating Substance Use Disorders Vol. 57 No. 1 Robert L. DuPont, Lisa J. Merlo Dr. Robert L. DuPont, board certified in psychiatry and addiction medicine, is president