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Detection of Alcohol Use in Monitored Aftercare Programs: A National Survey of State Physician Health Programs
Abstract
Monitored aftercare of health care professionals with documented substance abuse problems is organized differently by individual states and state licensing boards. A comparison of the physicians’ health aftercare programs used by each state could yield useful information regarding more effective methods of aftercare monitoring.
A 36-question phone interview was conducted with directors of physician monitoring aftercare programs in 46 states regarding their current methods of drug testing. Results indicate that surreptitious alcohol use is a significant concern for all monitoring aftercare programs, yet there is no clear indication of the best methods for detecting alcohol use. Few state programs are utilizing a new, specific test for the presence of ethyl glucuronide (EtG), a minor metabolite of alcohol metabolism (see related article on page 14). In addition, wide variation exists between state programs and there is no clear consensus or standards with regard to testing frequencies, methods of randomization and specific tests for alcohol.
Suggested future improvements in the testing and monitoring of health care providers enrolled in aftercare programs may enhance detection of relapse so that all aftercare programs can help assure the abstinence of their health care professionals in recovery as well as protect public safety.
... Most programs reported always testing for the client's drug of choice, but a few did not. 18 "We thought some of the states really did not test frequently enough, nor did they test for a wide enough range of drugs for the population they were monitoring," says Sucher, one of the study's coauthors. The problem with infrequent testing is that drugs vary in how long they can be detected after ingestion. ...
Tremendous strides have been made in the identification, treatment and monitoring of physicians who abuse alcohol or other drugs. Nevertheless, balancing the desire to help such physicians against the need to protect the public remains a perennial challenge for medical boards. This article offers suggestions for medical boards on establishing a positive working relationship with their state physician health programs (PHPs). Boards and PHPs have distinct yet complementary missions, and the facilitation of trust and communication between these two entities is critical. The article also reviews current trends in treatment and aftercare, including more individualized treatment planning and more extensive and sophisticated drug testing.
... Fifteen directors considered EtG testing to be an important means for this improvement. 12 The results of the current study support this recommendation. Limitations to the current study include the fact that all subjects were notified of the additional EtG alcohol test and the testing period was limited to two months. ...
Aftercare monitoring programs for health care professionals with documented substance abuse problems are managed differently by various states and their respective licensing boards. Many programs have reported surreptitious alcohol use as a significant concern, yet there is no clear indication of the best methods for detecting alcohol use since the detection of ethanol is difficult due to its limited half-life in saliva, urine and serum. Ethyl glucuronide (EtG), a minor metabolite of alcohol metabolism, is only present in urine when alcohol has been consumed. EtG testing may therefore improve the detection of alcohol use by health care professionals in monitored aftercare programs.
This study compared urine ethanol (Medpro B panel) and urine EtG in specimens from 126 clients enrolled in Arizona’s physician health aftercare monitoring program. Each client was tested twice per month for a two-month period in 2004. Of the 504 tests, there were no positive urine ethanol results using a standard, lab determined minimum cutoff level of 20mg/dL. There were four positive EtG results (one percent positive rate) using a minimum cutoff level of 100ng/mL. The four positive EtG results imply the presence of four false negative urine ethanol results. Therefore, the results suggest that the EtG test is more sensitive for alcohol detection and should be considered for future improvements in the testing and monitoring of health care providers enrolled in aftercare programs.
... For example, physician health programs currently monitor abstinence in over 9,000 physicians who have been identified as having alcohol problems (Skipper et al., 2004). A recent survey of physician health programs in 46 states found that many use traditional and new alcohol biomarkers to monitor abstinence (Jansen et al., 2004). Determining whether program participants have relapsed to drinking is a special concern for such programs, given the public service performed by these professionals. ...
During the past decade, advances have been made in the identification, development, and application of alcohol biomarkers. This is important because of the unique functions that alcohol biomarkers can serve in various applied settings. To carry out these functions, biomarkers must display several features including validity, reliability, adequacy of temporal window of assessment, reasonable cost, and transportability. During the past two decades, several traditional alcohol biomarkers have been studied in multiple human studies. Meanwhile, several new, promising biomarkers, including various alcohol metabolites and alcohol biosensors, are being explored in human studies. In addition, researchers have explored using biomarkers in combination and using biomarkers in combination with self-reports, resulting in increased sensitivity with little sacrifice in specificity. Despite these advances, more research is needed to validate biomarkers, especially the new ones, in humans. Moreover, recent advances in high-throughput technologies for genomics, proteomics, and metabolomics offer unique opportunities to discover novel biomarkers, while additional research is needed to perfect newly developed alcohol sensors. Development of more accurate biomarkers will help practicing clinicians to more effectively screen and monitor individuals who suffer from alcohol use disorders.
The practice of medicine is stressful and demanding and does not exclude physicians from having to cope with the usual stressors of life outside of medicine. Medicine’s current practice environment, dwindling resources, diminished compensation, litigious practice climate, and increasing limits on physician autonomy have led to increased stress, decreased professional satisfaction and in some, disruptive behavior. Doctors are vulnerable to the same diseases, imperfections and flaws as everyone else. External demands and pressures combined with internalized high expectations have made today’s physicians especially susceptible to burnout, depression, anxiety, fatigue, cardiovascular disease, substance abuse and dependence, disability, fractured interpersonal relationships and suicide. The self-policing nature of the medical profession requires that all physicians are ethically obligated to report an impaired physician. The creation of Physicians’ Health Programs (PHPs) in all 50 states is a confidential resource for physicians to self-refer or for colleagues or healthcare facilities to refer one about whom they have concern.
Dr. L is a senior partner in a large practice associated with an academic center and a professor of dermatology at the local medical school. Though not currently chair of the department, he has served in that role in the past. At a recent Christmas celebration for the department, he was observed to drink heavily throughout the evening. As the evening wore on, he became louder, more belligerent and began to slur his words. He was somewhat incoherent when he tried to provide a toast to the assembled group. Later, he drove himself home in his car. No one at the event confronted him or attempted to keep him from getting into his car at the end of the evening. A few days later, one of his partners tried to broach the evening’s events with Dr. L, saying that he was concerned about him. Dr. L became angry and defensive. He could not remember all the details of his behavior at the dinner, but was aware that he had “probably had a little too much” and “may have said some inopportune things.” He insisted he had just “had a good time like everyone else.” Nevertheless, he reluctantly agreed to apologize to some of his colleagues. When approached by Dr. L, they each quickly “let him off the hook,” laughing with him and dismissing his behavior as just “blowing off some steam.”
Ethylglucuronid hat sich in der forensischen Diagnostik aufgrund seiner hohen Spezifität für vorangegangenen Alkoholkonsum und seinem Nachweisfenster in Urin von bis zu fünf Tagen als Alkoholkonsummarker etabliert. Im ersten Teil dieser Arbeit wurden Proben von zwölf Leichen bei Obduktionen entnommen und mit LC-MS/MS auf EtG analysiert. Bei neun Leichen konnte EtG nachgewiesen werden, die entsprechenden Blutalkoholkonzentrationen betrugen 0,4 bis 3,7 ‰. In drei Fällen wurde kein EtG nachgewiesen, zwei von diesen hatten positive BAK von 1,0 ‰ bzw. 0,1 ‰, die vermutlich postmortal durch Bildung von Fäulnis-Alkohol zustande gekommen waren. Im Knochenmark aus postmortal entnommenen Rippen wurden EtG-Konzentrationen von 0,77 bis 9,36 µg/g gemessen. Damit waren EtG-Konzentrationen hier in allen Fällen niedriger als in der Galle (1,1 - 42,31 µg/mL), in acht von neun Fällen niedriger als im Blut (2,24 - 20,46 µg/mL) und vergleichbar oder höher als in Muskel-Proben. Die höchsten EtG-Konzentrationen wurden in acht Fällen im Urin gefunden (14,89 - 508,7 µg/mL). In einem Fall, in dem die Ethanolresorption noch nicht abgeschlossen war, besaß die Leber eine höhere EtG-Konzentration; im Lebergewebe wurden in allen anderen Fällen die zweithöchsten EtG-Konzentrationen (6,68 bis 76,73 µg/g) nach Urin gefunden. Im zweiten Teil der Arbeit wurde die Stabilität von EtG in postmortalen Proben sowie im Urin von gesunden Probanden untersucht. In den post-mortem-Proben (Leber, Muskulatur, Blut) wurde über vier Wochen Lagerung bei Raumtemperatur (RT, 20 - 27 °C) - weder nach Zugabe von 1 ‰ Ethanol noch ohne Ethanolzugabe - eine Neubildung von EtG beobachtet. Bei EtG-positiven Gewebeproben konnte nach vier Wochen Lagerung im Schnitt noch etwa ¾ des EtG zu t0 nachgewiesen werden. Im Urin kam es weder bei Kühlschrank-Lagerung (4 °C) noch bei RT über zwei Monate zu einer Neubildung von EtG. In den EtG-positiven Proben war die Substanz über die gesamte Versuchsdauer stabil. In der praktischen Anwendung kann die Bestimmung von EtG z.B. zu einer Abgrenzung von getrunkenem Alkohol zu Fäulnisalkohol dienen. Bei langen Leichenliegezeiten kann auch Knochenmark zum Nachweis von EtG eingesetzt werden. Die in Knochenmark gemessenen Konzentrationen waren geringer als in Urin, Leber oder Blut, aber mit LC-MS/MS noch gut detektierbar. EtG ist sowohl in Urin als auch in postmortalen Geweben und Blut auch bei RT länger als einen Monat nachweisbar. Ethyl glucuronide (EtG) has shown to be a reliable marker for alcohol consumption. In these studies postmortem tissue samples and body fluids have been analysed to assess EtG concentrations and the stability of EtG in urine samples has been examined. Postmortem EtG concentrations in rib bone marrow, liver, muscle, fat tissue, urine, blood and bile have been determined by LC–MS/MS. Samples have been taken from twelve corpses during autopsies. In nine corpses EtG could be detected, corresponding blood ethanol concentrations (BAC) were 0.04–0.37 g%. In three cases, no EtG has been found; two of these cases showed postmortem BACs – possibly due to putrefaction – of 0.01 and 0.1 g%. In rib bone marrow, which is easily accessible during autopsy, EtG concentrations (0.77–9.36 µg/g) have been lower than in blood (2.24–20.46 µg/mL) in eight of nine cases and comparable or higher than in muscle tissue. Therefore, rib bone marrow has been found suitable as matrix for EtG determination. The highest EtG concentrations have been found in urine in all but one case, where the resorption of ethanol had been incomplete. Second highest EtG concentrations have been detected in liver samples. In two cases with putrefaction, EtG could not be detected. In these cases, the detectable ethanol might have been produced partially or in total by postmortem fermentation. The stability of ethyl glucuronide under conditions of degradation has been examined in urine samples of nine volunteers and in postmortem tissue (liver, skeletal muscle) and blood taken from seven corpses at autopsies. Analysis has been performed by LC-MS/MS. EtG concentrations in urine samples ranged from 2.5 to 296.5 µg/mL. When stored at 4 °C in air tight test tubes EtG concentrations remained relatively constant; when stored at room temperature for 5 weeks in ventilated vials, variations of EtG concentrations ranged from a 30 % decrease to an 80 % increase, with an average of 37.5 % increase. Liver and skeletal muscle tissue of three corpses with positive blood alcohol concentrations (BAC, ranging from 0.106 to 0.183 g%) were stored for 4 weeks and analysed periodically. EtG concentrations decreased 27.7 % on average in 4 weeks storage at room temperature but EtG still was detectable in all samples with initial EtG concentrations higher than 1 µg/g. Blood and liver samples of four corpses with negative BACs were been stored at room temperature after addition of 0.1 g% of ethanol and no new formation of EtG has been observed.
We compared the characteristics and treatment outcomes of substance-impaired physicians monitored by two different programs in Oregon: a probationary program administered by the Oregon Board of Medical Examiners and the confidential, voluntary Diversion Program for Health Professionals. Demographic, substance use, and treatment outcome variables were obtained by a retrospective medical record review from 41 physicians monitored by the Oregon board and 56 physicians monitored by the diversion program during a 3-year study period. Compared with physicians monitored by the Oregon board, physicians in the diversion program were younger, more likely to be in training programs and less likely to be in hospital-based practice settings, more often reported by immediate rather than third-party contacts, more likely to choose in-state inpatient treatment than out-of-state treatment, and less likely to have concurrent mental illness diagnoses (P < .05 for all comparisons). Short-term relapse rates did not differ statistically between the groups (22.0% for the Oregon board group, 14.3% for the diversion program group). The higher number of younger physicians and physicians in training and tendency toward increased reporting by immediate contacts in the diversion program suggested earlier intervention than in the Oregon board group.
Of 40 participants of a two-year program for rehabilitating alcohol- and other-drug-dependent physicians, 15 have completed 24 months of treatment and monitoring, eight have completed 12 to 23 months, ten have completed one to 11 months, and seven discontinued treatment before completion. Of the 33 treated physicians, 31 have returned to full practice and 22 have experienced no relapse. The prognosis is quite favorable for most impaired physicians if appropriate treatment, monitoring, and follow-up are provided.
(JAMA 1982;247:2253-2257)
Ethyl glucuronide (EtG) is considered to be a promising candidate marker of alcohol consumption, but exhibits a short window of detection in blood or urine. Keratinized tissues are known to retain foreign substances and to provide a greater retr ospective window of detection than body fluids. Therefore, post-mortem hair, skin swabs, and stratum corneum samples were collected from four subjects with a reported history of alcohol misuse and from seven subjects with a report of regular, socially accepted drinking behav- iour, and were investigated for EtG. Additionally, certain specimens were collected from three children, who had not yet consum ed any alcoholic beverages. EtG was detectable in most of the hair and stratum corneum samples as well as in perspiration stains from alcohol- consuming subjects. The results indicated that EtG might be formed locally in very small and highly variable amounts. The most important finding was that EtG cannot be expected to be generally detectable in keratinized tissues or perspiration stains from alcohol- drinking subjects, whereas a positive result is always associated with recent alcohol consumption.
Substance abuse continues to increase and permeate all sectors of US society including the medical profession. This article details the importance of testing everyone associated with health care organizations, including physicians, as a means of protecting patient welfare, increasing quality of care, and reducing negligence lawsuits, as well as providing treatment and recovery opportunities for those with addictions.
Nine states have legislated impaired physician programs administered by state medical boards (2), by independent agencies (4), or by medical societies through contracts with medical boards (3). All other state programs are administered by medical societies. California's diversion program has been in effect for more than 10 years. It was the first program for alcohol- and drug-addicted physicians in the country administered by the state agency that also disciplines physicians. Of the physicians who enrolled in this program, 72% have completed it successfully. A total of 618 physicians have been accepted into the program since its inception, with 247 physicians currently participating.
Of 40 participants of a two-year program for rehabilitating alcohol- and other-drug-dependent physicians, 15 have completed 24 months of treatment and monitoring, eight have completed 12 to 23 months, ten have completed one to 11 months, and seven discontinued treatment before completion. Of the 33 treated physicians, 31 have returned to full practice and 22 have experienced no relapse. The prognosis is quite favorable for most impaired physicians in appropriate treatment, monitoring, and follow-up are provided.
Ethyl glucuronide (EtG) is considered to be a promising candidate marker of alcohol consumption, but exhibits a short window of detection in blood or urine. Keratinized tissues are known to retain foreign substances and to provide a greater retrospective window of detection than body fluids. Therefore, post-mortem hair, skin swabs, and stratum corneum samples were collected from four subjects with a reported history of alcohol misuse and from seven subjects with a report of regular, socially accepted drinking behaviour, and were investigated for EtG. Additionally, certain specimens were collected from three children, who had not yet consumed any alcoholic beverages. EtG was detectable in most of the hair and stratum corneum samples as well as in perspiration stains from alcohol-consuming subjects. The results indicated that EtG might be formed locally in very small and highly variable amounts. The most important finding was that EtG cannot be expected to be generally detectable in keratinized tissues or perspiration stains from alcohol-drinking subjects, whereas a positive result is always associated with recent alcohol consumption.
An impaired physician is one unable to fulfill professional or personal responsibilities because of psychiatric illness, alcoholism, or drug dependency. Current estimates are that approximately 15% of physicians will be impaired at some point in their careers. Although physicians may not have higher rates of impairment compared with other professionals, factors in their background, personality, and training may contribute and predispose them to drug abuse and mental illness, particularly depression. Many physicians possess a strong drive for achievement, exceptional conscientiousness, and an ability to deny personal problems. These attributes are advantageous for "success" in medicine; ironically, however, they may also predispose to impairment. Identifying impairment is often difficult because the manifestations are varied and physicians will typically suppress and deny any suggestion of a problem. Identification is essential because patient well-being may be at stake, and untreated impairment may result in loss of license, health problems, and even death. Fortunately, once identified and treated, physicians often do better in recovery than others and typically can return to a productive career and a satisfying personal and family life.
Ethyl glucuronide is a minor metabolite of ethanol, and its presence in urine can be used as a laboratory test to detect recent alcohol intake, even for some time after the ethanol is no longer measurable. A simple analytical procedure was developed based on direct injection of urine diluted with a deuterated internal standard into an electrospray liquid chromatographic-mass spectrometric (LC-MS) system. A novel LC system using a porous graphite column (Hypercarb) enabled an isocratic elution with retention times of 5-6 minutes. The intra- and inter-assay coefficients of variation were 2-12%, and the measuring range was 0.1-1,500 mg/L (0.45-6,750 micromol/L). Ethyl glucuronide was found to be stable in urine for more than 4 days at room temperature, and no artifactual formation was observed on storage of urine samples fortified with 1% ethanol. Ethyl glucuronide was not detected in urine samples collected after abstinence from alcohol. Intake of a very low amount (7 g) of ethanol produced ethyl glucuronide values up to 8.4 mg/L after 4 hours and was still detectable at 6 hours. When the method was applied for routine screening of 252 clinical urine samples (range, 0-1,240 mg/L), it fulfilled the need for a simple and reliable assay to be used in the evaluation of urinary ethyl glucuronide as a routine test of recent alcohol intake.
Background:
Considerable lives and money could be saved if one could detect early stages of lapsing/relapsing behavior in addicted persons (e.g., in safety-sensitive workplaces) and could disclose harmful drinking in social drinkers. Due to the serious public health problem of alcohol use and abuse worldwide, markers of alcohol use have been sought. Both ethyl glucuronide (EtG) and phosphatidyl ethanol (PEth) appear to have high sensitivity and specificity and a time frame of detection that may elucidate alcohol use not detected by standard testing. Our aim was to assess their potential for detecting recent covert alcohol use under controlled conditions.
Methods:
Thirty-five forensic psychiatric inpatients in a closed ward who had committed a substance-related offense ( section sign 64 StGB), were followed for 12 months. The complete time spectrum of possible alcohol consumption was covered by the complementary use of breath and urinary ethanol (hours), urinary EtG (days), %carbohydrate-deficient transferrin (CDT)/PEth (weeks), and gamma-glutamyltranspeptidase (GGT)/mean corpuscular volume (MCV) (weeks-months).
Results:
Fourteen of the 146 urine samples examined were positive for EtG. In all EtG-positive cases, patients reported alcohol consumption of between 40 and 200 g of ethanol 12-60 hr prior to testing. Urinary and breath ethanol were positive in only one case. In the blood samples, PEth was not positive in any case and %CDT did not exceed the reference value. Isoelectric focusing showed no abnormal Tf subtypes.
Conclusions:
The findings emphasize the diagnostic and therapeutic usefulness, specificity, and sensitivity of EtG as a marker of recent alcohol use. Such a test is needed in numerous settings, including alcohol and drug treatment (to detect lapse/relapse), in safety-sensitive work settings where use is dangerous or in other settings where use may be inappropriate (e.g., such as driving, workplace, pregnancy, or monitoring physicians or other professionals who are in recovery and working), or for testing other groups (such as children or those with medical problems) where alcohol use would be unhealthy or unsafe. The health, social and socioeconomic benefits arising from the future use of these markers is hard to overestimate.
The sick physician: impairment by psychiatric disorders, including alcoholism and drug dependence
American Medical Association, Council on Mental Health. "The sick physician: impairment by
psychiatric disorders, including alcoholism and drug dependence," JAMA 1973; 233: 684-687.