Meeting Meeting March 3, 2009 March 3, 2009 Impaired Health Impaired Health Professionals: Professionals: Identifying Potential Identifying Potential for Public Harm for Public Harm Elinore F. McCance-Katz, MD, PhD Elinore F. McCance-Katz, MD, PhD Professor of Psychiatry Professor of Psychiatry University of California San Francisco University of California San Francisco State Medical Director State Medical Director California Department of Alcohol and Drug Programs California Department of Alcohol and Drug Programs
Impaired Health Impaired Health Professionals: Identifying Professionals: Identifying Potential for Public HarmPotential for Public Harm
Elinore F. McCance-Katz, MD, PhDElinore F. McCance-Katz, MD, PhDProfessor of PsychiatryProfessor of Psychiatry
University of California San FranciscoUniversity of California San FranciscoState Medical DirectorState Medical Director
California Department of Alcohol and Drug ProgramsCalifornia Department of Alcohol and Drug Programs
Can Substance Abuse Issues be Defined Can Substance Abuse Issues be Defined to Apply to All Healing Arts?to Apply to All Healing Arts?
Yes!Yes!Any healthcare professional with patient contact can harm a patient Any healthcare professional with patient contact can harm a patient when impaired (intoxicated, under the influence, in withdrawal)when impaired (intoxicated, under the influence, in withdrawal)Examples (not complete and these specifics can be extended to Examples (not complete and these specifics can be extended to other professions):other professions):Physicians: inappropriate/substandard care; inability to practice Physicians: inappropriate/substandard care; inability to practice safely; prescription forgerysafely; prescription forgeryNurses: impairment in workplace, diversion, denial of pain Nurses: impairment in workplace, diversion, denial of pain medication to patients; prescription forgerymedication to patients; prescription forgeryPharmacists: Diversion, inability to accurately fill prescriptionsPharmacists: Diversion, inability to accurately fill prescriptionsCNAs: inability to provide direct care to patients who cannot care for CNAs: inability to provide direct care to patients who cannot care for themselves; patient abusethemselves; patient abuseHome health aides: inability to assist with ADLs; diversionHome health aides: inability to assist with ADLs; diversionPsychologists/Therapists: poor judgment can lead to ineffective Psychologists/Therapists: poor judgment can lead to ineffective therapy; abuse of patientstherapy; abuse of patientsEtc., etc….Etc., etc….
Is Treatment an Effective Means of Is Treatment an Effective Means of Resolving Substance Abuse Issues?Resolving Substance Abuse Issues?
Physician Health Programs (treatment/monitoring/sanctions) in the Physician Health Programs (treatment/monitoring/sanctions) in the U.S. are being evaluated to determine their effectiveness. U.S. are being evaluated to determine their effectiveness. 5-year follow up study (n=804) 5-year follow up study (n=804) 19% of impaired physicians failed the monitoring program (usually 19% of impaired physicians failed the monitoring program (usually by relapse early in treatment) by relapse early in treatment) 80.7% successfully completed treatment and returned to practice 80.7% successfully completed treatment and returned to practice under monitoring under monitoring Alcohol or drug use was detected by urine drug screening in 19% of Alcohol or drug use was detected by urine drug screening in 19% of the remaining physicians over 5 years, 26% had multiple relapses. the remaining physicians over 5 years, 26% had multiple relapses. Relapsers were removed from practice. Relapsers were removed from practice. At 5 years:At 5 years:
78.7% of program participants were working as physicians78.7% of program participants were working as physicians 10.8% had their licenses revoked10.8% had their licenses revoked 3.5% retired3.5% retired 3.7% died3.7% died 3.2 % unknown3.2 % unknown
McLellan AT, Skipper GS, Campbell M, DuPont RL. McLellan AT, Skipper GS, Campbell M, DuPont RL. BMJBMJ. 2008 Nov 4;337:a2038. 2008 Nov 4;337:a2038
What are the Indicators of Substance Abuse?What are the Indicators of Substance Abuse?
Mechanisms for Boards to be aware of unsafe practice Mechanisms for Boards to be aware of unsafe practice limitedlimitedUsual way that regulatory agencies become aware of SA Usual way that regulatory agencies become aware of SA problems (and other issues in professional practice) is problems (and other issues in professional practice) is through lodging of a complaintthrough lodging of a complaintComplaints investigated by Enforcement; determination Complaints investigated by Enforcement; determination of validity to complaintof validity to complaintOther: public record of substance-related offense (DUI), Other: public record of substance-related offense (DUI), possession/intent, other public records of criminal/civil possession/intent, other public records of criminal/civil proceedings may come to attention of Board, etc.proceedings may come to attention of Board, etc.
What are the Indicators of Substance Abuse?What are the Indicators of Substance Abuse?
Reliance on healthcare settings to report Reliance on healthcare settings to report behavior indicative of impairmentbehavior indicative of impairment
Alcohol on breathAlcohol on breath DUIDUI TremorsTremors Often late MondaysOften late Mondays Frequent call-outsFrequent call-outs Mood SwingsMood Swings Drowsy or sleeping at workDrowsy or sleeping at work Slurred speech on phoneSlurred speech on phone Inappropriate ordersInappropriate orders Inconsistent work performanceInconsistent work performance Deteriorating physical appearance; weight lossDeteriorating physical appearance; weight loss Missing medicationsMissing medications Unusual prescribing practicesUnusual prescribing practices
When Should Substance Abuse Become of When Should Substance Abuse Become of Interest/Concern to Boards/Bureaus?Interest/Concern to Boards/Bureaus?
Relationship of substance use to patient Relationship of substance use to patient harm or potential for patient harmharm or potential for patient harm
Questions of ability to practice safelyQuestions of ability to practice safely
Questions of ability to deliver high quality Questions of ability to deliver high quality care (standard of care issues)care (standard of care issues)
What is a Major/Minor (Lesser) What is a Major/Minor (Lesser) Substance Abuse Violation?Substance Abuse Violation?
Major: when demonstrable patient harm has occurredMajor: when demonstrable patient harm has occurred E.g.: Patient suffers pain because their analgesic E.g.: Patient suffers pain because their analgesic
medications have been divertedmedications have been diverted During intoxication/withdrawal, patient receives wrong, During intoxication/withdrawal, patient receives wrong,
inappropriate, or substandard care causing harminappropriate, or substandard care causing harm Use at workUse at work Practitioner comes to work under the influence and cannot Practitioner comes to work under the influence and cannot
provide necessary care to patientsprovide necessary care to patients Evidence for selling of medications/drug distributionEvidence for selling of medications/drug distribution
What is a Major/Minor (Lesser) What is a Major/Minor (Lesser) Substance Abuse Violation?Substance Abuse Violation?
Minor (Lesser): evidence of substance use Minor (Lesser): evidence of substance use disorder without patient harmdisorder without patient harm E.g.: diversion of medications for personal E.g.: diversion of medications for personal
use with no evidence of a patient being use with no evidence of a patient being denied pain relief; use of waste, diversion of denied pain relief; use of waste, diversion of stock supply or samplesstock supply or samples
Evidence of impairment at work, but no Evidence of impairment at work, but no patient harm (practitioner was detected and patient harm (practitioner was detected and stopped from working)stopped from working)
What Factors/Criteria Should Be Used to What Factors/Criteria Should Be Used to Determine the Level of Violation?Determine the Level of Violation?
Action taken by Board should be based on Action taken by Board should be based on level of threat to patient safetylevel of threat to patient safetyWere patient(s) harmed? (If not, is there a Were patient(s) harmed? (If not, is there a likely risk of harm?)likely risk of harm?)How did harm occur and severityHow did harm occur and severityCriminal activity Criminal activity Underlying cause: Underlying cause: Can the practitioner be rehabilitated? Can the practitioner be rehabilitated? Should a practitioner be allowed to return to Should a practitioner be allowed to return to
practice?practice?
Requirements of SACC: Formulation of Uniform Standards Requirements of SACC: Formulation of Uniform Standards that Boards Shall Use in Dealing with Substance-Abusing that Boards Shall Use in Dealing with Substance-Abusing
LicenseesLicenseesRequirements for clinical diagnostic evaluation and qualifications of evaluator(s)Requirements for clinical diagnostic evaluation and qualifications of evaluator(s)Requirements for removal from practice for evaluation and treatmentRequirements for removal from practice for evaluation and treatmentRequirements governing board communications with employers about statusRequirements governing board communications with employers about statusStandards governing testing of body fluids/tissuesStandards governing testing of body fluids/tissuesStandards of meeting attendanceStandards of meeting attendanceStandards used in determining type of treatment neededStandards used in determining type of treatment neededWorksite monitor standardsWorksite monitor standardsProcedures when positive test is obtained/confirmedProcedures when positive test is obtained/confirmedConsequences for major/minor violations; consideration of deferred prosecutionConsequences for major/minor violations; consideration of deferred prosecutionCriteria for return to practiceCriteria for return to practiceCriteria to petition for reinstatement of full and unrestricted licenseCriteria to petition for reinstatement of full and unrestricted licenseIf the Board uses a vendor for diversion services:If the Board uses a vendor for diversion services:
Standards for reporting non-complianceStandards for reporting non-compliance Standards for vendor’s approval process for providers of services including toxicology screening, Standards for vendor’s approval process for providers of services including toxicology screening,
group facilitators, worksite monitorsgroup facilitators, worksite monitors Standards for discontinuation of providers that fail to provide timely serviceStandards for discontinuation of providers that fail to provide timely service Standards for termination and reporting licensee to BoardStandards for termination and reporting licensee to Board
Extent of confidentialityExtent of confidentialitySchedule for external auditsSchedule for external auditsMeasurable criteria for determining if public is being protected and whether program is Measurable criteria for determining if public is being protected and whether program is effective in assisting licensees in recovering from substance abuse in the long termeffective in assisting licensees in recovering from substance abuse in the long term
How to Assure Adherence to StandardsHow to Assure Adherence to Standards
Regulation/statute determining:Regulation/statute determining: Uniform reporting requirementsUniform reporting requirements Penalties for failure to reportPenalties for failure to report Enforcement of the statuteEnforcement of the statute
Statute providing immunity from civil liability for Statute providing immunity from civil liability for those reporting/acting on report (monitoring) in those reporting/acting on report (monitoring) in good faith (i.e.: no evidence of malicious intent)good faith (i.e.: no evidence of malicious intent)
How to Assure Adherence to StandardsHow to Assure Adherence to Standards
Obtain a new monitoring program that must Obtain a new monitoring program that must adhere to the standards set forth in this adhere to the standards set forth in this committeecommitteeProgram must have written policies and Program must have written policies and proceduresproceduresDocumentation must be meticulousDocumentation must be meticulousClients must be given copies of policies and Clients must be given copies of policies and procedures for program participationprocedures for program participationAuditing can check for quality of monitoring and Auditing can check for quality of monitoring and adherence to requirementsadherence to requirements
How to Assure Adherence to StandardsHow to Assure Adherence to Standards
Confidentiality: Depends on individual circumstances. If Confidentiality: Depends on individual circumstances. If patient harm or violations of law are alleged; case will patient harm or violations of law are alleged; case will not be confidential. If completely voluntary and no patient not be confidential. If completely voluntary and no patient harm or other allegations; participation will be harm or other allegations; participation will be confidential.confidential.Anyone with a substance use disorder has right to Anyone with a substance use disorder has right to confidential treatment (CFR 42)confidential treatment (CFR 42)Those with substance use disorders may be more likely Those with substance use disorders may be more likely to seek treatment/monitoring if confidentiality is to seek treatment/monitoring if confidentiality is maintainedmaintainedMonitor needs to be able to report in cases of Monitor needs to be able to report in cases of confidential clients who are believed to represent confidential clients who are believed to represent imminent danger to patients (without fear of lawsuit for imminent danger to patients (without fear of lawsuit for reporting)reporting)
How to Assure Adherence to StandardsHow to Assure Adherence to Standards
Monitoring program should be a single entity to Monitoring program should be a single entity to assure consistency and to avoid clients assure consistency and to avoid clients “negotiating” as to where they can get the most “negotiating” as to where they can get the most lenient monitoring lenient monitoring
Monitoring program should be run by a credible, Monitoring program should be run by a credible, not-for-profit entity; revenue in excess of not-for-profit entity; revenue in excess of operating expenses should be put into the operating expenses should be put into the program servicesprogram services
How to Assure Adherence to StandardsHow to Assure Adherence to Standards
Monitoring program should have a medical Monitoring program should have a medical director (physician) who can evaluate and director (physician) who can evaluate and diagnosediagnose
Program diagnosis needs to be prevailing Program diagnosis needs to be prevailing diagnosis and that on which diagnosis and that on which treatment/monitoring plan is basedtreatment/monitoring plan is based
No practice while taking mood-altering No practice while taking mood-altering substances in those with SUDssubstances in those with SUDs
Majority with Majority with Substance Use Substance Use Disorders Return to Disorders Return to PracticePractice
Number of Adverse Number of Adverse Outcomes with Outcomes with Patients for Monitored Patients for Monitored Physicians: 0 over 5 Physicians: 0 over 5 yearsyears
0
20
40
60
80
100
RTP/App 98 6 0
In Rx 9 0 0
No RTP 9 4 4
CD Psych Med
% % RTPRTP 9191 6060 00
Data from Virginia Health Practitioners’ Intervention Program, 2007
