Anne M. Fletcher said:
01/23/13
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.”
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?”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.”
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).
