Professional Assistance Program-NJProfessional Assistance Program-NJPresents: Presents: ““Healthcare Professional Healthcare Professional

ImpairmentImpairment””

Louis E. Baxter, Sr., M.D., FASAMLouis E. Baxter, Sr., M.D., FASAM Executive Medical Director PAPNJExecutive Medical Director PAPNJ

Past President - American Society Addiction MedicinePast President - American Society Addiction MedicineAmerican Board of Addiction Medicine – DirectorAmerican Board of Addiction Medicine – DirectorDirector-At-Large, American Board of Addiction Director-At-Large, American Board of Addiction

MedicineMedicineNational Association Drug Court Professionals 2009-National Association Drug Court Professionals 2009-

20132013

ObjectivesObjectives

• Attendees will learn about Healthcare Attendees will learn about Healthcare Professional ImpairmentProfessional Impairment

• How to Identify and Refer to How to Identify and Refer to TreatmentTreatment

• Attendees will learn how impairing Attendees will learn how impairing conditions are identifiedconditions are identified

• How treatment plans are developedHow treatment plans are developed• Attendees will learn the Attendees will learn the ““benefitsbenefits”” of of

enrollment in the Programenrollment in the Program

HISTORICAL DATAHISTORICAL DATA

• 1974 … AMA Council On Behavioral Health 1974 … AMA Council On Behavioral Health Published Published ““The Sick PhysicianThe Sick Physician””

• Recommended The Development Of Recommended The Development Of Committees And Programs To Address The Committees And Programs To Address The IssueIssue

• Recommended Legislation To Treat Rather Recommended Legislation To Treat Rather Than to Punish The Sick PhysicianThan to Punish The Sick Physician

• JCAHO MANDATE ... 1/1/01JCAHO MANDATE ... 1/1/01

• JCAHO MANDATE … 2/1/04JCAHO MANDATE … 2/1/04

THE PROGRAMTHE PROGRAM

• Established as the PHP-MSNJ in 1982; nowEstablished as the PHP-MSNJ in 1982; now PAP-NJPAP-NJ … 1st Full time Program in US … 1st Full time Program in US

• ““VoluntaryVoluntary”” Participants Participants• Evaluations; Treatment; Monitoring; & Evaluations; Treatment; Monitoring; &

Advocacy; Advocacy; ““Hospital Authorized PartyHospital Authorized Party””• All Diseases/Disorders of ImpairmentAll Diseases/Disorders of Impairment• Education and Prevention ProgramsEducation and Prevention Programs• NATIONAL REPUTATIONNATIONAL REPUTATION• Buprenorphine TherapyBuprenorphine Therapy

PROGRAM MISSIONPROGRAM MISSION

• To Provide A Means To To Provide A Means To IdentifyIdentify, , Evaluate, And Evaluate, And TreatTreat Healthcare Healthcare Professionals Who May Have Professionals Who May Have DISEASES OF IMPAIRMENTDISEASES OF IMPAIRMENT

• To To Protect The Public SafetyProtect The Public Safety• To Provide To Provide Expert MonitoringExpert Monitoring• To Document To Document RecoveryRecovery• De-StigmatizeDe-Stigmatize Diseases Of Diseases Of

ImpairmentImpairment

DISORDERS OF IMPAIRMENTDISORDERS OF IMPAIRMENT

• Alcohol Use DisordersAlcohol Use Disorders

• Drug Use DisordersDrug Use Disorders

• Psychiatric DisordersPsychiatric Disorders

• Disruptive DisordersDisruptive Disorders

• Psychosexual DisordersPsychosexual Disorders

• Metabolic DisordersMetabolic Disorders

• Physical DisordersPhysical Disorders

• Aging DifficultiesAging Difficulties

REFERRAL SOURCESREFERRAL SOURCES

• ColleaguesColleagues• Office Staff PersonnelOffice Staff Personnel• Residency Program DirectorsResidency Program Directors• Professional School DeansProfessional School Deans• Hospital JCAHO CommitteesHospital JCAHO Committees• Family MembersFamily Members• State Licensing Boards (SBME)State Licensing Boards (SBME)• Attorney GeneralAttorney General’’s Offices Office• Out Of State Physician Health ProgramsOut Of State Physician Health Programs’’

Behavioral Indicators of Behavioral Indicators of Professional ImpairmentProfessional Impairment• LiesLies• Academic dishonestyAcademic dishonesty• Refuses counseling when recommendedRefuses counseling when recommended• Touches clients inappropriatelyTouches clients inappropriately• Inappropriate boundariesInappropriate boundaries• Displays anger against specific gender, race, Displays anger against specific gender, race,

sexual orientationsexual orientation• Misrepresents his or her skill levelMisrepresents his or her skill level• Sexually harasses clients / othersSexually harasses clients / others• Deficient interpersonal skillsDeficient interpersonal skills• Difficulty receiving supervisionDifficulty receiving supervision• Disruptive or dominating Disruptive or dominating

Clinical Signs and Symptoms of Co-Clinical Signs and Symptoms of Co-Worker Worker Impairment Impairment • Strong Odor of alcohol or mouthwash, mintsStrong Odor of alcohol or mouthwash, mints• Hand tremors in the AMHand tremors in the AM• Excessive perspirationExcessive perspiration• Sleeping or dozing off while at workSleeping or dozing off while at work• Frequent absenteeism without notice; latenessFrequent absenteeism without notice; lateness• Unexplained disappearances from workUnexplained disappearances from work• Confusion and memory lossConfusion and memory loss• Frequent bathroom breaksFrequent bathroom breaks• Volunteering for overtime or being at work Volunteering for overtime or being at work

unexpectedlyunexpectedly• Heavy drug wastes and or shortagesHeavy drug wastes and or shortages• Poor record keeping and medication errorsPoor record keeping and medication errors

AGE RELATED IMPAIRMENTSAGE RELATED IMPAIRMENTS

• Cognitive ImpairmentCognitive Impairment …metabolic, …metabolic, organic, medication?organic, medication?

• Cerebral Vascular Accidents Cerebral Vascular Accidents … motor, … motor, speech, cognitivespeech, cognitive

• Longstanding Metabolic EffectsLongstanding Metabolic Effects … …hypertension, diabeteshypertension, diabetes

• DepressionDepression … spousal death, retirement, … spousal death, retirement, financial worriesfinancial worries

• Dementia … Dementia … all causesall causes• Physical DisabilityPhysical Disability

THE PROCESSTHE PROCESS

• Initial Interview - Initial Interview - ““Face - To - FaceFace - To - Face””

• Review Of Referral InformationReview Of Referral Information

• Alcohol And Drug Use HistoryAlcohol And Drug Use History

• Previous Drug And Alcohol Treatment Previous Drug And Alcohol Treatment HistoryHistory

• Psychiatric HistoryPsychiatric History

• Past Medical HistoryPast Medical History

THE PROCESSTHE PROCESS

• Legal HistoryLegal History

• Family HistoryFamily History

• Review All Pertinent DataReview All Pertinent Data

• Psychiatric EvaluationPsychiatric Evaluation

• Comprehensive Medical ExaminationComprehensive Medical Examination

• Neuropsychological EvaluationNeuropsychological Evaluation

• Random Urine TestRandom Urine Test

DIAGNOSISDIAGNOSIS

• Compilation Of All The DataCompilation Of All The Data

• DSM-V Criteria For Substance UseDSM-V Criteria For Substance Use

• DSM-V Criteria For Psychiatric DSM-V Criteria For Psychiatric DisordersDisorders

• Laboratory Test Results For Metabolic Laboratory Test Results For Metabolic DisordersDisorders

• Results Of Psychometric TestingResults Of Psychometric Testing

• Psychosexual Evaluations (p.r.n.)Psychosexual Evaluations (p.r.n.)

TREATMENT PLANNINGTREATMENT PLANNING

• Selection Of Level Of Care … ASAM Selection Of Level Of Care … ASAM Criteria (ASAM-PPC 2)Criteria (ASAM-PPC 2)

• Referral To Appropriate Therapist Referral To Appropriate Therapist (Experience with Healthcare (Experience with Healthcare Professionals)Professionals)

• Monthly Monthly ““Face To FaceFace To Face”” Visits Visits• Random Urine TestingRandom Urine Testing• Provider Treatment Progress ReportsProvider Treatment Progress Reports• Quarterly Reports to referral sourceQuarterly Reports to referral source

TREATMENT WORKSTREATMENT WORKS

• Full Treatment Experience (Detoxification; Full Treatment Experience (Detoxification; Rehabilitation; Maintenance) Rehabilitation; Maintenance)

• General Population recovers @ 77% @ 1yrGeneral Population recovers @ 77% @ 1yr

• Physicians Recover @ 92 % @ 1 yrPhysicians Recover @ 92 % @ 1 yr

• Detoxification & Rehab Only @ 33% @ 1yrDetoxification & Rehab Only @ 33% @ 1yr

• Detoxification Alone @ < 10% @ 1 yrDetoxification Alone @ < 10% @ 1 yr

Treatment Outcome Treatment Outcome ComparisonsComparisons

• Alcoholism … 50-70% abstinentAlcoholism … 50-70% abstinent• Opioid Dependence … 50-80% abstinentOpioid Dependence … 50-80% abstinent• Cocaine Dependence … 50-60% abstinentCocaine Dependence … 50-60% abstinent• Nicotine Dependence … 20-40% abstinentNicotine Dependence … 20-40% abstinent• Diabetes (relapse) … 30-50% stable Diabetes (relapse) … 30-50% stable • Hypertension (poor control) … 50-60%Hypertension (poor control) … 50-60%• Asthma (multiple ER visits) … 60-80%Asthma (multiple ER visits) … 60-80%(Gaber, Davidson, 1992; McLellan 2002)(Gaber, Davidson, 1992; McLellan 2002)

IMPAIRMENT REVIEW IMPAIRMENT REVIEW COMMITTEECOMMITTEE• Established By Regulations 1994Established By Regulations 1994

• A Committee Of The SBMEA Committee Of The SBME

• 5 Voting Members : 2 State Board of 5 Voting Members : 2 State Board of Medical Examiners; 2PAPNJ; 1 Medical Examiners; 2PAPNJ; 1 Commissioner AppointeeCommissioner Appointee

• Reviews Each PAP Case By Code Reviews Each PAP Case By Code NumberNumber

• Enrolls Appropriate Cases Into Enrolls Appropriate Cases Into ARPARP

ALTERNATE RESOLUTION ALTERNATE RESOLUTION PROGRAMPROGRAM• Allows For The Monitoring Of Physicians Allows For The Monitoring Of Physicians

Without Formal Administrative ActionWithout Formal Administrative Action

• Allows For Continued Monitoring Of Allows For Continued Monitoring Of Physicians In Recovery From Diseases Physicians In Recovery From Diseases Of ImpairmentOf Impairment

• Provides Opportunities For Physicians Provides Opportunities For Physicians To Anonymously Seek Help For Their To Anonymously Seek Help For Their Illnesses Without Punishment Illnesses Without Punishment

ALTERNATE RESOLUTION ALTERNATE RESOLUTION PROGRAMPROGRAM

• Initial Reports And Follow Up Reports Initial Reports And Follow Up Reports

• Revision Of Treatment Plans As Per Revision Of Treatment Plans As Per Impairment Review CommitteeImpairment Review Committee

• Discharge Or Release From Program Discharge Or Release From Program After Five YearsAfter Five Years

• Allows For Allows For ““NoNo”” Answers On Biennial Answers On Biennial License Renewal ApplicationsLicense Renewal Applications

IMMEDIATE IMMEDIATE REPORT OF REPORT OF RELAPSERELAPSE

Addiction Treatment TerminologyAddiction Treatment Terminology

• DSM-IV-TRDSM-IV-TR Diagnosing for Psychiatric and Diagnosing for Psychiatric and Substance Use DisordersSubstance Use Disorders

• ““Dependence / AddictionDependence / Addiction”” (3 or more criteria) (3 or more criteria)• ““AbuseAbuse”” ( less than 3 criteria) ( less than 3 criteria)• ““Use DisorderUse Disorder”” ( no criteria are met for required ( no criteria are met for required

previous 12 month period)previous 12 month period)• ““SlipSlip”” indicates short period of use; no patient indicates short period of use; no patient

endangerment; no return to previous level of useendangerment; no return to previous level of use• ““RelapseRelapse”” indicates a return to previous use indicates a return to previous use

pattern; prolonged period of time; risk of patient pattern; prolonged period of time; risk of patient harm; noncompliant with recommendationsharm; noncompliant with recommendations

• ““UseUse”” does not equal does not equal ““impairmentimpairment””

SUMMARYSUMMARY

• Professional Assistance Program Professional Assistance Program (PAP)(PAP) … … 1982 as PHP1982 as PHP

• Treatment WorksTreatment Works• Impairment Review Committee Impairment Review Committee (IRC)(IRC) • Alternate Resolution Program Alternate Resolution Program (ARP)(ARP)• TreatmentTreatment And And AdvocacyAdvocacy While While

Protecting The Public SafetyProtecting The Public Safety• ““ Hospital Authorized PartyHospital Authorized Party”” JCAHO JCAHO• Buprenorphine Induction ProgramBuprenorphine Induction Program• 609-919-1660609-919-1660