The Impaired Healthcare Professional: Treatment vs. Criminality

A Policy Proposal

Duane M. Stillions, MDMPH Capstone Project

May, 2011

Capstone and MPH Advisor:Peter Pronovost, MD

Presentation Outline

Presentation Outline

• Part 1: The Impaired Physician• Part 2: The Policy Challenge• Part 3: Stakeholders for Policy Change• Part 4: Law and Medicine for a Policy Proposal

Part 1: The Impaired Physician

Definition

“Impairment of a healthcare professional is the inability or impending inability to practice according to accepted standards as a result of substance use, abuse or dependency.”1

Part 1: The Impaired Physician

Incidence

• 10-15 % of Healthcare providers misuse drugs/alcohol during their professional career1

• Men > Women2,3

• Opiate and Benzo abuse 5 times higher than public4

Part 1: The Impaired Physician

Incidence, Cont.

• Medical Specialties with the highest rates5,6,7:• Anesthesiologist: alcohol and parenteral opiates• Psychiatrists: benzodiazepines• Emergency Room physicians: cocaine and marijuana

• Other Healthcare professions with high rates7:• Nursing, Dentistry, Pharmacy, Veterinary Medicine

Part 1: The Impaired Physician

Physician Health Programs

• Representative organizations in nearly all 50 states, including the District of Columbia

• Serve as the primary advocate for the recovering impaired physician.

• 5-year contractual agreement10:• Outpatient treatment• Therapy• Attendance of 12-step meetings• Random drug screen monitoring

• Established relationships with the State Boards of Medicine

Part 1: The Impaired Physician

From Immorality to the Disease Concept

• American Medical Association 1973 landmark policy paper: “The Sick Physician”8

• 1983: American Society of Addiction Med. (ASAM)9

• 1990 the AMA recognizes Addiction Medicine as a medical specialty1

• Contributions by the field of Psychiatry:• Diagnostic and Statistical Manual of Mental Disorders• Addiction Psychiatry Fellowship

Part 2: The Policy Challenge

Treatment vs. Criminality

• Conflicting Approaches to Managing Addiction11,12:• Medical or criminal problem• “Cops-versus-docs framing”

• 3 models of management: • prevention • treatment • law enforcement

Prevention

• Educate the public on the dangers of alcohol and drug abuse.

• Public health administrations, the media, local schools, and NGO’s.

• Narrow audience• External/social pressures• Limited Success

Part 2: The Policy Challenge

Treatment

• Disease Model: Bio-Psycho-Social model13

• Genetics and brain chemistry• Psychological disease• Social factors

• Treatment success is dependent upon deconstructing the three arms

• Ineffective retention and limited resources• Limited Success

Part 2: The Policy Challenge

Law Enforcement

• Predicated on individual acts of free will14

• Focus on the social contributions to addiction• Erect barriers to affect supply and demand15

• Poor Funding and Resources; Overwhelming caseload• Limited Success

Part 2: The Policy Challenge

The Policy Challenge

• State Medical Board: punitive actions• Physician Health Programs: treatment and advocacy• Law Enforcement Agencies: lack of criminal

prosecution• Result: Change in tone and actions against impaired

physicians• Law enforcement task forces16

• Increased and more public punitive actions by medical boards

• Closure in January 2010 of the California state PHP17.

Part 2: The Policy Challenge

Part 3: Stakeholders for Policy Change

Federation of State Physician Health Programs

• Formal oversight organization for individual state Physician Health Programs (PHP)18.

• PHP: Primary advocacy organization for impaired physicians

• Forum for education and exchange of information• Common standards for state PHP’s

Federation of State Medical Boards of the United States, Inc

• Committee on Physician Impairment (1995 Report)19

• 3 Goals:1. Establish guidelines, rules and regulations for state PHPs2. Protect the public via education campaigns3. Improve the capacity of state medical boards to supervise

impaired physicians

• Report lacks specific causes for and descriptions of disciplinary actions.

• Report does not discuss the potential criminality associated with the impaired physician.

Part 3: Stakeholders for Policy Change

U.S. Dept of Justice: Office of Diversion Control

• “Drug Addiction in Health Care Professionals” 201020:• Issues surrounding abuse of prescription controlled

substances• Message consistent with the AMA, APA, and ASAM

• DEA: give clear lines for criminal prosecution• Sales and Distribution.

• DEA: Federal Register of Notices of Rules (2003)21: • Theft or significant loss of controlled substances• Reporting, Investigation and Prosecution

Part 3: Stakeholders for Policy Change

Law and Medicine

• Goals of the Policy: • Public Safety• Policy to encourage impaired providers to seek

help

Part 4: Law and Medicine: A Policy Proposal

Part 4: Law and Medicine: A Policy Proposal

Law: 3 Proven Legal Frameworks

• 1. Amnesty• Executive or legislative act through which a state can

restore an individual or group of individuals who may have been guilty of an offense to a position of innocence22.

• Amnesty is granted before prosecution.• Amnesty is NOT a pardon23.• Promotes offenders to come forward.• Offers opportunity for individuals to address issues and

reintegrate into society.

Law: 3 Proven Legal Frameworks• 2. Diversion Program• First-time offenders to participate in counseling that

pertains to underlying criminal activity rather than proceed through the court system24.

• With successful completion, misdemeanor charges are dismissed. Therefore, avoid criminal charges and record.

• 3. Sanctioned Programs• Requires complete compliance with a heavily monitored

drug treatment program25.• Any deviation from the “sanctioned track” results in

immediate penalties (predetermined sanctions).

Part 4: Law and Medicine: A Policy Proposal

Law and Medicine Together

• What to do about the impaired physician with a history of diversion of controlled substances?• First-time offender, No criminal activity, No harm to

patients or public.

• Apply principles of Amnesty, Diversion Program, and Sanctioned Program.

• Notification of state board of medicine and PHP.• Immediate admission to inpatient treatment.• The 5-year monitoring contract with the BOM/PHP

will serve as a “sanctioned track” in collaboration with law enforcement.

Part 4: Law and Medicine: A Policy Proposal

Benefits

• Communication and collaboration between law enforcement and state BOM/PHP.

• Supports guidelines for specific penalties for deviations from sanction/monitoring contracts.

• Maintains an avenue for criminal prosecution and a permanent criminal record for noncompliance.

• Penalties immediate:• Prosecution: incarceration, fines, probation• Immediate suspension of licensures• Loss of employment

Part 4: Law and Medicine: A Policy Proposal

Conclusion

• Important public health issue• Remove the veil of shame and denial• Complex• Collaboration and transparency• Improve public awareness• Return the impaired physician to good health• Public Safety and Trust

Part 4: Law and Medicine: A Policy Proposal

Reference

References1. Baldisseri, M. R. (2007). Impaired healthcare professional. Critical Care Medicine, 35(2

SUPPL.), pS106.2. Brewster, J. M. (1986). Prevalence of alcohol and other drug problems among physicians.

JAMA: The Journal of the American Medical Association, 255(14), 1913-1920. 3. Niven, R. G., Hurt, R. D., Morse, R. M., & Swenson, W. M. (1984). Alcoholism in physicians.

Mayo Clinic Proceedings.Mayo Clinic, 59(1), 12-16. 4. Hughes, P. H., Brandenburg, N., Baldwin, D. C.,Jr, Storr, C. L., Williams, K. M., Anthony, J. C., &

Sheehan, D. V. (1992). Prevalence of substance use among US physicians. JAMA: The Journal of the American Medical Association, 267(17), 2333-2339.

5. McLellan, A. T., Skipper, G. S., Campbell, M., & DuPont, R. L. (2008). Five-year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ (Clinical Research Ed.), 337, a2038. doi:10.1136/bmj.a2038

6. Mansky, P. A. (1996). Physician health programs and the potentially impaired physician with a substance use disorder. Psychiatric Services (Washington, D.C.), 47(5), 465-467.

7. Gallegos, K. V., Veit, F. W., Wilson, P. O., Porter, T., & Talbott, G. D. (1988). Substance abuse among health professionals. Maryland Medical Journal (Baltimore, Md.: 1985), 37(3), 191-197.

8. The Sick Physician: Impairment by psychiatric disorders, including alcoholism and drug dependence. (1973). Journal of the American Medical Association, 223(6), 684-687.

9. ASAM history. (2010). Retrieved 03/23, 2011, from http://www.asam.org/History.html

Reference

References

10. Health practitioners' monitoring program. (2008). Retrieved August/2, 2009, from http://www.dhp.state.va.us/enforcement/hpmp.htm ; http://www.vahpip.org/

11. David F. Musto, M. D. (1999). The American Disease: Origins of narcotic control (3rd ed.). New York: Oxford University Press. doi:0195125096

12. Boyum, D., & Reuter, P. (2001). Reflections on drug policy and social policy. In P. B. Heymann, & W. N. Brownsberger (Eds.), Drug addiction and drug policy (1st ed., pp. 239-264). Cambridge, Massachusetts: Harvard University Press. doi:0-764-00327-6, p239.

13. McCarty, J. (2006). The bio-psycho-social approach to addiction: An introduction. Retrieved july/21, 2010, from http://addictions.wordpress.com/2006/02/12/the-bio-psycho-social-approach-to-addiction-a-summary/

14. Vaillant, G. E. (2001). If addiction is involuntary, how can punishment help? In P. B. Heymann, & W. N. Brownsberger (Eds.), Drug addiction and drug policy (1st ed., pp. 144-167). Cambridge, Massachusetts: Harvard University Press. doi:0-674-00327-6

15. Kleinman, M. A. R. (2001). Controlling drug use and crime with testing, sanctions, and treatment. In P. B. Heymann, & W. N. Brownsberger (Eds.), Drug addiction and drug policy (1st ed., pp. 168-192). Cambridge, Massachusetts: Harvard University Press. doi:0-674-00327-6

16. U.S. Department of Justice Office of the Inspector General. (2007). Coordination of investigations by department of justice violent crime task forces. No. Report Number I-2007-004). Washington, D.C.: U.S. Department of Justice

Reference

References17. Cavanaugh, M. A. (2010). The end of California’s physician health program for drug & alcohol

diversion. EverythingAddiction, (January 20, 2010), July/21. Retrieved from http://www.everythingaddiction.com/public-policy/addicted-doctors/the-end-of-californias-physician-health-program-for-drug-alcohol-diversion/

18. Federation of State Physician Health Programs. (2005). FSPHP guidelines and Policy/Position statements. Retrieved 03/24, 2011, from http://www.fsphp.org/

19. Ad Hoc Committee on Physician Impairment, Federation of State medical Boards of the United States, Inc. (1995). Report of the ad hoc committee on physician impairment. Retrieved 03/25, 2011, from http://fsmb.org/grpol_policydocs.html#1995

20. Office of Diversion Control. (2010a). Drug addiction in health care professionals. Retrieved 03/25, 2011, from http://www.deadiversion.usdoj.gov/pubs/brochures/drug_hc.htm

21. Nagal, L. M. (2003). Reports by registrants of theft of significant loss of controlled substances. (21 CFR Part 1301 No. DEA-196P RIN 1117-AA73). Washington, D.C.: Department of Justice. Retrieved from http://www.deadiversion.usdoj.gov/fed_regs/rules/2003/fr0708.htm

22. Wikipedia: Amnesty. (2011). Retrieved 03/25, 2011, from http://en.wikipedia.org/wiki/Amnesty

23. Hill, G. N., Hill, K. T. & The Gale Group. (2008). TheFreeDictionary: Amnesty. Retrieved 03/25, 2011, from http://legal-dictionary.thefreedictionary.com/Amnesty

24. Diversion program. (2011). Retrieved 03/26, 2011, from http://en.wikipedia.org/w/index.php?title=Diversion_program

25. Harrell, A. (May, 1997). Recent findings from the evaluation of the D.C. superior court drug intervention program. Washington, DC: Urban Institute.