LESSONS FROM THE PHYSICIAN HEALTH PROGRAM (PHP) EXPERIENCE FOR TODAY'S NATIONAL OPIOID EPIDEMIC

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1 LESSONS FROM THE PHYSICIAN HEALTH PROGRAM (PHP) EXPERIENCE FOR TODAY'S NATIONAL OPIOID EPIDEMIC Robert L. DuPont, M.D. President, Institute for Behavior and Health, Inc. 2 nd Annual Symposium on Addiction Opioid Addiction: The Highs, The Highways, The Hope September 23, 2016

2 THE NEW OPIOID EPIDEMIC IS MOSTLY NOT RELATED TO THE TREATMENT OF PAIN It is mostly about substance use disorders which usually begin in adolescence It is also about long-term poly drug use, including alcohol

3 WELL-KNOWN OBSTACLES TO ALL ADDICTION TREATMENT Most people with substance use disorders (SUDs) do not think that they have a disorder, do not want to stop using and they do not want treatment Most patients referred to treatment do not enter treatment Many patients who enter treatment drop out before completion Relapse after treatment is common

4 TREATMENT TODAY Addiction is a life-long, potentially lifethreatening, disease but treatment for SUDs is typically in brief episodes of care Patients are often treated for one substance at a time (e.g., treatment focused on opioid use) and other substance use is not addressed Many patients continue to use alcohol and other drugs while in treatment (i.e., harm reduction)

5 USE OF MEDICATION IN TREATMENT The primary treatment response to today s prescription opioid and heroin epidemic is opioid substitution therapy (OST) Mostly buprenorphine, plus a little methadone Much less use of naltrexone, an opioid antagonist

6 THE PROBLEM Medications only work while they are taken Opioid dependence is a life-long disease But OST, like other SUD treatments, is mostly short-term What happens to patients when they leave OST?

7 A GOOD METHADONE PROGRAM

8 A GOOD BUPRENORPHINE PROGRAM

9 3 MISSING ELEMENTS IN TODAY S APPROACH TO TREATING OPIOID USE DISORDERS 1. Definition of long-term recovery as the goal of all treatment and post-treatment interventions Including no use of alcohol, marijuana or other drugs 2. Provision of sustained post-treatment monitoring and professional and peer support 3. Insistence by others around the SUD patients on sustained abstinence PHPs show the path to sustained recovery

10 LESSONS FROM THE PHPS PHPs extend the period of accountability for abstinence to 5 years Physicians in PHPs transition from treatment to home, return to work, utilize skills they learned in treatment while knowing that any return to substance use produces serious consequences Immersion in Alcoholics Anonymous (AA) and Narcotics Anonymous (NA)

11 PHP CARE Zero tolerance for any substance use with frequent random tests for drugs and alcohol and immediate, serious consequences for any missed or positive tests Including the risk of losing their licenses to practice medicine Evaluation and intervention Monitoring contract, usually for 5 years Formal treatment Long-term monitoring and support

12 IMPRESSIVE LONG-TERM OUTCOMES A national study of 16 PHPs showed that over the course of 5 years, the vast majority of physicians were practicing medicine and were drug- and alcohol-free The same outcomes were found among physicians with opioid use disorders without using OST

13 DRUG TEST RESULTS Physicians with opioid use disorders had the same low rate of positive drug tests as their peers with alcohol use disorders or other non-opioid use disorders Any Positive Test Alcohol Only (n=204) Any Opioids (n=339) Non-Opioids (n=159) Yes 40 (20%) 77 (23%) 39 (25%) No 162 (80%) 259 (77%) 118 (75%)

14 FOLLOW-UP STATUS Physicians with opioid use disorders were as successful completing their monitoring contract and returning to work in medicine as their peers Status at Follow- Up Alcohol Only (n=204) Any Opioids (n=339) Non-Opioids (n=159) Completer 119 (58.3%) 220 (64.9%) 101 (63.5%) Extender 34 (16.7%) 57 (16.8%) 30 (18.9%) Failed to complete 51 (25.0%) 62 (18.3%) 28 (17.6%)

15 TAKE-AWAY FINDINGS Regardless of the substance(s) physicians previously used, more than three-quarters of PHP participants remained abstinent throughout their monitoring period and beyond Physicians with opioid use disorders were able to remain abstinent from alcohol and all other drugs, without buprenorphine or methadone* *1 physician was treated with methadone for chronic pain

16 THE CHALLENGE FOR ADDICTION TREATMENT Finding ways to extend the PHP model for the treatment of opioid use disorders Integrating elements of the model into routine health care, as is increasingly done for all serious chronic disorders with focus on prevention, intervention, treatment and lifetime monitoring to prevent and detect relapses This is the New Paradigm for long-term recovery

17 THANK YOU!

18 INSTITUTE FOR BEHAVIOR AND HEALTH, INC. IBH is a 501(c)3 non-profit organization that develops strategies to reduce drug use For more information and resources visit the IBH websites:

19 REFERENCES + RESOURCES DuPont, R. L., Compton, W. M. & McLellan, A. T. (2015). Five-year recovery: A new standard for assessing effectiveness of substance use disorder treatment. Journal of Substance Abuse Treatment, 58, 1-5. DuPont, R. L., McLellan, A. T., Carr, G., Gendel, M & Skipper, G. E. (2009). How are addicted physicians treated? A national survey of physician health programs. Journal of Substance Abuse Treatment, 37, 1-7. DuPont R. L., McLellan A. T., White W. L., Merlo L., and Gold M. S. (2009). Setting the standard for recovery: Physicians Health Programs evaluation review. Journal for Substance Abuse Treatment, 36(2), DuPont, R. L., Seppala, M. D. & White, W. L. (2015). The three missing elements in the treatment of substance use disorders: lessons from the physician health programs. Journal of Addictive Diseases, 35(1), 3-7. Institute for Behavior and Health, Inc. (2014). The New Paradigm for Recovery: Making Recovery and Not Relapse the Expected Outcome of Addiction Treatment. Rockville, MD: IBH. Available: Institute for Behavior and Health, Inc. (2014). Creating a New Standard for Addiction Treatment Outcomes. Rockville, MD: IBH. Available: McLellan, A. T., Skipper, G. E., Campbell, M. G. & DuPont, R. L. (2008). Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. British Medical Journal, 337:a2038. Merlo, L. J., Campbell, M. D., Skipper, G. E., Shea, C. L., & DuPont, R. L. (2016). Outcomes for physicians with opioid dependence treated without agonist pharmacotherapy in physician health programs. Journal of Substance Abuse Treatment, 64,