By Mark Gold, MD
“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
What does this article argue about PHPs?
This article forcefully argues that by prohibiting MAT and requiring abstinence-only treatment courses, PHPs are not offering health care practitioners with OUD the most effective or responsive treatment available. PHPs, the review notes, usually involve a routine of drug testing for 5 years following 60-to-90 days of residential treatment. The 60-to-90 day provision of treatment is, critically, abstinence-based. Since 1973, dedicated state provision of treatment for health care professionals has been the norm in the field, after receiving support from the American Medical Association. This move came on the heels of a push by medical professionals in the 1970s seeking treatment options specified to the needs of the health care sector. How could practitioners struggling with substance use disorders or mental health challenges, yet charged with the assessment and treatment of these conditions in their patients, best receive treatment themselves? Of course, you could take the opposite side of this argument and say that resource constraints keep everyone else from accessing the same treatment given safely and effectively to MDs.
PHP outcomes have looked remarkable in many findings, but don’t appear equally remarkable for all medical specialists. A recent study of family physicians with SUDs found that they did not complete the monitoring contract at 5 years relative to other physicians.8 The authors of this New England Journal of Medicine article suggest that one reason some PHPs discourage or even prohibit MAT is because of concerns about how medication could impact fitness for duty. They argue that there is a lack of direct evidence to support such concerns, and point to a RAND study for the Department of Defense that said available research results on the topic can’t support “strong conclusions.” The authors also observe that medication provided to treat other conditions, such as heart problems or anxiety and depression, may also affect on-the-job performance but aren’t prohibited for medical professionals. Given MAT’s effectiveness for many patients, this article argues, why not make it an option? And they note that evidence on the relative effectiveness of PHPs still suggests that the programs do not work for over a quarter of nurses, and a quarter of physicians. The article pointedly asks: could health care professionals unsuccessful in PHPs find more success with MAT in treating their diseases?
Why is this important?
PHPs could be a kind of gold standard for treatment, or a sign of entitlement because they’re for physicians—any program involving physicians must be superior, this logic runs. Physicians with SUD receive an intensity, duration, and quality of care rarely available to others.9 Providing intensive and prolonged residential and outpatient treatment is generally more expensive than MAT. Though known to be effective, contingency management by itself is not generally used in long-term treatment because of its costs.10 PHP’s really get some things right, like extended treatment and using urine testing as one outcome. They are also generally very good at evaluating and treating all comorbidities, providing peer group therapy, and working with family, colleagues, and employers to provide additional support and monitoring. Only longer term, controlled studies of medical professionals with OUD will help us decide costs and benefits.
It is also worth noting that PHPs have been particularly effective for physicians in need of treatment for non-opioid SUDs, for which MAT has not been developed. Still, I prefer not to look at this in black and white terms. And it’s important to look at outcomes medical professionals might have in common with other OUD patients. In most instances, outcomes such as overdose, death, or forfeited licenses could demonstrate comparable program efficacy. Physicians and nurses have demanding, stressful jobs that often lead to considerable sleep deficits and exhaustion—combined with access to substances of abuse, these structural aspects of the profession can put practitioners at high risk for SUD.11
This New England Journal of Medicine article does a good job of raising questions and asking how much sense it makes for medical professionals to advocate for the adoption and increased availability of evidence-based MAT options while not advocating for those options for themselves. I have also discussed this question for methadone.12 PHPs may have a different philosophy about naltrexone, safe and effective and approved non-agonist MAT treatment for OUD. But what about buprenorphine or buprenorphine plus naloxone or methadone?
It is possible that, with many types of OUD, some treatments may work better, for example, for early onset conditions than they do for late onset conditions, or for OUD with depression than for OUD without it. Anesthesiologists are a special, high-risk group for OUD13 and for SUD in general. I remember when anesthesiologists were first advised to treat their OUD with traditional PHP treatment plus injectable naltrexone. Then, as return-to-work and relapse experiences were reported, PHP practice policy mandated MAT plus PHP.14 PHP practices differ from state to state but it’s generally advisable to have an open mind and individualize treatment as much as possible. PHP programs work and there is no reason not to trust them to do the best thing for physicians in their states of operation. We should listen to the patient and work together on OUD treatment plans.15 The medical profession carries important weight in its recommendations, which is precisely the reason that so many committed health care practitioners work for sound public health policy. As Dupont and McLellan have shown, PHPs offer a great opportunity to promote long-term treatment, recovery, and return to premorbid function. We need direct scientific study, not assumptions, to make sense of what works, when, and for whom.
DuPont, R.L., Compton, W.M., McLellan, A.T. (2015) Five-Year Recovery: A New Standard for Assessing Effectiveness of Substance Use Disorder Treatment. J Subst Abuse Treat
Warner, D.O., Berge, K., Sun, H., Harman, A., Hanson, A., Schroeder, D.R. (2013) Substance Use Disorder Among Anesthesiology Residents, 1975-2009. JAMA
Merlo, L.J., Gold, M.S. (2008) Prescription opioid abuse and dependence among physicians: hypotheses and treatment. Harv Rev Psychiatry
Petry, N. M. (2011) Contingency management: what it is and why psychiatrists should want to use it. The psychiatrist
DuPont, R.L., McLellan, A.T., White, W.L., Merlo, L.J., Gold, M.S. (2009) Setting the standard for recovery: Physicians' Health Programs. J Subst Abuse Treat
Merlo, L.J., Greene, W.M., Pomm, R. (2011) Mandatory naltrexone treatment prevents relapse among opiate-dependent anesthesiologists returning to practice. J Addict Med
Merlo, L.J., Campbell, M.D., Skipper, G.E., Shea, C.L., DuPont, R.L. (2016) Outcomes for Physicians With Opioid Dependence Treated Without Agonist Pharmacotherapy in Physician Health Programs. J