relapse recovery in pharmacists

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Page 1: Relapse Recovery in Pharmacists
Page 2: Relapse Recovery in Pharmacists

Relapse:Road to Recovery

Dr. Jay Piland MDPalmetto Addiction Recovery CenterPecan Haven Adolescent Addiction Center

Page 3: Relapse Recovery in Pharmacists

Objectives1) Define the Prevalence of Addiction in the Pharmacy Profession & other

Health Care Professionals2) Outline Factors associated with the risk of addiction in Health Care

Professionals3) Describe the success and relapse rates in Pharmacists & other Health

Care Professionals4) Apply the Chronic Disease Management Model (CDM) of care,

continuity, and contingency management in the recovering Health Care Professional

5) Explore how the environmental influences can impact the development of addiction & relapse risks for the recovering Health Care Professional

6) Describe concepts of a Relapse Prevention PlanRoad to Recovery

Page 4: Relapse Recovery in Pharmacists

Addiction

• …primary, chronically relapsing disease of the 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.

Road to Recovery

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Road to Recovery

Page 6: Relapse Recovery in Pharmacists

Road to Recovery

Page 7: Relapse Recovery in Pharmacists

• Compulsion to seek and take a drug or stimulus, loss of control in limiting intake, and emergence of a negative emotional state (e.g., dysphoria, anxiety, irritability) when access to the drug or stimulus is prevented.

• Addiction Cycle—Binge/intoxication stage to Withdrawal/negative affect stage to the Preoccupation/anticipation(craving) stage

Road to Recovery

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Neurocircuitry of Addiction

Derived from: Koob G, Everitt, B and Robbins T, Reward, motivation, and addiction. In: Squire LR, Berg D, Bloom FE, du Lac S, Ghosh A, Spitzer NC (Eds.), Fundamental Neuroscience, 3rd edition, Academic Press, Amsterdam, 2008, pp. 987-1016.

Road to Recovery

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Road to Recovery

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“Brain Disease”

• Brain Cells adapt to substances and the excessive bombardment by substances produces dysfunctional adaptations that become embedded in the neuronal circuitry

Road to Recovery

Page 11: Relapse Recovery in Pharmacists

“Brain Disease”

• Brain Cells adapt to substances and the excessive bombardment by substances produces dysfunctional adaptations that become embedded in the neuronal circuitry

• New patterns of neuronal firing in the centers of the brain reward system develop so that the addicted brain is functionally and morphologically different from a non-addicted brain

Road to Recovery

Page 12: Relapse Recovery in Pharmacists

Road to Recovery

QuestionQuestion 1. The addiction cycle and neurobiology of addiction involve long term changes which would include all except:A. The dorsal Prefrontal Cortex functions as the “Go System” which

become overactiveB. The Ventral Prefrontal Cortex function as the “Stop System” which is

lost/diminished during addictionC. The CRF (cortisol releasing factor) and NE/dynorphin are involved in

the Withdrawal/Negative Effect stage which produces many of the withdrawal signs & symptoms.

D. The brain is no longer “plastic” or cannot be “rewired” after the age of 18, so adolescence can use substances like Cannabis without any concern of potential long-term changes in their neuronal circuits.

Page 13: Relapse Recovery in Pharmacists

Road to Recovery

Question• Question 1. The addiction cycle and neurobiology of addiction

involve long term changes which would include all except:A. The dorsal Prefrontal Cortex functions as the “Go System” which

become overactiveB. The Ventral Prefrontal Cortex function as the “Stop System” which is

lost/diminished during addictionC. The CRF (cortisol releasing factor) and NE/dynorphin are involved in

the Withdrawal/Negative Effect stage which produces many of the withdrawal signs & symptoms.

D. The brain is no longer “plastic” or cannot be “rewired” after the age of 18, so adolescence can use substances like Cannabis without any concern of potential long-term changes in their neuronal circuits.

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Road to Recovery

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Defining Co-occurring Disorders

Mood Disorders Anxiety Disorders Post-Traumatic Stress Disorders

Antisocial Personality Disorders

Borderline Personal-ity Disorders

Severe Mental Illness0%5%

10%15%20%25%30%35%40%45%

Addiction Treatment Provider Estimates by Psychiatric Disorder

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16

Lifetime Prevalence of SUD for Each MHD

Bipolar Disorder 56%

Schizophrenia 47% Major Depression 27% Any Anxiety Disorder 24% PTSD 30-75%

Borderline Personality Disorder

23%

Eating Disorder 23-55%*

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Likelihood of a Suicide Attempt

Risk Factor

• Cocaine use• Major Depression• Alcohol use• Separation or Divorce

NIMH/NIDA

Increased Odds Of Attempting Suicide

62 times more likely41 times more likely8 times more likely11 times more likelyECA EVALUATION

Page 18: Relapse Recovery in Pharmacists

DSM 5 Diagnostic Criteria11 Criteria in 4 groupings (2-3=mild, 4-5=moderate, 6+=severe)

Impaired ControlInability to quit or cut down, using more than intended, time spent, craving

Social (Functional) ImpairmentSchool, Work, Home Obligations Not MetSocial and Relationship ProblemsSocial, Occupational, Recreational Activities Abandoned

Risky Use (Using Despite)Hazardous SituationsPhysical or Mental Illness/Psychological Problems

Pharmacological (Physiological)Tolerance and Withdrawal

Road to Recovery

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Changing Lexicon of SUD

• DSM-V Terminology & Criteria has sought to correct confusion regarding misperceptions created by language in previous DSM– ABUSE—pattern of use that results in considerable

social, interpersonal, or legal problems or hazardous use– DEPENDENCE/Addiction—uncontrolled use resulting in

considerable physical/psychological problems and impairment (continual/compulsive use of self-administered chemicals despite the problems related to their use)

Road to Recovery

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“Misuse” of Prescription Drugs

• Any deviation from Prescribed Use– Using a medication without a prescription—No Rx – Using more or for longer periods than prescribed– Hoarding pills for future use—Stash– Obtaining a Prescription fradulantly – Changing the route of administration—to

circumvent the safety features—abuse – Acquiring multiple prescriptions for the same or

similar medications—Doctor Shopping

Road to Recovery

Page 21: Relapse Recovery in Pharmacists

Spectrum of Substance Use Disorders

Misuse

20% 65% ?%

RegularUse

Zerouse Mild Moderate

Severe

“Pickle Line”adapted from Ray Baker MD

Healthy No Problem Use Related Problem

Substance Use Disorders

Road to Recovery

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DSM 5 Diagnostic Criteria11 Criteria in 4 groupings (2-3=mild, 4-5=moderate, 6+=severe)

Impaired ControlInability to quit or cut down, using more than intended, time spent, craving

Social (Functional) ImpairmentSchool, Work, Home Obligations Not MetSocial and Relationship ProblemsSocial, Occupational, Recreational Activities Abandoned

Risky Use (Using Despite)Hazardous SituationsPhysical or Mental Illness/Psychological Problems

Pharmacological (Physiological)Tolerance and Withdrawal

Road to Recovery

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Road to Recovery

Questions• 2. All of the following are True except one—which?:• A. There is a Higher lifetime prevalence of SUD in patients

with Schizophrenia & Bipolar Disorder compared to Depression & Anxiety.

• B. Having a legal problem such as charges for armed robbery (arrest) is part of the new criteria for SUD in DSM V.

• C. Borderline Personality Disorder often interferes with treatment in women & men.

• D. It is possible that the higher risk of suicide in the cocaine user with SUD is due to extreme levels of impulsivity.

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Road to Recovery

Questions• 2. All of the following are True except one—which?:• A. There is a Higher lifetime prevalence of SUD in patients

with Schizophrenia & Bipolar Disorder compared to Depression & Anxiety.

• B. Having a legal problem such as charges for armed robbery (arrest) is part of the new criteria for SUD in DSM V.

• C. Borderline Personality Disorder often interferes with treatment in women & men.

• D. It is possible that the higher risk of suicide in the cocaine user with SUD is due to extreme levels of impulsivity.

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Road to Recovery

Questions

Question #3 Which of the following best characterizes substance use disorders and recovery? A. Acute, short-term problemB. Chronic, Lifelong processC. Disease with no known risk factorsD. Condition to which those with expertise are

immune.

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Road to Recovery

Questions

Question #3 Which of the following best characterizes substance use disorders and recovery? A. Acute, short-term problemB. Chronic, Lifelong processC. Disease with no known risk factorsD. Condition to which those with expertise are

immune.

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“Mind you, only one doctor out of ten recommends it.”

Road to Recovery

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“Sometimes it’s not so much seeing the light as feeling the heat.”

Road to Recovery

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PERCOCET“For

distribution to patients in the office as

needed.”M: 20,000

PHP Referral

Road to Recovery

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From Discovery to RecoveryAddictive Disease in Pharmacists

• Substance Abuse/Dependence—SUD – Lifetime Prevalence: 10 to 15%– 1 in 7 Pharmacists in Lifetime– SUD most serious illness to afflict pharmacists in their first 15 years of

practice

– Versus Physicians/MD/DO– (SUD Lifetime Prevalence: 8-10%--Self Report Response)

– Hughes PH, Brandenburg N, Prevalence of Substance Use Among US Physicians. JAMA 1992; 267:2333-8

– Prior Studies estimate Prevalence 10 to 14%– Annual Incidence: 1 to 2 % (when alcohol excluded)

Road to Recovery

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Addictive Disease in Pharmacists• 58.7% of Pharmacists reported using a non-prescribed drug at least

once in their lifetime

• 20% of Pharmacists report that they had used a prescription drug without a prescription at least 5 times or more in their lifetime

• At least 20% and up to 50% of Pharmacist may misuse prescription drugs

• Prevalence of drug use during the previous year was higher for pharmacists (12.8%)—many reported lifetime use of minor opiates, anxiolytics, and stimulants

Road to Recovery

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“Impaired Pharmacist”

• Refers to pharmacist with psychiatric, cognitive, behavioral, or general medical problem that have the potential to adversely affect the pharmacist’s ability to perform specific duties.

Road to Recovery

Page 33: Relapse Recovery in Pharmacists

Pharmacists

• NIDA SUD Numbers—Prevalence

– General US Population Chemical Dependency 10 to 15 %

– Health Care Professionals SUD 8 to 12 %

– Pharmacists Chemical Addiction 11 to 15%

Road to Recovery

Page 34: Relapse Recovery in Pharmacists

Specific Greater Risk Factors for Addictive Disease in HCP—Health Care Professionals

-Genetic Predisposition (FH of dependence)

-Environmental Stressors (shift work, high level of job responsibility, job dissatisfaction)

-Inadequate Education & Training on AD regarding the psychological aspects of addiction, criteria for addiction, and recovery from addiction

-Omnipotence & Belief that knowledge of the pharmacodynamics of medications will ensure safety from AD

-Greater Accessibility

-Social Factors—lack of peer, academic, or occupational discouragement

-Peer Reinforcement of self-medication practices

-Dual Diagnosis (relapse risk) & Comorbid Medical DiagnosisRoad to Recovery

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Road to Recovery

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Road to Recovery

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Road to Recovery

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Road to Recovery

“Occupational Hazard”Recovering substance-impaired pharmacists’ views regarding occupational risks for addiction

J Am Pharm Assoc 2012;52 (4): 480-491

• 6 groups comprised of pharmacists N=32• 32 of 37 pharmacists participated (86.5%) and represented 22% of Washington States Pharmacists under monitoring

contract

• 27 Reported how they had been introduced to misuse of drugs (4 had been referred to PRN for alcohol and illicit drug use)

• Common Reasons:– Recreational Purposes “a high was always welcome”—Positive experiences– Prescription drugs easier to manage than…– Legitimate medical use of the drugs– Lead to Pleasurable sensations (recreate)– Denial that they might be vulnerable to addiction (valid Rx)– Misuse of psychotropic medications– Self-medicate for stress or other mental health symptoms– Co-occurring Disorders particularly at risk– Stressful career and associated problems “Privileged to have such a job”– Using Recreational Drugs in place of psychiatric medications prescribed

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Road to Recovery

“Occupational Hazard”Recovering substance-impaired pharmacists’ views regarding occupational risks for addiction

J Am Pharm Assoc 2012;52 (4): 480-491

• 6 groups comprised of pharmacists N=32• 32 of 37 pharmacists participated (86.5%) and represented 22% of Washington States Pharmacists under monitoring

contract

• 27 Reported how they had been introduced to misuse of drugs (4 had been referred to PRN for alcohol and illicit drug use)

• Common Reasons:– Recreational Purposes “a high was always welcome”—Positive experiences– Prescription drugs easier to manage than…– Legitimate medical use of the drugs– Lead to Pleasurable sensations (recreate)– Denial that they might be vulnerable to addiction (valid Rx)– Misuse of psychotropic medications– Self-medicate for stress or other mental health symptoms– Co-occurring Disorders particularly at risk– Stressful career and associated problems “Privileged to have such a job”– Using Recreational Drugs in place of psychiatric medications prescribed

Page 40: Relapse Recovery in Pharmacists

Road to Recovery

“Occupational Hazard”Recovering substance-impaired pharmacists’ views regarding occupational risks for addiction

J Am Pharm Assoc 2012;52 (4): 480-491

• Risks Associated with the Pharmacy Profession:– Access to Prescription Drugs– Stressful Work Environment– Culture– Barriers to Treatment Access– Education

Page 41: Relapse Recovery in Pharmacists

Road to Recovery

Barriers for HCP’s seeking and receiving assistance

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Road to Recovery

The Addicted Pharmacist and the Effect of Their EnvironmentUniversity of Findlay College of Pharmacy

PRN Survey (N 171—25%)

• Demographics

– Race 94% White, 1% African American, 0.5% Asian, 2% American Indian, 2% Preferred not to say

– Males 74% Females 26%– Ages(years) 3% 20-29, 21% 30-39, 21% 40-49, 49% 50-64, 6% >65– Marital Status 56% married, 21% divorced, 14% single/never married, 3.5%

widowed, 2% domestic partnership, 2% preferred not to say– Currently Practicing 67% Yes 33% No– Geographical area of Practice 38% Metropolitan, 33% Rural, 28% Suburban– Current Alcohol/Tobacco use: 25% Tobacco Products, 2% drink alcohol, and

73% do not use

Page 43: Relapse Recovery in Pharmacists

Road to Recovery

The Addicted Pharmacist and the Effect of Their EnvironmentUniversity of Findlay College of Pharmacy

PRN Survey (N 171—25%)

• Prior to becoming a Pharmacist– 68% found to be abusing drugs or alcohol

• Of those 33% abused Illicit Drugs

• Of those 20% abused Prescription Drugs

• Of those 59% abused Alcohol

Page 44: Relapse Recovery in Pharmacists

Road to Recovery

The Addicted Pharmacist and the Effect of Their EnvironmentUniversity of Findlay College of Pharmacy

PRN Survey (N 171—25%)

• Age of First Use

– Between 16 and 20 years old 42%– With 16 being the average overall age of first use

– Between ages 13 to 15 years old 30%

Page 45: Relapse Recovery in Pharmacists

Road to Recovery

The Addicted Pharmacist and the Effect of Their EnvironmentUniversity of Findlay College of PharmacyPRN Survey (N 171—25%)

95% (164 of 171) participants specified setting

Page 46: Relapse Recovery in Pharmacists

Road to Recovery

The Addicted Pharmacist and the Effect of Their EnvironmentUniversity of Findlay College of Pharmacy

PRN Survey (N 171—25%)

40%

30%

4%

12%

8%6%

Class of Substance Used

OpiatesAlcoholotherBenzodiazepinesStimulantsMuscle Relaxers/Barb.

Page 47: Relapse Recovery in Pharmacists

Road to Recovery

The Addicted Pharmacist and the Effect of Their EnvironmentUniversity of Findlay College of Pharmacy

PRN Survey (N 171—25%)

• Reasons for starting Use:– 22% Stress

– 16% Experimenting & Liked Feeling it gave them

– 13% Social Inhibition

– 12% Depression/Anxiety/Escape

– 10% Major Life Event (Sexual Trauma, Death, etc)

Page 48: Relapse Recovery in Pharmacists

Road to Recovery

The Addicted Pharmacist and the Effect of Their EnvironmentUniversity of Findlay College of Pharmacy

PRN Survey (N 171—25%)

• From Discovery To Recovery

11%

1 to 5 Years42%

5 to 10 Years23%

> 10 Years24%

Length of Practice With Active Addiction

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Road to Recovery

The Addicted Pharmacist and the Effect of Their EnvironmentUniversity of Findlay College of Pharmacy

PRN Survey (N 171—25%)

• From Discovery to Recovery

– 29% Sought Treatment on their Own– 71% Intervened Upon

– 38% Attempted Suicide

Page 50: Relapse Recovery in Pharmacists

Road to Recovery

Signs and Symptoms of Possible SUD in Pharmacists

Professional• Work performance alternates between periods of high and low productivity• Absence from work without notice, frequent absenteeism or tardiness• Unexplained, lengthy disappearance during work hours• Sleeping or dozing while on duty• Unreliable in keeping appointments, meeting deadlines• Inappropriate prescriptions for large doses of narcotics• Heavy drug waste and/or drug shortages in the pharmacy• Sloppy record keeping, increase in medication order entry errors• Volunteering for overtime, coming to work when not scheduled• Poor interpersonal relations with colleagues, staff, and patients• Increasing personal and professional isolation

Page 51: Relapse Recovery in Pharmacists

Road to Recovery

Signs and Symptoms of Possible SUD in Pharmacists

Physical• Changes in sleeping patterns, eating habits• Deterioration in appearance and personal hygiene• Changes in speech patterns (e.g., slurred, faster or slower speech)• Frequent bathroom breaks• Excessive perspiration• Confusion, memory loss, difficulty concentrating• Personality changes, mood swings• Wearing long sleeves when inappropriate• Odor of alcohol on the breath or strong odor of mouthwash or mints to

mask the alcohol• Hand tremor resulting from alcohol withdrawal (as in the morning)

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Road to Recovery

• 2/3 of pharmacists in recovery treatment programs are discovered by their state board of pharmacy, a peer, or another HCP

• Some discovered by law enforcement caught abusing a substance or engaging in a related illegal activity

• Many may actually believe their own knowledge of medications will somehow prevent them from becoming addicted or dependent

• Many studies show that HCP’s may believe their knowledge of drug therapy justifies self-treatment

Page 53: Relapse Recovery in Pharmacists

Road to Recovery

The Addicted Pharmacist and the Effect of Their EnvironmentUniversity of Findlay College of Pharmacy

PRN Survey (N 171—25%)

• From Discovery to Recovery• 93% attended Some form of Rehabilitation

– Of which 63% Successful on First Attempt– Of which 18% Successful on Second Attempt– Of which 11% Successful on Third Attempt

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Road to Recovery

The Addicted Pharmacist and the Effect of Their EnvironmentUniversity of Findlay College of Pharmacy

PRN Survey (N 171—25%)

• Three Most Common Triggers– Stress

– Depression/Unhappiness

– Pain (Emotional and/or Physical)

Page 55: Relapse Recovery in Pharmacists

Road to Recovery

Questions

Question #4 For which of the following are pharmacists at higher risk than non-health care professionals?A. Alcohol AbuseB. Abuse of Illicit DrugsC. Prescription Drug AbuseD. Nonprescription Drug Abuse

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Road to Recovery

Questions

Question #4 For which of the following are pharmacists at higher risk than non-health care professionals?A. Alcohol AbuseB. Abuse of Illicit DrugsC. Prescription Drug AbuseD. Nonprescription Drug Abuse

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Road to Recovery

Questions

Question #5 Which of the following might increase an individual’s risk of substance use disorder?A. Low Stress JobB. Colleagues who condone self-medicationC. Female SexD. Limited Knowledge of Medications

Page 58: Relapse Recovery in Pharmacists

Road to Recovery

Questions

Question #5 Which of the following might increase an individual’s risk of substance use disorder?A. Low Stress JobB. Colleagues who condone self-medicationC. Female SexD. Limited Knowledge of Medications

Page 59: Relapse Recovery in Pharmacists

Road to Recovery

Questions

Question #6 Which of the following is True regarding pharmacists who are affected by substance use disorders?A. Most are identified by law enforcementB. There are no telltale outward signs to watch forC. They are an anomaly since knowledge of drug

therapy prevents substance abuseD. Peers are important in their discovery

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Road to Recovery

Questions

Question #6 Which of the following is True regarding pharmacists who are affected by substance use disorders?A. Most are identified by law enforcementB. There are no telltale outward signs to watch forC. They are an anomaly since knowledge of drug

therapy prevents substance abuseD. Peers are important in their discovery

Page 61: Relapse Recovery in Pharmacists

Road to Recovery

Not your usual Pharmacist• The New Republic

Going Under by Jason ZengerleA doctor's downfall, and a profession's struggle with addiction. Post Date Wednesday, December 31, 2008

14

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Road to Recovery

Page 63: Relapse Recovery in Pharmacists

Road to Recovery

J.C. Pharmacist at Medicap• J.C. 46 year old male retail pharmacist from Baton Rouge, LA• Developed recurrent back pain after a strain upon lifting a heavy box. Had a

HNP L1-L3 diagnosed at 40 with RX (hydrocodone).• At age 44 had Disc Surgery at L1-L3, with fair results and was abruptly “cut-

off” from hydrocodone after surgery.• Received DUI (BAL 0.12%) after LSU Football Game for which reported to his

Board at age 45• At age 45, he “reinjured” his back after his surgical recovery so he began

taking some of his wife’s hydrocodone so that he could work better—made him “feel better” about his troubled marriage and gave him “extra energy” to work.

• Asked to go for AME/APE—Addiction Assessment• Thinks that his life has been going very well, except for his recent surgery and

it’s resultant “damage” to his marriage.

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Road to Recovery

J.C.’s Comprehensive Assessment

• Multidisciplinary Treatment Team for a “Biopsychosocialspiritual Assessment” – AME/APE, H&P– Psychological/Neuropsychological Testing– Family Assessment– Collection of Collateral Information– Hair and Body Fluid Drug Testing– Spiritual History– Pain Evaluation

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Road to Recovery

J.C.’s Comprehensive Assessment

• Multidisciplinary Treatment Team for a “Biopsychosocialspiritual Assessment” – AME/APE, H&P– Psychological/Neuropsychological Testing– Family Assessment– Collection of Collateral Information– Hair and Body Fluid Drug Testing– Spiritual History– Pain Evaluation

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Road to Recovery

J.C.’s Comprehensive Assessment

• Multidisciplinary Treatment Team for a “Biopsychosocialspiritual Assessment” – AME/APE, H&P– Psychological/Neuropsychological Testing– Family Assessment– Collection of Collateral Information– Hair and Body Fluid Drug Testing– Spiritual History– Pain Evaluation

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Road to Recovery

J.C.’s Comprehensive Assessment

• Multidisciplinary Treatment Team for a “Biopsychosocialspiritual Assessment” – AME/APE, H&P– Psychological/Neuropsychological Testing– Family Assessment– Collection of Collateral Information– Hair and Body Fluid Drug Testing– Spiritual History– Pain Evaluation

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Road to Recovery

J.C.’s Findings• Smoked at age 12 and Drank alcohol at age 15 with binge pattern of drinking 18 to 25.• Family History of Alcoholism in Paternal GF & GM• Early Childhood Trauma—at age 8 to 9.• “Slow Learner” between 7 to 12, but no testing for ADHD• Began Hydrocodone for back pain by MD at age 40 which was ‘chronic’ until surgical intervention at age 44

—with nausea, diarrhea, body aches, and insomnia upon stopping.• Hair Sample Analysis revealed high levels of hydrocodone and amphetamine throughout last 4 months at

age 46 and his UDS is positive for Ambien.• Has Never been spiritual despite having been raised in a “strict Baptist home”• Drug Use Hx—social alcohol drinker with prior “binge pattern” of drinking until age 25. Took

Hydrocodone as prescribed every six hours until age 44.• Collateral History: Jerry’s work supervisor has seen his concentration shorten and his patience has

shortened with his coworkers and clients—over the last two years. Wife reports that Jerry isolates himself when at home and often “volunteers” to work extra hours. He used to coach his son’s baseball team, but over the past four years has not coached and rarely goes to games. She has had only two prescriptions for hydrocodone in the last year (#30 each) and did not know he took her meds. Jerry has not been able to sleep since his DUI about six weeks ago. She thinks that Jerry became very depressed after his back surgery which resolved after six months, but he began isolating himself again about six weeks ago when he suddenly became more depressed again.

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Road to Recovery

J.C.’s Findings• Smoked at age 12 and Drank alcohol at age 15 with binge pattern of drinking 18 to 25.• Family History of Alcoholism in Paternal GF & GM• Early Childhood Trauma—at age 8 to 9.• “Slow Learner” between 7 to 12, but no testing for ADHD• Began Hydrocodone for back pain by MD at age 40 which was ‘chronic’ until surgical intervention at age 44—with nausea,

diarrhea, body aches, and insomnia upon stopping.• Hair Sample Analysis revealed high levels of hydrocodone and amphetamine throughout last 4 months at age 46 and his UDS

is positive for Ambien.• Has Never been spiritual despite having been raised in a “strict Baptist home”• Drug Use Hx—social alcohol drinker with prior “binge pattern” of drinking until age 40. Took Hydrocodone as prescribed

every six hours until age 44.• Collateral History: Wife reports that Jerry isolates himself when at home and often “volunteers” to work extra hours. She

has had only two prescriptions for hydrocodone in the last year (#30 each) and did not know he took her meds. Jerry has not been able to sleep since his DUI about six weeks ago. She thinks that Jerry became very depressed after his back surgery which resolved after six months, but he began isolating himself again until about six weeks ago when he suddenly became more depressed again.

• Later in Treatment (after six weeks): Jerry admits that he had significant pain while taking the hydrocodone (increasing his dose) up to 80 to 100mg daily, after stopping the opioids he noticed all of his pain symptoms resolved after about four to six weeks.

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Road to Recovery

CDM

Chronic Disease Definition

• A chronic disease is one last 3 months or more (US National Center for Health Statistics)

• A disease that is long lasting or recurrent– Recurrent diseases relapse repeatedly, with

periods of remission in between.

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Road to Recovery

• Conceptualization of addiction as a chronic disease is supported by comparison of its manifestations, course, etiologic factors (genetic and environment), pathophysiology, and response to treatment with other chronic medical illnesses (DM II, asthma, HTN).

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Road to Recovery

Principles of Chronic Disease Management CDMadapted from: Dr. Richard Lewanczuk, Senior Medical Director, Primary Care, Chronic

Disease Management, Alberta Health Services

• Population stratified by risk• Case finding, (screening)• Continuum of care options• Patient defined goals• Multidisciplinary approach• Care coordination and system supports• Range of disease management strategies with

education • Ongoing, long-term follow-up

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Road to Recovery

Principles of Chronic Disease Management CDMadapted from: Dr. Richard Lewanczuk, Senior Medical Director,Primary Care, Chronic

Disease Management, Alberta Health Services

• Population stratified by risk (FH/Childhood/Co-occurring/exposure to substances)• Case finding, (screening)—H&P/AME/Tox/CAGE/Collateral• Continuum of care options—Customization/self-management skills/Linkages to

community support/Systematic monitoring of clinical status & relapse risk—Clinic/IOP/Residential

• Patient defined goals—engage patient—system defined abstinence/Lifestyle and Health/Reduced Disease-related Morbidity

• Multidisciplinary approach—Continum of Providers• Care coordination and system supports—PRN/Providers• Range of disease management strategies—Stabilization,Education,Lifestyle

Counseling,Relapse Prevention,Counseling,Pharmacotherapy,Long-term monitoring– Toxicology

• Ongoing, long-term follow-up

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Road to Recovery

Chronic Care Model CDM

• Continuing contact over time between patients and service providers, rather than short-term intervention during acute episodes.

• Interventions to promote patient self-management of his/her addiction

• Links to patient oriented community resources• Using accurate and timely patient data to

monitor progress and guide intervention

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Road to Recovery

Community Support Services—CDM

Diabetes Mellitus• Family Counseling and

support• More

Addiction• Aftercare Groups• Family Counseling and

support• 12 Step Programs• More

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Road to Recovery

Relapse ?—CDM

Diabetes Mellitus• Yes!

– Poor glucose control– Target organ pathology

possible– Family and occupational

consequences

• But good control possible with life-long adherence to treatment strategies

Addiction• Yes!

– Relapse to substance use– End Organ Pathology possible– Family, Social, Occupational

consequences

• But long-term abstinence possible with life-long adherence to recovery strategies

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Road to Recovery

Cure?—CDM

Diabetes Mellitus• No!• Good Control possible• ?Remission

Addiction• No!• Good Control Possible• Remission possible

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Road to Recovery

CDM Levels of Care(Lewanczuk)

Case Management

Specialty Clinics Provide Care for Complex Cases

Primary

Care Physicians, teams, PCNS are supported to supply the

best care for

the

largest number

of people

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Road to Recovery

PHP’s/PRN’s

Tertiary Interventio

ns and Treatment Coordination, Case Management, and CDM Monitoring

Secondary Access to Services for Early Intervention and Treament

Primary Prevention and Education

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Road to Recovery

PHP/PRN Services:• Information and Advice• Intervention Services• Assessment• Referral for Treatment• Case Management

Monitoring• Advocacy• Family support• Education and Prevention• Not Treatment

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Road to Recovery

Intervention

• Important considerations for intervention and treatment– Patient safety– Prompt response and resource availability– Medical Stabilization/withdrawal management– Support (Family Support)– Suicide Risk– Work Responsibilities covered– Reporting obligations—accountability

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Assessment

• Community Based Clinical Resources– Comprehensive Assessment Services– Addiction Treatment Services

• Individual clinicians, outpatient programs, residential treatment– Psychiatrist– GP psychotherapist– Psychologists– Mental Health Treatment Services– Family Doctors– Addiction and Family counselors

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Treatment of Addiction HCP’s• Abstinence Based• Often Inpatient• Detox• Education• Group Support• Twelve Step Facilitation• Pharmacotherapy (NB. Opioid agonist Rx seldom needed)• Identification of co-morbid disorders• Family Support• Long-Term monitoring/case management

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•American Society of Addiction Medicine Patient Placement Criteria – 2nd Edition Revised (ASAM PPC-2R) dimensions of care

Dimension 1: Acute Intoxication and/or Withdrawal Potential Dimension 2: Biomedical Conditions and Complications Dimension 3: Emotional, Behavioral or Cognitive Conditions and

Complications (suicidality) Dimension 4: Readiness to Change Dimension 5: Relapse, Continued Use or Continued Problem Potential Dimension 6: Recovery/Living Environment

DETERMINING LEVEL OF CARE

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DETERMINING LEVEL OF CARE

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Level I: Outpatient treatment.

Level II: Intensive outpatient treatment, including partial hospitalization.

Level III: Residential/medically monitored intensive inpatient treatment.

Level IV: Medically managed intensive inpatient treatment.

DETERMINING LEVEL OF CARE

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Case Management/Coordination• Clinical case coordinator for each HCP• Receive Reports from all monitoring components

including workplace• Random Toxicology Testing (urine, hair, other)• Facilitate communication amongst treatment providers• Resource identification as needed• Prompt response to relapse or prodrome• Routine interviews and annual review with participant• Progress and advocacy reports for third parties• Identify and respond to family and other concerns

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CDM—Coordination & Monitoring

• Contact with Colleagues• Referral AME/Treatment• Acting as intermediary with Board, employer,

colleagues, or staff to facilitate return to work• UDS• Monitoring of HCP’s Behavior

– (Phone contacts, his/her attendance at weekly monitoring meetings/aftercare, workplace monitor with regular reports regarding functioning on the job)

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Behavioral1%

SUD--Mild2%

SUD--Moderate to Severe39%

Psychiatric33%

Concurrent Disorders22%

Substance Use3%

Contracts by Type 2013 N=177 OMA

Behavioral SUD--Mild SUD--Moderate to SeverePsychiatric Concurrent Disorders Substance Use

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Concurrent Problems and Disorders

• SUD seldom present in isolation– Psychiatric Disorders– Trauma– Behavioral Dependencies (Sex, gambling, etc.)– Physical Health problems (chronic pain

syndromes)– Family Problems

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Family: Addiction is a Family Disease

• Support• Psychoeducation• Recovery Services in support of Physician

spouse• Referral for personal services

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Applying Occupational Health Principles

• Safety-Sensitive Profession• Workplace education and accommodations are often

required• Participate in return to work planning with the

participant and the workplace• Fitness for work measured by performance on a range

of work tasks from low to higher risk• Scrutiny and accountability in the workplace is

necessary• Monitor long-term for Health and Recovery

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Questions• Question #7 Pharmacists who develop SUD are more

likely to have had certain earlier life experiences, all of the following are true except:

• A. Very few Pharmacist with SUD ever experienced use of drugs/alcohol prior to the age of 18.

• B. Many would have had a family history of SUD.• C. Early Life Trauma would have been a risk factor for SUD

later in life.• D. Adolescence who are treated with Stimulants for ADHD

(which is “misdiagnosed” in childhood), will have a greater risk for SUD than if they had not received Stimulants.

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Questions• Question #7 Pharmacists who develop SUD are more likely to

have had certain earlier life experiences, all of the following are true except:

• A. Very few Pharmacist with SUD ever experienced use of drugs/alcohol prior to the age of 18.

• B. Many would have had a family history of SUD.• C. Early Life Trauma would have been a risk factor for SUD later in

life.• D. Adolescence who are treated with Stimulants for

“misdiagnosed” ADHD in childhood), will have a greater risk for SUD versus those adolescence who had never received stimulants.

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Questions• Questions #8. : Find the correct Answer(s):• T/F The majority of referrals to PHP’s who ultimately sign

monitoring contracts have some form of psychiatric diagnosis.• T/F The PHP/PRN’s are the only entity that makes return to work

recommendations.• T/F The PHP/PRN are seldom involved in any form of

intervention with professionals.• T/F The PHP/PRN is a participants advocate, as long as that

participant is engaged in his program of recovery and meeting his monitoring requirements.

• T/F In the CDM of care for addiction—Relapse is rarely a concern and the goal is to achieve a cure.

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Questions• Questions #8. : Find the correct Answer(s):• T/F The majority of referrals to PHP’s who ultimately sign

monitoring contracts have some form of psychiatric diagnosis.• T/F The PHP/PRN’s are the only entity that makes return to work

recommendations.• T/F The PHP/PRN are seldom involved in any form of

intervention with professionals.• T/F The PHP/PRN is a participant’s advocate, as long as that

participant is engaged in his program of recovery and meeting his monitoring requirements.

• T/F In the CDM of care for addiction—Relapse is rarely a concern and the goal is to achieve a cure.

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Relapse:Road to Recovery

Dr. Jay Piland MDPalmetto Addiction Recovery CenterPecan Haven Adolescent Addiction Center

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CDM: Performance Measures Help Guide Care

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“Blueprint” StudyMcLellan et.al., BMJ, Nov. 2008

• 16 American PHPs retrospective longitudinal study• 904 consecutive MDs with SUDs, 647 monitored• 81% never relapsed over five years• 79% licensed and working after five years• 11% revoked• 3.5% retired• 3.5% died• 3% status unknown

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Relapse Risk (Washington State PHP) (Domino, et. al. JAMA, Mar 23,

2005)Retrospective Cohort Study

• Relapse rate: 25% (74 of 292 cases between 1991- 2001)

• Increased relapse risk if:– Concurrent psychiatric disorder (HR 5.79)– Family history of substance use disorder (HR 2.29)– Previous major relapse (HR 1.69)– Combinations of these adds to cumulative risk – Major Opioid/Dual Diagnosis/Family History (HR 13.25)

• No increased relapse risk:– Drug of choice

• Including major opioid as long as above factors absent– Specialty– Gender

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OMA PHP Relapses - 5 Year Program First 100 monitored participants

Brewster, Kaufmann et al; BMJ Nov 2008

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LIFE SATISFACTION* BY PROGRAM YEAR - OMA PHP

YEAR IN PROGRAM* Mean of 14-items: 4-Very satisfied; 3-Satisfied; 2-Dissatisfied; 1-Very dissatisfied

R2 = .813; Regression constant = 3.266; Slope = 0.0498 (p = .037)

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PFSP Program Evaluation 2008: Did PFSP make a difference for participants in case

coordination?

90% of responding participants reported that the problem that had caused them to access the program had improved (46% responded)

• Overall wellness• Job effectiveness• Relationships with

others

full 76% partial 14%full 71% partial 14%

full 71% partial 24%

Overall life satisfaction• Beginning of case coordination

3.7/10• Conclusion of last interaction

8.1/10

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Special Issues of Return to Work

• PHP/PRNs usually spell out the conditions for a HCP’s return to practice via a contract.

• Most Regulator’s specify only that the HCP return to work should be based on her/his ability to practice with “reasonable skill and safety”—leaving judgement up to treatment team

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Special Issues of Return to Work• Assessment of her/his:

– Acceptance of SUD diagnosis– Understanding of addiction as a chronic disease requiring lifelong attention– Completion of SUD treatment, with support of treatment team to resume work– Documentation of sustained abstinence(UDS).– Treatment and status of Co-occurring Mental Disorders– Judgment and cognition (neuropsychological testing)– HCP’s ability to manage stress and triggers– Support Network including Family support– Estimated risk of Relapse– Motivation to follow an established continuing care plan– Occupational Factors:

• Legal/Licensure Requirements Satisfied• Workplace monitor/supervisor identified and accepts responsibilities• Necessary Workplace modification or practice restrictions have been agreed to

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Special Issues of Return to Work• Staged Process• May have limited work hours, tasks, time of day, or settings• May face restrictions to access to mood-altering medications• Workplace monitor in contact with PHP/PRN (release for communication in

effect at all times)• Settings of practice limited to provide for easier monitoring/better

accountability• Accountability System for dispensing/administering addicting drugs to

patients– Not being the person in the practice to check a patient’s medications for compliance– Keeping track of prescriptions written for controlled substances– Using double locked systems for addicting substances on premises– Periodic checking of wastage from injectable opioids to assure all vials and their

contents are properly accounted for & have not been diverted

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Special Issues of Return to Work

• Risk Factors for Relapse in HCP’s• Use of Potent Opioids (Fentanyl, Sufentanil,

morphine, and meperidine)-especially IV opioids

• Co-occurring Mental Disorders• Family History of Addiction• Use of Multiple Drugs

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Behaviors and Beliefs associated with Higher Rates of Recovery—HCP’s

• Involvement in or strong sense of affiliation with Alcoholic Anonymous

• Acceptance of addiction as a disease• Ability to be Honest• Acceptance of Spiritual Principles

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Contingency Contracts• Typically five years or more in duration and impose

conditions upon the physicians behavior in return for a pathway to recovery and return to practice (provides the basis for subsequent actions—eval/assessments):– Withdrawal from practice until can return safely– Avoidance of all addicting substances & Behaviors– Participation in adequate Treatment– Participation in weekly group sessions—facilitated – Random Drug Testing– Regular contact with PHP/PRN to monitor behaviors– Factors determining readiness to return to practice safely

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“Effective” Treatment Involves:

• Monitoring • Monitoring • Monitoring

– During and after Treatment

– And during Return to Work

– Fortified by Swift & Meaningful Interventions if components of the contract are not maintained

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Questions

Question #9 What percentage of pharmacists can be expected to recover from substance use disorders with participation in formal recovery programs?A. 25%B. 45%C. 65%D. 85%

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Questions

Question #9 What percentage of pharmacists can be expected to recover from substance use disorders with participation in formal recovery programs?A. 25%B. 45%C. 65%D. 85%

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Questions

Question #10 Which of the following might be most likely to increase the risk of relapse in pharmacists affected by substance abuse?A. A Brief RelapseB. Skipping group meetingsC. Acceptance of the diagnosisD. Extended Treatment

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Questions

Question #10 Which of the following might be most likely to increase the risk of relapse in pharmacists affected by substance abuse?A. A Brief RelapseB. Skipping group meetingsC. Acceptance of the diagnosisD. Extended Treatment

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Questions

Question #11 Pharmacists can access their state’s recovery program through which of the following?A. www.na.orgB. www.aa.orgC. www.drugabuse.govD. www.usaprn.org

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Questions

Question #11 Pharmacists can access their state’s recovery program through which of the following?A. www.na.orgB. www.aa.orgC. www.drugabuse.govD. www.usaprn.org

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Questions• Question #12 Early reporting of addiction and related

disorders in HCP’s are important for which of the following reasons?

A. Minimization of risk of harm to patients.B. Delay can increase the risk of progression of the condition

for the HCP.C. Avoidance of multiple legal issues (licensure, civil liability,

or liability of employer, or criminal liability of the impaired HCP in the case of a medication error).

D. Minimization of “collateral” damage to HCP family and personal relationships.

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Questions• Question #12 Early reporting of addiction and related

disorders in HCP’s are important for which of the following reasons?

A. Minimization of risk of harm to patients.B. Delay can increase the risk of progression of the condition

for the HCP.C. Avoidance of multiple legal issues (licensure, civil liability,

or liability of employer, or criminal liability of the impaired HCP in the case of a medication error).

D. Minimization of “collateral” damage to HCP family and personal relationships.

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Questions

• Question #13 Relapse Risk for HCPs is significantly increased by all of the following except:

• A. Use of Major Opioid and Dual Diagnosis• B. Family History of Substance Use Disorder• C. Male Gender• D. A History of a Prior Relapse

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Questions

• Question #13 Relapse Risk for HCP is significantly increased by all of the following except:

• A. Use of Major Opioid and Dual Diagnosis• B. Family History of Substance Use Disorder• C. Male Gender• D. A History of a Prior Relapse

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Questions

• Question #14. Use of Contingency Management (contracts) in the chronic disease model/management of PRN’s:

• A. Involve giving rewards for negative drug screens• B. Involve applying swift & strict enforcement of

contractual consequences for a positive drug screen• C. Do not motivate meeting attendance by PRN

participants.• D. Seldom are effective in the Professional population

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Questions

• Question #14. Use of Contingency Management (contracts) in the chronic disease model/management of PRN’s:

• A. Involve giving rewards for negative drug screens• B. Involves applying swift & strict enforcement of

contractual consequences for a positive drug screen• C. Do not motivate meeting attendance by PRN

participants.• D. Seldom are effective in the Professional population

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Relapse:Road to Recovery

Dr. Jay Piland MDPalmetto Addiction Recovery CenterPecan Haven Adolescent Addiction Center

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Relapse:

• Definition varies according to source text.• Addiction Medicine-Fourth Edition 2009:• Uses terms Lapse, Relapse, and Recovery.• Some argument over what constitutes a

Relapse-but not from PHP programs. Use a higher standard of complete abstinence from mood altering substances.

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Lapse

• Marlatt defines as the initial episode of use of a substance after a period of abstinence.

• Not really recognized for professionals.

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Relapse:

• “ a discrete phenomenon or a process of behavioral change”

• “an unfolding process in which the resumption of substance use is the LAST event in a long series of maladaptive responses to internal or external stressors or stimuli”

• “ a continuous process defined by a series of transgressive behaviors”

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Interventions Do Work

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Behavior Patterns

• It’s the behavior stupid.• Mechanism of response to stressors and

stimuli—I.E.—LIFE.• Response can be healthy or maladaptive

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Recovery

• Recovery is defined as a long-term and ongoing process rather than an endpoint.

• Specific areas of change during the process of recovery include physical, psychologic, spiritual, behavioral, interpersonal, sociocultural, familial, and financial.

• Recovery tasks and areas of clinical focus are contingent on the phase of recovery .

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Stages of Relapse:

• Used by PHP and RNP programs nationwide.• 3 stages of relapse.• Evidence shows progression over time.• Measurement of severity of relapse but not

necessarily indicative of recommended corrective actions from monitoring programs.

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Level 1 Relapse

• A level 1 relapse consists of missing therapy meetings, support groups, dishonesty, or other behavioral infractions.

• Note-no mention of substances.

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Level 2 Relapse

• A level 2 relapse involves the reuse of drugs or alcohol but outside the context of medical practice.

• Not necessarily a person’s drug of choice.

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Level 3 Relapse

• Involves the use of drugs or alcohol within the context of medical practice.

• Main goal of PHP programs is to prevent this occurence.

• PHP’s, PRN’s, and RNP’s primary directive: Protect the Public.

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Consequences

• Different for professionals than the general public because we present a greater danger than just to ourselves.

• “Physicians who have difficulty maintaining abstinence should be removed from the workforce until treatment providers….feel that the physician is safe to return to work.”

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Consequences 2

• “ The point in time when a physician is safe to practice is best determined by a joint decision of the physician’s treatment provider and the monitoring PHP.”

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Determinants of Relapse

• Marlatt’s Relapse Taxonomy:• Intrapersonal Determinants

– Self Efficacy– Outcome Expectancies– Cravings– Motivation– Coping– Emotional States

• Interpersonal Determinants

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Intrapersonal Determinants

• Self-efficacy: refers to the individuals beliefs in their capabilities to organize and carry out specific courses of action to attain some goal or situation specific task.

• This construct is intimately related to the individual’s coping abilities.

• The patient’s personal belief in his or her ability to control substance use is a reliable predictor of relapse.

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Self-Efficacy

• If you believe you can you will.• Confidence in your ability to control your

substance use is intimately related with your coping skills.

• Coping behaviors should be thoroughly assessed during treatment and appropriately targeted for interventions.

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Outcome Expectancy

• A factor enhancing the likelihood of relapse is the set of cognitive expectancies that individuals develop regarding the expected outcomes of substance use.

• If it feels good do it. Not a good plan.• Treatment should focus to some extent on

changing the individual’s outcome expectancies regarding substance use.

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Craving

• Defined as a cognitive experience focused on the desire to use a substance.

• Closely related to outcome expectancies.• Different from behavioral urges.• Treatment should also include an evaluation

of cravings and appropriate readjustment based on outcome expectancies.

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Motivation

• Gorski: The degree to which a person’s behavior differs from their ideal behavior beliefs is the degree of that person’s insanity.

• The person’s desire for self improvement and commitment to change is a strong predictor of relapse.

• Ambivalence toward change is the enemy of recovery.

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Coping

• “Based upon cognitive-behavioral model of relapse, the most critical predictor of relapse is the individuals ability to utilize adequate coping strategies in dealing with high-risk situations.”

• One of the most effective coping strategies available is mindfulness and meditation.

• Foundation of behavioral change.

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Emotional States

• Studies show a strong link between negative affect and relapse to substance abuse.

• It is the cornerstone of effective recovery; affect is a strong determinant of subsequent behavior.

• Two things you can control: Attitude and Behavior. They are intimately associated.

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Interpersonal Determinants

• Functional support or the level of emotional support is highly predictive of long term abstinence and recovery.

• Behavioral therapy which incorporates partner support in treatment goals is one of the top three empirically supported treatment methods for alcohol problems.

• Al-Anon is born.

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Top 10 ways to Prevent Relapse

• 1) Help patients understand relapse as a process and event, and learn to identify warning signs.

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RP• 2) Help patients identify their high risk

situations and develop effective cognitive and behavioral coping.

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RP

• 3) Help patients enhance their communication skills, interpersonal relationships, and develop a recovery social network.

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RP

• 4) Help patients reduce, identify, and manage negative emotional states.

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RP• 5) Help patients identify and manage cravings

and cues that precede cravings.

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RP

• 6) Help patients identify and challenge cognitive distortions.

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RP

• 7) Help patients work toward a more balanced lifestyle.

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RP

• 8) Consider the use of medications in combination with psychosocial treatments.

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RP

• 9) Facilitate the transition between levels of care for patients completing residential or hospital based inpatient treatment programs, or structured partial hospital or intensive outpatient programs.

• PRN’s PHP’s RNP’s CM

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RP

• 10) Incorporate strategies to improve adherence to treatment and medication.

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Susan P. Rx Relapse ?• Susan is a 35 year old Pharmacist who was treated for alcohol SUD at the

age of 24. After treatment she enrolled in the PRN monitoring and signed a 5 year monitoring contract.

• After the completion of her five year contract at the age of 29 she had been very engaged in her peer support recovery program (AA, Caduceus, Continuing Care, and UDS monitoring) but stopped going about six months before the end of her contract.

• Three months prior to completion of her contract, Susan discovered she was pregnant—she had noticed a significant mood change(depression) and an increase in her anxiety level due to difficulty with her supervisor at work (Hospital Pharmacy). She also was increasingly anxious due to her infidelities which occurred with another coworker who was a 22 year old pharmacy student—which she ended at 8 months into her pregnancy—after being involved with him for several months.

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Susan P Rx Relapse ?

• Is Susan P. in Relapse?

• Would she benefit from being in a social recovery Network?

• How could she be better managing her “negative emotional state”?

• What emotions are driving that “state”?

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Susan P Rx Relapse?• She had a child (son) who was born about six months after completing her

monitoring contract(out of meetings for about 1 year. She did have to undergo a C-section and the birth was complicated with some fetal distress prior to delivery—yet no anomalies were noted in the infant. Susan received a Rx for Percocet 10mg after the C-section and took three refills. (when taking the Percocet—she began to think about a repeated dose within 1 hour of last dose and could not get it off her mind)

• Susan returned to work after only 8 weeks at home after the C-section. She had stopped having contact with her sponsor as she was no longing attending AA meetings (not enough time). Also her sponsor had advised her to end the previous relationship after Susan had only one sexual encounter with him at age 33—she did not follow the suggestions—the relationship continued for several months. She had been working with a girl in early recovery but stopped working with her after stopping the meetings.

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Susan P. Rx Relapse

• Is Susan in Relapse?

• What Level?

• What did she not do with her pregnancy/delivery?

• What could Susan have done with Cravings?

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Susan P Rx Relapse ?• Susan returned to her habit of smoking cigarettes (she had stopped at age 24)

only two weeks after her son was born. Susan also began to experience recurring episodes of dysphoria within that same time frame, she also experienced recurring “flash-backs” of early childhood sexual trauma she experienced at the age of 8 by an “uncle”. She would have recurrent thoughts of being worthless and not being able to do anything right—she began to think that her tendency to “gamble” was the reason for sexual trauma “flash-backs”.

• She was responsible for filling the Pyxis machines with all of the narcotics when she returned to work from maternity leave—so she progressively increased her use up to 25 Percocet tablets daily. She took “50 Percocet capsules” in a “suicide attempt” when her supervisor began to perform internal Pyxis pharmacy audits. She now presents for an addiction assessment after getting out of the acute care hospital.

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Susan P Rx Relapse?

• 15. Does Cigarette Smoking increase her risk of relapse?

• 16. What should she do about “flash-backs”?• 17. What should she do about cognitive

distortions?• 18. Should she be on MAT? Vivitrol?• 19. What is most appropriate next step?

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Susan P. Rx Relapse?True/False?

21. Relapse Prevention plans should always be started at the middle/end of treatment.

22. Performing a relapse autopsy is always useful.

23. Most HCP’s who relapse, always loose their license and ability to practice their profession.

24. Many HCP’s who have an early relapse, often are able to achieve and improved footing/foundation of a recovery program.

25. IDAA. Look us up www.ida.org

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Dr. Jay Piland MDPalmetto Addiction Recovery CenterPecan Haven Adolescent Addiction Center