Characteristics and outcomes of doctors in a substance dependence monitoring programme in Canada: prospective descriptive study

doi:10.1136/bmj.a2098

Published 3 November 2008, doi:10.1136/bmj.a2098
Cite this as: BMJ 2008;337:a2098

Research

Characteristics and outcomes of doctors in a substance dependence monitoring programme in Canada: prospective descriptive study

Joan M Brewster, assistant professor¹, I Michael Kaufmann, medical director², Sarah Hutchison, senior director, information management³, Cynthia MacWilliam, associate director²

¹ Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada, ² Ontario Physician Health Program, Ontario Medical Association, Toronto, ³ Ontario Medical Association, Toronto

Correspondence to: J M Brewster jmbrewster{at}sympatico.ca

Abstract

Objective To describe the characteristics at enrolment and outcomesof doctors in a substance dependence monitoring programme inCanada.

Design Prospective descriptive study.

Setting Provincial physician health programme, Canada.

Participants All 100 doctors consecutively admitted to a substancedependence monitoring programme and followed until completionof monitoring or on leaving the programme.

Main outcome measure Relapse during long term monitoring forfive years.

Results Ninety per cent of the doctors enrolled on the programmewere men, 66% were married or living with a partner, 44% hadhad previous treatment for substance dependence, and 36% hadhad previous psychiatric treatment. Smokers were over-representedcompared with the general population of US doctors (38% v 5%).During the monitoring period 71% of participants had no knownrelapse. An additional 14% went on to complete the programme,after some form of relapse. In total, 85% of the doctors successfullycompleted the programme.

Conclusion In this cohort of doctors enrolled on the OntarioPhysician Health Program for substance dependence, most weremen who were dependent on alcohol or opioids. Smokers were over-representedcompared with the general population of US doctors. Eighty fiveper cent successfully completed the programme.

Introduction

Programmes to help doctors who are dependent on substances suchas drugs and alcohol exist in every US state¹ and every Canadianprovince,² in collaboration with medical associations or regulatorybodies. The British Medical Association also has developed apeer support programme.³ Descriptions of participants with drugrelated problems in physician health programmes consistentlyshow that alcohol is the most common drug of choice, followedby opioids, and that multiple drug use is common.⁴ ⁵ ⁶ ⁷ Femaledoctors are generally under-represented as participants.⁶ ⁷⁸ Among these doctors, long term recovery rates are higher thanthose for substance use disorders in the general population,often exceeding 85%.⁴ ⁸ ⁹ ¹⁰

In Canada the Ontario Physician Health Program is among thelargest of such programmes and, by 2002, had enrolled 100 doctorsfor monitoring recovery from substance dependence. Recoveringdoctors who choose monitoring are enrolled by a case managerfrom the programme after they have been diagnosed as dependenton substances, successfully treated, and established in earlystable remission. Contract requirements for monitoring includevisits to an addiction medicine doctor, visits to a family doctorfor routine health needs, attendance at facilitated health professionalsupport groups, attendance at mutual support groups in the community,monitoring in the workplace, and random screening of urine foralcohol and drugs of misuse. The usual agreement for monitoringis five years of continuing progress in recovery. Contingenciesbuilt into the monitoring agreement can result in details ofthe case being reported to the College of Physicians and Surgeonsof Ontario, the regulatory body, when aspects of the contractare breached.

By the end of 2007 all of the first 100 doctors enrolled onthe Ontario Physician Health Program for monitoring of substancedependence had completed contracts. We describe these doctorsand their outcomes.

Methods

Participants were the first 100 doctors enrolled in the OntarioPhysician Health Program for monitoring of substance dependenceafter the formation of the programme in 1995. All were diagnosedas dependent on substances according to criteria of the Diagnosticand Statistical Manual of Mental Disorders, fourth edition,and treated for substance dependence, usually in a residentialabstinence based programme for 4-6 weeks, before entering themonitoring programme.

Intake measure and outcome measure (relapse)
On entering the monitoring programme, the doctors completeda clinical intake questionnaire detailing personal characteristics,history of substance misuse in the family, professional educationand practice, licensure, history of substance use, treatmenthistory, psychiatric history, and experience of physical andemotional abuse.

While being monitored by the physician health programme, anyuse of alcohol or an illicit drug or use of any psychoactivedrug not prescribed by a participant’s doctor was consideredto be relapse. Relapse ranges from single use to full resumptionof dependence on substance use. After brief relapse, participantsmay continue the monitoring programme to successful completion;more serious relapse may lead to the doctor having to restartthe programme under a new contract or leaving the programme.

Data analysis
The data were analysed using SPSS version 15.0. We summarisedthe characteristics of participants using frequencies for categoricalvariables and means and standard deviations for continuous variables.

Results

The table

shows the personal characteristics of the participants,details of their practices, and drug and treatment historieson entry to the monitoring programme. In total, 90% of participantswere men; two thirds (66%) were married or living with a partner.The mean (SD) age at enrolment was 45 (11) years, with a mean(SD) years experience of medical practice of 16 (11) years.Almost a half (48%) were in general practice or family practice.Most practised patient care in single or group practices, andmost practised in urban areas, communities of 100 000 or more.These characteristics were generally similar to the populationof Ontario doctors (Member Services Department, Ontario MedicalAssociation). The licences of two thirds (69%) of participantswere unaffected at the time of enrolment; the remainder (31%)were suspended or restricted (mostly to prevent the prescribingof narcotics). Two thirds of participants enrolled to satisfya requirement of the College of Physicians and Surgeons of Ontario.

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Participants’ personal characteristics and history of drug use and treatment at enrolment in the Ontario Physician Health Program

Half of the participants (51%) used alcohol as their primarydrug of choice, one third opioids (37%), and the remainder (36%)other drugs such as benzodiazepines, stimulants, or illicitdrugs such as cannabis or cocaine. Nearly half (44%) had receiveddrug related treatment at some time before the most recent treatment.More than a third (38%) were current smokers, higher than thecurrent rate of smoking among the general population of US doctors,which is about 5%.¹¹ Thirty six per cent of the participantshad had psychiatric treatment in the previous five years. Morethan half (60%) reported ever experiencing some form of physicalor emotional abuse.

During the monitoring period 71% of participants had no knownrelapse. An additional 14% went on to complete the monitoringprogramme after some form of relapse. In total, 85% of the doctorssuccessfully completed the programme.

Discussion

Doctors who entered the Ontario Physician Health Program forsubstance dependence were typically middle aged, married mendependent on alcohol or opioids. Overall, 85% of the participantssuccessfully completed the programme.

The strength of our study is that the participants were 100doctors consecutively admitted for monitoring of substance dependencein a physician health programme, without selection. Resultswere accumulated over 10 years, the time taken for 100 doctorsto complete at least five years of monitoring.

One possible weakness of the study is that the characteristicsof doctors entering the programme could change over this timespan. Measures on the intake questionnaire were by self reportand subject to the limitations of that method. Possibly we failedto identify some relapses, leading to misclassification of outcomes.The relatively small number of participants prevented us fromstudying the relation between characteristics of the participantsat intake and relapse.

This profile of the personal characteristics of the participantsand their practices is typical of other reports of participantsin physician health programmes, where women are under-represented.⁴⁵ ⁶ ⁷ ⁸ The high rate of smoking among the participants comparedwith the general population of US doctors (38% v 5%) and thehigh success rate is comparable to that of other North Americanphysician health programmes that report outcomes for monitoringsubstance dependence.⁴ ⁸ ⁹ ¹⁰

Doctors entering a substance dependence monitoring programmeare more likely to be men and to be smokers than other doctors.They are usually known to the licensing body. Their primarydrugs of choice are alcohol or opioids. A structured monitoringprogramme after abstinence based primary treatment for thesesubstance dependent doctors, with regulatory contingencies forlack of adherence, can produce successful results. Further researchis needed to examine the relation of the characteristics ofthe doctors and components of the programme to relapse, so thatmonitoring can be tailored to the specific needs of participants.

What is already known on this topic

Studies have shown a highrate of successful outcomes in doctors enrolled in monitoringprogrammes for substance dependence

What this study adds

Ina sample of 100 doctors consecutively admitted to a physicianhealth programme, most were men and the drugs of dependencewere alcohol or opioids

After abstinence based residentialtreatment, 85% of the doctors successfully completed the comprehensiveprogramme of monitoring with contractual contingencies

Cite this as: BMJ 2008;337:a2098

Contributors: JMB contributed to the design of the intake questionnaireand the study design, reviewed the literature, analysed thedata, and led the writing of the paper. IMK designed the monitoringprogramme, contributed to the study design, and had a majorrole in writing the paper. CMacW administered the monitoringprogramme in later years, ensured accurate data collection andentry, and reviewed the paper. SH administered the monitoringprogramme early in the programme, ensured accurate data collectionand entry, and reviewed the paper. JMB and IMK are the guarantors.

Funding: This research was funded by the Ontario Physician HealthProgram. JMB was paid as a consultant to carry out data analysesand write the paper. The other authors are employees of theOntario Physician Health Program or the Ontario Medical Association,and their participation in the research was part of their employment.The research interpretation and outcomes are independent ofthe funding.

Competing interests: None declared.

Ethical approval: This study was a secondary analysis of ananonymous clinical database. It was approved by the Health SciencesResearch Ethics Board of the University of Toronto.

Provenance and peer review: Not commissioned; externally peerreviewed.

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