MANAGING PEOPLE WITH ADDICTIONS March 6, 2014 Bottom Line Conference Ray Baker MD HealthQuest Occupational Health

KEY POINTS •  Addictions – basic medical model •  Red flags: signs & symptoms •  Communicating with/motivating the addicted worker •  Necessary information for the DM professional •  Assessment and Treatment •  Contingency management and medical monitoring •  Safety sensitive vs non safety sensitive workers – what’s the difference?

POTENTIAL CONFLICTS

•  Dr. Baker receives no funding from and pharmaceutical company or treatment provider •  Dr. Baker is a partner in HealthQuest Occupational Health Corp •  Dr. Baker is a principal, medical consultant and medical review officer with Alliance Medical Monitoring

JOHN 48 YR OLD ENGINEERING DEPT SUPERVISOR

JOHN: WORK HISTORY

•  12 year employee: steady, reliable until 18 mo ago •  Began to miss time, performance erratic •  Conflict with his manager •  Making paranoid accusations

WENDY – 34 YEAR OLD CLERICAL WORKER

WENDY

•  Excellent employee til 2 years ago •  Unexplained absences from work with, vague, undocumented medical time off •  Moody, occasionally rude – complaints from employees/visitors •  Rumours of drug use

FRED 46 YR OLD DRIVER

FRED •  Off work frequently since back injury 7 years ago (WCB) •  In past was reprimanded for AOB at work •  Recently off work for 3 months due to reinjury/ back pain •  Insurer became aware of probable addiction •  Insurer could not send him back to safety sensitive work bc liability

JOE – 32, LANDFILL LABOURER (OPERATES EQUIPMENT)

JOE •  Joe has gotten in every kind of trouble: fights, absenteeism, angry outbursts, can’t operate municipal vehicles bc recent impaired conviction •  Disciplinary process reached end of road •  After meeting with union Joe “self-disclosed” he had alcohol problem

—  10 % of employees will experience a substance use disorder (NIDA – 2009) —  People with mental disorders twice as likely to have substance use disorder (WHO-CAMH 2004, Vaccarino, Rotzinger) —  Addictions mimic mental disorders: (depression, stress-related conditions, anxiety, panic, bipolar, psychosis)

ALCOHOLISM: THE MEDICAL IMPOSTER •  •  •  •  •  •  •  •  •  •  •  •  • 

High blood pressure Enlarged heart Ulcers and reflux (serious heartburn) Accidental injuries Sleep disorders, sleep apnea Anxiety, panic, social phobia Depression, bipolar disorder, stress/burnout Seizures Type 2 diabetes Easy bruising and bleeding Dental (periodontal) disease Sexual dysfunction Dementia, delirium

OTHER DRUG-RELATED CONDITIONS •  Depression caused by depressant drugs: sedatives, marijuana, stimulants •  Psychosis caused by stimulants: cocaine, methamphetamine, caffeine •  Anxiety/panic caused by sedatives •  Pain caused, made worse by pain killers •  All drugs of abuse can cause: sleep disturbances, sexual dysfunction, memory loss, confusion, incoordination

ADDICTION •  Pathological relationship with mood altering activity with life-damaging consequences •  DSM IV – ABUSE •  Hazardous or harmful use – consequences but no loss of control •  DSM-IV - DEPENDENCE •  Impaired control over use of drug •  Continued use despite consequences •  Increasing pre-occupation with getting/using •  Tolerance/withdrawal (sometimes – not always)

ALCOHOL & DRUG USE

Dependence Zero use 20%

Regular Use 65%

Abuse 5-10%

Pickle Line

Early

Mid-stage Workplace becomes aware

Late

DSM 5 (MAY 2013) CHANGES •  Eliminates abuse, dependence: replaces with Substance Use Disorders •  11 diagnostic criteria •  2-3 = mild •  4-5 = moderate •  6 or more severe •  Eliminates legal consequences as dx criteria •  Problematic for occupational addiction medicine, may ignore

SO – HOW ARE ADDICTS DIFFERENT?

•  Neurobiology is altered •  Inability to adequately self-soothe •  Difference may be congenital (high genetic risk) or acquired (post-trauma, psych. comorbidity, heavy long-term use) •  Lack key coping skills (missing puzzle pieces)

—  Attendance —  Performance —  Behaviour —  Safety Training workplace personnel to diagnose symptoms of drug intoxication would be nearly impossible Instead, have supervisory staff do their jobs (manage attendance, performance, behaviour) but do them well.

BEHAVIOURS •  •  •  •  •  •  •  • 

Isolation & social withdrawal Forgetting previous conversations Irritability & mood swings Mood changes after breaks Angry outbursts & interpersonal conflict Defensiveness, blaming Unreasonable resentment Increased absenteeism, lateness & schedule confusion

POSSIBLE RED FLAGS (DISABILITY CASE MGR) •  The fat file •  The common medical secondary diagnoses of alcoholism (slide 12) •  Long term use of benzodiazepines •  Multiple addictive prescriptions (benzo’s, opioids, stimulants) •  Failure to respond to conventional treatment •  Many family docs over the years •  Many drop in clinics •  Chronic pain on escalating doses of opioids – no evidence of benefit

MORE RED FLAGS •  Difficult to track down •  Emotionally volatile, angry •  Splitting (enabling professionals running interference) •  Spouse or partner calls •  Multiple, prolonged absences •  Medical marijuana •  Your epigastric sign •  You bend the rules for them •  Others???

GETTING UNSTUCK: WHAT INFO DO YOU NEED? •  What is (are) the diagnoses? •  Is this person fit/safe to work? •  Who are the stakeholders (union, regulatory body, insurer, treaters) are they on board? •  Are all diagnoses/problems being simultaneously addressed/treated? •  Is appropriate treatment (intensity/modality) available •  What are the steps in treatment (weaning, inpatient detox, residential treatment, outpatient treatment, phsrmacological treatment, community stabilization, •  Are there other barriers? (home, partner, sick role, unsfe workplace)? •  Is there a long-term relapse prevention plan? •  Can we use contingency management? •  Is this person motivated to do the things they can do?

JOHN - INTERVENTION •  In meeting w supervisor, confronted with attendance, performance, behaviour •  Asked if he needed help, offered EFAP •  Nothing changed •  Formal meeting, advised of possible discipline •  No info from MD •  Sent to Occ Health •  Occ health determined probable addiction •  Referred for Addiction Medicine Evaluation

WENDY •  2 supervisor interviews, no change, •  Heading down disciplinary path •  Agreed to go to EFAP •  EFAP recognized serious addiction, recommended Addiction IME

THE IMPORTANCE OF ASSESSMENT

Biomedical Addictions Pain

ATTEMPTING TO TREAT WITHOUT ASSESSMENT IS LIKELY TO FAIL BECAUSE OF MISSED DIAGNOSIS/ PROBLEMS/SECRETS •  Must include biological, psychiatric, addictions and psychosocial components in order to find all concurrent problems •  Generates extensive report: multiple diagnoses with comprehensive treatment plan •  Provides roadmap for recovery •  Basis for coupling benefits to compliance (both disability insurance, and return to work) •  Abridged document goes to HR, LR, RTW coordinator (no confidential medical/personal info): •  Ability to work, length of disability, workplace accommodations

JOHN: IME

•  John appeared to have depression and psychotic delusions •  2 years ago, lonely, met 22 yr old sex trade worker •  Attempted to rescue her •  Supplied her with money •  She got him started using crack •  Cocaine psychosis

WENDY •  Assessment revealed

•  Mid-stage alcoholism, onset in adolescence •  History of childhood emotional trauma •  Recurrent depression requiring psychiatric care •  Mom of 2 kids, no childcare •  Wanted to try outpatient Rx

FRED

•  IME: longstanding, mid-late alcoholism Stopped drinking almost entirely 7 years ago when Tylenol #3>Percocet>Oxycontin progression began •  Suffers chronic pain, made worse by the drugs •  Level of function poor, mental status poor, feels like isolated victim, blames everyone

JOE IME INTERVENTION: “SELF DISCLOSURE” •  Dishonest during IME, likely he’s been abusing wide variety of substances since early teens •  Acts like personality disorder (antisocial/ narcissistic) •  No motivation to change (just motivated to get out of trouble) •  Resisted going to treatment, ridiculed 12 Step and other mutual support groups

•  Remember the underlying problem … •  Effective treatment must concurrently address all diagnoses (psychiatric, medical, addictions) •  Treatment must be staged: detox then education & refusal skills, then relapse prevention activities •  Without thorough diagnostic assessment treatment planning is impossible

—  Inpatient/outpatient detox —  Psychoeducation —  Mutual support groups (AA, NA, CA, RR, WFS, etc., etc.) —  Residential (eclectic) treatment programs —  Harm reduction measures: safer use —  Pharmacotherapies (acamprosate, disulfiram, naltrexone) —  Agonist (methadone, buprenorphine) therapies —  Relapse prevention programs —  Evidence-based psychotherapies (CBT, MET, 12-SF) —  Complementary adjunctive – acupuncture, nutrition, religious, nutritional

—  Telephonic support in treating addictions at least as effective as in-person counselling —  Growing evidence of association between 12 step involvement and long-term recovery —  Professionals receiving mandatory medical monitoring have by far best outcomes of any group studied

RESIDENTIAL TREATMENT OUTCOMES (MONTH 11-12 POST-TREATMENT ABSTINENCE)

No Counselling Weekly Counselling No AA/NA

Weekly AA/NA

45%

76%

69%

88% N. Hoffman - 1988

LONG-TERM RECOVERY

What happens after “treatment” much more important than what happens during “treatment” Spend your resources accordingly

• 

They have to want to stop drinking/drugging a MYTH

•  Contingency management MOST EFFECTIVE intervention/treatment of addictions •  Compliance= benefits: non-adherence = consequences •  The only safe RTW strategy if safety sensitive or “highly responsible” –(health professionals) •  Supported by medical evidence & jurisprudence

is

— Does not prove impairment — Selects for certain types of drugs — Important new testing (EtG) – detects alcohol for up to 5 days — Plays an essential role in motivating recovering people to stay clean & sober — Is not difficult to beat (just for fun, google beat drug test )

—  An extension of Occupational Addiction Medicine treatment plan —  Essential for safe RTW —  Monitor cannot have therapeutic relationship w EE —  Performed by trained professional (BBB) —  Monitor records and reports adherence to relapse prevention plan —  Regular interviews in person or telephonic —  Always includes drug testing —  Regular compliance reports to oversight body —  Non-compliance (range of seriousness) results in range of consequences

JOHN •  Sent to low-intensity, longer term treatment (inpatient) psychosis disappeared •  Learned effective coping skills •  With CBT became happier •  Embraced mutual support groups (AA, NA, CA)

JOHN •  Returned to work at 10 mo •  Monitored relapse prevention agreement for 2 years •  Now 5 years since intervention – John has been promoted, serves as role model •  Newly married, baby on the way

WENDY •  Highly motivated •  Continued working, engaged in intensive outpatient treatment •  Family doc and psychiatrist carefully managing her depression •  Signed on with monitor to ensure safety and ongoing compliance •  Loves AA •  Got a great sponsor

WENDY •  After initial ‘pink cloud’ Wendy had a slip, got very drunk over a weekend at 3 months sober •  Self-identified, tightened up her recovery activities •  Had to dump an abusive boyfriend who sabotaged her recovery •  Now 3 years sober (completed monitoring), continues with AA meetings •  Top notch reliable employee

FRED •  Referred to abstinence based residential treatment (with medical staff), weaned from all drugs •  After period of resistance (and worsening pain) he started to recover •  Learned effective skills for handling emotional and physical discomfort •  AA and physical exercise •  6 months later was ready for GRTW

FRED •  2 year monitoring included his MD, PharmaNet reviews, reporting to ER •  Did well in mutual support groups (AA) •  Lost weight, quit smoking, exercises regularly •  When monitoring ended he asked that it be continued •  Attendance now same as peer group

JOE •  Eventually after long delays, fights between union, insurer, employer, caregivers Joe entered treatment centre •  Following initial treatment signed monitored relapse prevention agreement •  Returned to work under Last Chance agreement

JOE •  Rude, dishonest with monitors •  Workplace noted no change in behaviour or attitude •  Attended minimal AA/Smart Recovery •  Caught providing substituted cold urine sample •  Fired

JOE •  Joe ended up homeless for a while •  Then got himself into recovery house for 6 months •  Gradually embraced AA/NA •  Now, 3 years later, he’s a year clean and sober, working part time •  Doing service work in AA •  Interested in becoming counsellor

BARRIERS TO EFFECTIVE DISABILITY MGMT •  EE resistance (built into the disorder) •  Codependent enabler (MD, psych, union, family, lawyer, employer) •  Workplace doesn’t want them back •  Your own (all of us) issues •  Stigma of this disorder (moral, self inflicted) •  Lack of education of treatment providers •  Dualistic, either/or approach (rather than holistic) •  Expensive: good treatment unisured •  Others?

THE PROBLEM OF THE NON-SAFETY SENSITIVE EMPLOYEE •  HR vs treatment efficacy •  Higher standard required (means sicker – later stage) •  They don’t do as well •  Only able to use contingency mgmt during insured disability or when approaching termination

DO’S AND DON’TS Do Use empathy, communicate regulary Use firm, consistent boundaries Keep all stakeholders in the loop Use contingency management Expect compliance and successful recovery Develop a black belt in boundaries Don’t Expect them to get well on their own, especially once they are off work Allow “splitting” Enable (depriving them the consequences of their behaviours)

SUMMARY •  Addictions are common (10%), chronic progressive disorders that are very treatable •  Most health professionals untrained in recognition and treatment •  Addictions masquerade as other medical/psychiatric disorders •  If true comorbidity is present, all diagnoses require concurrent treatment •  Good quality assessment necessary to provide roadmap for recovery and basis for medical monitoring •  Contingency management results in by far the highest rates of successful recovery •  Disability management coordinators are the most important professional in putting it all together

Thank You Dr. Ray Baker Assoc. Clin. Prof. UBC Medical Director HQ Occ Health 604-718-6929 www.healthquest.ca