Published 12/1/2013
|
Terry Stanton
Relapse rates for alcoholics and other addicts who attempt to abstain are discouragingly high; in the general population, 40 percent to 60 percent or more relapse within a year, even among those who participated in 12-step programs. For physicians, however, the toll of addiction and the challenges of recovery are intensified.
Doctors with substance use disorders face dire professional consequences if their condition and associated behavior lead to discipline by state or professional boards. Loss of license is the extreme sanction, but short of that, physicians who enter into public consent orders or other censure may face a lifetime of stigma and obstacles—ranging from difficulty finding employment or obtaining hospital privileges to exclusion from provider panels and censure by professional associations.
For those willing to confront their problem and undergo appropriate treatment, however, state-based physician health programs (PHPs) can help them maintain their professional standing while straightening out their lives.
Gary D. Carr, MD, who is board-certified in addiction medicine, explains that the impetus for the rise of PHPs was a 1970s Oregon study that found that approximately 25 percent of physicians whose licenses were revoked later took their own lives. The finding prompted an effort to establish an alternative to revocation that would enable addicted physicians to rehabilitate and preserve their careers while serving the top priority of patient safety.
Today 47 states have PHPs. Key to their success is willing participation by the physician. This means that addicted physicians must either volunteer that they have a problem or, if they are reported by other individuals—such as a colleague or a patient—promptly submit to the program of treatment and recovery outlined by the PHP.
“If a physician is reported, the PHP will visit him or her and offer help,” says Dr. Carr, a past president of the Federation of State Physician Health Programs. “If the physician agrees to work with the PHP, the medical board will not take formal public action. If the physician declines, the board will become involved. Most physicians will prefer to work with the PHP and get an evaluation.”
In some cases, even physicians who resist participating end up in the program. “Many don’t think they have a problem—denial is part of the disease,” Dr. Carr says. He notes that PHPs use a core group of about 20 nationally recognized evaluation/treatment facilities that “are pretty good at gathering collateral information. If there is an issue, they can ferret it out. If they say the physician has an addictive illness and needs treatment, the doctor has a diagnosis. That can be a turning point. After treatment, most are grateful for the process and recognize that they needed the help.”
Physicians under PHP supervision follow a course of therapy typical for addicted individuals. Because public safety is involved, monitoring may extend to 5 years, with regular toxicology testing.
Record of success
Case administration varies by state, but PHPs share common traits, says Dr. Carr. “They generally demand total abstinence and 12-step–based recovery. They require accountability—weekly meetings and toxicology screens. Almost all require a designated workplace monitor.”
As PHPs have matured, their resources have grown and services have become more comprehensive. “We’ve seen better funding and the addition of addictionologists and addiction psychiatrists,” Dr. Carr says. The groups are networked, which enhances their individual capabilities. “If one state has a unique case, expert opinion from around the country is available.”
The programs have been successful in guiding physicians to recovery and lasting sobriety. One large study found a 22 percent relapse rate over a 7.2-year monitoring period, far better than that seen in the general population (Fig. 1).
“We’ve heard that addicts can’t be treated; they’ll just do it again,” says Dr. Carr. “I hope PHPs are teaching us all that these folks can be treated and recover.”
The reason that physicians have such a high success rate is multifactorial, according to Dr. Carr, who himself has been in recovery for 21 years. “First, physicians get good evaluation and good treatment,” he says. “They also get ‘contingency management’ for an average of 5 years. They are expected to make the meetings, provide urine specimens, and be accountable, to maintain the privilege of practicing medicine. It’s a carrot-and-stick approach. And it’s effective; these docs get sober. It’s a wonderful thing to watch.”
Dr. Carr is careful to note that physicians with addiction are often inaccurately described as “impaired.” He explains, “Impairment is a functional classification and not an accurate term. With physicians, their practice is the very last thing to go. By the time the addiction starts to affect their practice, they’ve lost family, friends, and community support. The American Society for Addiction Medicine talks about progression of the illness, which at some point can morph into overt impairment. The goal of the PHP is to identify and assist physicians before they become overtly impaired.”
Although PHPs represent enormous progress for the medical profession and its approach to alcoholism and substance abuse, many physicians in influential positions still do not fully recognize that addiction is a disease of the brain and the body.
“We all grew up thinking that addiction is bad behavior, a moral issue, or a character problem. In our society—including law enforcement and medical boards—we want addiction to be a ‘thinking illness,’” explains Dr. Carr. “We want it to live in the cerebral cortex of the brain, when in fact it lives in the midbrain, which doesn’t think. Its sole purpose is to keep us alive. It tells us to get food, water, and shelter and to avoid pain.
“Once addiction is established, the midbrain looks at addiction as something necessary for survival,” he continues. “It prompts people to use. It is important to remember that relapse is not willful misconduct but a hijacked brain.”
In states that have transitioned from a punitive to a supportive posture, the real success is in identifying addicted physicians earlier and in greater numbers. “When Mississippi, where I practice, made the change, referrals went up almost 500 percent,” Dr. Carr says. “In West Virginia, referrals have risen almost 1,000 percent. If supportive systems exist, people who were hesitant to report now know that their addicted partners or colleagues can get help. Their practice may be interrupted, but they won’t be ruined.
“In a nonpunitive system, the referral source shifts,” he continues. “Doctors get reported much earlier in the disease process. The early reporting is critical to public safety.”
A safer public
Although some medical boards or board members still resist the PHP model and philosophy of rehabilitation, he finds much to celebrate. “To the boards, I say thank you. Boards have a difficult job. On the one hand, a doctor will never hurt someone if his license is taken away. Boards may be concerned that if something goes amiss during rehabilitation, the board can be blamed. By and large, boards display courage and integrity when they partner with a PHP,” says Dr. Carr.
“For every story of a physician doing something amiss, there are 10,000 success stories that never get told. I think everyone wins. The public is safer in a state where physicians have the ability to admit they need help.”
Physicians with an addiction illness and the people around them should be aware that the disease is treatable and a path to recovery is available. “Partners and hospital staffs need to know this is not an issue of right or wrong; this is an issue of wellness or illness,” Dr. Carr says.
“Physicians need to know that things have changed. Addicted physicians can get help without losing their medical licenses or their lives. The denial can be profound. A doctor who is concerned about a partner or colleague needs to make the call. Once the person gets help, he or she will be grateful.”
Terry Stanton is a senior science writer for AAOS Now. He can be reached at tstanton@aaos.org
Addicted Physicians Additional Resources: