Characteristics and Outcomes of Health Care Professionals with Substance Use Disorders in the Unites States: A Retrospective Descriptive Study

Abstract

Substance use disorders (SUD) among healthcare professionals (HCPs) are significant and persistent problems. The risk factors for relapse during first year of enrollment in recovery monitoring programs are unknown. Moreover, it is unknown if the use of opioids is associated with a higher relapse rate compared with alcohol and non-opioids. The objective of this study is to examine the characteristics of HCPs with SUD that cause them to relapse during their first year of enrollment in recovery monitoring programs. Also, to gain a better understanding of the impaired HCPs by developing composite descriptions of: 1) relapsed versus non-relapsed; and 2) opioid users versus non-opioid users. A retrospective cohort study of 1755 HCPs enrolled in recovery monitoring programs in the United States, followed up between 2003 and 2016. This study aims to investigate initial differences in characteristics between subjects who relapsed and did not relapse as well as between subjects who are opioid users and non-opioids. Moreover, the study will examine if opioids are the primary drug of choice among people who relapse. The primary outcome measure of this study are factors associated with relapse or being an opioid user. Opioid users were (n=423, 26%) and only (n=48, 3%) who had first relapse. There was no significant association between first relapse and being an opioid user (p value > 0.05). In fact, there was a significant association between age and marital status with first relapse (p value < 0.05). Gender, age, marital status, and location has significant association with being opioid users (p value < 0.05). Divorced, Separated, and Widowed are 3.194 (95% CI: 1.535 – 6.644) times more likely to relapse than Single HCPs while Cohabitating and Married are 1.751 (95% CI: 0.885 – 3.464) times more likely to relapse than Single HCPs. Males were 1.344 (95% CI: 1.042 – 1.734) times more likely to be an opioid user than females. Subjects 40 years of age and older are 0.389 (95% CI: 0.306 – 0.495) times more likely to be an opioid user than those under the age of 40. In conclusion, the risk of relapse with substance use was increased in HCPs who are Divorced, Separated, and Widowed as well as Cohabitating and Married. The risk of being an opioid user was increased in male HCPs and those 40 years of age and older. These observations should be considered in monitoring the recovery of HCPs in order to inform healthcare policy makers or providers to improve the health and wellbeing of HCPs in the workplace.

Introduction

Substance use disorder (SUD) is a major health problem in the United States (U.S.) and, in simple terms, it means the misuse of drugs and/or alcohol. In 2013, more than 8% of the U.S. population aged 12 or older have SUD [1]. Health care professionals (HCPs) are at risk for this disorder due to several risk factors and SUD in HCPs has become a serious and complex issue for patient safety. General risk factors include social factors such as family history of the disorder, psychiatric factors such as depression, and biological factors such as genetic predisposition. Specific risk factors for HCPs include easy access to drugs, stressful work environments, and the belief that drugs assist with coping [2].

HCPs with SUD are referred to recovery monitoring programs such as Physicians Health Programs (PHPs) and Alternative-to-Disciplines programs (ATD) [3, 4]. The purpose of these recovery monitoring programs is to help addicted HCPs seek assistance and avoid punitive interventions. Therefore, HCPs can maintain their licenses while maintaining their sobriety. Moreover, patient safety will be improved because of deterring relapse time among HCPs.

A key feature of recovery monitoring programs for HCPs is the agreement contract. This contract includes several requirements that need to be done on regular basis such as urine tests, follow-up with outpatient treatment programs, and attendance at 12-step meetings. These requirements vary from program to program and are customized per profession therefore the outcomes also may vary.

Literature Review

Studies showed that rates of SUDs among HCPs are similar to the general population, but HCPs demonstrate significantly higher levels of opioid abuse [5, 6, 7]. However, another study showed that in cases where multiple drug use is common, as with HCPs, alcohol is the most used drug, followed by opioids [8]. Moreover, HCPs appear to be vulnerable to SUD because of work-related stress, easy access to drugs, and personal matters such as physical or psychological health needs, financial issues, and family relations [9]. Thus, patient safety may be placed at risk when HCPs practice with active, untreated SUD [10]. In addition, HCPs with SUD are more likely to prescribe drugs for themselves and gain access to drugs when they administer patient medication [9].

Recovery monitoring programs aim to protect the public by helping the HCPs remain sober [11].  Recovery monitoring programs typically require HCPs with SUD to sign a contractual agreement to monitor their compliance to the program’s requirements to ensure the HCPs are not impaired when practicing and thus enhance patient safety.  These requirements include random drug tests, attendance at outpatient treatment programs, attendance at 12-step meetings and other support groups. The length of programs and frequency of urine testing as well as other requirements varies with profession and state (See Appendix 1). Once the agreement is signed, the HCP will be supervised and monitored for which he/she will be referred to the regulator in case of relapse or failure to adhere to the agreement [14]. A relapse occurs when a HCP uses alcohol or other drugs non-medically, as well as fails to be compliant with the treatment session.

There are various treatment programs in the United States in which most of the published data on the outcomes of these programs are limited to physicians who are treated and monitored by PHPs [14, 15, 20]. However, fewer studies focused on other types of clinicians who are referred to ATD, such as nurses [7, 12, 13]. PHPs and ATDs provide coordination, monitoring, and expertise in the care of HCPs, which has led to positive outcomes when combined with treatment [14, 15]. The ultimate positive outcome is relapse avoidance, thus ensuring patient safety as well as helping HCPs to maintain their licensure.

There are several factors that contribute to successful recovery as well as positive outcomes among HCPs due to the monitoring program [16]. According to McLellan et al. (2008), physicians have high rates of recovery when involved in long-term continuing care and monitoring programs [15]. In addition, monitoring HCPs with random drug tests after treatment is an effective way in maintaining high abstinence rates [17]. Furthermore, longer monitoring programs are more likely to improve the long-term success rate in addicted HCPs [18].

A majority of HCPs with SUD have been found to use alcohol and those who used drugs primarily have used benzodiazepines and opiates [5, 8]. According to one study by Domino et al. (2005), use of major opioids is associated with a higher relapse rate compared with alcohol and non-opioids [20]. The objective of their study was to test the hypothesis that chemically dependent HCPs using a major opioid (e.g., fentanyl, sufentanil, morphine, meperidine) as their drug of choice are at higher risk of relapse. They found that twenty-five percent (74 of 292 individuals) had at least 1 relapse in which the use of a major opioid increased the risk of relapse significantly in the presence of a coexisting psychiatric disorder (HR, 5.79; 95% CI, 2.89-11.42). They concluded that the risk of relapse with substance use was increased in HCPs who used a major opioid or had a coexisting psychiatric illness or a family history of a SUD.

Regarding gender, one study found that female gender was associated with a higher risk for drug use than male among physicians. According to Lin et al. (2013), female physicians are more likely to suffer role strain, role deprivation, and gender role conflict [9]. The majority of chemically dependent nurses were female and caucasian, while their mean age was 40 years [19].

Regarding profession, physicians and nurses are considered high-risk for SUDs due to the enormous amounts of stress that they deal with because of their jobs [30, 31]. Among physicians, the disciplines typically associated with substance abuse are emergency medicine, anesthesiology, and psychiatry [22]. Similarly, among nurses, the disciplines typically associated with substance abuse are also emergency medicine, anesthesiology, and psychiatry [29].

Previous studies lack the risk factors that contribute to the likelihood of relapse after initial treatment for substance use. Virtually every study of chemical dependency among HCPs has had relatively short follow-ups, limitations in statistical methods or analyses, and variable intensity of monitoring. Moreover, previous studies focused on only physicians and their disciplines, or only nurses and their disciplines, while our study is looking at the HCPs in total. Thus, the purpose of this study is to give a broad sense of what characteristics of all these HCPs is associated with a relapse. Another purpose of this study is to develop a composite description of relapsed HCPs versus non-relapsed HCPs. Moreover, this study is to develop also a composite description of opioid users versus non-opioid users among HCPs. The composite will be useful to gain a better understanding of the impaired HCPs, and to evaluate the effectiveness of current programs for treatment and monitoring. In addition, by identifying the various potential determinants of relapse among HCPs could inform healthcare policy makers or providers to improve the health and wellbeing of HCPs in the workplace.

Using the data from a cohort of 1755 HCPs enrolled in recovery monitoring programs in the United States, this study aims to investigate initial differences in characteristics between subjects who relapsed and did not relapse as well as between subjects who are opioid users and non-opioid. Moreover, the study will examine if opioids are the primary drug of choice among people who relapse. The primary outcome measure of this study a determination of the factors associated with relapse or being an opioid user. The secondary outcome measure is to determine if opioids are associated with a higher rate relapse in HCPs since using of major opioids has been associated with a higher relapse rate compared with alcohol and non-opioids [20].

Methods

To address the aims of the proposed study, a secondary data analysis will be conducted for outcome data collected on a cohort of 1755 HCPs who enrolled in a recovery monitoring program between 2003 and 2016. This program monitored participant demographics, results, drug history, and compliance with contract using Recovery Management Services (RMS) by FirstLab.

FirstLab (now FirstSource Solutions) is a full service compliance management solutions company founded in 1989 as a subsidiary of FHC Health Systems (now RID Ventures, LLC), of Norfolk Virginia [23]. FirstLab has provided drug and alcohol testing services as well as managing substance abuse testing programs to meet the needs of its diverse client base, which includes Fortune 500 companies, law enforcement agencies, state and municipal governments, and treatment facilities. FirstLab created RMS for professional health monitoring programs to offer a customized menu of services, test panels and payment options that met the unique needs of different industry and state monitoring programs. In 2008, FirstLab acquired National Confederation of Professional Services, Inc. (NCPS), of Newport News, Virginia. This acquisition made FirstLab the largest administrator of professional health monitoring services in North America, with clients nationwide.

The RMS monitors HCPs with SUD using a web-based data collection and management system that provides regulatory bodies (e.g. state licensing boards) across the U.S. with secure, consistent, and reliable compliance monitoring tools. Information from the RMS database includes the following: participant demographics (e.g. age, gender, race/ethnicity, marital status, location), results (e.g. overall result of tested drugs), drug history (e.g. drug of choice), and compliance with contract (e.g. frequency of required testing) as well as length of time in the program.

The analytic sample of the proposed study will consist of 1755 HCPs who were monitored for at least one year between 2003 – 2016. The primary dependent variable in the proposed study is relapse rate in their first or second year. Since the data file does not have exact enrollment date, subjects who relapsed in the second year were included for two reasons: subjects might relapse in their first year assuming their start date was in the second half of the year; second is to maximize sample size of relapsed group therefore increasing validity. HCPs will be divided into two groups: HCPs with no relapse and HCPs with at least one relapse. A relapse occurs when HCPs had a positive drug test, confirmed positive, and reconfirmed positive within their first year in the program.

The independent variables are age, gender, marital status, location, and drug of choice. The age has been classified into two groups: “under 40” and “40 and older”, in order to examine if young adults (under 40) are at higher risk of being opioid users [25]. Marital Status has been stratified into three groups: “Single”, “Married and/or Cohabitating”, and “Divorced, Separated, or Widowed”. Also, location has been grouped into four major areas: “Northeast”, “Midwest”, “South”, and “West” according to the U.S. Census Bureau [24]. HCPs are considered opioid addicts when their primary drug of choice is an opioid. Drug of choice will be categorized into four groups: opioids, cocaine, alcohol and non-opioids (See Table 1).

Table 1: Drug of choice categories