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The Wrong Rx for Addicted Doctors

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By Anne M. Fletcher

01/23/13

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But much about PHPs runs counter to what science shows is most effective. For instance, most evidence shows that outcomes are better when clients have a say in what happens in treatment and when approaches are not confrontational. Yet in most PHPs, treatment is mandated if you want to keep your license—and, as Boyd and Knight write, “physicians have little choice but to cooperate with any and all recommendations if they wish to continue practicing medicine.” And use of medications to prevent relapse, including those for opioid addiction, is reportedly rare.

Independent addiction treatment professionals who have worked with PHP participants told me another side of the “positive outcomes” story. One of them referred to these programs as “one of the biggest rackets in the business” and a “disgusting aspect of the addiction treatment world.” An addiction counselor reported that she’s seen PHP participation result in “depression, divorce, suicide attempts and financial devastation.”

“I am well aware of MDs and others who get caught up in PHPs when they have minor problems or no substance problems at all and then can’t get out of the system," said Tom Horvath, PhD.

Mark Willenbring, MD, founder of the new Alltyr treatment clinic in St. Paul, Minnesota, and former director of treatment and recovery research at the National Institute of Alcohol Abuse and Alcoholism, referred to PHPs as "too often appearing arbitrary and capricious," and expressed concern about the conflict of interest that occurs when facilities that evaluate professionals then recommend residential treatment in their own rehab. 

Ted B. backed this up, saying, "My evaluation was not done by an outside agency but by the staff at the treatment center.... Even before my evaluation, at the 'intervention' done by the PHP, airplane tickets to the rehab magically appeared along with an escort to make sure I got on and off the plane at the right place." 

According to a survey of physician PHPs, most refer participants to the same 12 to 15 treatment programs. Tom Horvath, PhD, director of the Practical Recovery rehab in San Diego, who is periodically consulted as an expert in such cases, said, “I think we all agree on close monitoring to assure abstinence from drugs and alcohol as the crucial element of public safety, however, many individuals sent to residential rehab are likely to do just as well in outpatient care or may not need to go to a treatment program at all.”

One psychologist said, “Of course PHPs have good outcomes—professionals are being monitored for five years, under threat of losing their professions. Also, you can’t generalize from this exceptional population to other populations.” In short, doctors, nurses and the like are a group with a lot going for them, not to mention profound motivation, so good outcomes are to be expected. It remains to be seen how these professionals would do if there weren’t a proverbial gun to their heads.

To understand more about long-term outcomes, University of Florida epidemiologist Linda Cottler, PhD, MPH, and colleagues submitted a grant proposal twice to the National Institute on Drug Abuse, but it wasn't approved for funding. She said reviewers were concerned about the validity of physician responses, but hopes to continue to pursue the study, as nearly all the PHPs were on board. Meanwhile, the Institute for Behavior and Health that DuPont founded is conducting an outcome study. However, physicians are being invited to participate (anonymously) through PHPs themselves, so it’s not a random sample. Dr. Cottler said, “Without a sample of all participants, you could get just the physicians who either loved it or hated it.”

Although DuPont noted that “it’s not easy to get referred to a PHP for formal evaluation—it’s not someone just smoking a joint somewhere,” mistakes are made. Horvath said, “I am well aware of MDs and others who get caught up in PHPs when they have minor problems or no substance problems at all and then can’t get out of the system. These individuals can be ordered to 90 days of residential treatment. While the public needs to be protected from substance-abusing professionals, they need protection from false accusations. It’s very difficult for a professional to contest an evaluation.” He once worked with a client who, for years, never had a positive test but was seen as uncooperative and was “harassed and essentially run out of practice” by a PHP because he refused to accept that he had an “addictive disease.”

What's more, some people feel betrayed when they reach out to these programs for help, as opposed to having been reported by an employer or a colleague for a drug or alcohol problem. Click here to read stories shared by two women.

Milwaukee psychologist Ned Rubin, PsyD, who used to direct a program for impaired medical professionals said, “The current PHP model has been around for decades, yet it hasn’t been tested against an alternative approach. Who’s to say that giving people more freedom of choice or having them take part in a totally different form of care wouldn’t bring about outcomes that are just as good or even better? And the argument that ‘it works well’ doesn’t justify anything that may be unethical, and certainly is demeaning and coercive. If they so choose, why not let people show that they have negative drug and alcohol screens but do it in some way other than going to residential treatment and attending AA and NA meetings? The mandate should be to change your behavior; how you go about changing your behavior should be up to you.”

Anne M. Fletcher is the author of Inside Rehab: The Surprising Truth About Addiction Treatment—and How to Get Help That Works (Viking, Feb. 2013) and Sober for Good: New Solutions for Drinking Problems—Advice From Those Who Have Succeeded (Houghton/Harcourt, 2001).

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