<div class="yourchoice"><strong>You chose: </strong>Discuss the personal aspects</div>
<div class="container">
<div class="inner"><div class="feedback neutral">You need to stay within the boundaries of the information you need in order to make decisions as an administrator and his boss. Remember you are not his counselor.
</div>
<div class="dialogue-container">
<div class="note">Dr. Adams starts to interview Dr. Wentworth regarding his addiction: </div>
<div class="administrator-dialogue">
<p> So, your problem started before coming here, is that right?</p>
</div>
<div class="patient-dialogue">
<p> Yes, it's been almost a year now. It started with some oxycodone prescribed for a back injury. But then I noticed how much it helped with the stress of my residency, so continued with fentanyl, because it was easy for me to get.</p>
</div>
<div class="administrator-dialogue">
<p> Has this only been IV use then?</p>
</div>
<div class="patient-dialogue">
<p> Yes, mostly just IV. I also scavenged fentanyl patches, because there’s still some medication left on them when they switch them out.</p>
</div>
<div class="administrator-dialogue">
<p> I'm truly sorry to see this happen. You are bright with lots of potential. I hope you do what it takes to turn this around. You will be escorted as you collect your things and leave the building now.</p>
</div>
<div class="patient-dialogue">
<p> Okay, thank you.</p>
</div>
<div class="note">After Dr. Wentworth leaves:</div>
<div class="administrator-dialogue">
<p> [gets on the phone] Nurse Boyd, please review the protocol for proper disposal of fentanyl patches with everyone. Someone hasn't been taking care to fold them sticky side inward. </p>
</div>
</div>
</div>
<div class="navigation">
<div class="question">Current options:</div>
<div class="continue">[[Report Dr. Wentworth to the state]] </div>
<div class="continue">[[No report if Dr. Wentworth seeks treatment himself]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Interview Dr. Wentworth - Question - B</p>
<div class="chapter"><strong>Ch 2 |</strong> Interview</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
</div>
<div class="yourchoice"><strong>You chose:</strong> Report Dr. Wentworth to the state</div>
<div class="container">
<div class="inner"><div class="feedback correct">Good choice in your role as the administrator</div>
<div class="dialogue-container">
<div class="note">While it is correct that you are mandated to report Dr. Wentworth, in a few states he might also choose to quickly report to the state's Healthy Physician Program himself. Your report would still be filed in conjunction with this voluntary reporting.</div>
<div class="administrator-dialogue">
<p> I am mandated to report you to the Physician Health Program. It is part of our professional guidelines and the laws and regulations governing the practice of medicine.</p>
</div>
<div class="patient-dialogue">
<p> Please don't do that. I'll lose everything I've worked for. Isn't there some other way to handle this privately? I don't want this made public. </p>
</div>
<div class="administrator-dialogue">
<p> If you voluntarily stopped practice as of right now and immediately and voluntarily requested treatment from the Physician Health Plan, you are fortunate that in this state it would not be made public.</p>
</div>
<div class="patient-dialogue">
<p> Would the state medical board know?</p>
</div>
<div class="administrator-dialogue">
<p> The Physician Health Program is under the state licensing board. But as long as there does not appear to be a threat to the public, they would keep the information private. In other words, you would not be able to practice and your patients would have to be transferred. Then your anonymity could be maintained by the board.</p>
</div>
</div>
</div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="return"> [[II. Meet with Dr Wentworth]]</div>
<div class="continue">[[Sections I and II Discussion]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Interview Dr. Wentworth - Discussion - ABC1</p>
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</div>
<div class="yourchoice"><strong>You chose:</strong> No report if Dr. Wentworth seeks treatment himself</div>
<div class="container">
<div class="inner"><div class="feedback incorrect">Incorrect, in your role as the administrator, Dr. Adams, you still need to file a report. While it is usually correct that you are mandated to report Dr. Wentworth, in a few states he might also choose to quickly report to the state's Healthy Physician Program himself. However, your report would still be filed in conjunction with this voluntary reporting.</div>
<div class="dialogue-container">
<div class="administrator-dialogue">
<p> I am mandated to report you to the Physician Health Program. It is part of our professional guidelines and the laws and regulations governing the practice of medicine.</p>
</div>
<div class="patient-dialogue">
<p> Please don't do that. I'll lose everything I've worked for. Isn't there some other way to handle this privately? I don't want this made public.</p>
</div>
<div class="administrator-dialogue">
<p> In this state, if you voluntarily stopped practice as of this moment and immediately requested treatment from the Physician Health Plan, it would not be made public.</p>
</div>
<div class="patient-dialogue">
<p> Would the state medical board know?</p>
</div>
<div class="administrator-dialogue">
<p> Not as long as there doesn't appear to be a threat to the public. Your anonymity can be maintained with the board.</p>
</div>
</div>
</div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="continue">[[Sections I and II Discussion]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Interview Dr. Wentworth - Discussion - ABC2</p>
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</div>
<div class="yourchoice"><strong>You chose:</strong> Discussion of Sections I and II</div>
<div class="container">
<div class="inner">
<div class="content">
In section one, you had the opportunity to: check fentanyl supply records, interview the reporting doctor, review the Prescription Drug Monitoring Program. You also had the opportunity to interview Dr. Wentworth's former residency program director, although this was not necessary, because you were able to learn everything you needed to know through the other means.
<br/>
In section two, you had the opportunity to: Discuss the work related problem, discuss the personal problem of addiction, and contact the Physician Health Program.
<strong>Symptoms of Impaired Physicians</strong>
<br/> The behavior and signs of being impaired exhibited by Dr. Wentworth are typical of an impaired health care professional:
<ul>
<li>Increased absences from professional functions</li>
<li>Appearing sleep deprived</li>
<li>Increased errors including prescriptions, record keeping, clinical decisions</li>
<li>Not responding to pages or phone calls</li>
<li>Patient complaints, decreased concern for patient well-being</li>
<li>Coming to work when not scheduled, loitering near drug supply</li>
<li>Increasing tardiness or absences</li>
<li>Signs out more of the drug being abused than peers</li>
<li>Seems confused, forgetful, unpredictable, or unable to concentrate</li>
<li>Makes detailed excuses</li>
</ul>(McGovern et al., 2000; AANA, 2016)
<br/> Other symptoms of being impaired that Dr. Wentworth has not exhibited include:
<ul>
<li>Emotional lability, unexplained anger and overreaction</li>
<li>Many accidental injuries, may be contrived to obtain narcotics</li>
<li>Withdrawal from peers, isolation</li>
<li>Requests extra call</li>
<li>Gradual decline in work performance</li>
<li>Increased difficulty with authority</li>
<li>Frequent illnesses or physical complaints</li>
<li>Dishonesty</li>
<li>Signs of alcohol use: tremors, especially returning to work after time off; alcohol on breath or perfume or mouthwash odor to cover it up</li>
<li>Seems intoxicated</li>
</ul>Note: The majority of addicted anesthesiologists use drugs intravenously.
<br/> (McGovern et al., 2000; AANA, 2016)
<br/>
<strong>Mandated Reporting</strong>
<br/> Most state boards mandate reporting an impaired physician. For example, Ohio’s state medical board rules state, “Any Board licensee having knowledge’ that a physician is impaired because of substance misuse ‘is required … to report that information to the Board. … [H]owever, … the [impaired] physician’s colleagues may be excused from reporting the physician’s impairment … if the [impaired] physician has completed treatment with a Board approved treatment provider and maintained uninterrupted sobriety, and violated no other provisions of the Ohio Medical Practice Act.” A few do not, for example, California’s medical practice act contains no mandatory reporting requirement. However reporting is encouraged by the board and confidentiality is assured. AMA policy also describes an ethical obligation "to report impaired, incompetent, and unethical colleagues." (Policy H-275.952)
<br/>
<strong>Physician Health Programs (PHP)</strong>
<br/> "PHP is a program of prevention, detection, intervention, rehabilitation and monitoring of licensees with potentially impairing illnesses, approved and/or recognized by the state medical board. PHPs are charged with oversight of licensees who are in need of evaluation and/or treatment. In addition, the PHP monitors licensees with illnesses that have the potential to interfere with the safe practice of medicine" (FSMB, 2011)
<br/> All states but 4 (California, Georgia, Nebraska and Wisconsin) have PHP programs. Formerly called Impaired Physician programs, these programs now include treatment for other forms of impairment than addiction, such as depression.
<br/> Dr. Wentworth has a fairly good chance of recovering and returning to practice with the Healthy Physician Program: One study of 16 programs followed physician completers of the program for 5 years and found 81% complete success rate has been reported. And 75% of those who tested positive did not re-test positive, after sanctions and more treatment (Skipper et al., 2008).
</div>
</div>
<div class="navigation">
<div class="question">Please continue to:</div>
<div class="continue"> [[III. Evaluation]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Interview Dr. Wentworth - Summary - ABCa</p>
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</div>
<div class="yourchoice"><strong>You chose: </strong>Substance use screening</div>
<div class="container">
<div class="inner">
<div class="feedback correct">Correct. In the role you are now playing of being Dr. Wentworth's provider at the substance use treatment facility, even though you are already aware of his fentanyl use, it is important to ask about other substance use as this may impact his treatment and recovery. </div>
<div class="dialogue-container">
<div class="provider-dialogue"><p>Could you please fill out these questionnaires? It is important that we understand all substances you are using.</p></div>
</div>
<div class="note"><u>Dr. Wentworth's Substance Use Assessment Results </u>
<ul>
<li><strong>AUDIT:</strong> Negative. 3/10. Reference value: 8 or more is positive for hazardous alcohol use. </li>
<li><strong>DAST:</strong> Positive for drug use: 14/28. Reference value: 6 or more is positive.</li>
<li><strong>Tobacco:</strong> Never used tobacco</li>
<li><strong>By interview:</strong> Patient denies use of drugs other than fentanyl. </li>
</ul>
</div>
</div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="return"> [[III. Evaluation]]</div>
<div class="continue">[[IV. Medication Assisted Treatment Options]]
</div></div></div>
<div class="footer"><p class="small">You are here: Evaluation - Question - B</p><div class="chapter"><strong>Ch 3 |</strong> Evaluation</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
</div>
<div class="yourchoice"><strong>You chose: </strong>Urine drug testing</div>
<div class="container">
<div class="inner"><div class="feedback incorrect">Correct. In your role as Dr. Wentworth's provider at the substance use treatment facility, you are responsible for ordering lab tests that are a part of his treatment structure. Urine drug testing is indicated. </div>
<div class="content">
Collection in the program and after release will be directly observed or dry room collection. It is important to get a baseline determination of his current level of fentanyl as well as an understanding of his use of other medications prior to starting his substance use treatment. In addition to testing specifically for fentanyl, add on tests were ordered for propofol and midazolam (Versed) because of their high rates of abuse by anesthesiologists who abuse drugs (Wright et al., 2012).
<br/>
<u>Dr. Wentworth's urine drug test results are below (Test (Code) - Result)</u>
<ul>
<li>Amphetamines (AMP) - Negative</li>
<li>Cocaine (COC) - Negative</li>
<li>MDMA (MDMA) - Negative</li>
<li>Methamphetamine (mAMP) - Negative</li>
<li>Opiate (OPI) - Negative</li>
<li>THC (THC) - Negative</li>
<li><strong>Add-ons</strong><ul><li>Fentanyl with metabolite confirmation - <strong>Positive</strong>
<ul><li>Fentanyl Results: 0.4 ng/mL Reference value: Cutoff: 0.2</li>
<li>Norfentanyl Results: 2.4 ng/mL Reference value: Cutoff: 1.0</li></ul></li>
<li>Propofol Glucuronide - Negative</li>
<li>Midazolam - Negative</li></ul></li>
</ul>
</div>
</div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="return">[[III. Evaluation]]</div>
<div class="continue">[[IV. Medication Assisted Treatment Options]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Evaluation - Question - D</p>
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</div>
<div class="yourchoice"><strong>You chose: </strong>Interview reporting doctor</div>
<div class="container">
<div class="inner"><div class="feedback correct"> Good choice, in your role as the administrator.</div>
<div class="content">The reporting doctor is called in for a meeting. Dr. Wentworth's direct supervisor also attends this meeting, along with Ms. Jackson, a member of the personnel department. During the course of the meeting, Ms. Jackson will be taking notes in order to file a formal report for Dr. Wentworth's file.</div>
<div class="dialogue-container">
<div class="administrator-dialogue">
<p> Thank you for meeting with me. I appreciate your coming forward with this information. We have to be careful to check reports of suspicious behavior by our medical staff, because patient's lives are at stake. I'd like to get more information and ask some questions.</p>
</div>
<div class="resident-dialogue">
<p> My residency program director said I could remain anonymous. Is that right? I wouldn't want Dr. Wentworth to know it was me who reported him. To tell you the truth, it could have been anyone who turned him in. Many of us have been talking about it.</p>
</div>
<div class="administrator-dialogue">
<p> Yes, you will remain anonymous. It sounds like you may have seen other suspicious behavior, besides noticing that he reported a vial broken when it was not broken. What have you noticed?</p>
</div>
<div class="resident-dialogue">
<p> Yes, there have been a number of other problems. He's been late to scrub-in at least twice when I've been there. He made a major error and administered a drug out of order, but noticed and corrected quickly. Sometimes he comes in on his day off, saying he wants to check on someone, and then just hangs around the drug supply area.</p>
</div>
<div class="administrator-dialogue">
<p> I see. Anything else?</p>
</div>
<div class="resident-dialogue">
<p> One time he was leaving and the nurse reminded him that a patient was still in pain and asking to see him. He said, "I don't know what to tell you. He's had the maximum dose of fentanyl. I gave it to him myself," and he kept walking to the elevator. </p>
</div>
</div>
<div class="content">At the conclusion of this meeting, Ms. Jackson writes up her formal report and the document is placed in Dr. Wentworth's personnel file.</div>
</div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="return">[[I. Review Available Information]]</div>
<div class="continue">[[II. Meet with Dr Wentworth]]</div>
<div class="continue">[[Insufficient evidence to interview Dr Wentworth]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Review Available Information - Interview reporting doctor</p>
<div class="chapter"><strong>Ch 1 |</strong> Review Information</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong>Review Prescription Drug Monitoring Program</div>
<div class="container">
<div class="inner"><div class="feedback incorrect">Incorrect. You may not review the drug monitoring program for Dr. Wentworth, because, you are playing the role of an administrator and his supervisor, so he is not your patient. However, with appropriate permissions you may review the prescribing records for his patients.
</div></div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="return">[[I. Review Available Information]]</div>
<div class="continue">[[II. Meet with Dr Wentworth]]</div>
<div class="continue">[[Insufficient evidence to interview Dr Wentworth]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Review Available Information - Review Drug Monitoring Program</p>
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<div class="yourchoice"><strong>You chose: </strong>Order Prescription Drug Monitoring Report</div>
<div class="container">
<div class="inner"><div class="feedback correct">Correct. In this situation, in the role you are now playing as Dr. Wentworth's provider at the substance use treatment facility, it is appropriate to check the Prescription Drug Monitoring Report.</div>
<div class="report">
<strong>Date:</strong> (Today's Date)<br/>
<strong>Prescription History Report for:</strong><br/>
<strong>ID:</strong> 55-555 <strong>Name:</strong> Wentworth, Peter <strong>DOB:</strong> 10/30/1986<table><tbody><tr><td><p><strong>Fill Date</strong></p></td><td><p><strong>Product</strong></p></td><td><p><strong>Strength/ Form</strong></p></td><td><p><strong>Qty</strong></p></td><td><p><strong>Days</strong></p></td><td><p><strong>Prescriber</strong></p></td><td><p><strong>Pharmacy</strong></p></td></tr><tr><td><p>1 year, 2 months before today</p></td><td><p>Oxycodone</p></td><td><p>20 mg tablet</p></td><td><p>180</p></td><td><p>30</p></td><td><p>GHG RRD5</p></td><td><p>0990990</p></td></tr></tbody></table><p><strong>Total Prescriptions Past Year: </strong>0</p><p><u>Prescribers for prescriptions listed:</u></p><p>GHG RRD5 - Blaine Johnson, MD</p>
<p><u>Pharmacies that dispensed prescriptions listed:</u></p><p>0990990 - HBS Pharmacy</p></div>
</div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="return">[[III. Evaluation]]</div>
<div class="continue">[[IV. Medication Assisted Treatment Options]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Evaluation - Question - E</p>
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<div class="yourchoice"><strong>You chose: </strong>Excerpt from interview with provider at intake</div>
<div class="container">
<div class="inner"><div class="feedback correct">Correct. In the role you are now playing of being Dr. Wentworth's provider at the substance use treatment facility, it is appropriate to complete an intake interview.</div>
<div class="dialogue-container">
<div class="note">Excerpt from his intake interview: </div>
<div class="provider-dialogue">
<p> Do you know what led you down this path?</p>
</div>
<div class="patient-dialogue">
<p> I had a prescription for oxycodone for a back injury and all the stress at work went away while I was on it. So it was so easy to just keep that feeling going with a little fentanyl siphoned off here and there.</p>
</div>
<div class="provider-dialogue">
<p> Easy in the moment, but not in the long run?</p>
</div>
<div class="patient-dialogue">
<p> Right. Will I ever be able to return to practice?</p>
</div>
<div class="provider-dialogue">
<p> Some people would say the temptation would be too great, with the easy access to fentanyl, to return to practice of anesthesiology. And they are right that the temptation makes it a challenge. Relapse rates are higher with a return to anesthesia practice. But we usually determine that on a case-by-case basis. You certainly should at least be able to return to other medical practice.</p>
</div>
<div class="patient-dialogue">
<p> How will you determine that? Can you really tell if I’ll relapse?</p>
</div>
<div class="provider-dialogue">
<p> One thing we do here is use a simulation program to evaluate whether exposure to the environment of an anesthesiologist is a trigger for you. It also can be used to do some desensitization of that triggered response.</p>
</div>
<div class="patient-dialogue">
<p> I’ve got to be able to get back to medical practice. I really messed up my life, didn’t I?</p>
</div>
<div class="provider-dialogue">
<p> You have already started taking steps to turn it around. We’ll do everything we can to help you with that.</p>
</div>
<div class="patient-dialogue">
<p> I worry that patients will find out and refuse my services, that no one will hire me.</p>
</div>
<div class="provider-dialogue">
<p> Building a new life after treatment will be part of your treatment plan. We will get to that in time. Right now it is important to focus on what you need to do for now and the solutions available to you in each moment.</p>
</div>
</div>
</div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="return">[[III. Evaluation]]</div>
<div class="continue">[[IV. Medication Assisted Treatment Options]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Evaluation - Question - C</p>
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<div class="yourchoice"><strong>You chose:</strong>III. Evaluation</div>
<div class="container">
<div class="inner"><div class="content">
In this section, you may review some of Dr. Wentworth's intake information regarding his substance use as he starts at a residential treatment facility affiliated with the Physician Health Network. <strong>You will now be acting in the role of the provider, a psychiatrist who specializes in addiction medicine at that substance use treatment facility.</strong> Dr. Wentworth will be your patient for the remained of this scenario.
<h4>Options Currently Available:</h4>
<div class="object"> [[Review medical history]]</div>
<div class="object"> [[Substance use screening]]</div>
<div class="object"> [[Excerpt from interview with provider at intake]]</div>
<div class="object"> [[Urine drug testing]]</div>
<div class="object"> [[Order Prescription Drug Monitoring Report]]</div>
</div></div>
<div class="navigation">
<div class="question">When you have completed your review of the above information, please continue to:</div>
<div class="continue"> [[IV. Medication Assisted Treatment Options]]</div>
</div>
</div>
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<div class="yourchoice"><strong>You chose: </strong>V. Residential Treatment Summary</div>
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<div class="inner">
<div class="content">
<strong>In this section, you had the opportunity to review four Medication Assisted Treatment options.</em></strong>
<br/>
<strong>Discussion</strong> Although the other medications would have been potentially more effective since their rates of relapse are lower, Dr. Wentworth elected to use naltrexone, which blocks opioid receptors, over the agonist methadone or the partial agonist buprenorphine, so that he would "never be suspected of drug misuse again." Buprenorphine and methadone are each abused sometimes, but naltrexone is not. However, these medications for treating opioid use disorder are often preferred because they are better at controlling cravings.(ASAM, 2015)
<br/> In addition to medication assisted treatment, Dr. Wentworth's residential treatment for opioid use disorder included:
<ul>
<li>Lifestyle changes: Regular exercise, healthy eating, regular participation in a 12-step group, and daily meditation</li>
<li>Counseling with an individual addiction specialist and group therapy</li>
</ul>
</div>
</div>
<div class="navigation">
<div class="question">Please continue to learn the discharge plan.</div>
<div class="continue">[[Discharge]]</div>
</div>
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<p class="small">You are here: Residential Treatment Summary</p>
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<div class="yourchoice"><strong>You chose: </strong>Key Points</div>
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<div class="inner">
<div class="content">
<ul>
<li>Reporting of impaired physicians is considered an ethical responsibility by the AMA and is mandated by most state licensing boards.</li>
<li>Every state has a Healthy Physician program that is responsible for assuring that impaired physicians receive appropriate treatment and monitoring.</li>
<li>Drug addiction is more common among anesthesiologists than other physicians.
<ul>
<li>Opioids are most common.</li>
<li>Intravenous use is most common.</li>
<li>A large percentage are young, still in residency.</li></ul></li>
<li>To be effective, treatment structure needs to be stronger than for non-physicians, especially with a return to practice.</li>
<li>Recovery is possible with a return to practice and long-term abstinence, but compliance with a strongly structured program is important.</li>
<li>Medication assisted maintenanace, whether with naltrexone injections as in Dr. Wentworth's case, or methadone or buprenorphine, should be continued long-term to avoid the high risk of relapse if they are stopped.</li>
<li>Consider giving patients on medication assisted treatment naloxone kits for use in the event of an overdose. Relapse can occur, and risk of overdose is high in individuals who relapse and do not realize they no longer have tolerance for a high dose of opioids</li>
</ul>
<br/>
</div>
</div>
<div class="navigation">
<div class="question">Continue to view references and resources:</div>
<div class="continue">[[References]]</div>
</div>
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<div class="footer">
<p class="small">You are here: Key Points</p>
<div class="chapter"><strong>Ch 6 |</strong> Key Points</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose:</strong>Resources</div>
<div class="container">
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<div class="content">
<ul><li> <a href="http://www.physicianhealthprogram.com/" target="_blank" rel="noopener noreferrer" data-raw="">Physician Health Program. Addiction Treatment for Doctors</a></li>
<li>Bright, RP, and L Krahn. “Impaired Physicians: How to Recognize, When to Report, and Where to Refer.” Current Psychiatry 6 (June 9, 2010): 11–20. <a href="https://www.mdedge.com/psychiatry/article/63943/impaired-physicians-how-recognize-when-report-and-where-refer" target="_blank" rel="noopener noreferrer" data-raw="">https://www.mdedge.com/psychiatry/article/63943/impaired-physicians-how-recognize-when-report-and-where-refer</a></li>
<li>CDC. “Fentanyl | Drug Overdose | CDC Injury Center” December 21, 2018. <a href="https://www.cdc.gov/drugoverdose/opioids/fentanyl.html" target=_blank">https://www.cdc.gov/drugoverdose/opioids/fentanyl.html</a></li></ul>
</div>
</div>
<div class="navigation"><div class="question">
END OF CASE. You may elect to return to the start:</div>
<div class="return">[[Retake The Experience|Welcome]]</div>
</div>
</div>
<div class="footer"><p class="small">You are here: Resources</p><div class="chapter"><strong>Ch 7 |</strong> Finish Case</div><div class="progress chapter7"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong>Discharge</div>
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<div class="note">
<br/><strong>Scenario:</strong> Fast forward in time to Discharge: Dr. Wentworth completed 90 days of residential treatment. He is being released from treatment and making arrangements for his follow-up treatment.
<ul><li>Medication-assisted treatment will continue indefinitely. Naltrexone injections were changed to monthly extended release injections before discharge. </li>
<li>Lifestyle changes started in residential treatment are to continue indefinitely</li>
<li>Dr. Wentworth will continue individual counseling initially and group therapy long-term.</li>
</ul>
</div>
<div class="dialogue-container">
<div class="content">Excerpt from Dr. Wentworth's exit interview:</div>
<div class="provider-dialogue">
<p> Congratulations on making through your first 90 days. Now we build on that by continuing your medication-assisted treatment with monthly long-acting naltrexone injections. You will need to call us every day to find out if you need to report for a urine drug test that day. Tests will continue to be observed and there will also be occasional hair analysis.</p>
</div>
<div class="patient-dialogue">
<p> Whew, that's rough. </p>
</div>
<div class="provider-dialogue">
<p> Well, as you know by now, structure is an important support. You should also know that since you have decided to return to practice, positive results would be reported to the licensing board. Let's talk about the other supports. Your release is also contingent upon agreeing to continuing your group therapy sessions, 12-step support.</p>
</div>
<div class="patient-dialogue">
<p> Yes I agree.</p>
</div>
<div class="provider-dialogue">
<p> You will meet with Dr. Jones before you leave to develop a plan to avoid cue exposure. Dr. Adams, the administrator from the hospital where you used to work, has arranged for enhanced security measures around the operating room, once you are cleared to return to work, which will include always having a witness for drug access and disposal and may include checking monitoring cameras. </p>
</div>
<div class="patient-dialogue">
<p> I understand.</p>
</div>
<div class="provider-dialogue">
<p> I have faith in you, but I also want to make sure you survive. Keep in mind that you no longer have tolerance for opioids. If you did have a relapse, your old dose would be fatal. It's also best to avoid all drugs and alcohol. They lower impulse control and it is critical that you are able to think clearly about your actions as you recover.</p>
</div>
<div class="patient-dialogue">
<p> That makes sense. OK.</p>
</div>
</div>
</div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="continue"> [[Key Points]] </div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Discharge</p>
<div class="chapter"><strong>Ch 5 |</strong> Discharge</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong>Check fentanyl supply and patient records</div>
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<div class="inner"><div class="feedback correct">Good choice in your role as an administrator.</div>
<div class="content">
You review the fentanyl supply records and audit Dr. Wentworth's patient records. You discover the following:
<ol>
<li>Dr. Wentworth has consistently signed out about 10% more fentanyl than anyone else. </li>
<li>Dr. Wentworth is the only one reporting broken vials of fentanyl. There were 3 broken vial reports since he came on staff. </li>
<li>Inventory for fentanyl was short by 1 vial last week. </li>
<li>Dr. Wentworth orders post-operative fentanyl more often than his peers and occasionally offers to administer it himself.</li>
<li>Dr. Wentworth has had three patients complain of insufficient pain relief. In all 3 cases, nursing notes say that Dr. Wentworth administered fentanyl instead of nursing staff. </li>
</ol>
</div>
</div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="return">[[I. Review Available Information]]</div>
<div class="continue">[[II. Meet with Dr Wentworth]]</div>
<div class="continue">[[Insufficient evidence to interview Dr Wentworth]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Review Available Information - Check fentanyl supply and patient records</p>
<div class="chapter"><strong>Ch 1 |</strong> Review Information</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong>II. Meet with Dr. Wentworth</div>
<div class="container">
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<div class="administrator-dialogue">
<p> Thank you for coming to see me, Dr. Wentworth.</p>
</div>
<div class="patient-dialogue">
<p> Certainly. Is there some problem?</p>
</div></div>
<div class="content">
<h4>Options Currently Available:</h4>
<div class="object">[[Discuss the work related problem]] </div>
<div class="object">[[Discuss the personal problem of addiction]] </div>
<div class="object">[[Contact the Physician Health Program]]</div>
</div>
</div>
<div class="navigation"><div class="question">When you have reviewed the information available in this section continue to.</div>
<div class="continue">[[III. Evaluation]]</div>
</div></div>
<div class="footer">
<p class="small">You are here: Interview Dr. Wentworth</p>
<div class="chapter"><strong>Ch 2 |</strong> Interview</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose:</strong>I. Review Available Information</div>
<div class="container">
<div class="inner">
<div class="content"><strong>Instructions:</strong> Scroll and select blue Case Information buttons to review all available information. When you have completed reviewing this information, scroll down to navigate to the next section using the orange buttons at the bottom of the page.<br/>In this scene, you adopt the role of Dr. Heather Adams who must deal with an administrative problem. Review the information she has available and make choices for her to the best of your ability. After you have explored all information on a page, continue by clicking the orange Navigation buttons at the bottom of each scene.
<h4>The Scenario:</h4>
Dr. Heather Adams, Chair of the Anesthesiology Department, has received a report of problematic behavior by a member of the medical staff. Dr. Peter Wentworth, a relatively new hire, has been reported for irregular behavior related to his prescribing of fentanyl. Second year resident, Raj Singh, reported to his Anesthesia Residency Program Director that he saw Dr. Wentworth report a broken vial of fentanyl when he was pretty sure that there was no broken vial. The program director relayed the information to Dr. Wentworth's superior, Dr. Adams. Dr. Adams has met with Dr. Wentworth previously over other problematic behavior that has been reported by nursing staff and one patient.
<h4>Please select from these options currently available for the administrator, Dr. Adams:</h4>
<div class="object">[[Review Employee Record]] </div>
<div class="object">[[Check fentanyl supply and patient records]] </div>
<div class="object">[[Interview reporting doctor]]</div>
<div class="object">[[Review Prescription Drug Monitoring Program]] </div>
</div>
</div>
<div class="navigation">
<div class="question">Continue to:</div>
<div class="continue">[[II. Meet with Dr Wentworth]] </div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Review Available Information</p>
<div class="chapter"><strong>Ch 1 |</strong> Review Information</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You Chose:</strong> Case Overview</div>
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<div class="header"><h4>Case Overview</h4></div>
<div class="content"><div class="patientimg"></div>
"I need help with my addiction." <i>~ Peter Wentworth, age 30, resident in anesthesiology</i>
<br/>
Dr. Wentworth's addiction started last year after he sustained a back injury while doing some weight lifting. He found that the opioid prescribed for his pain also helped relieve the stress of his residency program. He presents now for substance use treatment, because he was reported by a fellow physician as a part of their state's Healthy Physician Program, which supports reporting by fellow physicians and mandatory compliance with evaluation. <br/>
This case will challenge you to recognize the circumstances in which a physician should be reported for drug-related impairment. It will reveal the process involved in recovery for an impaired physician including:
<ul>
<li> Protections and privacy for physician patients treated for substance use</li>
<li>Ways that a physician's recovery can be facilitated</li>
<li>The unique personal circumstances and challenges when a physician is impaired, such as the effects on their reputation and potential continued cue exposure with a return to work</li>
<li>The potential effect of an impaired physician on patients, colleagues, and the practice</li>
<li>The approach and success rates of Healthy Physician Programs</li>
</ul>
Reviewing this case may benefit physicians who are considering seeking treatment for problematic substance use.
<strong>Instructions:</strong> Scroll down and click on the orange button at bottom to navigate to next passage
</div>
</div>
</div>
<div class="navigation"> <div class="question">Please continue to review the available information.</div>
<div class="continue">[[I. Review Available Information]]</div>
</div>
</div><div class="footer">
<p class="small">You are here: Case Overview</p>
<div class="chapter"><strong>Ch 1 |</strong> Medical Record</div>
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</div></div>
<div class="yourchoice"><strong>You chose:</strong> Review medical history</div>
<div class="container">
<div class="inner"><div class="feedback correct">Correct. In the role you are now playing of being Dr. Wentworth's provider at the substance use treatment facility, it is appropriate to review his medical history.</div>
<div class="content">
<strong>Summary of Medical History</strong><br/>
<strong>Patient Name:</strong> Peter Wentworth<br/>
<strong>Vital Signs:</strong> BP: 122/80; Pulse: 76; Resp: 16; BMI: 27<br/>
<strong>Age/Occupation:</strong> 30 y/o anesthesiologist<br/>
<strong>Chief Complaint:</strong> Referred for possible addiction to fentanyl<br/>
<Strong>Relevant Past Medical History:</strong> (date 1 year ago) Strained lower back during heavy lifting.<br/>
<strong>Medications:</strong> No currently prescribed medications, no over-the-counter medications. Oxycodone prescribed one year ago for 4 weeks.<br/>
<strong>Substance Use:</strong> Drugs: Illicit fentanyl use.<br/>
<strong>Alcohol Use:</strong> Occasional; Tobacco: Never used<br/>
<strong>Family History:</strong> Married, wife Ashley; son Liam age 1. Father - moderately severe alcohol use disorder; Mother - mild alcohol use disorder<br/>
</div>
</div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="return"> [[III. Evaluation]]</div>
<div class="continue">[[IV. Medication Assisted Treatment Options]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Evaluation - Question - A</p>
<div class="chapter"><strong>Ch 3 |</strong> Evaluation</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong>Insufficient evidence to interview Dr Wentworth</div>
<div class="container">
<div class="inner"><div class="feedback incorrect">
<div class="content">Incorrect. This is plenty of evidence to initiate a discussion with Dr. Wentworth. If, while playing the role of the administrator, you wait for absolute proof, patients' lives could be lost. You can be discrete in your investigations so that his reputation is not affected. There may be a temptation to handle "grey" cases without concrete evidence of diversion by just letting the doctor go for other reasons. This results in impaired physicians getting hired somewhere else and potentially harming other patients.</div></div>
</div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="return">[[I. Review Available Information]]</div>
<div class="continue">[[II. Meet with Dr Wentworth]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Review Available Information - Check fentanyl supply and patient records - Insufficient evidence to interview Dr Wentworth</p>
<div class="chapter"><strong>Ch 1 |</strong> Review Information</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong>Discuss the work related problem</div>
<div class="container">
<div class="inner"><div class="feedback correct">Good choice in your role as the administrator</div>
<div class="dialogue-container">
<div class="administrator-dialogue">
<p> (not mentioning the report) Dr. Wentworth, there are several anomalies in our fentanyl records with your name attached. What do you know about that?</p>
</div>
<div class="patient-dialogue">
<p> (stutters) Nothing. I'm surprised. You tell me.</p>
</div>
<div class="administrator-dialogue">
<p> An increase in broken vials, all signed out to you; an increase in department use of fentanyl traced to your high use of fentanyl sometimes when most of your colleagues would not use it; short inventory last week for fentanyl, and most alarmingly, offering to administer fentanyl to patients yourself, when it would normally be done by a nurse and more than one of those patients complaining of insufficient pain relief.</p>
</div>
<div class="patient-dialogue">
<p> (No response, breaks eye contact)</p>
</div>
<div class="administrator-dialogue">
<p> I understand that if you have a problem, you would be reluctant to admit it. Your career is at stake. But patient's lives are at stake, too, and so you should know that I will pursue this as far as I need to in order to get to the bottom of it and protect them. With your cooperation, if you need help, we could do this as discretely as possible and get you connected with help if you need it. </p>
</div>
<div class="patient-dialogue">
<p> There's nothing to cooperate about. I am only using fentanyl appropriately. It wasn't my fault that a vial or two broke. And I see nothing wrong with administering a medication myself as long as I let nursing staff know. </p>
</div>
<div class="administrator-dialogue">
<p> You should know that a number of work-related behavior problems have also been reported unofficially: tardiness, missed meetings, missed pages. If what you say is true, that you have no problem, then would you submit to a drug test right now?</p>
</div>
<div class="patient-dialogue">
<p> (No response from Dr. Adams for a long pause. Then, after a long sigh, he responds.) Okay, yes I have a problem. It is probably best that it come out.</p>
</div>
<div class="administrator-dialogue">
<p> We'll need a blood test to look for potential blood born pathogens you may have passed to patients if you shared their needle and a list of all patients you may have infected.</p>
</div>
<div class="patient-dialogue">
<p> Okay. I'll take the test, but I never shared their needles. I never would risk that. Honest. </p>
</div>
<div class="administrator-dialogue">
<p> Understood, but I just want to emphasize the importance of this situation. You will be escorted to the drug testing and, if the results are positive, your privileges will be immediately revoked until such time as determinations can be made about potential treatment and rehabilitation. Do you understand?</p>
</div>
<div class="patient-dialogue">
<p> Yes, I understand.</p>
</div>
</div>
</div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="return">[[II. Meet with Dr Wentworth]]</div>
<div class="continue">[[Report Dr. Wentworth to the state]]</div>
<div class="continue">[[No report if Dr. Wentworth seeks treatment himself]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Interview Dr. Wentworth - Question - A</p>
<div class="chapter"><strong>Ch 2 |</strong> Interview</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
</div>
<div class="yourchoice"><strong>You chose:</strong> Contact the Physician Health Program</div>
<div class="container">
<div class="inner"><div class="feedback correct">Good choice in your role as the administrator. In this case, instead of the administrator contacting the state initially, she waited to give Dr. Adams a chance to do it first because in her state that is permissable, and Dr. Wentworth was interested in this option. Dr. Adams still needed to file a report, too, however. </div>
<div class="dialogue-container">
<div class="note">
Dr. Wentworth decided to look into seeking help voluntarily from the Physician Health Program and called them before Dr. Adams contacted them.</div>
<div class="counselor-dialogue">
<p> Hello, Dr. Wentworth? I had a message from you that you would like information about our Physician Health Program?</p>
</div>
<div class="patient-dialogue">
<p> Yes. I have been using fentanyl and it was recently discovered by a colleague. I had a system that worked in my residency program. I knew how they did their inventories and when they would start to get suspicious. But when I started at a new hospital, they didn’t run things the same way (sounds irritated). They noticed that I had too many reports of broken or wasted vials and a problem with the inventory. They escorted me out of the hospital immediately - that was so embarassing. I've pretty much lost everything. I'm feeling pretty lost right now. I'm not even sure why I'm talking to you. I mean, why bother.</p>
</div>
<div class="counselor-dialogue">
<p> That's a lot to go through. I want to reassure you that there is help available. Let me just check in with how you're doing right now, though. Have you had any thoughts of hurting yourself or not wanting to live?</p>
</div>
<div class="patient-dialogue">
<p> No, nothing like that. It's just such a shock, you know. I'm taking it in. </p>
</div>
<div class="counselor-dialogue">
<p> You are one of the fortunate ones; about one in 5 addictions like this among anesthesiologists are discovered through a fatal or near-fatal overdose.</p>
</div>
<div class="patient-dialogue">
<p> I know, and believe me that scared me. I even thought about getting a dose of naloxone to treat opioid overdose and giving it to my wife just in case anything ever happened. I was about to quit, you know, maybe using buprenorphine, but then I got reported.</p>
</div>
<div class="counselor-dialogue">
<p> I’m glad you contacted us instead, because that probably wouldn’t have been enough. </p>
</div>
<div class="patient-dialogue">
<p> Really?</p>
</div>
<div class="counselor-dialogue">
<p> Really. Most people need a lot of support along with medication-assisted treatment, such as buprenorphine. The treatment we recommend most often for fentanyl addiction in physicians is a residential treatment program. That way you have no access to the drug and you get the support you need.</p>
</div>
<div class="patient-dialogue">
<p> That’s what I feared. How long?</p>
</div>
<div class="counselor-dialogue">
<p> Usually 2-3 months, and then continuing outpatient treatment and monitoring for a long time (Skipper et al., 2008). We find that staying connected to the program for at least 5 years is best.</p>
</div>
<div class="patient-dialogue">
<p> Would I be in there with the heroin addicts?</p>
</div>
<div class="counselor-dialogue">
<p> Only the physicians who are addicted to heroin. Physician health programs have their own treatment programs, under the jurisdiction of the state licensing board. You would be treated with a group of your peers. </p>
</div>
<div class="patient-dialogue">
<p> And it can be successful?</p>
</div>
<div class="counselor-dialogue">
<p> Yes, that’s why the physician health programs exist. I've seen figures like a 70% success rate after 5 years (Skipper et al., 2008).</p>
</div>
<div class="patient-dialogue">
<p> I would like to enroll? What's next?</p>
</div>
<div class="counselor-dialogue">
<p> It's best to get started as soon as possible. Can you come in today? [They continue to arrange for an intake appointment.]</p>
</div>
</div>
</div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="return">[[II. Meet with Dr Wentworth]]</div>
<div class="continue">[[Report Dr. Wentworth to the state]]</div>
<div class="continue">[[No report if Dr. Wentworth seeks treatment himself]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Interview Dr. Wentworth - Question - C</p>
<div class="chapter"><strong>Ch 2 |</strong> Interview</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
</div>
<div class="yourchoice"><strong>You chose </strong>References</div>
<div class="container">
<div class="inner">
<div class="content">
American Association of Nurse Anesthetists. Signs and behaviors of impaired colleagues. Available at <a href="https://www.aana.com/practice/health-and-wellness-peer-assistance/About-AANA-Peer-Assistance/substance-use-disorder-workplace-resources/signs-and-behavior-of-impaired-colleagues" target="_blank" rel="noopener noreferrer" data-raw="">https://www.aana.com/practice/health-and-wellness-peer-assistance/About-AANA-Peer-Assistance/substance-use-disorder-workplace-resources/signs-and-behavior-of-impaired-colleagues</a> Accessed 02/13/2019.
American Society of Addiction Medicine (ASAM). The ASAM National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use. American Society of Addiction Medicine. June 1, 2015. Available at: <a href="http://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement1b630f9472bc604ca5b7ff000030b21a.pdf?sfvrsn=0" target="_blank" rel="noopener noreferrer" data-raw="">http://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement1b630f9472bc604ca5b7ff000030b21a.pdf?sfvrsn=0</a> Accessed 02/13/2019.
Bryson EO, Silverstein JH. Addiction and substance abuse in anesthesiology. Anesthesiology. 2008 Nov; 109(5): 905–917. Available at: <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2766183/" target="_blank" rel="noopener noreferrer" data-raw="">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2766183/</a> Accessed 02/13/2019.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016; ePub: March 2016: DOI: <a href="http://dx.doi.org/10.15585/mmwr.rr6501e1er" target="_blank" rel="noopener noreferrer" data-raw="">http://dx.doi.org/10.15585/mmwr.rr6501e1er</a>. Available at: <a href="http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm" target="_blank" rel="noopener noreferrer" data-raw="">http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm</a> Accessed 02/13/2019.
Federation of State Medical Boards. Policy on Impaired Physicians. Available at <a href="https://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/grpol_policy-on-physician-impairment.pdf" target="_blank" rel="noopener noreferrer" data-raw="">https://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/grpol_policy-on-physician-impairment.pdf</a> Accessed 02/13/2019.
McGovern MP, Angres DH, Leon S. Characteristics of physicians presenting for assessment at a behavioral health center. J Addict Dis. 2000, 19(2): 59-73.
Rose J.S., Campbell M., Skipper G. Prognosis for emergency physician with substance abuse recovery: 5-year outcome study. West J Emerg Med. 2014; 15(1): 20-25. Available at: <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3952884/" target="_blank" rel="noopener noreferrer" data-raw="">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3952884/</a> Accessed 02/13/2019.
A Thomas McLellan chief executive officer, Skipper GS, Campbell M. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ. 2008; 337:a2038. Available at: <a href="http://www.bmj.com/content/337/bmj.a2038" target="_blank" rel="noopener noreferrer" data-raw="">http://www.bmj.com/content/337/bmj.a2038</a> Accessed 02/13/2019.
Vivitrol. Vivitrol (naltrexone for extended-release injectable suspension). ©2013-2016 Alkermes, Inc. Available at <a href="https://www.vivitrol.com/" target="_blank" rel="noopener noreferrer" data-raw="">https://www.vivitrol.com/</a> Accessed 02/13/2019.
Wright EL, McGuiness T, Moneyham LD, et al. Opioid abuse among nurse anesthetists and anesthesiologists. AANA Journal. 2012; 80(2). Available at: <a href="https://www.aana.com/docs/default-source/aana-journal-web-documents-1/opioidabuse-0412-p120-128.pdf?sfvrsn=807a48b1_8" target="_blank" rel="noopener noreferrer" data-raw="">https://www.aana.com/docs/default-source/aana-journal-web-documents-1/opioidabuse-0412-p120-128.pdf?sfvrsn=807a48b1_8</a> Accessed 02/13/2019.
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<div class="question">Please continue to view:</div>
<div class="continue">[[Resources]]</div>
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<p class="small">You are here: References</p>
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<div class="welcomeheader" id="vepatient"></div>
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<div class="welcomeimg">
<div class="patientimg"></div>
<div class="patientinfo"><strong>Peter Wentworth</strong>
<p>"I need help with my addiction."</p>
<div class="continue">[[Case Overview]]</div>
<div class="note">Instructions: In this case, you will interact with Dr. Peter Wentworth, an anesthesiologist with an addiction to fentanyl. In this clinical simulation, you will make choices acting first in in the role of an administrator (Parts I and II) and then, in the part of a clinician (Parts III).</div>
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<div class="yourchoice"><strong>You chose: </strong>IV. Medication Assisted Treatment Options</div>
<div class="container">
<div class="inner">
<div class="dialogue-container">
<div class="note">Medication-assisted treatment for opioid use disorder will be part of Dr. Wentworth's treatment. </div>
<div class="provider-dialogue">
<p> I'd like to review your options for medication-assisted treatment, Dr. Wentworth. You may or may not already be familiar with them. Basically, there's buprenorphine, methadone, or naltrexone. </p>
</div>
<div class="patient-dialogue">
<p> I'm familiar with them, and would like to avoid the possibility of any drug test I may have to take in the future coming up "positive", even if it is for a drug that is prescribed for treatment purposes. I'm going to be going through what looks like a pretty nasty divorce and my wife is asking that I be tested regularly in order to see my son, and some judges may not be sympathetic to narcotics used to treat addiction itself. I don't want anyone to be able to say I'm still dependent on a narcotic. </p>
</div>
<div class="provider-dialogue">
<p> In that case, after detoxification, for which we can use methadone or buprenorphine to manage your symptoms, I recommend .... </p>
</div>
</div>
</div>
<div class="navigation">
<div class="question">Please select a treatment for Dr. Wentworth:</div>
<div class="continue">[[Buprenorphine]]</div>
<div class="continue">[[Methadone]]</div>
<div class="continue">[[Naltrexone]]</div>
<div class="continue">[[No further medication assisted treatment]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Medication Assisted Treatment Options</p>
<div class="chapter"><strong>Ch 4 |</strong> Treatment Options</div><div class="progress chapter4"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose </strong>Buprenorphine</div>
<div class="container">
<div class="inner"><div class="feedback correct">Correct. This is one possible treatment. Review the dialogue to learn more. </div>
<div class="dialogue-container">
<div class="note">Excerpt from his intake interview: </div>
<div class="patient-dialogue">
<p> ...My ex-wife is asking that I be tested regularly in order to see my son. So I don't want anyone to be able to say I'm still dependent on a narcotic. </p>
</div>
<div class="provider-dialogue">
<p> In that case, after detoxification, for which we can use methadone or buprenorphine to manage your symptoms, I recommend naltrexone injections. Naltrexone offers the advantage over the other two FDA approved medication-assisted treatments for opioid use disorder, that naltrexone is not a narcotic. It's not quite as good at controlling cravings as buprenorphine or methadone, but it meets your criteria. </p>
</div>
<div class="patient-dialogue">
<p> That sounds good. I'm not as familiar with them as the other medications. What would treatment be like? </p>
</div>
<div class="provider-dialogue">
<p> It's a gluteal intramuscular injection. You need to go 7-10 days with no opioids before starting naltrexone to avoid precipitating withdrawal. We could start with daily injections while you are here to make sure this is a good treatment choice for you. Then we could switch to monthly injections of extended release naltrexone (Vivitrol) before you are released. There's just one dose, 380 mg, that's used for everyone. We would do a drug screen before each injection. Careful injection is important to avoid site reactions, so I recommend it be administered by a provider who is familiar with the techniques to reduce risk of reactions.</p>
</div>
<div class="patient-dialogue">
<p> OK. I appreciate you going over the warnings. I want to go ahead with it.
</p>
</div>
<div class="provider-dialogue">
<p> There are just a few more warnings. You should know that there is increased risk of overdose as you get near the end of an injection period and that you will be more sensitive to opioids, especially at that time. We would send you home with a naloxone kit. It would be best if you have someone close to you who you will see most often learn to use it. </p>
</div>
<div class="patient-dialogue">
<p> I do have a new girlfriend. We'll see if she's still there when I leave here.(laughs)</p>
</div>
<div class="provider-dialogue">
<p> (smiles with empathy)Finally, keep in mind that the medication is just part of recommended treatment. Counseling and social support are also essential. We'll start that here in residential treatment and it should also be continued long-term.</p>
</div>
<div class="patient-dialogue">
<p> Whew, O.K. Let's get started.</p>
</div>
</div>
<div class="note">Naltrexone would have better met Dr. Wentworth's requirements: Reference: www.Vivitrol.com, 2016
</div>
</div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="return">[[IV. Medication Assisted Treatment Options]]</div>
<div class="continue">[[V. Residential Treatment Summary]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Medication Assisted Treatment: Buprenorphine</p>
<div class="chapter"><strong>Ch 4 |</strong> Treatment Options</div><div class="progress chapter4"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
</div>
<div class="yourchoice"><strong>You chose: </strong>Methadone</div>
<div class="container">
<div class="inner"><div class="feedback neutral">This is one possible treatment. Review the dialogue to learn more.</div>
<div class="dialogue-container">
<div class="note">Excerpt from his intake interview: </div>
<div class="patient-dialogue">
<p> ...My ex-wife is asking that I be tested regularly in order to see my son. So I don't want anyone to be able to say I'm still dependent on a narcotic. </p>
</div>
<div class="provider-dialogue">
<p> In that case, after detoxification, for which we can use methadone or buprenorphine to manage your symptoms, I recommend naltrexone injections. Naltrexone offers the advantage over the other two FDA approved medication-assisted treatments for opioid use disorder, that naltrexone is not a narcotic. It's not quite as good at controlling cravings as buprenorphine or methadone, but it meets your criteria. </p>
</div>
<div class="patient-dialogue">
<p> That sounds good. I'm not as familiar with them as the other medications. What would treatment be like? </p>
</div>
<div class="provider-dialogue">
<p> It's a gluteal intramuscular injection. You need to go 7-10 days with no opioids before starting naltrexone to avoid precipitating withdrawal. We could start with daily injections while you are here to make sure this is a good treatment choice for you. Then we could switch to monthly injections of extended release naltrexone (Vivitrol) before you are released. There's just one dose, 380 mg, that's used for everyone. We would do a drug screen before each injection. Careful injection is important to avoid site reactions, so I recommend it be administered by a provider who is familiar with the techniques to reduce risk of reactions.</p>
</div>
<div class="patient-dialogue">
<p> OK. I appreciate you going over the warnings. I want to go ahead with it. </p>
</div>
<div class="provider-dialogue">
<p> There are just a few more warnings. You should know that there is increased risk of overdose as you get near the end of an injection period and that you will be more sensitive to opioids, especially at that time. We would send you home with a naloxone kit. It would be best if you have someone close to you who you will see most often learn to use it. </p>
</div>
<div class="patient-dialogue">
<p> I do have a new girlfriend. We'll see if she's still there when I leave here. (laughs) </p>
</div>
<div class="provider-dialogue">
<p> (smiles with empathy)Finally, keep in mind that the medication is just part of recommended treatment. Counseling and social support are also essential. We'll start that here in residential treatment and it should also be continued long-term. </p>
</div>
<div class="patient-dialogue">
<p> Whew, ok. Well, let's get started. </p>
</div>
</div>
<div class="note">Naltrexone would have better met Dr. Wentworth's requirements: Reference: www.Vivitrol.com, 2016
</div>
</div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="return">[[IV. Medication Assisted Treatment Options]]</div>
<div class="continue"> [[V. Residential Treatment Summary]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Medication Assisted Treatment: Methadone</p>
<div class="chapter"><strong>Ch 4 |</strong> Treatment Options</div><div class="progress chapter4"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
</div>
<div class="yourchoice"><strong>You chose:</strong>Naltrexone</div>
<div class="container">
<div class="inner"><div class="feedback correct"> This is one possible treatment. In the following dialogue, you will learn that this option best meets Dr. Wentworth's requirements. Review the dialogue to learn more. </div>
<div class="dialogue-container">
<div class="patient-dialogue">
<p> ...My ex-wife is asking that I be tested regularly in order to see my son. So I don't want anyone to be able to say I'm still dependent on a narcotic. </p>
</div>
<div class="provider-dialogue">
<p> In that case, after detoxification, for which we can use methadone or buprenorphine to manage your symptoms, I recommend naltrexone injections. Naltrexone offers the advantage over the other two FDA approved medication-assisted treatments for opioid use disorder, that naltrexone is not a narcotic. It's not quite as good at controlling cravings as buprenorphine or methadone, but it meets your criteria. </p>
</div>
<div class="patient-dialogue">
<p> That sounds good. I'm not as familiar with them as the other medications. What would treatment be like? </p>
</div>
<div class="provider-dialogue">
<p> It's a gluteal intramuscular injection. You need to go 7-10 days with no opioids before starting naltrexone to avoid precipitating withdrawal. We could start with daily injections while you are here to make sure this is a good treatment choice for you. Then we could switch to monthly injections of extended release naltrexone (Vivitrol) before you are released. There's just one dose, 380 mg, that's used for everyone. We would do a drug screen before each injection. Careful injection is important to avoid site reactions, so I recommend it be administered by a provider who is familiar with the techniques to reduce risk of reactions.</p>
</div>
<div class="patient-dialogue">
<p> OK. I appreciate you going over the warnings. I want to go ahead with it.</p>
</div>
<div class="provider-dialogue">
<p> There are just a few more warnings. You should know that there is increased risk of overdose as you get near the end of an injection period and that you will be more sensitive to opioids, especially at that time. We would send you home with a naloxone kit. It would be best if you have someone close to you who you will see most often learn to use it. </p>
</div>
<div class="patient-dialogue">
<p> I do have a new girlfriend. We'll see if she's still there when I leave here. (laughs)</p>
</div>
<div class="provider-dialogue">
<p> (smiles with empathy)Finally, keep in mind that the medication is just part of recommended treatment. Counseling and social support are also essential. We'll start that here in residential treatment and it should also be continued long-term.</p>
</div>
<div class="patient-dialogue">
<p> Whew, ok. Well, let's get started. </p>
</div>
</div>
<div class="note">Naltrexone best meets Dr. Wentworth's requirements: Reference: www.Vivitrol.com, 2016
</div>
</div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="return">[[IV. Medication Assisted Treatment Options]]</div>
<div class="continue">[[V. Residential Treatment Summary]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Medication Assisted Treatment: Naltrexone</p>
<div class="chapter"><strong>Ch 4 |</strong> Treatment Options</div><div class="progress chapter4"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
</div>
<div class="yourchoice"><strong>You chose: </strong>No further medication assisted treatment</div>
<div class="container">
<div class="inner"><div class="feedback incorrect">Incorrect. No further treatment after detoxification is associated with a very high relapse rate. Current guidelines for treating opioid used disorder recommend long term maintenance on an FDA-approved medication assisted treatment (Dowell et al., 2016). Naltrexone would have met Dr. Wentworth's requirements.</div>
<div class="content">Review this excerpt from Dr. Wentworth's intake interview: </div>
<div class="dialogue-container">
<div class="patient-dialogue">
<p> ...My ex-wife is asking that I be tested regularly in order to see my son... So I don't want anyone to be able to say I'm still dependent on a narcotic. </p>
</div>
<div class="provider-dialogue">
<p> In that case, after detoxification, for which we can use methadone or buprenorphine to manage your symptoms, I recommend naltrexone injections. Naltrexone offers the advantage over the other two FDA approved medication-assisted treatments for opioid use disorder, that naltrexone is not a narcotic. It's not quite as good at controlling cravings as buprenorphine or methadone, but it meets your criteria. </p>
</div>
<div class="patient-dialogue">
<p> That sounds good. I'm not as familiar with them as the other medications. What would treatment be like?</p>
</div>
<div class="provider-dialogue">
<p> It's a gluteal intramuscular injection. You need to go 7-10 days with no opioids before starting naltrexone to avoid precipitating withdrawal. We could start with daily injections while you are here to make sure this is a good treatment choice for you. Then we could switch to monthly injections of extended release naltrexone (Vivitrol) before you are released. There's just one dose, 380 mg, that's used for everyone. We would do a drug screen before each injection. Careful injection is important to avoid site reactions, so I recommend it be administered by a provider who is familiar with the techniques to reduce risk of reactions. </p>
</div>
<div class="patient-dialogue">
<p> OK. I appreciate you going over the warnings. I want to go ahead with it. </p>
</div>
<div class="provider-dialogue">
<p> There are just a few more warnings. You should know that there is increased risk of overdose as you get near the end of an injection period and that you will be more sensitive to opioids, especially at that time. We would send you home with a naloxone kit. It would be best if you have someone close to you who you will see most often learn to use it. </p>
</div>
<div class="patient-dialogue">
<p> I do have a new girlfriend. We'll see if she's still there when I leave here. (laughs) </p>
</div>
<div class="provider-dialogue">
<p> (smiles with empathy)Finally, keep in mind that the medication is just part of recommended treatment. Counseling and social support are also essential. We'll start that here in residential treatment and it should also be continued long-term. </p>
</div>
<div class="patient-dialogue">
<p> Whew, ok. Well, let's get started. </p>
</div>
</div></div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="return">[[IV. Medication Assisted Treatment Options]]</div>
<div class="continue">[[V. Residential Treatment Summary]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Medication Assisted Treatment: No further medication assisted treatment</p>
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</div>
<div class="yourchoice"><strong>You chose: </strong>Review Employee Record</div>
<div class="container">
<div class="inner"><div class="feedback correct">Good choice in your role as an administrator</div>
<div class="content">
<strong>Employee Record</strong><br/>
<strong>Name:</strong> Peter Wentworth<br/>
<strong>Age:</strong> 30<br/>
<strong>Hiring Date:</strong> (date 3 months ago)<br/>
<strong>Previous position:</strong> Residency in Anesthesiology, St Ambrose University Hospital<br/>
<strong>References:</strong> Strong recommendation by former residency program director; moderately endorsed by two other anesthesiologists from St. Ambrose<br/>
<strong>Problems Reported:</strong><ol><li>(date 1 week ago) Dr. Wentworth missed a department staff meeting with no notice. Disposition: Emailed a copy of the department's policy for attendance at department meetings to Dr. Wentworth.
<li>(date 2 weeks ago) Dr. Wentworth was reported for not responding to pages three times. The reporting nurse also noted that Dr. Wentworth has seemed distracted and forgetful, which has resulted in several minor errors in his documentations in patient records that he corrected when she brought them to his attention. She thinks he appears to be sleep deprived. Disposition: Anesthesia Chair, Dr. Adams, met with Dr. Wentworth who explained that he has an infant son who wakes him at night a lot which has been interfering with his sleep. He promised to take steps to assure that he gets more sleep and to be more careful.</li>
<li>(date 1 month ago) Patient complained of "poor bedside manner" by Dr. Wentworth during pre-op visit. With further inquiry, the complaint was distractedness, curtness, and lack of empathy. No witnesses. Disposition: Dr. Adams discussed the problem with Dr. Wentworth who denied there was a problem. He attributed the patient's complaint to dysphoria caused by acute pain. He agreed to be careful and show empathy in his communications with patients. </li></ol>
</div>
</div>
<div class="navigation">
<div class="question">Where would you like to go next?</div>
<div class="return">[[I. Review Available Information]]</div>
<div class="continue">[[II. Meet with Dr Wentworth]]</div>
<div class="continue">[[Insufficient evidence to interview Dr Wentworth]]</div>
</div>
</div>
<div class="footer">
<p class="small">You are here: Review Available Information - Review Employee Record</p>
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