Treatment of the Addicted Dentist

Treatment of the Addicted Dentist Omar S. Manejwala, M.D. William J. Farley Center www.farleycenter.com Overview • • • • • • **Context The Addicted Dentist Interventions for Dentists The Residential Treatment Model Continuing care and return to work Relapse and Recovery 2 Context • Financial pressures, Decrease in public opinion Being looked on as perfect, Dentists attempt to assume that role – – – – Problems with family life, the Dental marriage Dentists are comforted by staff, patients effusive praise Addiction is ignored or enabled Conspiracy of silence • Excusing missed appointments, even steadying dentists hands! • Chemical dependency is the same disease among dentists and non-dentists, but because of specific barriers, certain modifications to intervention, treatment and aftercare are needed in this population. 3 Dentistry is Difficult • • • Jerry Gropper: “Eye of a sculptor, hands of a surgeon, tact of a diplomat, insight of a therapist, knowledge of a scientist and financial acumen of a businessman” Demanding profession, high standards, externalized locus of esteem are a setup for “failure” and shame. 4 Dentist tendencies • • • • • • Perfectionism and compulsivity Limited capacity for self-observation Use profession as a defense against feelings Self prescription which begins innocently can progress to dependence Fears about loss of licensure and loss of livelihood often cause office staff, hygienists and even peers to protect the secret Therefore, disease tends to be further progressed at the time of intervention 5 Additional Relevant Observations… • • • • • • Dentists often work in isolation, even when in group practices. Boundaries can be relaxed, especially in smaller communities. Boundary education is lacking. Affairs with office staff or patients can occur Mechanical work can defocus from emotional/interpersonal interactions Male dentists often surrounded by female receptionists, dental hygienists and dental assistants Staff livelihoods depend on continued success of the dentist, so enabling is common 6 Additional Relevant Observations… • • Physical aspects of work may result in dentists having pain issues that complicate treatment and recovery (frequently back pain) Social phobia, social anxiety, cluster A and C traits may have biased career selection – Obsessive compulsive, perfectionist and/or isolation-driving personality traits 7 Additional relevant factors • • • • • Patient anxiety and fear drives dentists behavior Dentists often incorporate the patients pain into their own visceral experience (McIlhiney 2006) Holding breath when giving inferior alveolar or palatal injections…a set up for anxiety Drive for perfection, often instilled in dental school, makes dentists less able to accept adequacy and humanity. Failure/rejection ensue. Exposure to Nitrous Oxide in dental school 8 Impact on the Dental Office Family Nancy Williams R.D.H., EdD. 2006 • “We should be come better employees since we caused his problem” – Healthy employees resigned – Others stay to “fix” the dentist – As a result, illness-density increases – “If we didn’t _______, he wouldn’t drink so much and would be nicer to us” – Most practices where these issues are addressed take 2-3 years to recover 9 Prevalence • • • Lifetime prevalence for alcoholism in dentists is probably comparable to general population. Lifetime prevalence for addiction is also probably comparable Dentists are at increased risk for dependence on pharmaceuticals and decreased risk for addiction to illicit drugs. 10 Overview • • • • • • Context **The Addicted Dentist Interventions for Dentists The Residential Treatment Model Continuing care and return to work Relapse and Recovery 11 The Addicted Dentist • • • • Typically, the dentists office is the last place that the symptoms of addiction appear Dentists are taught that the workplace is sacred Disruptions in family, personal health, community, social, spiritual and leisure life can all occur while workplace remains relatively undisturbed Even very small intrusions of addiction into the dental office should be taken extremely seriously in dentists 12 Progression of Injury • • • • • • • Family Community Finances Spiritual and emotional health Physical Health Job Performance Gallegos et al 1988 13 Alcohol dependence • • • • • • Odor on the breath Late arrival at the office Calling in sick on Monday or Friday Tremors, diaphoresis, pallor Deterioration of charting, handwriting Episodes of intoxication in social settings 14 Self-Prescribing • • • • • • Writing prescriptions for self, family members Requesting prescriptions from colleagues Requesting that patients bring in unused medications Increased number of Nitrous cylinders per month Intimate relationship with pharmaceutical representatives Using sample drugs, especially unscheduled “non-addictive” medications – Ultram , Provigil, Ambien, Sonata, Lunesta 15 • • • Q: How safe is nitrous oxide/oxygen? A: Very safe. Nitrous oxide/oxygen is perhaps the safest sedative in dentistry. It is nonaddictive. It is mild, easily taken, then quickly eliminated by the body. Your child remains fully conscious, keeps all natural reflexes, when breathing nitrous oxide/oxygen. www.aapd.com downloaded on 8/15/07 16 Signs and Symptoms • • • • • • • • • • • • Initially: Chaotic personal and professional lifestyle Poorly explained accidents and injuries Family and marital discord Long sleeves and tinted glasses Deterioration in appearance Significant weight change Irritability or hostility when confronted Increased use of cologne, perfume, breath fresheners Resumption of tobacco use Spending sprees, gambling, risky investments Increasing medical problems and symptoms requiring medication • • • • • • • • • Later: Deterioration in handwriting and quality of record-keeping Failure to adhere to schedule – Late mornings Failure to make appropriate referrals or to request consultation when appropriate Altercations with patients, peers or office staff Poorly explained complications and misdiagnosis Change in prescribing habits Inappropriate and inconsistent telephone interactions Change in type of controlled substances kept in the office or requested from drug reps 17 Dentists • • • Are placed in a superior position in their practice; being constantly in this role can limit their ability to see their own vulnerabilities Are in a position to access reinforcing agents Work unsupervised 18 The only pathognomonic sign is witnessed selfadministration of drugs. There is NO explanation for that activity other than one requiring evaluation 19 Look for withdrawal! • Signs and Sx of withdrawal – Diaphoresis – Tremor – Mydriasis – Rhinorrhea – Myalgias – Nausea – Vomiting 20 Overview • • • • • • Context The Addicted Dentist **Interventions for Dentists The Residential Treatment Model Continuing care and return to work Relapse and Recovery 21 Prior to intervention… • • • • • • MAINTAIN CONFIDENTIALITY Information gathering Document facts and behavior Confirm identified signs; don’t rely on rumor Have compelling evidence sufficient to report to disciplinary authority if individual refuses treatment Contact wellness committee for guidance 22 Intervention • • • • You are not making a diagnosis. That’s my job. You are referring the person for a medical evaluation. Requires careful preparation Transportation, escort and intake appointment must be lined up and ready to go. Should be done as soon as possible after evidence of diversion identified 23 Intervention cont’d • • • • • The GOAL is to obtain a multidisciplinary evaluation by a team of experts who specialize in evaluation of impaired dentists The intervention is advocacy oriented Don’t deviate from prior decisions or negotiate Resort to threat of license discipline IF necessary Expect hostility, threat of lawsuit and denial – Infrequent but possible 24 Intervention cont’d • • Present evidence; facts not opinions or judgment DO NOT LEAVE THE PERSON ALONE – Suicide risk • Expect hostility, threat of lawsuit and denial – Infrequent but possible 25 Reporting… • • Admission to evaluation or treatment is not reportable if it can be a medical leave of absence National Practitioner Databank reporting required for hospitals/health care entities, state boards, professional societies, malpractice payers – If adverse actions taken by medical societies, licensure boards or hospital boards – Medical malpractice payments – Adverse clinical privileging actions – Exclusions from medicare/medicaid 26 The Multidisciplinary Evaluation • • • • • Highly specialized topic Involves addiction psychiatrist, psychological evaluation, neuropsychiatric testing, addiction medicine evaluation, family assessment, collateral interviews Takes several days to complete Can be conducted on an ambulatory or residential basis as needed Goal is to identify diagnosis and recommend appropriate treatment 27 Overview • • • • • • Context The Addicted Dentist Interventions for Dentists **The Residential Treatment Model Continuing care and return to work Relapse and Recovery 28 Risks inherent in lower levels of tx • • • • • • • May in some cases be acceptable… State specific, culture of dental boards Tendency to treat relapse punitively Dentists are highly skilled at seeming well and minimizing or suppressing evidence of living environment deficiency and psychosocial stressors Spouse, coworker may paint rosy picture to avoid work interruption (enabling) Lower levels of treatment may have reduced peer density May result in career annihilation 29 Some factors that may support attempts at lower levels of care • • • • • • • • • • • Availability of high quality, peer-based ambulatory programs Family system healthy and supportive of recovery Period of abstinence prior to treatment entry Absence of psychiatric co-morbidity or character pathology Absence of other risk factors (e.g. pain syndromes) Cognitive function intact Board culture tolerant of relapse Support by CDP for this approach Lack of resources (although this approach may render the dentist out of work longer) Above determined by multidisciplinary evaluation. If ambulatory treatment is being considered, sometimes a residential evaluation is best suited to determining this 30 Modified Residential Treatment • Goals of Treatment – – – – – Safe medical withdrawal “Detox” Development of abstinence-based lifestyle Nurture identity apart from dentistry Exposure to and assimilation into 12-step programs Developing and practicing recovery skill set under stressful and unpredictable circumstances – Identify and address relapse warning signs – Internalize need for surrogate decision making across psychosocial domains 31 Modified Residential Treatment • • • 12-step approaches must be integrated into each component High frequency physician visits during treatment Effective treatment programs are multidisciplinary – – – – – – – – – – – – Addiction medicine specialist Addiction psychiatrist Family Therapist / Family Program Modalities that reduce impact of intellectualization (esp. Art Therapy) Psychologists Primary Care Physicians Clergy Social Workers Individual and group counselors Nutritionists Grief counselors Others (e.g. pain specialist, accupuncture, etc) 32 Modified Residential Treatment • • • • Phased treatment approaches with a high degree of peer exposure are the most successful Residential --> Supervised Living + Partial Hospitalization --> Outpatient treatment Aftercare and monitoring are crucial to successful outcomes Success rates are disputed, but most agree that outcomes are far in excess of nonprofessional treatment. 33 Modified 12-step facilitation • • • Therapy group with high peer density allows exploration of resistance to 12-step approaches Misunderstanding and incorrect assumptions about AA/NA are some of the common drivers of treatment failure Requires highly skilled therapists who can detect AND address “model student” profiles, superficial adherence, covert acting out, intriguing etc. 34 Dual Diagnosis Hygiene • Given prevalence of dual diagnosis, effective treatment for dentists must include: – Educating patients on how, whether and when to discuss their psychiatric treatment – How to address resistance in 12-step community to management of comorbidities – Treatment must address the difference between terminal uniqueness and actual heterogeneities 35 Therapeutic Visits • • • • • • Critical aspect of treatment Allow recovering dentist to face community re-entry in a structured, supported, time-limited fashion Typically involves family interaction, 12-step meeting attendance May involve meeting with wellness committee Sometimes involve monitored naltrexone/ antabuse Visit home is then processed with peer group, physician and therapist 36 Overview • • • • • • Context The Addicted Dentist Interventions for Dentists The Residential Treatment Model **Continuing care and return to work Relapse and Recovery 37 Dentists • • • Return to work recommendations for dentists should include establishment and monitoring of an intoxicant-free workplace Addiction to drugs not typically used in dentistry also occurs, and can attenuate risk of return to work N20 addiction has a special set of issues – Tendency by so many to view this as innocuous – Relapse on nitrous even when not drug of choice • • Staff should be supportive of a return to work Locums work not a good idea 38 Return to Work • Highly complex topic requiring intense, comprehensive multidisciplinary assessment with particular attention to addiction, psychosocial and environmental variables 39 Factors that support return – Internalization of disease concept – 12-step immersion successful – Open family communication, good family relations – Family supports RTW – Committed to recovery and monitoring contract – Accepts pharmacotherapy if indicated – Balanced lifestyle with inter-domain transparency – No major psychopathology – Affective or anxiety disorder controlled – Good treatment experience 40 – Treatment team supports RTW Factors that increase risk – – – – – – – – Relapse has occurred after adequate treatment Multiple substance dependence Use of parental agents (including inhaled agents) Barriers to 12-step involvement Inability to tolerate cognitive dissonance Superficial engagement, alexithymia etc Failure to establish identity apart from professional Continues to interpret intermittent use etc as maintenance of control – Psychiatric illness, affective lability, social phobia etc – Still struggling with acceptance of need for surrogate 41 decision making Significant Risk – – – – – – – – – – – Multiple substance dependence Multiple relapses Evades monitoring detection for long periods Severe psychopathology Fundamental opposition to recovery principles Unhealthy work environment or coworkers don’t support return Treatment characterized by unyielding pattern of failed rule adherence or failure to peer-bond Poor bonding in 12-step program Severe family dysfunction, intoxicants in home Limited psychosocial support 42 Lack of identity apart from professional Successful returns demonstrate: • • • • Completion of an effective, structured treatment program that involves family and significant others Well motivated, honest, no denial, excellent recovery program Returning to a supportive work environment An RTW agreement that has been implemented prior to starting work 43 Typical re-entry agreements… • • • • • • • • • 5 year monitoring period and commitment to total abstinence from intoxicants Contract includes the addicted dentist, and the dental well-being committee Monitored naltrexone or antabuse may be appropriate in some cases Required treatment for comorbidities Random, monitored assays for use of intoxicants Weekly aftercare groups 12-step attendance 3-4x/week Regular interaction with a peer monitor and Dental Wellbeing Committee A single PCP who prescribes all medications 44 Typical features of return to work agreement cont’d • • • Limited work hours initially – May involve time-off period first No handling intoxicants until cleared Workplace monitor* 45 Overview • • • • • • Context The Addicted Dentist Interventions for Dentists The Residential Treatment Model Continuing care and return to work **Relapse and Recovery 46 Relapse • • • • • Fundamentally different from treatment failure Requires a period of recovery Approach to treatment must be specialized Identifying relapse risk factors, personal relapse dynamic and addressing/practicing interventions at various points along the relapse process Specialized relapse groups work best 47 Relapse cont’d • • • • • • Risk for relapse is greatest in the first 2 years of recovery Denial, which is a lack of acceptance of the disease on a personal and emotional level (rather than simply a cognitive level) is a risk factor Highly insidious disease symptom which can seduce the addict into believing that the facts and experiences of their prior state no longer apply to them Dentists are particularly at risk of believing that selfknowledge will attenuate their risk of relapse, leading to a dangerous overconfidence Terminal uniqueness as a cognitive distortion Resignation may point to psychiatric comorbidity 48 Relapse risk factors cont’d • • • • • • Poor family dynamics Dishonesty Cross-addiction Stress Isolation Other addictive behaviors – Gambling, sexual compulsivity, overeating, over exercising as substitution behaviors increase risk of relapse 49 Relapse protective factors • • • • • Knowledge and acceptance at a personal and emotional level of the disease One day at a time attitude Involvement (rather than simply attendance) in 12-step programs and having a “Strong” sponsor Ongoing development of personal, spiritual and non-chemical coping skills Network of supportive relationships in a variety of domains (family, work, recovery) 50 51