Alcohol and Substance Use Disorders in Veterinary Medicine Part 3
This is our third and final article in the series of alcohol and substance use disorders and its impact on veterinary medicine. In the previous two articles, we discussed:
The diagnostic criteria for alcohol and substances use disorders
The prevalence and costs associated with alcohol and substance use disorders
The impact of AUD/SUD on veterinary medicine
The history of addiction treatment in the U.S.
The advancements in the neurobiology of addiction
The Americans with Disability Act of 1990
Today, we’ll discuss the AVMA’s guidance on impairment; the assessment process for AUD/SUD; the American Society of Addiction Medicine (ASAM) Criteria and treatment; and recovery, including return to practice.
Assessment and Treatment Specific to Veterinarians
Veterinary medicine, like human medicine, is considered a “safety-sensitive” profession by state licensing boards and other professional organizations. This means their job duties could affect the safety of others. As such, the American Veterinarian Medical Association (AVMA) provides guidance on the issue of impairment. The Principle of Veterinary Medical Ethics of the AVMA, under The Principles with Supporting Annotations, Section 3 (9), states (https://www.avma.org/resources-tools/avma-policies/principles-veterinary-medical-ethics-avma),
Veterinarians who are impaired must not act in the capacity of a veterinarian and shall seek assistance from qualified organizations or individuals. Colleagues of impaired veterinarians should encourage those individuals to seek assistance and to overcome their impairment.[i]
Impairment issues as a result of mood-altering substances can result in the suspension or revocation of someone’s veterinary license. However, each state, including the District of Columbia, has a state board of veterinary medicine that recognizes impairment from mood-altering substances as a medical illness (or disability).
Most state licensing boards offer a confidential non-disciplinary alternative for a person working in a safety-sensitive field, such as veterinary medicine. When a veterinarian is ready to return to work, there is a process that not only protects the public, but also the veterinarian. The next section outlines the process of treatment.
Assessment
If a healthcare professional has an impairment as a result of alcohol or substance misuse, a professional assessment is recommended. The assessment should be performed by a physician with a certification in addiction medicine, preferably a psychiatrist. Although any physician with a certification in addiction medicine can conduct an assessment, a psychiatrist will also be able to evaluate for any co-occurring disorders (depression, mood disorder, etc.), which occurs in approximately 38% of persons diagnosed with either AUD or SUD.[ii]
Solo practitioners can provide an assessment, but a three- or four-day in-patient assessment is considered a more robust evaluation and is often preferred by monitoring organizations, such as a Professionals Health Program. An in-patient assessment is conducted by a team of behavioral health professionals that include a psychiatrist, a psychologist, a psychiatric nurse, a mental health professional (e.g., social worker), and other clinical staff. The assessment team typically works at an inpatient facility that specializes in working with healthcare professionals, such as nurses, physicians, and veterinarians and is familiar with the unique role healthcare professionals serve.
Whether it is a sole practitioner or an assessment team, the American Society of Addiction Medicine Criteria, or the ASAM Criteria serve as a comprehensive set of guidelines for patient assessment and placement in treatment (if warranted). The next section will discuss the ASAM Criteria.
American Society of Addiction Medicine
In a previous section, we discussed the diagnostic criteria for an alcohol and substance use disorder using either the DSM-5-TR[iii] or the ICD-11.[iv] In this section we’ll discuss the criteria used to determine the level of impairment from mood-altering substances. The level of impairment is used to help determine whether someone is in need of treatment, and if so, whether inpatient or outpatient.
The American Society of Addiction Medicine (ASAM) was founded in 1954 seeking to “improve the treatment of alcoholism and other addictions, educating physicians and medical students, promoting research and prevention, and enlightening and informing the medical community and the public about these issues.”[v] In addition to their many CME courses, they also provide an Addiction Medicine Certification for physicians as a medical subspecialty.
The ASAM Criteria for treatment guidelines for patients are considered not only the standard but is now considered the national criteria (U.S.) for providing an accurate assessment and treatment recommendations. The Six Dimensions of the ASAM Criteria[vi] ( https://www.asam.org/asam-criteria/about-the-asam-criteria) are:
Acute Intoxication and/or Withdrawal Potential
Exploring an individual’s past and current experiences of substance use and withdrawal
Biomedical Conditions and Complications
Exploring an individual’s health history and current physical health needs
Emotional, Behavioral or Cognitive Conditions and Complications
Exploring an individual’s mental health history and current cognitive and mental health needs
Readiness to Change
Exploring an individual’s readiness for and interest in changing
Relapse, Continued Use or Continued Problem Potential
Exploring an individual’s unique needs that influence their risk for relapse or continued use
Recovery Environment
Exploring an individual’s recovery or living situation, and the people and places that can support or hinder their recovery.
When the ASAM Criteria has been completed, the results are used to inform the evaluation team through the ASAM Continuum of Care tool (https://www.asam.org/asam-criteria/asam-criteria-software/asam-continuum) of the appropriate level of care for a patient. The four levels of care are:
Level 1: Outpatient
Level 2: Intensive Outpatient (IOP) / Partial Hospitalization
Level 3: Residential / Inpatient
Intensive Inpatient
Treatment
Treatment for an AUD/SUD begins with a professional assessment, followed by a level of care that ranges from outpatient, intensive outpatient (IOP), or inpatient depending on the severity of the impairment. For inpatient treatment, a length of stay can be from 45-90 days. It is a structured daily routine that includes:
Individual therapy
Specialized group therapy that addresses the needs of healthcare professionals
Education on addictions
Symptom management
Life skills education
Gender-specific classes
Nutrition groups
Group activities
Family therapy
Treatment is often thought of as a one-time event, but addiction medicine defines an AUD or SUD as a chronic medical illness. Similar to other chronic medical illnesses like Diabetes or heart disease, an addiction requires daily adherence to what is referred to as a Recovery Plan. Recovery Plans are developed in collaboration with a treatment provider and serve as a map for living and working without the use of mood-altering substances.
Once a healthcare professional is deemed safe to practice medicine, they can return to work. This is usually done in coordination with a Professionals Health Program, who will incorporate the discharge treatment plan into a monitoring agreement.
Professionals Health Program
Several states have their own Veterinary Professional Program or a Professionals Health Program that offer a confidential non-disciplinary alternative for healthcare professionals impaired from mood-altering substances or mental illness. A Professionals Health Program serves to provide monitoring for healthcare professionals to ensure they are safe to practice medicine. A monitoring agreement usually incorporates the treatment recommendations made by a treatment provider or inpatient facility and include random toxicology testing, workplace monitoring, etc.
An example of a monitoring agreement may include weekly individual and group psychotherapy with a licensed mental health professional who specializes in AUD and SUD. Often a monitoring agreement plan will include a workplace monitor who is someone familiar with the individual’s work and is in a supervisory role. Each monitoring agreement is individually tailored for each person to help them sustain their recovery.
Professional monitoring can vary from one to five years, depending on the licensing board requirements or the treatment recommendations made by an addiction professional or treatment facility. Outcome studies on the abstinence rates for physicians who complete a 5-year monitoring program are 78% in the U.S.[vii] Numerous replication studies have confirmed this.
Please consult your state veterinary board for a list of organizations that offer a confidential non-disciplinary alternative.[viii]
https://www.avma.org/advocacy/state-local-issues/state-wellbeing-programs-veterinary-professionals
Resources
National Institute on Alcohol Abuse and Alcoholism. The NIAAA website provides information on various aspects of alcohol and its effects on people as well as getting help. https://www.niaaa.nih.gov/
National Institute on Drug Abuse. A Federal agency supporting scientific research on drug abuse, substances, and its consequences. https://nida.nih.gov/
National Council on Alcoholism and Drug Dependence. NCADD is an advocacy organization addressing alcoholism and drug dependence in the U.S. The NCADD website provides education as well as resources related to alcohol and substance misuse. https://ncadd.us/
International Doctors in Alcoholic Anonymous. IDAA is a worldwide fellowship of more than 9,900 healthcare professionals and their families who strive to help one another to achieve and maintain recovery from addictions. Caduceus meetings are located on this site for members. There is an annual membership fee and one must be a recovering healthcare professional in order to become a member. https://www.idaa.org/
Alcoholics Anonymous. AA is a fellowship of people who come together to solve their drinking problem. AA uses what is referred the 12-Steps and is overwhelmingly required for healthcare professionals in monitoring programs. AA is free. https://www.aa.org/
Narcotics Anonymous. NA offers recovery to addicts around the world. NA uses what is referred the 12-Steps and is overwhelmingly required for healthcare professionals in monitoring programs. NA is free. https://www.na.org/
Federation of State Physician Health Programs. The FSPHP is an on-line resource for the U.S. states and Canadian providences that offer information on monitoring. https://www.fsphp.org/state-programs
Conclusion
In this series on alcohol and substance use disorders, we’ve discussed the diagnostic criteria used, the ASAM Criteria, the neurobiology of addiction, and assessment and treatment for veterinarians. We also outlined the process assessment, treatment, and monitoring as part of a non-disciplinary alternative to license suspension or revocation.
The resources provided offer a more comprehensive explanation of addiction and its effects on the brain. AA/12-Step resources have been provided as they are the most often utilized in conjunction with monitoring programs. A Cochran Review, internationally recognized as the highest standard in evidence-based health care, found AA/12-Step to be more effective than other established treatments such as Cognitive Behavioral Therapy (CBT) and just as effective as other treatments.[ix]
References
[i] American Veterinarian Medical Association. (2022a). Principles of veterinary medical ethics of the AVMA. Retrieved on-line, May 16, 2022: https://www.avma.org/resources-tools/avma-policies/principles-veterinary-medical-ethics-avma
[ii] Han, B., Compton, W.W., Blanco, C., and Colpe, L.J. (2017). Prevalence, treatment, and unmet treatment needs of U.S. adults with mental health and substance use disorders. Health Affairs 36, No. 10: 1739-1747. 10.1377/hlthaff.2017.0584
[iii] American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Arlington, VA, American Psychiatric Association, 2022.
[iv] World Health Organization. (2019). ICD-11: International classification of diseases (11th revision). Retrieved from https://icd.who.int/
[v] American Society of Addiction Medicine. (2021). Constitution and bylaws, constitution, article 1, name, purposes, and organization, section 2, purposes. Retrieved on-line, May 16, 2022: https://sitefinitystorage.blob.core.windows.net/sitefinity-production-blobs/docs/default-source/aboutus/asam-constitution-and-bylaws.pdf?sfvrsn=e0ec0ff4_3
[vi] American Society of Addiction Medicine. (2022). About the ASAM criteria. Retrieved on-line, May 16, 2022: https://www.asam.org/asam-criteria/about-the-asam-criteria
[vii] DuPont, R., McLellan, A.T., White, L.W., Merlo, L.J., and Gold, M.S. (2009). Setting the standard for recovery: Physicians’ health programs. Journal of Substance Abuse Treatment 36, 159-171.
[viii] American Veterinarian Medical Association. (2022b). State wellbeing programs for veterinary professionals. Retrieved on-line on May 16, 2002: https://www.avma.org/advocacy/state-local-issues/state-wellbeing-programs-veterinary-professionals
[ix] Kelly, J.F., Humphreys, K., and Ferri, M. (2020). Alcoholics anonymous and other 12-step programs for alcohol use disorder. Cochrane Database of Systematic Review, Issue 3. Art. No.: CD012880. DOI: 10.1002/14651858.CD012880.pub2.