This article was downloaded by: [ECU Libraries] On: 25 April 2015, At: 11:52 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Psychoactive Drugs Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujpd20
The California Physicians Diversion Program's Experience with Recovering Anesthesiologists a
Chet Pelton & Richard M. Ikeda a
b
Physicians Diversion Program , Medical Board of California
b
Medical Board of California , 1434 Howe Avenue, Suite 100, Sacramento , California , 95825 Published online: 20 Jan 2012.
To cite this article: Chet Pelton & Richard M. Ikeda (1991) The California Physicians Diversion Program's Experience with Recovering Anesthesiologists, Journal of Psychoactive Drugs, 23:4, 427-431, DOI: 10.1080/02791072.1991.10471613 To link to this article: http://dx.doi.org/10.1080/02791072.1991.10471613
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
The California Physicians Diversion Program's Experience with Recovering Anesthesiologists Downloaded by [ECU Libraries] at 11:52 25 April 2015
Chet Pelton* & Richard M. Ikeda, M.D. ** Abstract - This article examines the effectiveness of the rehabilitation of anesthesiologists who are addicted to alcohol or other drugs. There has been some concern and discussion about allowing anesthesiologists who are add icted to alcohol or other drugs to continue practicing in their spec ialty. This article analyzes success rates. relapse rates . and failure rates among the anesthes iologists and residents of anesthesiology in the California Physicians Diversion Program for chemically dependent doctors. Of the 255 physicians who have successfully completed the program during the ten years prior to March 1990. 35 were practicing anesthesiologists. including six resident anesthesiologists. Although doctors in this specialty are more at risk for manifesting addiction to alcohol and other drugs , California's experience demonstrates that they have an equal chance of recovery and contradicts the pessimism about reco very in anesthesiologists. Keywords - addiction. anesthesiologists. diversion. physicians
Over the past ten years , 255 physicians from all medical spec ialties have completed their recovery from drug addi ction through the California Physicians Diversion Program for an overall success rate of 73% (Ikeda & Pelton 1990) . Of these successful physicians, 35 were anesthesiologists. Sixteen anesthesiologists failed in the program during the same period, yielding an overall success rate of 69 % for this specialty. Of the 35 recovering anesthesiologists. 33 (96%) continued practicing in their specialty. These figures contradict the pessimism expressed by some over the possibility of ever rehabilitating anesthesiologists (Menk et aJ. 1990). What explains California's success in rehabilitating anesthesiologists, a group others consider more difficult to treat than physicians from other specialties? The major factor influencing successful recovery for all persons is follow -up after the initial treatment for chemical dependency. The type of drug abused and the setting for exposure to the drug are not good predictors of success or failure. If a person goes regularly to support group meetings, is
tested regularly for sobriety, and takes corrective action whenever a slip or relapse occurs, that individual has a good prognosis for long-term recovery. Under the aegis of the Medical Board of California (MBC), the California Physicians Diversion Program provides such a structure for long-term recovery and monitoring of a physician while protecting the public from impaired physicians (Buxton 1990) . An additional factor for successful recovery may be the motivation for impaired physicians to maintain their medical licensure. Even though some physicians' licenses are not immediately at risk, there is usually an awareness that eventually they could lose both license and livelihood. For any program of recovery, these varied elements must be refined and integrated to create an atmosphere of hope, motivation. and day-to-day success. The California Physicians Diversion Program contains all these components.
THE PHYSICIANS DIVERSION PROGRAM In 1980. special legislation created a dedicated program outside the usual disciplinary pathway to rehabilitate the chemically dependent or the mentally ill physician (Gualtieri, Cosentino & Becker 1983). Before the change
·Program Manager, Physicians Diversion Program, Medical Board of California. • · Chief Medical Consultant, Medical Board of California, 1434 Howe Avenue. Suite 100, Sacramento, California 95825. Journal ofPsychoactive Drugs
427
\bl. 23(4), Oct -Dec 1991
Pelt on & Ikeda
Ca lifor nia Diver sion Program
TABLE I DESCENDING RISK OF IMPAIRMENT: COMPARISON BY MEDICAL SP ECIALTY OF LICENSED CALIFORNIA PHYSICIANS AND PHYSICI ANS IN DIVERSION IN 1989
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Medical Specialty Anesthesiology Emergency medicine GeneraVFamily practice Thoracic surgery Obstet rics/Gyn ecology Psychia try Surg ery Plastic surgery Dermatology Internal medicine Pediat rics Neurol ogy Radiology Ophthalmology Urology Patho logy Other
Percent of Licensed California Ph yslclans"
Percent of Physicians In Diver sion
5.0 2.8 13.6 .4 6.1 6.9 6.1
17.4 6.5 25.1 .4
1.0 1.7 16.2
7.2 2.7 4.9 3.1
6.0 6.5 4.9 .8
1.2 11.3 4.5 1.6 2.8
1.6
1.6
.8
2.5 18.2
1.2 7.4
-Data obt ained from the California Medical Association, Brochure: Our List, May 1989 .
in law, the abuse of alcohol or oth er dr ugs was punished by administrati ve ac tion aga inst the ph ysici an 's medical license. Re habi litation and rec overy were left up to the chemicall y dependent physic ian. Because this approach yielded dismal resul ts and risked a po tentially large loss of valuable human skill s to soc iety, the law was changed and the California Physicians Diversion Program was created. Eve n with this change , however, if the phy sician was guilty of incompetence or gros s negligence along with his or her add iction, the physician was no t allowed into the program . That policy was amended in 1984. Now while the doctor is bei ng disciplined for gross neg ligence or incompetence by suspension or probation, he or she is allowed into the diversi on program for rehabilitation from addiction. The Ca lifornia Physicians Diversion Program has been in effect for more than ten years (Ikeda & Pelt on 1990 ). It provides an alternate pathway to the old disci plinary ac tion taken by MBC again st impaired physicians. Over 50% of the physicians curren tly in the program have entered voluntarily without complaints or discip linary action filed against them . The alternative pathway stresses strict controls to ensure patient protection while allowin g the physician to continue in the practice of medicine if he or she can do so sa fely and competently during the course of treatm ent and rehabi litation for addi ction . The formal organiza tion is made up of three parts: (1) Journal of Psychoact ive Dr ugs
a well-trained , full-time civil service staff providi ng monitori ng and admi nis tration; (2) six Div ersion Eval uati on Com mittees (DECs), eac h compri sed, by stat e sta tute, of three voluntee r physicians and two nonphysician volunteers, all expert" in addicti on medic ine; and (3) facilitators under individual contracts to lead diversion group meetings. Each cand idate in the diversion prog ram is first eval uated by a DEC . Th is committee deter mines whether the physician desiring entry into the program represents a danger as a medical practitioner, and then proposes a long term treat ment and mon itoring plan for each ph ysician in the form of an agreement, which genera lly requi res the physician to attend two diversion group meetings and two or more 12-Step pro gram meetings each week . Th e ma jority of agreem ents are for five years, but most candi dates co mplete the program s uccess fully in fou r yea rs. The diversion group meetings are facilitated by skilled and experienced perso ns train ed in drug co unse ling. The divers ion gro up fa cili tat or mo nito rs th e p h ysician's progress and ta kes random bo dy fluid spe cim en s. Eac h physician with hospital pri vileges must infor m the hos pita l's Well- Being Committee that he or she is in the program. In 1990, by a change in Californ ia state regulations , hospitals were mandated to have such co mmittees to assist physicians who have substa nce abuse problems or menta l illness . When a phy sician docs not have hosp ital priv ileges, an equi valent monitor is recruited at the physician's 428
\bl. 23(4), Oct - Dec t991
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Pelton & Ikeda
work site. To complete the program successfully, a chemically dependent physician must be free of alcohol and other drugs for a minimum of two years. In addition, the physician must demonstrate a change of life-style that will support sobriety for the rest of his or her life. This evaluation is made by the five-member DEC.
TABLE II PRIMARY DRUG OF CHOICE OF ANESTHESIOLOGISTS Drug Opioids Meperid ine Fentanyl Morphine Alcohol Tranquilizers Stimulants Inhalants Sedatives
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ANESTHESIOLOGISTS IN RECOVERY
N
%
13 5 I 10 3
37 14 3
28
I 0
9 6 3 0
35
100
This study is based on a content analysisof individual case files of the physician anesthesiologists with alcohol or other drug problems who entered the California Physicians Diversion Program, and it represents a thorough review of ten years of data from a well-documented, highly structured, and carefully monitored program. This compilation of data from the California Physicians DiversionProgram may be useful in suggestingpolicy recommendations for any physic ian diversion program. Of the 630 physicians of all specialties who entered the program between January 1, 1980, and March 1, 1990, 96 (15%) were anesthesiologists. During this time, 35 (69%) anesthesiologists completed the program successfully. Sixteen (31 %) were unsuccessful. As of March 1, 1990,45 anesthesiologists were still enrolled in the program. The experienceof physicians in California's diversion program provides a reasonable basis for assessing the relative success or failure of anesthesiologists in a substance abuse recovery program. In this program, physicians are closely monitored for three to five years. While in the program, the physician is closely supervised by the case manager, group facilitator, condition monitor, and the hospital Well-Being Committee. Urine tests are taken randomly in and outside of group meetings. Longer-term recovery is also considered in this study. Relapses after successful graduation from the program would, in all likelihood,come to the attention of the MBC. The diversion program frequently finds out through the recoveringcommunity network about graduates who have relapsed.
In questioning why anesthesiologists may be at greater risk to become addicted, several concepts were examined (Gallegosetal. 1988;Talbot & Wright 1987). First, the abuse of meperidine, fentanyl, and other drugs appears to be linked to availability and accessibility of the drug. For example, it appears that only anesthesiologists abuse fentanyl because it is not readily available to other physicians. Second, the controls in the operating room are more easily circumventedthan in other areas of medical practice because of the crisis conditions under which drugs are often administered. Third, many anesthesiologists have a fascination and curiosity about anesthetics and what anesthesia feels like for the patient. This curiosity often leads to initial experimentation with the drug. Finally, this medical specialty will attract detail- and control-oriented physicians who seek a structured environment without the stressors inherent in dealing with people. Some anesthesiologists commented that their choice of specialty was based on the short-termness of the contact with patients as people, in contrast to the usual patientdoctor relationship. Those control-orientedphysicianswho are addiction prone are at risk for drug use when their environment does not respond as they would have predicted.
Greater Risk among Anesthesiologists Anesthesiologists represent only 5% of the licensed physicians in California. In contrast, anesthesiologistsrepresent 17.4% of physicians in California 's diversion program (see Table I). When comparing the percent of anesthesiologists in the program to the percent of licensed anesthesiologists in California, the risk for chemical dependency is about 3.5 times greater than for the other physicians. These figures are comparable to those found in other studies of recovering physicians (Talbot et al. 1987; Gualtieri, Cosentino & Becker 1983).
Drug of Choice Of the 35 successfully rehabilitated anesthesiologists, 19 (54%) used opioids as their primary drug of choice ; compared to nearly 30% of all physicians in diversion who used opioids as their primary drug. Specifically, meperidine was preferred by 37% of all impaired anesthesiologists; fentanyl by 14%. In addition, 30% preferred alcohol as their primary drug of choice (see Table II), as compared to 36% of physicians from all specialties who preferred alcohol. Fifty percent of the anesthesiologists who abused opi-
Journal ofPsychoactive Drugs
Total
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Califor nia Diversion Program
ident anesthesiologists, none relapsed while participating in the program. Two residents are still participants in diversion. In contrast, 23% of all residents relapsed while in the program. The downside of this experience is that two of the four residents who completed the program successfully have subseq uently reentered the div ersion program. However, they now are doing well in the program. In retrospect, it was judged by the present authors that on e resident had been let out of the program too early so th at he could accept a position in another state. Th e other resident did e xhibit a life-style deemed adequate to remain clean and sober, but nev ertheless relapsed.
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oids were placed on naltrexone. In many instances, alcoholi c phy sicians in the program were placed on disulfi ram (An tabu se). Su ccess Rates Of the 5 1 anesthes iologists who co mpleted the diversion program as of March I, 1990, 35 (69%) completed the program successfully. In comparison, 255 (73%) physicians in all specialties completed the prog ram successfully. Amon g anesthesiolog ists using opioids, 19 (76%) com plet ed the program successfull y. This success ra te is adj usted to ex cl ude physicians who died fro m causes other th an their addictive d isea se. Those who died because of the ir addiction ar e included as fa ilures . Some stud ies of an esthesiologists in recovery hav e co nsidere d relapses as failures, conclud ing that an esthesiologists addicted to alcohol and other drugs should not be allowed to continu e in their specialties (M enk et aI. 1990). Ho we ver, slips and/or rel apses are not uncommon for any pe rso n in recovery. For man y phys icians, slips or relapse s ca n serve as va lua ble learni ng experie nces th at can, if handled properly, stre ngthen their recovery program (Go rsk i 1990).
Anesthesiologists Restricted from Practice Seven of the 35 anesthesiologists who completed the program succ essfully were asked not to practic e medi cin e temporarily while they underwent treatm ent or other inten sive th erapy. All seven we re limited in thei r practice until such tim e as the DEC judged th at they were able to func tion safe ly in medicin e again. One physi cian was restricted fro m practicing anesthesiology for an extended pe riod. Two physici ans were enc ouraged not to practi ce anesthesiology because of a high risk of relapse; they were guided into other specialties. T he records of four physician s in this study lack ed sufficient in formation to de term ine w he the r they had been restricted from practice. The rem aining 21 physicians were deemed fit by their DEC s to practice med icine in their specialty under cl ose monitoring.
R el apse R a tes A relapse in the divers ion program is defined as a positi ve urine test, se lf-repo rted abuse o r the report of abuse by a case man ager , works ite monitor or family mem ber. Using any amoun t of psych oactive substance is considered to be a rel apse even if it has been prescribed by anoth er physician withou t first informing the DEC case co nsultant. Physicians who relapse in this highly structured program are unlikel y to put pat ien ts at risk. Mos t relapses occur on off-duty hou rs and often invol ve quanti ties of alcohol or other drug s that wo uld be considered acceptable for th e nonaddictcd phy sici an. Of the 35 anesthe sio log ists wh o we re successfu l in completing the program, 26 % relapsed at lea st once while in the program as compare d to 40 % of all ph ysicians who rel ap se d while in div er sion . O f th e 19 anesthesiologists who used opioids, five (16 %) relapsed. Seventeen physicia ns of all specia lties re turned to d iversion a second time aft er succe ss fully completing the progr am; five (29 %) of these p hy sician s were anesthes iologi st.".
CONCLUSION Th e experience of the California Physicians Diversion Program indicates tha t anesthesiologists may be at greater risk for becoming chemically dependent than other phy sicians. Co ntrary to a prev a iling m isc onceptio n, ho we ver, the rec overy ra te of anes thesiologists in the highly structured California Physicians Di version Program is abou t the sam e as for other specialties. This comparable success rate also app lies to resident anesthesiologists. Thi s same reco very experience should apply for ancsthesiologists in any highly structured progra m where the ph ysician is mo nitor ed for meeting atte ndance, sobr iety, and relapse mana gemen t for long periods after initial treatme nt Previous studies re flec ting low recovery rates for anesthesio logists ar c probably an accurate reflection of the trea tme nt o utco me of any no nmonitored or short-term program where one slip or relapse is co nsidered to be treatment failu re. T he experience of the Cal iforn ia Ph ysi cians Diversion Program provides hope for successful treatment of all che mi cally depende nt ph ysi c ians , incl ud ing an esthes io log ists, while protecting the public safety.
R es id en t An esthesi ologists Six anesthesio logi sts have en tered the program while they were residen ts. Fo ur have completed the program succes sfully. Thi s result is consistent with the 60% of all reside nts from all spe c ia lt ies w ho ha ve com p leted the d iversion pro gram suc cessfully. Twenty-t wo res idents of all specialties have entered the program sinc e 1980; 13 have co mpleted the program successfully. Of the six res-
Journal ofPsychoactive Drugs
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REFERENCES Ikeda, R.M. & Pelton, C. 1990. Divenion programs for impaired physicians. WesterllJournal ofMedicine Vol. 152: 617-621. Menk, E.J.; Baumgarten, R.K.; Kingsley, C.P.; Culling, R.D . & Middaugh, R. 1990. Success of reentry into anesthesiology training programs by residents with a history of substance abuse . Journal ofthe Americall Medical Association Vol. 263(22): 3060-3062. Talbot, G.D .; Gallegos, K.V.; Wilson, P.O. & Porter, T.L. 1987 . The Medical Association of Georgia's impaired physician program. Review of the first 1000 physicians: Analysis of specialty. Journal ofthe American Medica; Association Vol. 257(21): 2927 -2930. Talbot, G.D. & Wright, C. 1987. Chemical dependency in health care professionals. Occupational Medicine : State of the Art Review Vol. 2(3) : 581-591.
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Buxton, M. 1990. Monitoring, reentry, and relapse prevention for chemically dependent health care professiooals. JourNJI ofPsychoactive Drugs Vol. 22(4): 447-450. California Medical Association. 1989. Brochure : Our List. San Francisco: California Medical Association. Gallegos, K.V.; Browne, C.H.; Veil,F.W. & Talbot, G.D. 1988. Addictioo in anesthesiologists: Drug access and patterns of substance abuse. Quarterly Review Bulletill Vol. 14(4): 116-122. Gorski, T.T. 1990. The Cenaps model of relapse prevention : Basic principles and procedures. Journal ofPsychoactive Drugs Vol. 22(2): 125-133. Gualtieri, A.C.; Cosentino, J.P. & Becker, J.S. 1983. The California experience with a diversion program for impaired physicians. Joumal ofthe American Medical Association Vol. 249(2): 226-229.
Journal ofPsychoactive Drugs
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\bl. 23(4) , Oct-Dec 1991
Journal of Psychoactive Drugs Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujpd20
The California Physicians Diversion Program's Experience with Recovering Anesthesiologists a
Chet Pelton & Richard M. Ikeda a
b
Physicians Diversion Program , Medical Board of California
b
Medical Board of California , 1434 Howe Avenue, Suite 100, Sacramento , California , 95825 Published online: 20 Jan 2012.
To cite this article: Chet Pelton & Richard M. Ikeda (1991) The California Physicians Diversion Program's Experience with Recovering Anesthesiologists, Journal of Psychoactive Drugs, 23:4, 427-431, DOI: 10.1080/02791072.1991.10471613 To link to this article: http://dx.doi.org/10.1080/02791072.1991.10471613
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
The California Physicians Diversion Program's Experience with Recovering Anesthesiologists Downloaded by [ECU Libraries] at 11:52 25 April 2015
Chet Pelton* & Richard M. Ikeda, M.D. ** Abstract - This article examines the effectiveness of the rehabilitation of anesthesiologists who are addicted to alcohol or other drugs. There has been some concern and discussion about allowing anesthesiologists who are add icted to alcohol or other drugs to continue practicing in their spec ialty. This article analyzes success rates. relapse rates . and failure rates among the anesthes iologists and residents of anesthesiology in the California Physicians Diversion Program for chemically dependent doctors. Of the 255 physicians who have successfully completed the program during the ten years prior to March 1990. 35 were practicing anesthesiologists. including six resident anesthesiologists. Although doctors in this specialty are more at risk for manifesting addiction to alcohol and other drugs , California's experience demonstrates that they have an equal chance of recovery and contradicts the pessimism about reco very in anesthesiologists. Keywords - addiction. anesthesiologists. diversion. physicians
Over the past ten years , 255 physicians from all medical spec ialties have completed their recovery from drug addi ction through the California Physicians Diversion Program for an overall success rate of 73% (Ikeda & Pelton 1990) . Of these successful physicians, 35 were anesthesiologists. Sixteen anesthesiologists failed in the program during the same period, yielding an overall success rate of 69 % for this specialty. Of the 35 recovering anesthesiologists. 33 (96%) continued practicing in their specialty. These figures contradict the pessimism expressed by some over the possibility of ever rehabilitating anesthesiologists (Menk et aJ. 1990). What explains California's success in rehabilitating anesthesiologists, a group others consider more difficult to treat than physicians from other specialties? The major factor influencing successful recovery for all persons is follow -up after the initial treatment for chemical dependency. The type of drug abused and the setting for exposure to the drug are not good predictors of success or failure. If a person goes regularly to support group meetings, is
tested regularly for sobriety, and takes corrective action whenever a slip or relapse occurs, that individual has a good prognosis for long-term recovery. Under the aegis of the Medical Board of California (MBC), the California Physicians Diversion Program provides such a structure for long-term recovery and monitoring of a physician while protecting the public from impaired physicians (Buxton 1990) . An additional factor for successful recovery may be the motivation for impaired physicians to maintain their medical licensure. Even though some physicians' licenses are not immediately at risk, there is usually an awareness that eventually they could lose both license and livelihood. For any program of recovery, these varied elements must be refined and integrated to create an atmosphere of hope, motivation. and day-to-day success. The California Physicians Diversion Program contains all these components.
THE PHYSICIANS DIVERSION PROGRAM In 1980. special legislation created a dedicated program outside the usual disciplinary pathway to rehabilitate the chemically dependent or the mentally ill physician (Gualtieri, Cosentino & Becker 1983). Before the change
·Program Manager, Physicians Diversion Program, Medical Board of California. • · Chief Medical Consultant, Medical Board of California, 1434 Howe Avenue. Suite 100, Sacramento, California 95825. Journal ofPsychoactive Drugs
427
\bl. 23(4), Oct -Dec 1991
Pelt on & Ikeda
Ca lifor nia Diver sion Program
TABLE I DESCENDING RISK OF IMPAIRMENT: COMPARISON BY MEDICAL SP ECIALTY OF LICENSED CALIFORNIA PHYSICIANS AND PHYSICI ANS IN DIVERSION IN 1989
Downloaded by [ECU Libraries] at 11:52 25 April 2015
Medical Specialty Anesthesiology Emergency medicine GeneraVFamily practice Thoracic surgery Obstet rics/Gyn ecology Psychia try Surg ery Plastic surgery Dermatology Internal medicine Pediat rics Neurol ogy Radiology Ophthalmology Urology Patho logy Other
Percent of Licensed California Ph yslclans"
Percent of Physicians In Diver sion
5.0 2.8 13.6 .4 6.1 6.9 6.1
17.4 6.5 25.1 .4
1.0 1.7 16.2
7.2 2.7 4.9 3.1
6.0 6.5 4.9 .8
1.2 11.3 4.5 1.6 2.8
1.6
1.6
.8
2.5 18.2
1.2 7.4
-Data obt ained from the California Medical Association, Brochure: Our List, May 1989 .
in law, the abuse of alcohol or oth er dr ugs was punished by administrati ve ac tion aga inst the ph ysici an 's medical license. Re habi litation and rec overy were left up to the chemicall y dependent physic ian. Because this approach yielded dismal resul ts and risked a po tentially large loss of valuable human skill s to soc iety, the law was changed and the California Physicians Diversion Program was created. Eve n with this change , however, if the phy sician was guilty of incompetence or gros s negligence along with his or her add iction, the physician was no t allowed into the program . That policy was amended in 1984. Now while the doctor is bei ng disciplined for gross neg ligence or incompetence by suspension or probation, he or she is allowed into the diversi on program for rehabilitation from addiction. The Ca lifornia Physicians Diversion Program has been in effect for more than ten years (Ikeda & Pelt on 1990 ). It provides an alternate pathway to the old disci plinary ac tion taken by MBC again st impaired physicians. Over 50% of the physicians curren tly in the program have entered voluntarily without complaints or discip linary action filed against them . The alternative pathway stresses strict controls to ensure patient protection while allowin g the physician to continue in the practice of medicine if he or she can do so sa fely and competently during the course of treatm ent and rehabi litation for addi ction . The formal organiza tion is made up of three parts: (1) Journal of Psychoact ive Dr ugs
a well-trained , full-time civil service staff providi ng monitori ng and admi nis tration; (2) six Div ersion Eval uati on Com mittees (DECs), eac h compri sed, by stat e sta tute, of three voluntee r physicians and two nonphysician volunteers, all expert" in addicti on medic ine; and (3) facilitators under individual contracts to lead diversion group meetings. Each cand idate in the diversion prog ram is first eval uated by a DEC . Th is committee deter mines whether the physician desiring entry into the program represents a danger as a medical practitioner, and then proposes a long term treat ment and mon itoring plan for each ph ysician in the form of an agreement, which genera lly requi res the physician to attend two diversion group meetings and two or more 12-Step pro gram meetings each week . Th e ma jority of agreem ents are for five years, but most candi dates co mplete the program s uccess fully in fou r yea rs. The diversion group meetings are facilitated by skilled and experienced perso ns train ed in drug co unse ling. The divers ion gro up fa cili tat or mo nito rs th e p h ysician's progress and ta kes random bo dy fluid spe cim en s. Eac h physician with hospital pri vileges must infor m the hos pita l's Well- Being Committee that he or she is in the program. In 1990, by a change in Californ ia state regulations , hospitals were mandated to have such co mmittees to assist physicians who have substa nce abuse problems or menta l illness . When a phy sician docs not have hosp ital priv ileges, an equi valent monitor is recruited at the physician's 428
\bl. 23(4), Oct - Dec t991
California Diversion Program
Pelton & Ikeda
work site. To complete the program successfully, a chemically dependent physician must be free of alcohol and other drugs for a minimum of two years. In addition, the physician must demonstrate a change of life-style that will support sobriety for the rest of his or her life. This evaluation is made by the five-member DEC.
TABLE II PRIMARY DRUG OF CHOICE OF ANESTHESIOLOGISTS Drug Opioids Meperid ine Fentanyl Morphine Alcohol Tranquilizers Stimulants Inhalants Sedatives
Downloaded by [ECU Libraries] at 11:52 25 April 2015
ANESTHESIOLOGISTS IN RECOVERY
N
%
13 5 I 10 3
37 14 3
28
I 0
9 6 3 0
35
100
This study is based on a content analysisof individual case files of the physician anesthesiologists with alcohol or other drug problems who entered the California Physicians Diversion Program, and it represents a thorough review of ten years of data from a well-documented, highly structured, and carefully monitored program. This compilation of data from the California Physicians DiversionProgram may be useful in suggestingpolicy recommendations for any physic ian diversion program. Of the 630 physicians of all specialties who entered the program between January 1, 1980, and March 1, 1990, 96 (15%) were anesthesiologists. During this time, 35 (69%) anesthesiologists completed the program successfully. Sixteen (31 %) were unsuccessful. As of March 1, 1990,45 anesthesiologists were still enrolled in the program. The experienceof physicians in California's diversion program provides a reasonable basis for assessing the relative success or failure of anesthesiologists in a substance abuse recovery program. In this program, physicians are closely monitored for three to five years. While in the program, the physician is closely supervised by the case manager, group facilitator, condition monitor, and the hospital Well-Being Committee. Urine tests are taken randomly in and outside of group meetings. Longer-term recovery is also considered in this study. Relapses after successful graduation from the program would, in all likelihood,come to the attention of the MBC. The diversion program frequently finds out through the recoveringcommunity network about graduates who have relapsed.
In questioning why anesthesiologists may be at greater risk to become addicted, several concepts were examined (Gallegosetal. 1988;Talbot & Wright 1987). First, the abuse of meperidine, fentanyl, and other drugs appears to be linked to availability and accessibility of the drug. For example, it appears that only anesthesiologists abuse fentanyl because it is not readily available to other physicians. Second, the controls in the operating room are more easily circumventedthan in other areas of medical practice because of the crisis conditions under which drugs are often administered. Third, many anesthesiologists have a fascination and curiosity about anesthetics and what anesthesia feels like for the patient. This curiosity often leads to initial experimentation with the drug. Finally, this medical specialty will attract detail- and control-oriented physicians who seek a structured environment without the stressors inherent in dealing with people. Some anesthesiologists commented that their choice of specialty was based on the short-termness of the contact with patients as people, in contrast to the usual patientdoctor relationship. Those control-orientedphysicianswho are addiction prone are at risk for drug use when their environment does not respond as they would have predicted.
Greater Risk among Anesthesiologists Anesthesiologists represent only 5% of the licensed physicians in California. In contrast, anesthesiologistsrepresent 17.4% of physicians in California 's diversion program (see Table I). When comparing the percent of anesthesiologists in the program to the percent of licensed anesthesiologists in California, the risk for chemical dependency is about 3.5 times greater than for the other physicians. These figures are comparable to those found in other studies of recovering physicians (Talbot et al. 1987; Gualtieri, Cosentino & Becker 1983).
Drug of Choice Of the 35 successfully rehabilitated anesthesiologists, 19 (54%) used opioids as their primary drug of choice ; compared to nearly 30% of all physicians in diversion who used opioids as their primary drug. Specifically, meperidine was preferred by 37% of all impaired anesthesiologists; fentanyl by 14%. In addition, 30% preferred alcohol as their primary drug of choice (see Table II), as compared to 36% of physicians from all specialties who preferred alcohol. Fifty percent of the anesthesiologists who abused opi-
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ident anesthesiologists, none relapsed while participating in the program. Two residents are still participants in diversion. In contrast, 23% of all residents relapsed while in the program. The downside of this experience is that two of the four residents who completed the program successfully have subseq uently reentered the div ersion program. However, they now are doing well in the program. In retrospect, it was judged by the present authors that on e resident had been let out of the program too early so th at he could accept a position in another state. Th e other resident did e xhibit a life-style deemed adequate to remain clean and sober, but nev ertheless relapsed.
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oids were placed on naltrexone. In many instances, alcoholi c phy sicians in the program were placed on disulfi ram (An tabu se). Su ccess Rates Of the 5 1 anesthes iologists who co mpleted the diversion program as of March I, 1990, 35 (69%) completed the program successfully. In comparison, 255 (73%) physicians in all specialties completed the prog ram successfully. Amon g anesthesiolog ists using opioids, 19 (76%) com plet ed the program successfull y. This success ra te is adj usted to ex cl ude physicians who died fro m causes other th an their addictive d isea se. Those who died because of the ir addiction ar e included as fa ilures . Some stud ies of an esthesiologists in recovery hav e co nsidere d relapses as failures, conclud ing that an esthesiologists addicted to alcohol and other drugs should not be allowed to continu e in their specialties (M enk et aI. 1990). Ho we ver, slips and/or rel apses are not uncommon for any pe rso n in recovery. For man y phys icians, slips or relapse s ca n serve as va lua ble learni ng experie nces th at can, if handled properly, stre ngthen their recovery program (Go rsk i 1990).
Anesthesiologists Restricted from Practice Seven of the 35 anesthesiologists who completed the program succ essfully were asked not to practic e medi cin e temporarily while they underwent treatm ent or other inten sive th erapy. All seven we re limited in thei r practice until such tim e as the DEC judged th at they were able to func tion safe ly in medicin e again. One physi cian was restricted fro m practicing anesthesiology for an extended pe riod. Two physici ans were enc ouraged not to practi ce anesthesiology because of a high risk of relapse; they were guided into other specialties. T he records of four physician s in this study lack ed sufficient in formation to de term ine w he the r they had been restricted from practice. The rem aining 21 physicians were deemed fit by their DEC s to practice med icine in their specialty under cl ose monitoring.
R el apse R a tes A relapse in the divers ion program is defined as a positi ve urine test, se lf-repo rted abuse o r the report of abuse by a case man ager , works ite monitor or family mem ber. Using any amoun t of psych oactive substance is considered to be a rel apse even if it has been prescribed by anoth er physician withou t first informing the DEC case co nsultant. Physicians who relapse in this highly structured program are unlikel y to put pat ien ts at risk. Mos t relapses occur on off-duty hou rs and often invol ve quanti ties of alcohol or other drug s that wo uld be considered acceptable for th e nonaddictcd phy sici an. Of the 35 anesthe sio log ists wh o we re successfu l in completing the program, 26 % relapsed at lea st once while in the program as compare d to 40 % of all ph ysicians who rel ap se d while in div er sion . O f th e 19 anesthesiologists who used opioids, five (16 %) relapsed. Seventeen physicia ns of all specia lties re turned to d iversion a second time aft er succe ss fully completing the progr am; five (29 %) of these p hy sician s were anesthes iologi st.".
CONCLUSION Th e experience of the California Physicians Diversion Program indicates tha t anesthesiologists may be at greater risk for becoming chemically dependent than other phy sicians. Co ntrary to a prev a iling m isc onceptio n, ho we ver, the rec overy ra te of anes thesiologists in the highly structured California Physicians Di version Program is abou t the sam e as for other specialties. This comparable success rate also app lies to resident anesthesiologists. Thi s same reco very experience should apply for ancsthesiologists in any highly structured progra m where the ph ysician is mo nitor ed for meeting atte ndance, sobr iety, and relapse mana gemen t for long periods after initial treatme nt Previous studies re flec ting low recovery rates for anesthesio logists ar c probably an accurate reflection of the trea tme nt o utco me of any no nmonitored or short-term program where one slip or relapse is co nsidered to be treatment failu re. T he experience of the Cal iforn ia Ph ysi cians Diversion Program provides hope for successful treatment of all che mi cally depende nt ph ysi c ians , incl ud ing an esthes io log ists, while protecting the public safety.
R es id en t An esthesi ologists Six anesthesio logi sts have en tered the program while they were residen ts. Fo ur have completed the program succes sfully. Thi s result is consistent with the 60% of all reside nts from all spe c ia lt ies w ho ha ve com p leted the d iversion pro gram suc cessfully. Twenty-t wo res idents of all specialties have entered the program sinc e 1980; 13 have co mpleted the program successfully. Of the six res-
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REFERENCES Ikeda, R.M. & Pelton, C. 1990. Divenion programs for impaired physicians. WesterllJournal ofMedicine Vol. 152: 617-621. Menk, E.J.; Baumgarten, R.K.; Kingsley, C.P.; Culling, R.D . & Middaugh, R. 1990. Success of reentry into anesthesiology training programs by residents with a history of substance abuse . Journal ofthe Americall Medical Association Vol. 263(22): 3060-3062. Talbot, G.D .; Gallegos, K.V.; Wilson, P.O. & Porter, T.L. 1987 . The Medical Association of Georgia's impaired physician program. Review of the first 1000 physicians: Analysis of specialty. Journal ofthe American Medica; Association Vol. 257(21): 2927 -2930. Talbot, G.D. & Wright, C. 1987. Chemical dependency in health care professionals. Occupational Medicine : State of the Art Review Vol. 2(3) : 581-591.
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Buxton, M. 1990. Monitoring, reentry, and relapse prevention for chemically dependent health care professiooals. JourNJI ofPsychoactive Drugs Vol. 22(4): 447-450. California Medical Association. 1989. Brochure : Our List. San Francisco: California Medical Association. Gallegos, K.V.; Browne, C.H.; Veil,F.W. & Talbot, G.D. 1988. Addictioo in anesthesiologists: Drug access and patterns of substance abuse. Quarterly Review Bulletill Vol. 14(4): 116-122. Gorski, T.T. 1990. The Cenaps model of relapse prevention : Basic principles and procedures. Journal ofPsychoactive Drugs Vol. 22(2): 125-133. Gualtieri, A.C.; Cosentino, J.P. & Becker, J.S. 1983. The California experience with a diversion program for impaired physicians. Joumal ofthe American Medical Association Vol. 249(2): 226-229.
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