Addiction Policy Forum Blog

7 min read

Physician substance use disorders: contingency management encourages recovery?

By Mark Gold, MD on December 26, 2019

“Imagine if,” write the authors of a review in The New England Journal of Medicine, “the medical profession barred anyone being treated with pharmacotherapy for depression from returning to practice, insisting that only physicians who had achieved remission with cognitive behavioral therapy were fit to practice.” Why might readers imagine this? Physicians and nurses with opioid use disorder (OUD) are encouraged or required to participate in physician health programs, or PHPs, state-based treatment programs studied by experts like McLellan, Dupont, and Merlo, among others.1 These programs are often focused on abstinence and have defined 5-year outcomes, including fitness for duty and return to work. This New England Journal of Medicine article makes a case for lifting bans on medication-assisted treatment (MAT) in some PHPs and orienting the programs around structural health challenges faced by medical professionals. 

It is certainly true that PHPs have a history of successful recovery, return-to-work rates, and premorbid function outcomes for physicians who are monitored and active in such programs. But all physicians are not the same. Substance Use Disorders (SUDs) are not the same, either, and physician specialties have different risks.2 Before the public heard of fentanyl, for example, it was a dangerous substance for anesthesiologists.3 And health care professionals and business executives can become political footballs in the MAT vs non-MAT dichotomy. 

I like to frame this discussion around personalized medicine. We do not currently have tests or other predictors gauging which person with OUD will best recover at 5 years, and with which treatment. Some studies on PHPs suggest that health care professionals have the best 5-year return-to-work and premorbid function outcomes reported. This may be due to the generally late onset of SUDs in physicians. It could be that a given PHP works because of contingency management—follow the program and you can continue to be a physician. Contingency management is one of the most effective behavioral interventions for OUD and used much more frequently in PHPs than in non-PHP treatment settings. But few psychiatrists or addiction specialists understand the overall utility and efficacy.4 

We need more research to figure this out, but physician intervention, treatment, and recovery has been a model for successful 5-year outcomes and multidisciplinary treatment.5 Some programs are strictly oriented around a non-medication approach, but others are more flexible. Some programs have mandated MAT, like those requiring naltrexone for anesthesiologists6 returning to work, but others may prohibit MAT. Merlo has reported on outcomes and on MAT utilization in this population. She found that “individuals with opioid use disorders managed by PHPs can achieve long-term abstinence from opioids, alcohol, and other drugs without opioid substitution therapy (OST ) through participation in abstinence-based psychosocial treatment with extended, intensive care management following discharge.”7

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7 min read

The fentanyl crisis is only getting worse

By Mark Gold, MD on October 31, 2019

Synthetic opioids like fentanyl accounted for around 3,000 deaths in 2013—by 2018, they accounted for over 30,000.1 Fentanyl is approximately 100 times more potent than morphine, 50 times more potent than heroin. Breathing can stop after use of just two milligrams of fentanyl. That’s about as much as trace amounts of table salt. “Ten years ago,” write the authors of a recent RAND report on the future of fentanyl, “few would have predicted that illicitly manufactured synthetic opioids from overseas would sweep through parts of Appalachia, New England, and the Midwest.” Drug epidemics and outbreaks can be surprising, taking unexpected forms at unpredictable moments in uncharacteristic patterns. But the fentanyl crisis is different. It isn’t just distressingly surprising or one more deadly drug epidemic in a grueling, tragic history of new contagions. Its magnitude, intensity, and sharp variations dwarf previous epidemics with which experts and officials are familiar, and its challenges for public health are novel and, so far, unmanageable. The recent RAND report is a comprehensive overview of the fentanyl crisis’s origins, present status, and, most disturbingly, future.

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4 min read

We have vaccines for polio and the flu, how about opioid addiction?

By Mark Gold, MD on August 22, 2019

Preliminary 2018 data from the Centers for Disease Control show a slight decline in drug overdose deaths.1 In the view of many experts, increased availability and use of Naloxone, education, and also increased access to Medication for Addiction Treatments (MAT) contributed to this decline.2 However, opioid use disorders and drug overdose rates remain extremely high nationally. Moreover, decreasing overdoses from prescription misuse and heroin should not distract from rising importation, misuse, and overdoses due to fentanyl, methamphetamine, and cocaine.3 With limited treatment options available for these substance use disorders, researchers are working to create novel approaches, using all technologies available, to prevent, treat, and improve the lives of patients and families. In a number of studies and trials, Tom Kosten and his colleagues at Baylor have looked at cocaine, methamphetamine, opioid and even fentanyl vaccines, showing promising results in reducing overdose, misuse, and treating substance use disorders.4 

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3 min read

Can CBD Help in the Treatment of and Recovery from Opioid Use Disorder?

By Mark Gold, MD on June 13, 2019

The physiological cravings that accompany addiction, along with memory cues and environment triggers specific to each patient can cause a recurrence of use or relapse. As such, effective treatment needs to address a person’s behavioral health and help them learn how to cope with stress and environmental triggers.

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3 min read

Risks of Opioid & Alcohol Use for Women Increase with Age

By Mark Gold, MD on June 6, 2019

Alcohol use is very prevalent among Americans - more than half of U.S. adults drank last month - and alcohol is the third leading cause of preventable death after tobacco and poor diet/physical inactivity.1,2 When coupled with prescription opioid use, drinking becomes especially dangerous.3 Women are at high-risk of experiencing these adverse health effects, which worsen with age. A recent study illuminates the repercussions of concurrent alcohol and prescription opioid use in older women.

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4 min read

Fentanyl-adulterated Cocaine: Strategies to Address the New Normal

By Mark Gold, MD on April 25, 2019

At the center of America’s deadly opioid epidemic, non-pharmaceutical fentanyl appears to be finding its way into illegal stimulants that are sold on the street, such as cocaine. Adulteration with fentanyl is considered a key reason why cocaine’s death toll is escalating. Cocaine and fentanyl are proving to be a lethal combination - cocaine-related death rates have increased according to national survey data. This has important emergency response and harm reduction implications as well—naloxone might reverse such overdoses if administered in time. A recent study by Nolan et. al. assessed the role of opioids, particularly fentanyl, in the increase in cocaine-involved overdose deaths from 2015 to 2016 and found these substances to account for most of this increase.

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