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Journal MSMA • VOL. LIX • NO. 10 • 2019
S C I E N C E O F M E D I C I N E
Physicians Helping Physicians: A Template for Success
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SCOTT HAMBLETON, MD
Physician Health Programs (PHPs) have a well-documented history of tremendous success in rehabilitating physicians. 1,2 Outcome data reported in one longitudinal study involving 16 PHPs indicated that 78% of the 904 physicians monitored for addictive disorders were sober after 5 years, without a single relapse. In Mississippi, 89.8% of the physicians monitored by the Mississippi Physician Health Program (MPHP) for addictive illnesses involving substances were sober, without a single relapse, in the 5-year period ending December 31, 2018. (Hambleton S. Annual Report to MPHP Board of Directors. Update on MPHP participants. May 2019). With few exceptions, these documented long-term rates of recovery are unparalleled in the general population of individuals with addictive illnesses.
Additionally, physicians monitored by PHPs are safe physicians. In the previously mentioned study of 904 physicians, there was only one case of documented patient harm during the period of monitoring and that case involved improper prescribing. Another study demonstrated that PHP monitoring is associated with a lowered risk of malpractice claims and that physicians constituted a 20% lower risk than the matched cohort, after monitoring. 3
Considering the epidemic of fatal drug overdoses in the United States, solutions to the underlying problem of addiction are desperately needed. The PHP approach to managing physicians with addictive disorders is unequivocally effective and hopefully will one day be utilized to help all individuals suffering from addictive illnesses.
Addiction, Impairment and Shame
Like no other condition, addiction is an insidious and remarkably effective disease process that ravages sufferers and all those who know and love the sufferer. Many people who have recovered from addiction report a sense of unimaginable hopelessness during active addiction, in some cases believing that death is the only legitimate way out. Addiction adroitly protects itself as a disease process and without treatment will progress, ensuring that the sufferer afflicted with it will lose everything: spiritual connectedness, relationships with family and friends, health, self-respect, the ability to practice medicine and ultimately life itself.
Becoming a physician is an incredibly arduous process, and successfully enduring the rigors of medical education and training requires remarkable perseverance. Not surprisingly, physicians with addiction will attempt to exert control over their substance use so that it does not impact their ability to practice medicine safely. However, even in physicians, control over substance use diminishes as the addiction progresses and may result in overt impairment.
An important point is that untreated addiction in physicians does not always manifest with overt impairment, and illness often predates impairment by a period of years. 1,2,4-7 Considering that addictive disorders are classified as mild, moderate or severe, it makes sense that earlier intervention is more efficacious than intervention in later stages of disease. Impairment is a functional classification, and an impaired physician is unable to fulfill patient care responsibilities safely and effectively. The risk of impairment is a primary reason to support early referral to a PHP to identify and treat addiction prior to its progression to functional impairment.
Shame is another prominent feature of addiction that contributes to the cycle of continuous substance use. Behavior that occurs during addiction is often harmful to others, and appropriate feelings of guilt, combined with the inability to stop using substances effectively, contribute powerfully to the addicted individual’s sense of shame. Unfortunately, the stigma of addiction promotes secrecy and increases resistance to seeking or accepting treatment. Shame is especially prominent in physicians who are trained to function independently and are reluctant to ask for help. Unfortunately, during the process of training, many physicians incorporate the idea that asking for help is a sign of weakness, which fosters the need for even more secrecy and results in persistent, untreated addiction.
Why are PHPs so successful?
Physician Health Programs (PHPs) have been in existence since the 1970s and have continued to evolve, with increasing effectiveness. 1,2,4-7 The Federation of State Physician Health Programs (FSPHP) is the national membership organization for PHPs and an invaluable resource for the Mississippi Physician Health Program (MPHP), providing tremendous leadership and guidance to all PHPs for the last thirty years. Additionally, the Mississippi State Board of Medical Licensure (MSBML) consists of physician members and an Executive Director with extensive knowledge about physician impairment and recovery. The MSBML strongly supports MPHP and the rehabilitative approach.
PHPs utilize contingency management, a type of behavioral therapy rooted in the basis of operant conditioning which modifies behavior by reinforcement or punishment. 8 Medical Boards are authorized to discipline a licensee and prohibit or restrict that licensee’s ability to practice medicine, which represents a highly effective stimulus to encourage compliance with PHP monitoring requirements. Ultimately, the promise of practicing medicine is a powerful reward or reinforcer that motivates physicians to comply with the monitoring process and is a major factor that contributes to PHP success. Quality treatment for addiction and long-term abstinence from addictive substances with intensive longitudinal monitoring utilizing prompt and meaningful consequences for non-compliance are the core elements that enable physician participants to recover from addictive illness successfully.
Drug Courts also have well documented success in reducing re-arrest rates for individuals with diagnosed substance use disorders who have been convicted of criminal offenses. 9 Like PHPs, they utilize contingency management styled long-term monitoring of participants. Cessation of substance use is documented with toxicology testing with positive tests resulting in prompt consequences, including incarceration.
Since the mid-1990s, Mississippi Physician Health Program (MPHP) has utilized a confidential, alternative-to-discipline monitoring process for physicians with potentially impairing substance use or mental health disorders. Before this, all referrals to MPHP were known and/ or disciplined by the Mississippi State Board of Medical Licensure (MSBML). By 1998, two years after MPHP began implementing a confidential monitoring process, the number of participants monitored by MPHP increased over 400%. Without the incentive of confidentiality, these physicians would not have participated in MPHP monitoring, continuing to practice medicine with untreated addiction, and increasing the likelihood that their addiction would progress to overt impairment and subsequent patient harm.
However, there are limits to confidentiality, and when a monitored physician participant in MPHP is unable or unwilling to comply with the monitoring process, MPHP is required to immediately notify the Mississippi State Board of Medical Licensure (MSBML) which may result in formal discipline, including licensure suspension or revocation.
When Medical Boards and PHPs work closely utilizing a confidential, rehabilitative approach, the incentive to participate in PHP monitoring increases dramatically, resulting in increased referrals to PHPs and earlier detection and treatment of addiction. Considering that over 95% of MPHP participants with addictive disorders are able to return to safe and productive medical practices and that other states with robust PHPs have similar rates of recovery it is apparent that PHPs functionally represent a “new paradigm” for addiction management, effectively setting a new standard which demonstrates that recovery (rather than relapse) can be the expected outcome of treatment for addiction.
Mississippi Physician Health Committee
Mississippi State Medical Association established the Mississippi Physician Health Committee (MPHC) to provide oversight and support to MPHP. MPHC consists of physicians who volunteer their time for free, providing the foundation of incredible experience and wisdom which supports all MPHP activities. Undoubtedly, MPHC is a major reason that the Mississippi Physician Health Program (MPHP) is so successful. MPHP primarily focuses on physicians with substance use disorders or other treatable psychiatric illnesses, as well as age related cognitive issues. MPHP also provides assistance and education related to professional burnout which now impacts the majority of practicing physicians. 10 As a result of the charitable service of these MSMA members, MPHP has helped hundreds of doctors and their families to recover and, in some cases, from seemingly hopeless situations. None of these miracles would have been possible without the compassionate vision of our founders and the selfless service of the physician volunteers of the Mississippi Physician Health Committee.
National Epidemic of Drug Overdose Deaths: Physician Leadership Needed
We are amid an epidemic of fatal drug overdoses unparalleled in our nation’s history. According to a report by the Council of Economic Advisors, the actual cost of the opioid crisis has been significantly underreported and likely exceeded $500 billion in 2015, representing 2.8% of GDP that year. 11 Based on preliminary data, more than 68,000 Americans died from drug overdoses in 2018, which represents an actual decline from the estimated 70,000 drug overdose deaths in 2017. 12 However, according to the Surgeon General’s Report on Alcohol, Drugs, and Health, which is the first report ever issued by the Surgeon General on the topic, one in seven Americans suffer from substance use disorders, and the vast majority will not receive treatment. 13
As leaders of the healthcare team, physician direction is desperately needed. Considering the tens of millions of Americans suffering from addiction and that less than 13% receive treatment, 14 a reasonable question is: How is this possible, in the United States? How is it possible that only 13% of the millions of Americans suffering from a treatable, potentially fatal illness receive treatment?
The Surgeon General explained that substance misuse has traditionally been seen as a social or criminal problem, and responsibility for treatment and prevention services was shifted away from health care systems to other entities, such as the criminal justice system. 13 As a result, people needing care for substance use disorders have had access to a very limited range of treatment options that were generally not covered by insurance. The report recommends the integration of prevention, treatment, and recovery services across health care systems. It makes sense that physicians, as leaders of the healthcare team, will need to step up to the challenge to ensure significant and lasting change throughout the healthcare system.
A Call for Action and Utilization of the PHP Model of Addiction Management
Monumental change is necessary to effectively address the crisis of untreated addiction in the United States. The decrease in overdose fatalities in 2018 indicates that we are on the right track. However, increased education about addiction is needed at every level of healthcare and especially with physicians. Lack of understanding about addiction as a brain disease has negatively impacted the actual practice of medicine and is clearly an underlying cause of the inappropriate use of opioid pain medication which has fueled the crisis of opioid related fatalities in the United States. 15 Ultimately, physicians are unequipped to manage addiction because of a lack of education. 15,16 Physicians receive excellent education and training related to treating the medical problems caused by addiction, but very little education and training related to preventing, identifying or treating addiction itself. Education of medical students and residents about addiction is not commensurate with education about other chronic illnesses, such as diabetes or heart disease. A report by the National Center on Addiction and Substance Abuse at Columbia University (CASA Columbia) harshly criticized the medical profession at every level, stating that, “most medical professionals who should be providing addiction treatment are not sufficiently trained to diagnose or treat it.”
Fortunately, change is happening. In July 2016, the Comprehensive Addiction and Recovery Act (CARA) was signed into law, expanding access to patients for addiction treatment in the United States. 17 The American College of Graduate Medical Education (ACGME) has begun to address the addiction related education gap in the United States with the development of program requirements for graduate medical education in addiction medicine. 18 Additionally, the American Association of Medical Colleges is partnering with several universities, including Harvard Medical School and Boston University School of Medicine to utilize a new set of 10 core competencies to shape opioidrelated education and training. Many regulatory agencies require prescriber education related to prescribing controlled substances, including the Mississippi State Board of Medical Licensure.
Hopefully, as physician education evolves, the PHP model of addiction management will be utilized in the development of addiction related educational material, especially related to the concept of addiction as a brain disease and the possibility of lasting recovery. While it is true that addiction is characterized as a chronic, relapsing illness, the experience of PHPs suggests that lasting recovery from addiction is a very reasonable expectation. 19 The Physician Health Program model of managing individuals with addictive disorders is unequivocally successful, and while presently this approach may not be feasible for all patients with addiction, optimistically it may one day become the template for managing addiction in all patients.
Acknowledgment: The author has no conflict of interest to disclose.
References
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17. U.S. Congress. S. 524 (114th): Comprehensive Addiction and Recovery Act of 2016. 2016. https://www.govtrack.us/congress/bills/114/s524. Updated July 14, 2016. Accessed July 16, 2019.
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19. American Society of Addiction Medicine. Public policy statement: Short definition of addiction. Chevy Chase, MD. American Society of Addiction Medicine; 2011. http://www.asam.org/docs/default-source/public-policystatements/1definition_of_addiction_short_4-11.pdf ?sfvrsn=0. Published August 15, 2011. Accessed August 22, 2016.
