The following are comments written by Tom Horvath, Ph.D., and submitted to the SACC:
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The evaluation proposed here is a tall order. The “acceptable professional standards” are not well established. Determining threat may require someone with the same license as the person being evaluated. “Threat” as used here is an all-or-none term, but in reality it is not all-or-none. No guidance is offered about how much risk is acceptable. If no risk at all, is anyone fit to practice?
The first aspect of an evaluation is determining the history, which points to the diagnosis. The professional may not be forthcoming or accurate about history. Determining the diagnosis under these conditions is difficult. The evaluator is not a private investigator, but might need to be to get the information needed.
The second aspect of an evaluation, making a prognosis, is equally problematic in substance abuse, because substance abusing individuals can change dramatically, with or without treatment, if sufficiently motivated. Treatment facilities don’t emphasize this point because it is bad for business. However, the DSM-IV-TR mentions specifically (page 221) that 20% or more of individuals with alcohol dependence achieve long-term sobriety without treatment. In fact I believe they have underestimated this percentage.
Recommendations for treatment are very problematic, because there are so many options for treatment. Evaluating professionals may only be familiar with some forms of treatment. Forcing professionals into treatment that is not well suited for them can be harmful to the professional, and ultimately to the public. As I will argue shortly, requiring clean tests would be a much more sensible approach, vs. requiring treatment.
Evaluations of professionals have often been done by a multi-disciplinary team, and often take several days. However, the facilities that conduct these evaluations have almost always recommended 90 days of residential treatment in their own facility. Such a recommendation if often ridiculous and purely self-serving. In the DOT regulations evaluators (SAPs, Substance Abuse Professionals) may not treat those they evaluate. A similar safeguard would be essential here.
These standards place too much faith in expert opinion and not enough faith in evidence. When professionals have substance abuse problems, and pose a risk to the public, they should be immediately suspended from practice until they test clean for a sufficient period of time. The “sufficient period of time” could be suggested by expert opinion, and would vary according to the severity of the problem. Continuation in practice would be dependent on continued clean tests. A second serious offense would suggest license termination.
I am recommending that temporary removal from practice be the first response, along with immediate and continuous drug testing. Frequency of drug testing should be based on the substance involved, and the evolving technologies available for drug testing. The evaluation should make recommendations about how long the testing should occur, and treatments the impaired professional, at his or her discretion, might consider (i.e., the treatment is recommended, but not required). What the state needs to ascertain is clean tests, not treatment compliance. Otherwise you are forcing impaired professionals into treatment, which is often not very helpful, and at worst promotes the illusion you are doing something when you may not be. The something you need to be doing is assuring non-use, which can only be accomplished by drug testing.
Comments on Uniform Standards 3-6, submitted by Dr. Horvath, May 4, 2009
posted here:
https://www.dca.ca.gov/about_dca/sacc/index.shtml
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#3.
I recommend that a professional’s involvement with the licensing board or diversion program be quite public. The fact that a professional has fallen under suspicion of substance problems, and is now undergoing testing, should at least be known to employers. If the professional tests clean, the allegations should be easy enough to get beyond. We live in a country that asserts that someone is innocent until proven guilty. If the professional does not test clean, then further actions will be taken, and it will be clear to all that substance problems are dealt with quickly and effectively.
#4.
Many of these details about the mechanics of testing are fine. But the serious flaw here is random testing. Testing needs to be continuous. Two examples:
If alcohol is being tested for: an EtG test covers 80 hours. There are 168 hours in a week. Monday/Friday testing can cover 160 hours, M-W-F covers the entire week with overlap. EtG testing needs to take into account that very low scores/results may not be alcohol consumption, but incidental contact.
If stimulants are being tested for, they are usually testable for 2-3 days. M-W-F is appropriate.
Scheduled testing is actually easier than random testing on the individual being tested. It is a known event, and can be planned for. Random testing requires much oversight by a diversion program and drug testing facility, and is cumbersome for participants. It introduces much noise into a system that needs to be simple.
After a long period of continuous testing, there should be some method for applying for reduced testing frequency. When this application should be allowed (months, years?) would be a good question for expert opinion. Random testing may have a use at that time.
#5.
These groups, like treatment, should be optional. Facilitators should be licensed professionals.
#6.
If a professional is testing clean, why should treatment be required? The ultimate outcome of treatment, as far as a licensing board should be concerned, is testing clean. Someone might be declared a “dry drunk” but if the professional functions well professionally that issue is not the board’s business. If the licensee can provide this outcome without treatment, why require treatment? If the threat of loss of license is not going to get someone clean, how much more help will attending treatment add?
Comments by:
A. Tom Horvath, Ph.D., ABPP (Clinical), founded in 1985 La Jolla-based Practical Recovery (
practicalrecovery.com), which offers a
self-empowering alternative to traditional disease-model and/or 12-step
addiction treatment. He is author of
Sex, Drugs, Gambling & Chocolate: A Workbook for Overcoming Addictions (Impact, 2003, 2nd ed.), and was president (1995-2008) of SMART Recovery (
smartrecovery.org), a self-empowering addiction support group, past president (1990-1991) and fellow of the San Diego Psychological Association, and past president (1999-2000) of the American Psychological Association’s Division on Addictions (Div. 50), the world’s largest organization of addiction psychologists (
apa.org). He has appeared with ABC News, CNN, and Time, and presents internationally.
Addiction evaluation and treatment, further comments, Standards 1-4 (submitted May 28, 2009), Introduction
Dear Ms. Lancara,
I am submitting further comments, primarily addressed to Standards #1 and #4. Thank you for reviewing my initial comments. I am attempting here to clarify and amplify my initial suggestions.
First, my background:
A. Tom Horvath, Ph.D., ABPP (Clinical), founded in 1985 La Jolla-based Practical Recovery (
practicalrecovery.com), which offers a
self-empowering alternative to traditional disease-model and/or 12-step
addiction treatment. He is author of
Sex, Drugs, Gambling & Chocolate: A Workbook for Overcoming Addictions (Impact, 2003, 2nd ed.), and was president (1995-2008) of SMART Recovery (
smartrecovery.org), an international, self-empowering, science-based, addiction support group, past president (1990-1991) and fellow of the San Diego Psychological Association, and past president (1999-2000) of the American Psychological Association’s Division on Addictions (Div. 50), the world’s largest organization of addiction psychologists (apa.org). He has appeared with ABC News, CNN, and Time, and presents internationally.
Summary:
Diversion programs for substance-abusing licensees have unrealistically, unsuccessfully and inconsistently attempted to do too much. Ironically, what they should do best, ensuring abstinence from substance use, no program actually does. Instead, programs test “randomly” for relapse. This approach is not acceptable when public safety is at issue.
The most important standards for the SACC are Standard #1 (evaluator) and Standard #4 (Drug Testing). For a licensee who is permitted to practice, the diversion program should (1) require abstinence (through a contract in which the licensee agrees to surrender the license if the abstinence agreement is breached), (2) have a professional evaluator evaluate the history and extent of the problem, and recommend and monitor a course of continuous drug testing, (3) ensure that the licensee is properly, adequately, and continuously tested, and (4) promptly suspend the license of any licensee who breaches the abstinence agreement, or depending on circumstances, recommend terminating the license. There should be no period of time in which a licensee could use drugs/alcohol and be undetected. Continuous drug testing, initially, would typically mean a 10-panel urine screen at least three times per week, along with an EtG test for alcohol (using an appropriate cutoff score). That level of drug testing should continue for at least one month. After one month, it becomes feasible to consider hair testing, which still allows for continuous testing, but is less expensive and requires testing much less frequently. The disadvantage of hair testing is that the test results will not be available as promptly. Hair testing should only be used once a licensee is judged to be at lower relapse risk. In two scenarios described below, the total cost of continuous drug testing is $4,200 (for a six month testing program), and $28,010 (for a five year program).
For a licensee who elects to withdraw from practice, or who is serving out a suspension, drug testing need not occur during the period of non-practice. However, once the licensee informs the board/program that s/he intends to return to practice, a period of one month or more of continuous clean testing should be required before practice resumes.
The testing guidelines need to be written flexibly enough to allow the inclusion of new technology as it becomes available. Group sessions or treatment recommendations should not be part of a diversion program’s activities. Removing these activities substantially lowers the cost for individuals who are on diversion contracts.
For licenses who are allowed to practice and provide health care services, drug testing should be continuous. There should be no period of time in which a licensee could use drugs/alcohol, and have that use go undetected. A random testing schedule could allow undetected use, and therefore is not acceptable when public safety is at issue. The moment of transition from urine testing (which allows quicker discovery of problems) to hair testing (which allows delayed discovery of problems) can be decided by the professional evaluator.
If a licensee elects to withdraw from practice (on his/her own initiative, or after confrontation), but intends to return to practice, I suggest NOT requiring drug testing during that time period. Weeks to months might be spent away from practice (in treatment, camping in the woods, etc.). However, once the intention to return to practice is announced, then a period of one month or more of continuous clean testing should be required before practice resumes. Of course, if the licensee stays out of practice for a year, as I recall, other laws apply (you can’t maintain a license if you are not active in your field).
Addiction evaluation and treatment, further comments, Standards 1-4 (submitted May 28, 2009), The role of the professional addiction evaluation
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A professional evaluation is needed to answer: 1) which substances to monitor? 2) how long urine testing should continue? 3) how soon hair testing could begin? 4) whether hair testing should be augmented by additional urine testing? 5) how long testing should occur before a return to practice? and 6) how long testing should continue?
Comments on these questions:
1) Normally monitor all illicit drugs, any classes of prescription drugs abused by this individual, and alcohol, but there may be legitimate exceptions to this guideline
2) How long is quick discovery of paramount importance? Urine testing has quick turnaround, and if done continuously happens 3 times a week. Quick discovery is ofparamount importance early in a case, and after relapses.
3) There should be a period of overlap, with urine testing continuing until a clean hair test has occurred. Hair tests normally cover the previous 90 days.
4) With public safety at issue, it seems wise, for a period of time, to provide a backup testing method. If hair is the primary method, random urine testing might be the backup.
5) When a minor issue is suspected, an initial testing period of one to two weeks may be sufficient to allow return to work. If someone has elected to defer beginning testing, one month seems a minimum time. If there are relapses after the initial return to work, I suggest adding an additional month, such that after your first relapse you need to test clean for two months, after your 2nd relapse you need to test clean for 3 months, etc. However, the nature of the relapse is critical. Relapses not directly or substantially affecting patient care may be dealt with as described. Relapses affecting patient care might lead to license revocation.
6) In cases where there is doubt about whether any
substance use or abuse has even occurred, only six months of testing may be necessary. If there is no doubt that problems have occurred, and if they have been considerable, up to five years of testing would be appropriate. After five years there is still a risk of relapse, but that risk compares favorably with the risk of developing new problems in the population who has never had them.
I am someone who is consulted as an expert on
diversion cases. In my opinion the six questions above are the only legitimate use for expert opinion on these cases. The professional evaluator will of course conduct an entire diagnostic evaluation, but the outcome of the evaluation will be nothing but recommendations about the drug testing. As I view it, drug testing, and making decisions based on that testing, should be the only activities that a diversion program should engage in.
If professional evaluators are allowed more input than recommending drug testing, such as recommending treatment, you get the conflict of interest that exists now (which means you can’t trust the recommendations). The number of facilities that regularly treat licensed professionals is small. I am not suggesting that any illegal activity has occurred, but the quid pro quo relationships between referral sources and treatment facilities seem strong and cozy.
If diversion programs do more than requiring and monitoring drug testing, they start ignoring, as they have, the crucial information (is there abstinence?) that they need to stay exclusively focused on.
Addiction evaluation and treatment, further comments, Standards 1-4 (submitted May 28, 2009), The role of a diversion board
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“Recovery” is the business of the licensee. Abstinence is the business of the diversion board.
The standards on drug testing that are adopted by the SACC need to be flexible enough to allow for developments in testing technology. The SACC needs to become more familiar with hair testing and EtG, both in use now, as well as emerging technologies. I have listed a few websites below. The SACC will need the ongoing advice of drug testing experts who are not affiliated with any drug testing vendors. The standards need to be written with the following scenario as a future possibility: Imagine a device the size of a nickel. You tape it onto someone’s body (shoulder, back, etc.). It is tamper-evident. It provides a continuous monitoring of their substance use (with data sent by radio transmission). It needs to be changed every 30 days, when the individual also gets a back-up hair test. Such a device would instantly let you know if someone were using, and/or it would prove non-use. Would we use such a device, or still rely on professional evaluators? The course of action I am proposing–3 times a week drug testing, EtG testing, and/or hair testing—is almost as effective as the imaginary nickel.
EtG:
http://www.redwoodtoxicology.com/services/etg_testing.html
hair testing (this is the vendor I normally use in San Diego):
http://www.expertdrugtesting.com/content/category/4/19/40/
Drug testing prices at the above vendor:
10 Panel w/out Expanded Opiates: $55.00, EtG: $55.00, 10 Panel Hair: $260.00
drug testing generally:
http://en.wikipedia.org/wiki/Drug_test
one large vendor’s services:
https://www.labcorp.com/
The major expenses that healers currently face are the required group meetings, and especially, the required residential treatment. These activities should NOT be required. Someone with minor problems can make a quick transition to hair testing, which is relatively inexpensive because it can be done much less frequently.
The experts are likely to keep attempting to persuade the SACC that addiction is a disease, and that expert opinion is needed to identify it. As I have previously noted, the DSM-IV-TR nowhere states that addiction is a disease. Even if addiction is a disease, what more can we legitimately ask of someone but abstinence? If evidence of good professional practice is also required, there are ways to obtain this evidence. However, professional evaluators sitting in their own offices are not in position to obtain this evidence.
Addiction evaluation and treatment, further comments, Standards 1-4 (submitted May 28, 2009), Example: Dr. Wrong Place
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Dr. Wrong Place:
Upset neighbors call the police to a loud Saturday night party at a Malibu mansion. Arrests get made. Dr. WP happens to be there, along with lots of cocaine. Dr. WP asserts he did not know the coke was there. However, the media reports HE was there. Although he is not among the arrested, suspicions of his drug use naturally arise, and there is a media frenzy: Will the Medical Board will actually “do something?” Dr. WP consults with his attorney on Monday, and on Tuesday calls the diversion board requesting to be enrolled in the diversion program.
Dr. WP and his attorney reason as follows. They know that Dr. WP will not be at the mercy of the potentially arbitrary judgments of the professional evaluators affiliated with the diversion program. Rather, his innocence can be established by continuous drug testing. The diversion board’s credibility will clear his reputation—the issue he is most concerned about–better than any of his own assertions. To be safe, the attorney and Dr. WP decide on an additional action, which will be kept secret unless needed. Every time Dr. WP takes a drug test for diversion, he will go to another collection site and get a second observed test (“just in case diversion tries any funny business”). Although his drug testing cost (as estimated below), and time commitment, are doubled, the second test provides peace of mind for Dr. WP. Note that peace of mind is unlikely for anyone subject to the potentially arbitrary decisions of others, and that an un-peaceful mind is not conducive to recovery in the individuals who need to recover. Dr. WP now feels confident that his reputation will be based on his own behavior, as established by drug testing.
In accordance with the diversion program, Dr. WP begins drug testing (urine screening–the 10 panel test, and an EtG test) by close of business Tuesday, and commences a Mon-Wed-Fri testing schedule thereafter. He is also discontinues practice immediately, until a substance use evaluation is conducted. He stops all alcohol and other substance use, and reports any prescribed psychoactive medications to diversion. It is understood that his Tues and Wed EtG test scores may be positive (the EtG test looks back 80 hours, for alcohol), but this information will not be held against him.
Dr. WP, eager to get back to practice and to clear his name, sets up an evaluation for the following Monday, nine days after the Malibu party. He authorizes the drug testing facility to release his testing results to Dr. Evaluator.
Dr. Evaluator finds Dr. WP’s account of that Saturday evening plausible. Dr. WP reports smoking pot several times nearly two decades ago, but denies any drug use or excessive alcohol use since that time. To Dr. E, Dr. WP appears to be a moderate drinker and not a drug user. There are no signs of alcohol or other drug withdrawal.
Dr. Evaluator sees drug test results from Tues and Wednesday (negative), and EtG results from Tues (positive, as expected). Urine test results are often available in 1-2 days, EtG results can take several days. Dr. Evaluator recommends that, if all tests (except Wednesday’s EtG) are negative, by the following Monday Dr. WP may return to practice, so long as he continues testing as required. He is to return for a follow-up visit with Dr. Evaluator in one month.
During this month, Dr. WP tests Mon-Wed-Fri, both a 10 panel drug screen and the EtG.
At the one month follow-up visit, Dr. Evaluator recommends changing the drug testing, because all testing has been negative. For the next 6 months Dr. WP will obtain a once a month hair test, as well as being on twice a month random urine screening and EtG. Although the hair test looks back 90 days (for drugs), 90 days is too long for a problem to be undetected, so monthly testing is recommended. A hair test for alcohol is not used, because it is much less reliable for alcohol. Although the random EtG does not provide continuous monitoring of alcohol use, as there has been no indication of alcohol problems this level of testing is judged sufficient. In cases of higher suspicion of alcohol problems, 2-3 tests per week could be indicated.
At the six month follow-up visit, all tests have been negative. Dr. Evaluator recommends that all testing stop, and that the case be closed. Dr. WP places a copy of his final letter from diversion on his website, and issues a press release.
Cost summary: two weeks off work; evaluation $1,000+; drug testing, $4200
Cost breakdown:
One evaluation and two follow-up visits with Dr. Evaluator (varies by locality, probably $1,000 minimum)
First month: 12 10-panel tests and 12 EtG tests, 24 x $55 = $1320
Months 2-7: 6 hair tests, 12 10-panel tests and 12 EtG tests, 6 x 260 = $1560; $1320
Comment: I describe Dr. Wrong Place because I once worked with an out-of-state professional whose circumstances were quite similar to Dr. WP. My client never had a positive test, for YEARS. However, the expert determined that this individual had “addictive disease,” based on the history. The client refused to accept this determination, and was viewed as uncooperative, even though the client fully cooperated with drug testing (and paid for additional testing, at my suggestion, to show a continuous record of abstinence). This professional was harassed and essentially run out of practice by the diversion board.
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Addiction evaluation and treatment, further comments, Standards 1-4 (submitted May 28, 2009), Example: Dr. Serious Troubles
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Dr. Serious Troubles:
Dr. ST is an anesthesiologist. The discrepancies between the medication logs and actual inventory finally get traced to him, just after he leaves for a two week vacation in Mexico.
On the day he returns to work he is confronted by his employer. Dr. ST breaks down, confesses all, but begs for another chance. His employer points out that if he elects to enter diversion, there can be a second chance. Otherwise, the employer is obligated to turn over what he knows to enforcement. The employer and Dr. ST jointly call the diversion board. After a discussion of his options, Dr. ST elects to enter treatment, and to defer the beginning of drug testing. At a treatment center of his choice he completes a detox and 3 week residential treatment program. He elects to take off an additional month, and to begin outpatient psychotherapy.
Four weeks after Dr. ST returned from vacation, and right after the completion of his three week residential treatment program, he is seen by Dr. Evaluator. Dr. ST could have delayed the evaluation longer, but he is now feeling some financial pressure and would like to return to work soon.
Dr. Evaluator recommends one month of negative testing as the condition of returning to practice. Dr. ST will test Mon-Wed-Fri, 10 panel and EtG. Dr. Evaluator also emphasizes to Dr. ST that abstinence is not the same as recovery, and that even though Dr. ST will be allowed to return to work once he can document sufficient abstinence, recovery occurs over a much longer time-frame. Dr. ST is encouraged to continue in his psychotherapy.
At a follow-up visit in 5 weeks the results of the previous 4 weeks of testing are available to Dr. Evaluator. All tests have been negative. Dr. ST continues on the same testing schedule for the next 90 days. He is to be seen again in 90 days plus one week. Ninety days in a new environment would be the time period of highest risk of relapse, and therefore close monitoring, in support of public safety, is essential.
At the second follow-up visit Dr. ST’s tests continue to be negative. For the next year he is placed on monthly hair testing, and once a week random 10-panel and EtG.
At the third follow-up visit Dr. ST’s tests continue to be negative. For the next year he continues with monthly hair testing, and once a month random 10-panel and EtG.
At the fourth follow-up visit Dr. ST’s tests continue to be negative. For the next approximately 2 and ½ years he continues with monthly hair testing and EtG.
Five years from the date Dr. ST was originally ordered to stop working he is released from the diversion program, if all testing has been negative.
Cost summary: eight weeks off work (but could have been only four); evaluation $1,500+; drug testing, $28,010
Cost breakdown:
One evaluation and four follow-up visits with Dr. Evaluator (varies by locality, probably $1,500 minimum)
First month: 12 10-panel tests, 12 EtG tests; 24 x $55 = $1320
Next 90 days: 36 10-panel tests, 36 EtG tests; 72 x $55 = $3960
Next year: 12 hair tests, 52 10-panel, 52 EtG tests; 12 x $260 = $3120; 104 x $55 = $5720
Next year: 12 hair tests, 12 10-panel, 12 EtG tests; $3120; $1320
Final 2.5 years approx: 30 hair tests, 30 EtG tests; 30 x $260 = $7800; 30 x $55 = $1650
Comment: Testing in this scenario is extensive for the first two years, partly because anesthesiologists are a high risk group. Some professionals are even suggesting anesthesiologists should not be allowed to return to anesthesiology if they develop addiction problems. The testing scheme suggested here allows those who can succeed to succeed, and allows for rapid detection of the rest, all based on solid evidence, not on the fallible opinions of professional evaluators. Although the costs in this case are substantial, they remain much less expensive than 90 days of residential treatment (at $20K per month or more), and months to years off work, which would almost certainly have been recommended for a case like this some diversion programs. I once worked with an out-of-state professional who was not allowed to return to work for 5 years. That individual would have gladly paid the fees listed above to return to work.
