February 25, 2009
Treating Drug-Addicted Doctors Is Good Medicine
Doctors who become addicted to alcohol and other drugs can be treated successfully and returned to medical practice with the help of special programs that couple referral to treatment and monitoring with rapid responses to noncompliance, University of Florida researchers report.
The study is the first national-level analysis of such Physician Health Programs, and confirms they are effective alternatives to simply punishing drug-addicted doctors. The findings are published in the March issue of the Journal of Substance Abuse Treatment.
More than three-quarters of doctors enrolled in state programs stayed drug-free over a five-year monitoring period. The results were the same regardless of whether the doctor's drug of choice was alcohol, crack cocaine, prescription drugs or other substances.
"Treatment works," said Dr. Mark Gold, psychiatry chairman at the UF College of Medicine and the McKnight Brain Institute. "It has been shown now to be safe and effective and cost-effective."
But it's not just for doctors, said Gold, who with UF colleagues pioneered evaluation and treatment for drug-addicted doctors. "It should be a model for treatment of anyone with these diagnoses."
In general, rates of illicit drug use are lower among physicians than the general public, but rates of prescription misuse are five times higher among physicians, according to a 2008 review Gold co-authored in the Harvard Review of Psychiatry.
Gold and others conclude that drug problems in doctors are related to medical specialties that put them in regular contact with drugs of addiction, ease of access to drugs, stress and lack of early detection. Addiction also appears linked to physician-suicide.
Physician Health Programs are not addiction treatment programs, however. Instead, they provide intensive, long-term case management and monitoring. Fifty-five percent of doctors enrolled are mandated formally by a licensing board, hospital, malpractice insurance or other agency. The rest are informally "mandated" by others such as employers, families and colleagues. Doctors sign contracts agreeing to abstain from drugs or face intensified treatment, being reported to their medical licensing boards or losing their license.
The programs aim to save the lives and careers of addicted physicians, and to protect the public by addressing substance use among doctors. They are also are an effective way to remove noncompliant doctors from the practice of medicine.
"This isn't to cover it up, it's quite the opposite," said Temple University psychiatry chairman Dr. David Baron, who oversees Pennsylvania's program. "It allows for quality treatment and to make sure that we're still ensuring the safety of the public." Baron was not involved in the current study.
Program measures include group and individual therapy, residential and outpatient programs, surprise workplace visits from monitors, and links to 12-step programs of Alcoholics Anonymous and Narcotics Anonymous. Doctor-patients get care not just for drug problems, but also for accompanying medical or psychiatric disorders. They pay for their treatment, drug tests and follow-up care.
The research, funded by the Robert Wood Johnson Foundation, evaluated 904 physicians admitted to 16 state-run Physician Health Programs from 1995 to 2001. Collaborators included founding National Institute of Drug Abuse Director and former drug czar Dr. Robert Dupont, A. Thomas McLellan, of the University of Pennsylvania, and Lisa Merlo, of UF.
Previous studies have shown that in individual states, and on a small scale, the programs are effective. The current study, first reported at the Betty Ford Institute, has the largest sample of physicians ever followed, and over the longest period.
Doctors in the programs had to abstain from alcohol or other drugs, and were tested frequently at random for five or more years. If tests revealed they had returned to substance abuse, swift action was taken -- doctors were reported to the medical board, which could lead to loss of their licenses.
"It's the idea of a carrot and a stick," said Dr. Scott Teitelbaum, director of the UF-run Florida Recovery Center, which treats addicted physicians referred from around the country. "There's always a level of resistance -- people never feel they need the level of care that's recommended. Someone might not agree with you, but if they want to practice medicine they have to comply."
Often, with the support of peers and growing realization that treatment is working, physician-patients' motivations change from simply wanting to obey the rules to wanting to change their lives, Teitelbaum said.
One-fifth of doctors were reported to their board during treatment and monitoring -- some more than once with multiple disciplinary actions taken.
But 78 percent of doctors in the programs had no positive drug tests during five years of intensive monitoring. And five to seven years after starting treatment, 72 percent were actively practicing medicine, without drug abuse or malpractice.
Eighteen percent left medical practice, while others relapsed into drug use. Three percent of those who didn't complete their programs had substance-related deaths or committed suicide.
Although the programs employed a variety of approaches, the researchers found that success was not related to specific therapists or modes of therapy, but rather to the long-term nature of the treatment.
Still, there are some "essential ingredients" that successful programs have in common, Gold said. Those include treatment extended over years -- not weeks or months -- and unambiguous success markers such as urine testing and return to work and normal family activities.
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