The Wrong Rx for Addicted Doctors
When health-care professionals with drug or alcohol problems get caught—or admit they have a problem—they often are mandated to monitoring programs. But these "PHPs" aren't all they're cracked up to be.
More than a decade after completing a treatment program for “impaired” professionals—sometimes called “diversion,” “peer assistance” or physician health programs (PHPs)—physician Ted B. still recalls it as “a miserable experience” that left an “indelible mark” on his life.
Ted got “caught up” in the PHP system after a bout with depression that he self-medicated with heavy drinking. It turned out that depression was a side-effect of the beta-blocker blood-pressure medication he’d been taking. Once off the medication, he no longer had any desire to abuse alcohol. Unfortunately, when he made the discovery, he had already been through four months of treatment at an expensive, PHP-mandated residential rehab, and then required to attend AA meetings. He was also subject to random drug tests and had to return to the rehab for yearly checkups. When he shared his discovery about the beta-blocker's psychological effect, which is actually quite well known, the PHP monitors, Ted said, “scoffed at it and soundly rejected it as my being in denial and needing more AA meetings and maybe a refresher course back at the rehab.”
Certainly, the public needs to be protected from the nurse who feeds her painkiller addiction by pilfering patients’ medications or the surgeon who shows up drunk in the operating room.
To avoid being "reported,” Ted said that he lived in fear—"fear of losing my license, fear of getting close to anyone, fear of having the wrong facial expression—all fears indoctrinated in me at the rehab in endless sessions and later reinforced by the PHP." Why was he afraid of being reported when he wasn’t even drinking? Ted explained, “Because the rehab would demand a return to treatment for ‘relapse thinking’ or other possible 'warning signs' such as depression, argumentativeness, unkempt appearance, gambling or having a dented car fender.”
Certainly, the public needs to be protected from health-care professionals like the nurse who feeds her painkiller addiction by pilfering patients’ medications or the surgeon who shows up drunk in the operating room. That’s one of the reasons why these special programs were established in most states to identify, treat and closely monitor doctors, nurses and other health-care professionals who suffer from drug and alcohol problems. Failure to comply with the recommendations of such programs can result in running afoul of your profession’s licensing board and possibly losing your license. However, in a recent Journal of Addiction Medicine commentary, J. Wesley Boyd, MD, PhD and John Knight, MD (who have many years of experience as associate directors of a PHP) discuss the coercive nature of these programs, and state that the relationships between PHPs and evaluation/treatment centers are “replete with potential conflicts of interest.”
In addition to serving in a watchdog role, such programs were established to help the health professionals themselves—both to assist with recovery and to save their careers. One of their benefits to the “impaired” professional is that they may allow him or her to keep on working, possibly with some restrictions on practice—for instance, prohibiting access to certain medications—all while getting long-term help for a drug or alcohol problem.
The way these programs work is that licensed health-care professionals avoid disciplinary proceedings that could result in loss of their licenses by agreeing to undergo evaluation, participate in addiction treatment and support meetings, have regular drug and alcohol tests, and have heightened monitoring if they relapse. PHPs provide a “case management role” and oversee the process of monitoring professionals, but they don’t usually consider themselves as providing treatment.
Typically, PHP “contracts” for physicians last five years, involve three months of residential or intensive outpatient treatment, include recommendations from the treatment programs they attend, and require intensive random urine-testing schedules that decrease in frequency as time goes on. This commonly means that each workday, the monitored doctors and nurses have to call a phone number or log in to a website to see if they must take a test that day, which usually means urinating in the presence of an observer. Participants typically have to cover the cost to attend treatment (if their insurance doesn’t pay for it), as well as most drug-testing expenses and sometimes some of the operating funds involved in the PHP.
State guidelines often specifically require frequent weekly AA, NA and health-professionals’ recovery support meetings, although some states allow people to attend non-12-step meetings, with frequency stipulations for meetings dropping as time goes on. When back at work, there’s some type of on-the-job monitoring by superiors and/or colleagues.
Touted as having better long-term outcomes than any interventions reported in the scientific literature—with some studies documenting recovery rates of between 70% and 96%—PHPs are often held up as a paragon for where all addiction treatment should be headed. The most notable research on their outcomes was summarized in 2009 in the Journal of Substance Abuse Treatment. Robert DuPont, MD, and colleagues discussed findings from 904 physicians revealing that, five to seven years after signing their PHP contracts, 72% percent were still licensed and practicing with no indications of substance abuse or malpractice, and 78% had not tested positive even once for drugs or alcohol. DuPont asked, “Where else in the addiction treatment field can you find results like that?”