Physician Health Program System of Care Management

Robert Dupont, MD
The Physician Health Program System of Care Management

Presented by Robert L. DuPont, MD

Transcript of Presentation:

Well, I am thrilled to be here with you today. How many people here work at PSI? Not everybody. I thought the group would mostly be that. Well, that’s interesting to me. I want you to know what I think about Dan Angres, and what he’s doing here. This is the state-of-the-art for treatment of addiction. What you see every day, and what you’re doing, is as good as it gets anywhere in the world. And I am here to honor Dr. Angres. And, also, a man who I revered for many years from here in Chicago: Marty Doot, who was also very much of a leader in this field, and somebody very, very special.

I’ve got some slides here that I’m going to start with but I’m going to bail out of the slides partway through so we can just talk to each other more openly. But I want to tell you how I got to this, what happened. As Dan said, I started in the addiction field. Let me say just a word about how that happened.

I finished my training after going to Emory, Harvard Medical School, Harvard for my residency and NIH. That’s a pretty classy background. But the question was, then I was to find a job. What am I going to do? And I had worked one day a week in a state prison in Massachusetts, called the Norfolk prison. And I fell in love with the prisoners and their stories. And so I went to work for The District of Colombia, Department of Corrections, which was a very unusual career choice.

And in that setting, the city of Washington, this nation’s capital, was experiencing a crime epidemic that was nationally focused on, it was called “the crime capital of the nation.” And so the question was, what was driving that? And as a new person coming into the Department of Corrections, that year 1968, I did drug testing of all the people coming into the prison, and discovered that 44% of them had heroin in their urine, and showed that the crime epidemic was driven by the heroin epidemic. And that was published in the New England Journal of Medicine which, again, kind of a classy place to publish things. And it changed the way the country thought about both and it changed my life. Because it got me hooked on heroin and heroin treatment and drug treatment. And everything else flowed from that.

But over this course of this nearly 50 years, it’s going to surprise you to learn that I got older over that time. I guess it surprised me, probably, more than it surprises you. But there came a time when I thought, about a decade ago, “Well, how good could outcomes be?” Because I was very aware of the failures of addiction treatment, having devoted my life to this. And I had many physicians as patients of mine, and I watched what happened to them in my practice. And so I said, okay, let’s think about what happens to them and what we can learn from that.

And so I recruited the world’s greatest evaluator of drug treatment, a professional named Thomas McLallen, president of the TRI, the Treatment Research Institute, to be my co-author. And we did the first national study of the state physician health program ever done. I’m going to show you some of the data from that. We got 16 programs that participated, and that’s 904 patients. And we looked at what was happening to them. So I’m going to tell you a little bit about that, but that’s how I got to the PHPs. It was because I was interested in what the limits were of this, how good could it be, and it was very interesting.

Okay, so here, the three things I want to talk about for our objective. First of all, it’s very odd, very odd, that addiction is a lifetime disease. It is not something like the cold, you get it and it’s gone. And the treatments are all short-term. Even the longest term treatment is short-term. That doesn’t fit. That doesn’t add up. And it’s full of important meaning to us.

Okay, second thing is what goes on in the PHP care system, it’s different. What characterises the system, how do you describe it? And you can’t see the bottom line here, but where I’m really going with this is that the standard physicians’ health care program is five years. And so, again I go back to Tom McLallen, my co-author on a paper that’s published about a year ago, that said all drug treatment–not just for physicians–all drug treatment should be evaluated on the treatment’s ability to produce stable, five-year recovery. Analogous to cancer. How good is this treatment, whether it uses medication or not, whether it’s residential or out-patient, any treatment, at producing five-year recovery? And that is sort of the result of my 10 years, to encourage the field to adopt that standard.

Okay, the standard now, when you say evidence-based treatment–many of you have seen that term, evidence-based treatment–is the standard that the FDA uses, which is that the people who are taking the medicine or receiving the treatment, are using 20% less opiates or other drugs than the people on placebo, and if they are, that’s called evidence. That’s not what I’m working on. I’m not talking about a 20% reduction in drug use, I’m talking about recovery. And that’s a huge difference.

Okay. What are the obstacles? The people who have substance use disorders don’t want treatment. And when you refer them to treatment, they don’t go. And when they do, they drop out. And when they complete, they relapse. And here is a number that no one else will ever use, because I’ve just come up with it, but to me it’s very compelling. The drug treatment field is starved for resources. Whether it’s government programs or health programs. It turns out that illegal drug users in the United States spend $100 billion dollars a year for drugs. The entire drug treatment field, including alcohol, all public and all private, cost $34 billion dollars a year. Drug users can pay for all the drug treatment in the country three times over every year with the money they’re paying cash. They don’t have credit in the drug sales, when they’re buying them. That tells you something very, very important about this entire field.

Okay. Now today’s treatment, I mentioned it’s a lifelong problem with episodes of care, and often for one treatment. And many patients, especially in medication-assisted treatment, continue to use drugs and alcohol while they’re in treatment. That would surprise you here, but that is the reality for most of the treatment. And here are the three missing elements.

First of all, the definition of long-term recovery is the goal of treatment. You just don’t hear that in most treatment programs. They don’t get to that as a way of thinking about what they’re doing. In fact, the goal most of them have is completing treatment. And completing treatment, it’ll be a number like 25% or 30%. It’s not 90%.

And then, here another thing that’s missing from most treatment. Provision of sustained post-treatment monitoring and professional and peer support. So it isn’t just what happens in the treatment, it’s what happens after the treatment. Insistence that others around the patients, of the sustained abstinence, and having consequences for use. All of those things are what the PHPs do, and none of those things are what’s happening in most drug treatment in the United States right now. It’s a very big change that I’m talking about.

Now, one of the things is that medicine is always changing. But it’s changing more now than in the past, and in very dramatic ways. And there is a movement in medicine that is extremely positive for the treatment of addiction. And that is to focus on serious, chronic conditions that are highly prevalent and expensive—it produces social costs—and have the healthcare system responsible for preventing those, for identifying them. For intervening, for treatment and monitoring of those for the lifetime of the person. That is the new standard for healthcare. And you think about applying that to substance use, and you see an entirely different landscape before you once you get to that frame of what it is. And it is very interesting to me, that the key, to me, is this long-term accountability of the healthcare system for these outcomes. Once you say, “That’s our job as doctors, as healthcare, to identify those problems, to intervene, to treat, to monitor. That’s our job.” That changes everything. That’s a whole different deal that we’re talking about.

Well, what happens in the physician’s health programs? The treatment as you know is a few months, maybe as little as three or one month. Some physicians are treated just with IOP, but mostly it’s residential, and mostly it’s one to three months, sometimes longer. Not less than one, usually. But its extended accountability of abstinence for five years. That’s a huge deal. And the fact that the physicians get all the support, and of course it’s their . . . it’s the immersion in Alcoholics Anonymous and Narcotics Anonymous, the 12-step fellowships, that’s absolutely central to what is going on.

Here’s some things, I think we’ve talked about those, I’m not going to worry about those. Here’s our results. [Of] the 904 physicians, 64% completed–this is a single contract, this is not their lifetime experience, just one episode of care. Think about this. This is what happened in one episode of care: 64% completed the contract, 16% extended the contract, and just shy of 20% failed their contract. Over that five-year period of time. Again, you think about how many interventions related to substance abuse where you have anything that looks even remotely like that over five years.

Then, physicians were mostly licensed and working. There were these . . . you can’t see down here; all the slides are going to be a problem. Some of them had their licenses revoked, you can’t see the bottom but it’s 11%. They had their licenses revoked. Okay, this is my favorite slide about this. The physicians have to have, every day, they’re subject to monitoring on a random basis. If they don’t show up, it’s considered a positive test. Of these physicians, in five years, 78% had no positive test for alcohol or drugs. And of the people who had any positive tests, two thirds, or 14% of the total, had only one positive test. So only 8% had more than one positive test in the five years of monitoring, which is really quite remarkable.

There’s no, virtually no use of psychopharmacotherapy. One patient was taking methadone but that was for the treatment of pain and not for the treatment of addiction. And 5.1% used naltrexone and much of that was used to treat alcohol, as opposed to opiates also.
Okay, this is a question that comes up about opiates, that the opiate patients. The physicians, basically, about half of them were alcohol, a third were opiates, and the sixth was everything else. And if you look here, you’ll see any positive test, the alcohol only had 20%, any opiates 23%, non-opiates 25%. I think this one is also very good.

Here’s the completers, of alcohol it was 58%, opiates 64 –65%, and 64% for the non-opiates. In terms of . . . there’s no statistical difference in the opiate from the alcohol. And that’s something that I think most of us see in treatment, it doesn’t really matter what the drug is the person is taking, the problem is the same. And that’s why the same treatment is used in most cases.

Now, we went further with that. That is to say, many people say, “Well, Bob, that’s good because they’re monitoring and they’re going to lose their license and I can imagine that they can do that. But what happens when they’re no longer monitored? What happens after that?”
So we did a preliminary study of 155 physicians who were five years or longer after their last mandatory monitoring. Okay? This is the stability, not . . . they were not, all of the physicians, they were the physicians who’d successfully completed. So the question was, of the people who complete successfully, what happens to them then? That’s the question.

And here we’re going to see what did happen. Okay, 89% completed their contract without any relapse, which fits with what you saw about the use, the 78% of them that had no positive test. And 96% five years later, were in recovery. Now we didn’t do a drug test, but the things that they said on this questionnaire were very convincing. Anyway, 96% considered themselves in recovery.

And we asked them, what of the things in your five years in the PHP, not in your treatment, which is a month or two or three, but in your five years [of monitoring], what was the most important thing? And we made them pick just one thing. And we had a long list of possibilities. It’s pretty striking to me that the most positive, highest level was 35% going to meetings, the 12-step fellowships. And that’s not too surprising.

But I think this is quite stunning, 26% said their treatment experience was the most positive experience and the treatment was only a month or so, out of the five years. But that treatment experience really mattered to these folks. And I think that sounds right to me, and it’s also very important.

Now, what I’ve done with this, is say, “Okay. How does that apply in other situations?” Dan was talking about that, and I think that that’s, you know, a very good question. How limited is this to physicians? And the pilots’ experience is very similar, and they have similar, stunning results from . . . not going to go into details with that, but that’s an assentation I wanted to make. The attorneys, not quite so much, but there’re some similarities. They have a little harder time with the strictness of the standard. But it’s basically a similar kind of experience.

There is . . . see, a question I’m asked, “How can we justify having a treatment approach that is so good for physicians and not able to deal with everybody?” and I think that’s something worth thinking about and looking at some of the criticisms that are made of this.
One, they are unique. And I want to just point out—and I’ll show you some data—that a similar approach is used in the criminal justice [system], in a program called [Hawaii’s Opportunity Probation with Enforcement] Hope Probation, and that is the most different demography that you could get from physicians. This is convicted felons. Average of seven prior arrests. High school dropouts, many unemployed, and in this case, smoked methamphetamine is the major drug that they have in Hawaii. And you’ll see here some results.

And here’s the elements of this, intensive random testing. These . . . these, it wasn’t all probationers, it was just the high-risk probationers that were in HOPE Probation, the ones who had failed or had a very bad background that predicted they were going to fail. And a zero tolerance for any violation, including any drug use. So they had the same kind of thing, every day they had to ask the question, “Do I have to go today?” If they had to go, on a random basis, and they didn’t show up, it was called a positive test just like the physicians. And it went on for years.

This is the result of one year of that testing. And a missed appointment was considered a—or a missed probation appointment, it wasn’t just drugs—it would be considered a violation. And what happened if they fail? What happened if they failed was that they’d go to jail, right then, for two or three days. That’s it. They don’t go for ten years. They just go for two or three days. But it’s that day. And what the judge who invented this approach said, “These folks are used to rolling the dice against ten years of prison. As long as it’s later and uncertain.” So you don’t know whether it’s going to happen.

And the criminal justice system, in its lack of wisdom, focused on long consequences that are uncertain and delayed. A terrible way to change people’s behaviour. And what this program, Hope Probation does, is right now. And that’s just what happens with the PHP. A single positive test and the doctor’s out of the practice. Right now. Boom. And that changes the behavior of the prisoners, the convicts, as well as the physicians, that approach to it.

Now, this is different. They don’t all have treatment. They are told they’re going to have to meet this standard, and if they need to use treatment to meet the standard, they’re provided treatment. They really, Judge Alm who started this, is a big believer in treatment. But what’s interesting is that most of the people can meet the standard without going to treatment. Even with a heavy addiction, which is surprising. And also unlike the health physician programs, they’re not required to go to 12-steps, but it’s encouraged and many do, but not all.

So here are the goals of the HOPE program, short-term and long-term. And here’s the results. Compare–this was a randomised control trial. So you have people in probation that’s usual, and HOPE Probation. [They’re] 55% less likely to be arrested for a new crime, 72% less likely to have a positive drug test, 61% less likely to miss appointments and 53% less likely to have probation revoked. And they had 48% fewer days of incarceration. You think, “Well they’ll be going to jail right away.” They have less incarceration than other people do when this is done. Now this approach in HOPE Probation is applicable to five million Americans who are on probation or parole, 80% of whom have substance use problems. That’s a very exciting application of this model.

Here’s the distribution of the positive tests over the one-year period of time. See 51% had none, which is pretty striking, 28% had one, 12% had two. And one outlier had six, in the course of that year of study. Again, a pretty impressive clinical population that lack leverage of this. And this is something that I think is really important to think about. There are many other ways to produce leverage. Besides the criminal justice system and the physician, itself, and that includes healthcare, that includes employment, settings elsewhere in the criminal justice system also.

But the key to me is the family. The key to me, is what the family’s going to do. And I was talking to Dan Angres about this. The family with somebody who’s got a substance abuse problem has a terrible dilemma. And that is if they’re tough, and say, “You’re going to have to . . . in this family, there’s going to be a condition for you to be drug-free and go to meetings.” Which is what the PHP is all about. They’ve got to deal with the blackmail that the patient actually brings up. And that is, “I’ll die. I’ll be on the street.” And some of them will. And how does the family handle that? It’s a very tough problem, but I feel it’s where our field is going to answer that question.

And so the interesting thing to me is to organize clinical care more generally in this concept. I’m going to go into that in detail. But here’s the five-year recovery standard. And this is published in our paper about this, that sustained abstinence as a way of measuring [successful] treatment and then bringing these other factors in to make that more likely to happen.

One of the things that we did need to do is have more research on this, and I would like to encourage folks here at PSI to think about using the standard for yourselves. Because you’re going to set the standard for long-term outcome. And I think it’s something very good. I like to say, what ought to happen in a treatment program is everybody who comes in, the people who are doing the treatment say, “Our goal, for you, is five-year recovery. And I want you to hold us accountable. And we’re going to hold you accountable and the family.” So everybody knows that’s what we’re trying to do here. We’re not trying to have a little less drug use. We’re talking about five-year recovery. And let’s talk about that.

And so, when they come in, we don’t only get data from the patient, but family, and say, “We want to keep track of how Sally is doing. And if we can’t get to Sally, we want to get to you. Because we want to keep track of that.” And I think you’re going to learn a lot from doing that.

And to go over, I started with make recovery, not relapse, the expected outcome of substance care treatment. Healthcare reform gives us a lot of potential for this. And I think the inspiration comes from the PHP. I’ve got a bunch of other slides, but I’m going to stop here. And I want to sort of come back to a couple of thoughts that I wanted to get you to think about with me.

And that is, how do we . . . why did the physician’s health programs come up with this idea? How did that happen? Cause it’s so different from . . . I’m a psychiatrist. If you talk to mental health people, they never talk like this. I mean this is an entirely, this couldn’t be more different from what the smartest mental health people would do. It’s entirely different. And it’s tougher. It’s a standard of what you’re expecting and you’re going to enforce it with consequences. There is nothing in health or mental health that’s like that.

So how did this happen? And why would it be doctors? And I have an idea about what it is and that is that this movement was very unusual because it was led by doctors in recovery. Dr. Talbot[?] was one of the leaders that got this started. And it grew out of another movement, the Employee Assistance Program, which worked in workplace settings and also focused on people in recovery themselves.

And I talked to Dr. Talbot about it, and I said, “How did you ever get this idea? Where did this come from?” And he said, because of his own experience. He had an idea that as long as you’re talking to the using drug addict, you’re not talking to the person, you’re talking to the drug. You’re not going to make this sale to that person. That person’s in a different place. These physicians that we did, with that follow-up, when they came, they were all mad. None of them wanted to be there. They thought it was unfair. They were railroaded. They wanted to hire a lawyer—100% of them think that.

So if you’re offering a treatment, and you’re going to please the person coming in, you got a problem with what you’re going to do. And you know, it isn’t just the addicts. It’s the families. The families’ feeling is, “You’re the experts! You fix him, I don’t know how to do that. I turn them over to you. Send him back fixed, or her, back fixed.” I’m telling you here today, that no treatment, even PSI’s excellent [treatment], ever fixed any addict. And it never will. Recovery is something that is a process that is for your life. And it requires work from that person in recovery.

Now what does treatment do? Why do we spend the money on treatment, if it doesn’t fix him? What treatment does, and it’s very precious and very valuable, is it defines the problem. So the person understands what’s wrong and has the tools to grasp that, and see that, whether it’s brain science or behavior or whatever else.

The treatment tells the story of the disorder or the disease and it teaches the person about that. Says how serious it is. Talks about what the consequences are. Talks about how they’re part of a community of this, it’s not just them. And then it does something else, and that is, it defines for the person the path to recovery. Here’s what you need to do, to manage that disease, not because you’re fixed, but you’re on a path and that path is what you need to be on to achieve the goal of recovery. It’s going to be a lot of work, but it’s very rewarding.

And one of the things that’s very exciting about going to meetings, and very exciting about the kind of treatment that is done here, is the new people can see the people who are further down the road. And that gives them a tremendous sense of hope. “Look at those people who are further down, what do they have, how did they get there?”

And one of the things I will say is about this word “recovery.” Now, I don’t know how many of you are involved in medication-assisted treatment, methadone or buprenorphine, and these others, but that is the dominate way this country is approaching the opiate problem, it’s through medication-assisted treatment. And in that world, there is none of the word ‘recovery’. The concept isn’t to not use. So those people do not have sobriety dates. Whereas everybody in recovery has a sobriety. It’s like their name, they wear it like a badge. I think that’s important. That’s a different way of thinking about what the problem is and what you’re doing about it. And it’s very, very fundamental.

Now, many of us in the recovery community, I think of myself like that, and you all like that, and the PSI people like that. What do we think about medication-assisted treatment? What do we think about methadone? What do we think about buprenorphine? And many people have a view that that’s just another drug, so you can’t be in recovery because you’re taking a drug, because those are agonists. Okay. I don’t have that view.

I told you how I got started in Washington, D.C, in the Department of Corrections. I started one of the biggest methadone programs in the country. That’s what NTA was. Methadone was invented by Vincent Dole and Marie Nyswander. They became my friends. When I went to New York, I stayed in their apartment. They came to dinner at my home. I was steeped in medication-assisted treatment. And Vincent Dole was a non-alcoholic trustee of AA, which people don’t realise. It’s pretty striking about that.

I did a study of a methadone program in Washington to show that 65% of the people in that program go to AA and NA meetings. The people running the program didn’t even know that. They felt that AA was helping them and that NA was helping them, which was also very interesting to think about it. So here’s what I have to say to you on this issue, this controversial issue.

If a person, an opiate addict, heroin, oxycontin addict, is taking methadone and buprenorphine as it’s prescribed—not shooting it—taking the dose that is prescribed–not selling it somewhere else and is not using alcohol and other drugs, I’m happy to call that person in recovery. To me, it’s the medicine. I don’t have a problem with that. Medicine is okay.

But! If that person is drinking, if that person is using other drugs, they’re not in recovery by being on methadone or buprenorphine. So I’m making a very sharp distinction here. And if we’re going to reach out to the people in MAT, we have to take that position. Otherwise we’re standing in front of a train that’s coming at us and that’s not smart. But by taking this position, I think we can help them focus on what they want to achieve. If you use the five-year standard, I think they’re going to do okay because they’ll have a fair number of people who do, over five years, stay with the program and who don’t use other drugs. I think us on the drug-free side are the ones who’re probably going to have the hardest time with that standard, not the easiest time with it.

But unless we have that modification, or accept that view, I don’t think the game goes on. And then it’s just, we’re fighting back and forth in a way that nobody wins. And in fact there’s a long history in drug treatment, of one treatment fighting another one, and the bottom line of that is to take away the public support for either of them. That’s not a winning strategy.

So what I’m here to say today is that the result of my nearly fifty years in this field of caring about addicted people, of watching . . . I have had patients of my own all through this time. I still have patients every week in my practice, now. I learn from the patients. They’re my teachers. I care about them. I think that where we are, where I am, is that this model, that is pioneered for more than 40 years in the PHP movement, sets the standard. And from that, everybody can learn. About what they need to do to make treatment better. So, that’s it. Any comments?

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