Our guest: Rebecca Payne, MD Medical Director, South Carolina Recovering Professional Program
In the critical world of healthcare, ensuring the well-being of both patients and professionals is paramount. Today, we’re joined by Dr. Rebecca Payne, Medical Director of South Carolina’s Recovering Professionals Program, a vital resource dedicated to helping healthcare professionals overcome substance use disorders (SUDs) and safely return to the workforce. But the program’s reach extends beyond solely addressing SUDs. Dr. Payne will shed light on the program’s insightful intake assessments, revealing that sometimes, the path to recovery diverges, with alternative mental health challenges needing different pathways to ensure both professional success and patient safety. Join us for a compelling conversation about second chances, patient protection, and the nuanced understanding of mental health within the healthcare field.
Transcript:
Terri
Welcome back, listeners, to diversion insights. My guest today is Doctor Rebecca Payne. She is the medical director for the South Carolina Recovering Professionals program. Some of you know, I’m kind of working my way through the states and their recovery programs. And so today we’re going to learn about South Carolina. Doctor Payne, welcome. Please tell us a little bit about you and your professional journey up until this point.
Dr. Payne
Sure. Absolutely. Thank you so much for having me, Terri. I’m really looking forward to this. So I actually joined the South Carolina recovering professional program about, it was in the middle of the pandemic, so in July of 2020. But prior to that, I’m a psychiatrist by training and completed my general psychiatry residency training at the Medical University of South Carolina. I fell in love with the treatment of addiction at that time and completed an addiction psychiatry fellowship there. And then I went into practice both on an inpatient unit and outpatient clinic treating comorbid psychiatric and mental health disorders at the University of South Carolina in their department there.
Dr. Payne
While I was in the department, because of my expertise in addiction psychiatry, I began receiving referrals to evaluate professionals that had the potential for impairment and that, you know, introduced me to a field, you know, I previously had little experience with and just really began enjoying that type of work. And so I actually sort of shifted gears, if you will, and completed forensic psychiatry fellowship in order to bring these two things together. And then shortly thereafter joined the recovering professional program in July of 2020. I thought working in that capacity brings, you know, psychiatry, addiction psychiatry, and then the ability to evaluate and look at things objectively all together very well.
Terri
Sure. Yeah. So I’m curious, because of your history with mental health and addiction and comorbidities, just anecdotally, do you feel that mental health issues are getting worse? I mean, you hear that it’s like, oh, it’s worse. I don’t know if we’re just more aware of it, more in tune, especially after COVID, where, you know, people were maybe speaking up a little bit more. Do you, do you feel it’s getting worse?
Dr. Payne
I think it’s a mix of all of those things. You know, obviously, we can’t ignore the impact that the pandemic has had on our collective mental health. But I will say, even before pre pandemic, as I was teaching medical students and residents, you know, my, I often said, I believe that comorbidity of mental health disorders and addiction was the rule rather than the exception. You just had to be able to interview the patient and ask the right questions regarding the mental health component. They’re so highly comorbid with one another. I do believe, though, that the pandemic has allowed. And post pandemic, you know, people do seem a little bit more willing to talk about mental health and the impact of mental health.
Dr. Payne
So I, you know, my best guess is it’s probably sort of a myriad of those factors coming together, that we are having more conversations about mental health, which is obviously a good thing.
Terri
Sure. Yeah. Probably always been there. Maybe some managed their mental health better prior to the pandemic, and then, of course, it’s more acceptable, shall we say, to talk about it now, because it’s not just you feeling like you’re alone. Everyone is saying, oh, this has affected. So people, I think, are more open to talking about it, I guess. All right, so tell us about the program. What licensed professionals does the South Carolina recovering professional program cover?
Dr. Payne
Sure. So we are. We are a state that actually covers all the healthcare professionals across the board. So in theory, we could potentially manage licensees for 30 different boards. So in theory, you know, we always. We don’t have licensees from all 30 of those boards at the same time. Our largest representation is from the board of nursing, board of medicine, board of dentistry, and then also from the board of pharmacy.
Terri
Okay. Yeah, I know. Board of dentistry has always fascinated me a little bit. I should probably have somebody on that can really speak to that field. They don’t have access, necessarily. Right. So I would guess it’s mostly prescription writing for themselves.
Dr. Payne
Well, it depends on what type of anesthetic they use in the office. So it could be, you know, nitrous oxide availability and accessibility. And then obviously, there’s, you know, the prescription writing, you know, alcohol being freely accessible to all. We see that quite a bit in that profession as well. So there is some accessibility depending on the person’s practice setting.
Terri
Okay. All right. Yeah, because I know they do. I’ve heard that more than once. They represent a pretty high percentage, which. Okay, yeah, I find that a little bit interesting, but we’ll dig into that another time. What is the mission of your program and what aspects of the recovery does it include? Assessment, treatment, monitoring, that type of thing.
Dr. Payne
Sure. Yeah. So our mission as the South Carolina Recovering professional program is to return the professional to safe practice. You know, a corollary to that is obviously also protecting the public. And oftentimes those two things, more often than not, they go hand in hand. So. But we are an alternative to discipline, if you will, program. Meaning we take people who are referred from their boards, we also take individuals who voluntarily come to us, and depending on the circumstances, they can participate in our program and remain anonymous to their board throughout the duration of their monitoring. We usually have somewhere about 30% of voluntary participants, but I can talk a little bit more about that in a minute in terms of what we do. So we are an entity that we assist the labor and Licensing and regulation board of South Carolina.
Dr. Payne
So when they refer someone to us that has a potential or there’s a concern about potential impairment, we do take information from the referral source, and that can be a host of different places or entities and determine what problems may be present. Sometimes that’s very clear, sometimes it’s not. And then we do refer for an evaluation that can look into some of the factors and then determine whether there’s a diagnosis that would warrant monitoring with the South Carolina recovering professional program. So I always like to point out that, you know, we. We don’t offer the treatment. We act as, you know, sort of a liaison, if you will, between the board and the participant. And our goal in that capacity is to get that person back to safe practice and protect the public.
Terri
Okay, so I imagine then you also are involved. If they come to you’re doing that full assessment, and you may turn them back out and say, this person does not have a substance use disorder. So the investigation that is going on, that’s your professional opinion? There’s something else. It’s a practice issue or what have you.
Dr. Payne
Absolutely. And we actually have looked into that, and this data is a little bit old, I believe 2018 to 2022, that five year period. But we did look into, you know, about 15% to 20% of individuals who are referred to us actually didn’t have a diagnosis that warranted monitoring.
Terri
Okay, interesting. And how can you give just a little bit of insight? Obviously, you’re the experts. You know, I’m thinking about, I perform an interview and I’m talking to somebody, and they just. No, no, no. You know, and I’m like, what goes into that assessment? I mean, how. I guess. I mean, my real question is, how is it easy? Is it for them to fool you that they don’t have anything going on?
Dr. Payne
Well, and so I think, you know, it is dependent upon the allegations that bring the person to us, or if this is someone who, you know, acknowledges that they have a problem and comes to us on their own or in referral from their employer, but oftentimes, so the evaluation can vary. I do conduct some of our evaluations in house, but when I’m looking at someone, I’m going to consider, you know, what is the allegation? I’m going to look at the toxicology that is available. And we typically do get initial toxicology as part of the intake process. If there’s collateral informants that they would permit us to speak with, we do that.
Dr. Payne
We can also request review of any medical records or treatment that they may have had, especially if the substance in question may be something that they were prescribed or potentially could have been prescribed, and that sort of a thing. So depending on the evaluator and the circumstances of the case, medical record review, looking at toxicology, considering collateral informants, and then obviously the clinical interview and history is very important. And then there was some. One of, oh, sometimes psychological or neurocognitive testing is also involved in that initial evaluation. Usually that’s if there is some concern regarding cognition, memory loss, et cetera and so on.
Terri
Okay. All right. So, yeah, you have access to a lot of things that somebody in my position certainly wouldn’t, and then I don’t have the expertise either for that piece of it. Okay, that sounds great. Now, you mentioned that the referrals could come from the licensing board, or a person can come directly from you or to you if it comes from a hospital. Are hospitals required to report to the licensing board, or can they go to you in lieu of the licensing board?
Dr. Payne
It depends. You’re going to hear a lot of it depends simply because in the practice acts here in South Carolina, it is divided by the different disciplines. And so nursing does have some statutes for required reporting, and the remainder of the disciplines refer to the hospital’s regulations also to typically the major organization for that discipline, their ethical code, like, such as the AMA or what have you. So we can get referrals in. I mean, it really can run the gamut, I would say. You know, usually when it’s an employer, you know, it could be the human resources, it could be from the employee assistance program if they identify an issue that they don’t feel like they’re capable of managing. You know, sometimes participants come on their own for various reasons. Right.
Dr. Payne
The prompting of a spouse for, you know, credentialing reasons, all of those types of things.
Terri
Okay. So the. The only sure way that the licensing board will not find out, because I believe you said that you won’t tell them, right. Is for, if somebody comes to you directly before there’s any involvement with the employer or anything. Is that correct?
Dr. Payne
Let me make sure I understand your question. So for somebody that comes voluntarily. Yes. So voluntary participants are handled a little bit differently according to their board’s preferences. As a general rule, if somebody comes into us voluntarily and they maintain adherence and they’re doing well in the program, those individuals can remain unknown to the board throughout the duration. Now you can get into some nuances when there’s, you know, issues of problems in terms of at what point does that individual then become known to the board? But that varies quite a bit. And obviously, you know, the circumstances under which that would take place could vary. We try, obviously, within reason to, I won’t say assist, but I guess that’s fine.
Dr. Payne
You know, try to be very clear with those voluntary participants, you know, what would the circumstances be in which you would not become volunteer, you know, at which time you would then become known to their board.
Terri
Okay, sure. Well, keeping in mind your mission of getting them safely back to work and protecting your patients, I suspect that if somebody came in voluntarily, went through the program, was successful participating, everything looked safe, then they could remain unknown to the board. But if it looked like this might be, they’re relapsing, they’re struggling, they’re not participating, what have you. Then it’s your duty to report them to the board because it’s a patient safety issue at that point.
Dr. Payne
Yeah, that’s exactly right. But generally, if they’re doing what’s been asked of them and things are going, you know, fine, they remain unknown.
Terri
Right. You give them that opportunity to remain unknown in your state. Do you know, and it, this may be different. I know some states, once the licensing board is made aware of it, whether you end up back at work or not and your license cleared, it remains on your license that you had that history. Do you, are you aware, I guess let’s just focus on nursing, if that’s your biggest.
Dr. Payne
Well, the board actually has discretion whether the final order is public or private. And so they, you know, I’ve seen them issue both. And again, it sort of vary depending upon the circumstances, but there is the possibility that, you know, there’s a private order issue, and that’s not something that is privy to the general public.
Terri
Okay. And if it is public, does it remain there forever?
Dr. Payne
That’s my understanding.
Terri
Okay. All right. Yeah. Okay. So you mentioned your program doesn’t participate in the treatment process, but how does it handle the monitoring process in terms of medication assisted treatment? That’s kind of a hot topic. Right. Like, is it okay to go back to work on mat, so how does your program handle that and what does the monitoring look like, if any? If they do go back on mat?
Dr. Payne
Sure. And again, in South Carolina, you know, we do manage many different disciplines, so it varies between. I’ll talk about the board of Nursing’s approach. And actually to do that, let me back up a little bit. So it was several years ago, I think it was late 2020, early 2021. You know, we, as RPP and some representatives from the board of nursing at that time formed a subcommittee to look at this issue and see, you know, what monitoring would look like if someone was on medication assisted treatment. And actually, I’m going to be more specific and say buprenorphine. So that was the particular mat that was considered by that subcommittee. And so over time in several, you know, several meetings, were able to outline what that would look like. And then that was presented to the full board for approval.
Dr. Payne
And the full board did approve their licensees to monitor while on buprenorphine under our program. And so your question, I believe, was, what does that look like? And so, you know, some of it depends on how the person comes in. You know, sometimes somebody comes in already on buprenorphine, and at that point in time, you know, we would be able to look at, you know, how long have they been on it? Has their dose been stable, what their treatment courses look like, et cetera and so on. Also to the evaluator when they come in. You know, the, that initial evaluation would consider those factors as well.
Dr. Payne
It’s a little, that scenario is a little bit different than if somebody, you know, for instance, there was an allegation regarding diversion of an opiate of some sort, and they were found to have an opioid use disorder and recommended for treatment with buprenorphine. So, you know, the process from that point would be, you know, they are expected to stabilize on a dose and have a prescriber that has training in the treatment of addiction once that dose has been stabilized. And that timeframe, there’s no specifics regarding that timeframe. It’s how long has the person been on it, and then whether it’s considered stabilized or not is between the participant and the treating provider.
Dr. Payne
And so at that time, when it’s determined to have be stable, you know, the board of nursing did make a request that some neurocognitive testing take place to ensure there was no cognitive impairment at that particular dose. And then, you know, once the participant completes that, assuming it was successful, you know, they are able to, you know, they’re monitoring with us through this process, and then they would monitor almost as if it was, you know, any other substance we do test for the presence of the buprenorphine. Not every single toxicology test, but, you know, randomly from time to time, and then oftentimes are in communication with the prescriber, particularly if there’s any, you know, concerns or anticipated medication changes, that sort of a thing. But we maintain that communication and then test for the presence of the.
Dr. Payne
Of the buprenorphine and then any other treatment recommendations that may have come from, you know, their evaluation process, we would follow along with that.
Terri
Sure. How long do you typically continue to monitor?
Dr. Payne
Well, in South Carolina, so it depends. And, you know, one thing, too, that I didn’t point out earlier, and I should have you. South Carolina. Traditionally, we started in 2000, and from 2000 until 2020, our program only monitored for impairing substance use disorders. In 2020, our scope was expanded by labor, licensing, and regulation in our state to include not only impairing substance use disorders, but also potentially impairing mental health disorders and also some professional issues, etcetera. So in terms of monitoring and the duration of monitoring, if we’re just talking about a substance use disorder that’s driven by the severity. So, you know, according to the Diagnostic and statistical manual, the fifth edition, DSM five, mild, moderate, or severe, is outlined. And so depending on what the severity of the substance use disorder is, that can inform the duration of monitoring.
Dr. Payne
If it’s a moderate or severe use disorder, it’s typically a five year monitoring period. If it’s mild, if the individual does well, they can actually finish in two. Now, if it’s an impairing mental health condition, oftentimes the duration of monitoring is really driven by the recommendation of the evaluator.
Terri
Okay. So does medication assisted treatment versus not play into how long they’re monitored?
Dr. Payne
It does not.
Terri
Okay.
Dr. Payne
You know, again, it just kind of goes back to what was the severity of the opioid use disorder? Presumably, if they’re on buprenorphine, it was moderate to severe, which would be five years.
Terri
Okay. And do you know, you talked about the nursing program. Our physicians allowed mat as well. And back to practice. Does it work the same for them?
Dr. Payne
No. So we have not had a similar process with the board of medical examiners. Participants would present before the board of medical examiners in those instances for further discussion.
Terri
Okay. All righty. Do you have any statistics on the rate of long term recovery for those that go through the program in South Carolina?
Dr. Payne
Don’t have long term statistics. I do. We keep statistics about recurrence to use of our participants that are currently in the program. Just honestly, it comes down sort of a logistics issue. You know, tracking people after they’re done can sometimes become sort of a bear. But, you know, our reoccurrence rates in our program, they typically hover around 15% while they’re in the program. And we could break it down by, you know, what year does that typically happen in those types of things?
Terri
Yeah, that would be interesting, actually, what year it happens. And it’s. I think that’s one concern. When they’re back to work, you know, how long do we need to treat this person as different? We need to really keep an eye on things extra versus. Okay, now they’re. They’re good. They’re good to go, you know, I don’t know when that happens. Probably different for everybody.
Dr. Payne
It is. And, you know, too, I think it is absolutely influenced by what does access look like? Sure. What was the, you know, what substance to the use disorder? Yeah, what type of substance? What was the use disorder also, too. And you’ve probably found this in looking at all the different states in their programs. You know, some states actually, you know, start the monitoring when the individual is, or the monitoring duration is measured while the person is in practice. So, you know, their monitoring period, for instance, wouldn’t start until they resumed working as a nurse. And then that monitoring period, say, is three years. So it’s three years working as a nurse. Monitoring. We don’t have that in South Carolina.
Dr. Payne
So once the individual, you signs the monitoring agreement with us, you know, monitoring starts at that time, whether they’re practicing in their field or not.
Terri
Okay. Yeah. And it also varies, I’m sure, with how much help they’re getting for that mental health piece of it, you know? Right. Are they addressing their issues, the other issues that go with that? Okay. So I always like to kind of humanize substance use disease for our listeners because I just think that gives a bigger picture, and it also lends the facility to being more open to the reentry process. If we realize that, you know, this is just another disease, and while, yes, it does affect patient safety, we can do things to mitigate that risk and also do something for the healthcare professional. Do you have any stories that you can share with us from those who went through your program and just had their lives changed with recovery?
Dr. Payne
So I’ve given this some thought. I don’t have any one particular example. I think what strikes me the most, so I’m approaching my fourth year in this role. What strikes me the most is at the end of a monitoring agreement or monitoring contract. We do an exercise interview and ask lots of different questions, what could have been better? How can we improve what, you know, and oftentimes the feedback that we get is, you know, I was angry. I was upset in the beginning, didn’t understand, you know, why I was being asked to do some of these things. And then, you know, at the end of it, they say, you know, thank you. This saved my life. If I didn’t have this accountability, even though I came in kicking and screaming, I got the treatment that I needed. It saved my life.
Dr. Payne
I have relationships now. I have stable employment. I have my self respect back. That’s theme that’s heard time and time again in those exit interviews is I didn’t want to be here initially, but now I’m, you know, eternally grateful. And oftentimes we, you know, at the end of monitoring professionals say, you know, tell me who I can talk to. Like, I’d love to talk to new people coming in and let them know, you know, I was scared, too. I was fearful, but it’s going to be okay. And actually it’s going to be, your things are going to get better. You can get back to life. And I think that’s, you know, every time one of those is conducted and we look at those on a quarterly basis, the feedback coming back from that because we’re constantly looking on, you know, at ways to improve.
Dr. Payne
But so that’s always encouraging to hear.
Terri
Yeah, yeah. And that is a message that I have heard time and time again. And I think that also is important for those at the facilities or that suspect that somebody has a substance use disorder. You know, what you tend to hear is, oh, no, but what if I’m wrong and, oh, no, I don’t want to, you know, rat them out or oh, no, that’s not my business, and, but you’re not doing them any favors. You know, they’ve got to get to the point where they get help and then come out the other side. And they will eventually, they won’t at the beginning, but they will eventually then appreciate how the person who initiated it essentially right and got them where they are because it had to start. Somebody had to kind of force their hand to get them started.
Dr. Payne
Well, and I think, too, you know, if there’s a fear of what, if there’s, I’m calling something that isn’t there, that’s okay. Like, that’s part of the reason, at least in South Carolina, that we do the evaluation is to determine, you know, is there something there? And like I said, sometimes we find, you know, there’s not. And so I’m just trying to allay some of those fears because I can understand, you know, I talk to medical students a lot about professional impairment or, and, you know, in medicine, in, you know, and I use that term sort of globally. So pharmacy, nursing, you know, whatever the profession is. But in medicine, I think we have this culture in which we’re fearful to say anything to our peer for lots of reasons. Right.
Dr. Payne
Whether that means we’re wrong, whether that means that, oh, gosh, if this person goes out, then that’s more work for, on our end, you know, or maybe there’s so many things that I think people have, you know, fear of in the health professions when broaching this topic of potential impairment.
Terri
Yeah.
Dr. Payne
Hopefully with time we can begin to, you know, allay some of those fears.
Terri
Yeah, agree. And that’s one reason why, you know, I wanted to talk to each of the states and find out what their program is, because I think that if you’re isolated in a facility and you’re monitoring for and finding these people, and then you’re just not sure what happens after. And so I think knowing the big picture, you knowing that in South Carolina at least, that there is a solid process and people won’t be accused needlessly if that’s not the situation. They’ll go through the assessment and then get help in other ways. If there’s something else that, you know, is going on and it’s not a substance use disorder, but if it is, then they get help for that, and then that was a good thing that, you know, they got started on that path.
Dr. Payne
Yeah, and it’s not uncommon. You know, when someone does have an evaluation, maybe they do identify, you know, some problems, but those aren’t necessarily something that warrants monitoring. So whether it’s, you know, under treated depression. Unidentified anxiety disorder, you know, we have that happen often. And, you know, the participant that had the evaluation, they would be our prospective participant, but, you know, they say, oh, well, I talked with this evaluator and, you know, were talking about, what are the criteria of generalized anxiety disorder? I didn’t know. I just thought I was high strung, you know, whatever. So it gives them a piece of information and we try to obviously, you know, choose good evaluators that can be thorough and consider all the, you know, all the potential factors that may be contributing.
Terri
Yeah, that all makes sense. Okay. Thank you very much for your time today and for sharing with us. This was great. South Carolina does some really great things all the way from, you know, the DHAC, partnering with the hospitals for the investigation. And your program sounds extremely solid. And it’s great. South Carolina’s has stuff to be jealous of, I think.
Dr. Payne
Well, we’re, you know, we’re proud of what we do. We love the work that we do. We find it very meaningful, and we’re, you know, constantly looking at best practices and how we can reach that for our professionals in our state.
Terri
Yeah, I think it’s great. All right, thank you very much, Doctor Payne.
Dr. Payne
Thank you.
