Boards must consider how best to protect the public while addressing practitioners who have substance use disorders. This article is based on a 2021 FSBPT Webinar by Brian Fingerson.
Substance abuse disorders are far more prevalent than most people realize. Regulators need to understand how they develop, how to recognize them, how they rise to the attention of licensing boards, and how boards should handle them. Most importantly, how does a board decide if a practitioner is safe to return to practice?
Before the Surgeon General's report in 2016 on illegal drugs, misuse of prescription pain relievers, and binge drinking, we only had anecdotal information indicating how prevalent substance abuse disorders were. The report finally gave us some hard facts and showed that substance abuse is more prevalent than previously thought. About 14.6% of people will develop a substance abuse disorder. The prevalence in a given year is about 8% of the population, similar to the rate of diabetes. This abuse rate translates to $400 billion in annual costs in health care and lost productivity.
The National Council on Alcohol and Drug Dependence defines alcoholism this way: "Alcoholism is a primary, chronic disease with genetic, psychological, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortion in thinking, most notably denial." This definition can also be useful when thinking of substance abuse disorders in general.
Alcohol and drug abuse is not new. However, we are becoming more aware of how it affects workplaces, schools, and communities. Any time a task requires alertness or quick reflexes, introducing a substance that causes impairment will increase the risk of serious accidents. Do you want your car mechanic, dentist, or babysitter to be affected by drugs? Of course not.
Health care professionals are at an increased risk of substance abuse due to having access to drugs of misuse. Additionally, their high knowledge of physiology and pharmacology may make them more susceptible to denial. This denial causes them to lie not only to themselves but also to those around them.
There are several warning signs colleagues should look out for:
Colleagues may notice these things and have suspicions, but what do they do? They may be hesitant to "snitch." Regulators need to remind practitioners they are bound to mandatory reporting by their license; if they fail to report someone, they are also liable and subject to disciplinary action.
Of course, some practitioners self-report. About 95% of practitioners self-report in Kentucky. Why do they ask for help? The four Ls: Life, Lover, Livelihood, or Law. Their physical body has reached a point where they cannot continue living the way they are living. A lover encourages them to get help or gives an ultimatum. Livelihood: the disease has affected their work. Finally, an intervention by law enforcement can make a profound impact on somebody. They don't have to reach the level of being arrested, hospitalized, or fired to realize they need help. If they want to self-report and receive help in Kentucky, they can contact the Kentucky Impaired Physical Therapy Practitioners Committee.
Sometimes someone comes to the attention of the board, and therefore the committee, who says they do not have a problem. Thus, the committee first determines if they actually have a substance use disorder. Denial is not just a simple defense mechanism. It also includes reducing awareness of the fact that continuing to use a substance is the cause of an individual's problems rather than a solution to those problems. Denial is a significant obstacle to recovering; this can be particularly true of licensed professionals. Licensed professionals often think they are too smart for something like this to take control. They do not want offers of help because they do not think they need help.
So, how do we determine that someone has a substance abuse disorder? According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, tolerance and withdrawal in and of themselves do not constitute indications that someone has a substance disorder. For example, patients on opioids often develop tolerance and may experience symptoms of withdrawal when they stop the medication. This does not mean they are addicted.
A better way to diagnose substance abuse disorders is through symptoms related to the loss of control, which are the symptoms in bold:
The number of symptoms an individual has helps specify how severe the problem is:
The committee helps emphasize to people with these issues that they have three options: they can sober up, get locked up, or die.
In terms of assessment, the Kentucky Professionals Recovery Network has found that sending practitioners to counselors for a brief, sixty-minute evaluation does not work. People lie. Therefore, if the committee suspects that someone has a substance use disorder, yet the practitioner denies it, the board will order a comprehensive professional evaluation. That includes an inpatient three to five-day complete workup with the whole battery of professional assessments, resulting in a detailed report for the committee and board.
Once the committee determines someone does have a problem, the committee helps them decide on and access treatment options. The committee also factors in comorbidities, for example, psychological issues, eating disorders, ADHD, and chronic pain. These factor into the type of treatment someone should receive. The committee offers at least three different treatment facilities to give them options.
The committee helps them with their accountability in their recovery to enable them to return to life without substances. The committee helps with treatment and monitoring because the first responsibility is to the public. However, the committee stresses to the practitioner that if the practitioner does not stay sober and alive, whether or not they have a license will be secondary.
A big part of the treatment and monitoring programs includes removing denial and setting up daily actions to reduce the risk of relapse. For example, if someone has chronic pain, you must also address that risk. The committee also provides education on how to protect themselves from cross addictions.
Once the practitioner is ready to return to practice, the committee helps them take the steps needed to regain their licensure. The committee sets up a contract that includes toxicology screenings, attendance at meetings, and other support mechanisms. Contracts are usually five years long. Research has shown that two-year contracts often result in relapses afterward. However, monitoring for five years greatly increases their chances of staying sober and thus remaining a productive member of society. These rehabilitation and monitoring programs do work.
Of course, just because somebody seeks help for a substance use disorder does not excuse them from the discipline that comes from a violation of a practice act or from a violation of a controlled substance law. The board's job is public protection, and those actions have public protection concerns. The board may approve only specific practice sites or apply other practice restrictions depending on the situation.
Boards should actively seek out this information by including reporting and disclosure requirements in their practice acts. Practitioners should be required to report issues, including things like DUIs or possession of controlled substances, on their initial licensure and renewal forms.
Now, what happens if they do have a history? There may be no need for services, depending on the situation. Even if someone has multiple arrests that are either alcohol or drug related, if the incidents are from the distant past, they may no longer be issues. Often in these situations, the Impaired Physical Therapy Practitioner's Committee will offer the practitioner a chance to work with them without having an official board order. The agreement would include an immediate temporary suspension clause if an issue did arise.
Other states have recovery programs. A jurisdictions' website should have information helping people report and get help for substance abuse issues. There should be services to have them appropriately assessed, treated, and followed once they get out of treatment. Good treatment works. The vast majority of people who have successfully completed these programs can and do return to practice.
Brian Fingerson, BS Pharmacy, RPh, FAPh, is a Consultant with and the former President of Kentucky Professionals Recovery Network, KYPRN, a practice formed by him in 2003 to educate health care professionals about Substance Use Disorders. KYPRN administers the recovery and accountability programs for multiple licensing Boards in Kentucky and is involved in assisting professionals with Substance Use Disorders in their recovery process and supporting their return to active practice. Fingerson has contracted with the Kentucky Board of Physical therapy since 2003 to administer their program. He earned his BS in Pharmacy degree from North Dakota State University in 1973.