Addiction Policy Forum Blog

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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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