Doctors with Addiction

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Physicians and other medical professionals have higher rates of addiction than the general population, but they respond better to addiction treatment. That’s the conclusion of Dr. Daniel Angres, seen on the front page of the most current issue of Internal Medicine News, Vol. 49, No. 3, February 15, 2016.

I get a copy of the Internal Medicine News every few weeks, and I always skim the articles. This week, front page coverage about addiction in physicians caught my eye.

This Dr. Angres said physicians who are appropriately treated for addiction have a five-year sobriety rate of around 80%. This is, of course, much higher than seen in non-physicians.

This news isn’t that new. Similar data has been described in early studies. [1-6]

I read this present article with interest, wondering if I would see new data, but the article appears to be a summary from a doctor with decades of experience treating physicians.

Studies of data collected on physicians with addiction show they’re more likely to misuse alcohol than any other drugs, but opioids are a close second, and then sedatives. Physicians are less likely than the general population to use street drugs. Presumably this is because they have access to prescription medication and are less likely to seek drugs from the street.

Long work hours, high stress, and poor self-care are thought to fuel much of physician drug use, but this idea is based more in theory than fact. As with the general population, mental health disorders are more frequent in physicians with addiction than in non-addicted physicians. Interestingly, one study showed that tobacco use, more than any other data collected from addicted physicians, was most strongly correlated with the presence of addictive disease. [8]

In one large study of physicians diagnosed with addictive disease who were under contract with the North Carolina Physicians Health Program, 85% of the physicians were male, and the average age at diagnosis was 44years old. Around two-thirds were married. Over half were mandated to undergo treatment by an agency such as hospital, medical board, malpractice insurer, or other less formal requests from spouses and practice partners.

Combining all available studies of addicted doctors, it appears psychiatrists and anesthesiologists were over-represented, meaning there were proportionately more of these specialists than one would expect from the number of these specialists. Both pathologists and pediatricians were under-represented.

Female physicians, same as females in the general population, have a telescoping of addictive disease. They tend to develop more severe addiction earlier than males. By the time female doctors enter treatment, they tend to have more severe addiction. They are also more likely to misuse sedatives than male doctors. and are more likely to have mood disorders with suicidal ideations. Female physicians tend to have harsher sanctions from medical boards than their male counterparts. [4]

Most states have physician health programs (PHPs), which are kind of like employee assistance for doctors, only with much more power. States have their PHPs set up in different ways, but usually the PHPs are separate from the medical boards. PHPs are set up to evaluate physicians for the presence of addictive disease, refer for appropriate treatment, and monitor recovery for a period of years. They are set up to be non-punitive, but if physicians relapse or don’t follow PHP recommendations, those doctors usually get reported to medical boards, where sanctions including loss of medical license are imposed.

PHPs may not do physician evaluations, but instead refer afflicted doctors to a treatment center for this evaluation. Many times, physicians are sent to specialty treatment programs who say they have special programs for physicians. Physicians tend to spend much longer in treatment than other people with the same addictive illness. It’s not at all unusual for a physician to be recommended to undergo inpatient treatment for three to six months.

PHP monitoring contracts usually extend for five years. This monitoring usually includes frequent random urine drug screens, aftercare treatment, and participation at 12-step meetings. In North Carolina, physicians are commanded to attend at least three 12-step meetings per week for their five- year monitoring contract.

On the other hand, PHPs frequently serve as advocates for physicians doing well in recovery. They can help these doctors with their malpractice insurers, hospitals, and other insurance companies.

While PHPs exist to help addicted physicians get the help they need, medical boards exist to protect the public from impaired physicians. Medical board actions are public records, which means safety-sensitive workers like doctors and nurses are not necessarily protected by the same privacy laws as other citizens.

As the article by Dr. Angres states, physicians have excellent recovery rates compared to other groups of people recovering from addiction. Doctors with addiction who get involved with a PHP have abstinence rates of 80% at five years.

We know there are some factors that predict a poorer outcome: injection of opioids as main drug of use, co-occurring psychiatric diagnoses, and continued use of nicotine. [7]

Lower rates of relapse in these recovering physicians are seen with lack of psychiatric co-occurring illness, longer time spent in professional treatment, participation in 12-step recovery, smoking cessation, and longer monitoring contracts (five years as opposed to three years). [7]

The article by Agres does mention the use of one medication to treat opioid-addicted physicians: naltrexone, which is an opioid blocker. This long article did not contain any mention of buprenorphine or methadone, except this vague sentence: “…medication-assisted treatment may be necessary for heroin addiction.”

I know most PHPs and medical boards won’t permit a doctor on methadone or buprenorphine to practice medicine, but it is very difficult to get these agencies to go on record one way or the other with their official position.

North Carolina’s Board of Nursing is a refreshing exception. The NC BON decided several years ago to allow nurses on buprenorphine and methadone to be licensed to work, though they do require significant input and advocacy from each recovering nurse’s treating physician. I recall they had decided to collect data from opioid-addicted nurses and compare outcomes of nurses in abstinence-only programs with nurses treated with buprenorphine and methadone. I don’t know if that study is ongoing, but it could contain some intriguing data.

Most medical boards and PHPs take the position that MAT impairs licensed professionals, but there’s scant data to support such a statement. In fact, available studies show pretty much the opposite. Some addiction medicine specialists – like me – feel denying evidence-based, potentially life-saving treatments to patients who work in safety-sensitive jobs is unethical, without established evidence showing harm from these treatments.

But then PHPs counter by saying that with success rates of 80% at five years, why consider MAT with methadone or buprenorphine, since it’s obviously not needed. Furthermore, many addiction treatment specialists say that if the treatment available to doctors were available to every opioid addict, MAT would be needed in relatively few people.

That may be true. None of the opioid-addicted patients I see can access three months of quality inpatient treatment, followed by aftercare for one year, and five years of monitoring with serious consequences for relapse. Even the ones with insurance may be able to go to inpatient treatment for several weeks, even one month if they are lucky. Maybe if all people could get the gold standard of opioid addiction treatment, we wouldn’t need to use MAT as much. I still believe some patients would require MAT. But right now, that’s not a realistic option for any of my patients.

I see both sides of the issue. And I also wonder what has happened to the 20% of medical professionals who had the gold-standard of treatment, and still relapsed. Did anyone talk to them about methadone and buprenorphine, if their main drug was opioids? Given the strongly 12-step oriented mindset of many PHPs, I suspect they weren’t told about this option.

  1. Dupont et al, “Setting the standard for recovery: Physicians’ Health Programs,” Journal of Substance Abuse Treatment, 2009, Vol. 36(2)159-171.
  2. Ganley et al, “Outcome Study of Substance Impaired Physicians and Physician Assistants Under Contract with North Carolina Physicians Health Program for the Period 1995-2000,” Journal of Addictive Diseases, Vol. 24(1) 2005, pp1-12.
  3. Paul Earley MD, FASAM, “Physician Health Programs and Addiction among Physicians,” Principles of Addiction Medicine, Fifth edition, 2014, WoltersKluwer pp602-621.
  1. Penelope Zeigler: PCSS-O – archived webinar 5/15: “Treating Substance Use Disorders in Health Professionals”
  2. Berge, K. H., Seppala, M. D., & Schipper, A. M. (2009). Chemical Dependency and the Physician. Mayo Clinic Proceedings, 84(7), 625–631.6.
  3. Boyd et al, “Ethical and managerial Considerations Regarding State Physician Health Programs,” Journal of Addiction Medicine, 2012, Vol. 6(4)243-2468.
  4. Stuyt et al, “Tobacco Use by Physicians in a Physician Health Program, Implications for Treatment and Monitoring,” American Journal on Addictions, 2009; Vol 18(2)103-108.

 

 

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5 responses to this post.

  1. I agree. This is also a civil rights issue. People with a substance use disorder are protected by the Americans With Disabilities Act (ADA), unless they are currently using illegal drugs. Physicians and other healthcare professionals are protected by the ADA too. While some people can overcome addiction to opioids without MAT, some people cannot. If MAT is safe and effective which it is, and if there is no evidence that a person who is successful on a stable dose of methadone or buprenorphine is impaired, then people in healthcare should be permitted to receive MAT, and should not face discrimination if they are receiving MAT.

    I have read a number of studies that purport to show impairments from methadone or buprenorphine, and I don’t believe that they stand up. Many such studies have flawed designs, e.g. comparing people who are abstinent with methadone-naive people who receive methadone before they can develop tolerance. Even assuming, for the sake of argument, that some people on MAT are impaired, many or most are not

    Even assuming, for the sake of argument, that MAT is not necessary for those privileged people who have access to better and more expensive treatment options, it is not true that everyone involved in healthcare professions can afford such treatment. Even assuming, for the sake of argument, that only a small proportion of those healthcare professionals who can afford other treatments are not successful, that is no justification for denying MAT to those who need it.

    Reply

  2. Posted by Alan Wartenberg MD on March 6, 2016 at 9:21 pm

    The vast majority of studies done, at least with methadone, although done many years ago by Mary Jane Kreek, do not show that stable doses of methadone, once at steady state, result in detectable impairment on a number of psychometric tests designed to show both cognitive and motor/sensory function. Considering the partial agonist effects of buprenorphine, that almost certainly will hold true for that drug as well. Despite this, many Boards of Medicine, Nursing and other Health Professions have refused to allow their licensees to be on MAT. I am not aware of any lawsuits or class action suits regarding this, but there should be.

    A more significant issue is that many PHP’s and Boards utilize a very limited number of programs to do assessment, and there are frequently significant conflicts of interest involved. These programs decide that virtually100% of those they assess need treatment (and this after prolonged and very expensive assessments, often not covered by insurance), and that treatment can be very prolonged and also not covered by insurance.

    We treated over 25 doctors and nurses in our program at a Boston teaching hospital, using the same treatment algorithms we used with anyone else, with most of them admitted for 3-5 days (a few directly admitted into outpt treatment) and then transferred to either a day or evening intensive outpatient program (day program was 2 weeks of 9-5 treatment, evening was 3 three-hour evenings for 6 weeks), both with family components. Monitoring by the PHP was carried out as it would be with anyone else. Our results were equal or better than published results (21 out of 25 returned to practice and were sober 2 years out) at vastly less cost and disruption to the lives of those involved (including their families)

    The almost uniformly applied 12 step treatment in most PHP sponsored programs and both the conflicts of interest and lack of due process has been disturbing to many of us and led to a recent publication in the Journal of Substance Abuse by two of my colleagues (Boyd J, Knight J: J Addict Med. 2012 Dec;6(4):243-6). While much good has been done by PHPs and professionally coerced treatment (and I was, I am pretty sure, patient number 1 in the history of the State of Wisconsin’s experience), harm has been done as well, including bankruptcies, family dissolution, severe depression and suicide, as well as inappropriate diagnoses and treatments of accused physicians. This has not only been true with substance abuse, but mental health and even “disruptive physician” issues.

    Reply

  3. The only lawsuit I know about is one in federal court in Pennsylvania in which I represented the nurse plaintiff. Pennsylvania originally prohibited any licensed professional from receiving MAT, and did so in her case. Subsequently, Pennsylvania changed the rules so that under certain circumstances, a person receiving MAT could continue to practice, but with certain limitations and additional testing requirements that were not imposed on persons who were in recovery but not receiving MAT. (The case involving the nurse ended without any decision on this issue.)

    Reply

  4. Posted by Robin Rathbun on March 7, 2016 at 9:31 pm

    I know of a physician successfully maintained on methadone after a severe relapse following conventional, lengthy residential treatment and contrast that with a tragic story of a physician with opioid addiction who passed away from an overdose after over 20 years of disciplinary hearings, treatment referrals, treatment and probation; 99 pages of public records by the medical board documenting his tragic history.

    Reply

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