By Tom Horvath, PhD
This article focuses on physicians with substance problems (and by extension all licensed professionals). However, the underlying idea, that those wanting to assist someone with substance problems should focus on ends not means, applies widely.
In most US states there is a state-recognized Physician Health Plan (PHP) which often controls how physicians who have substance problems are dealt with. Similar plans exist for other licensed professionals. These organizations do much beneficial work. No one wants a licensed professional with substance problems. The national organization for PHPs is: https://www.fsphp.org, the Federation of State Physician Health Plans.
In this article I focus on some major problems with PHPs (and the parallel organizations). The idea has arisen that because of the enormous level of trust we want to be able to have in physicians, if they have substance problems, they somehow need a dramatically higher level of treatment than other individuals. Instead, they need is rigorous substance monitoring.
Ironically, one of the best predictors of how effectively one can address an addictive problem is their “recovery capital.” Recovery capital is the set of resources (money, family, friends, good employment, a sense of meaning in life, etc.) available to the individual, to assist them in the process of resolving an addictive problem. Physicians tend to have high recovery capital.
One study found that physicians who participate in both lengthy treatment (often residential treatment) and five years of monitoring after returning to work had a very high success rate (perhaps the highest rate ever found in an addiction treatment study). Apparently based on this study lengthy treatment (often months of residential care) is now deemed the “standard of care.” Ironically for a science-oriented profession, no one has tested what happens when there is monitoring alone. Ultimately trust can be maintained not by treatment (which is of uncertain outcome), but by rigorous monitoring.
Just as too little treatment can be insufficient, too much treatment can be harmful. The negative impact of going off to residential treatment can be substantial, given the cost of the treatment ($1,000 per day or more would not be surprising), the loss of income, and the life disruption of being away for perhaps several months. That disruption occurs not only for the physician, but also the physician’s family, and often the physician’s colleagues, who may need to take on extra work in the physician’s absence. Compensating for that disruption upon returning from treatment is an additional stress.
In some cases our goal may be to remove the physician from practice for a very long time, perhaps permanently, and perhaps to pursue criminal charges. In such cases there is no point in requiring treatment. In most cases, however, our goal is to support the physician in returning to full functioning. Making the change process more burdensome than it needs to be is counterproductive.
Upon completing an initial course of treatment, the physician typically returns to substance monitoring and perhaps limited or supervised practice. Substance monitoring involves being drug tested in an ongoing way. We might expect that the monitoring would be complete (if the professional uses the substance, it will be detected). However, in my experience of these cases, often the testing is random (perhaps averaging once per week). If the professional did use it might not be detected.
It is in the financial interest of organizations that specialize in treating physicians to adopt a standard of care that requires a large amount of treatment, even if the scientific evidence for this standard is lacking. It is perhaps also in their financial interest to suggest a monitoring plan that is less than fully rigorous. If the physician realizes the lack of rigor in their plan, it might be harder to cope with temptation. With detected use the physician can get sent back to treatment, perhaps even longer this time (cha-ching!).
As stated earlier, most physicians, have substantial recovery capital. Given such capital, an alternative approach once a substance problem has been identified would be to require an initial period of abstinence (a week or weeks, months in a severe case), but not require treatment.
Why abstinence? Perhaps in the future we will have the technology to monitor blood alcohol level (BAL) in real time (an implanted device?). Under those conditions a zero BAL at work, and a BAL .05 or lower at any other time (and only a few times a week), might be the requirement (.08 is drunk driving). At present, however, abstinence is easiest to monitor and would only be required for the monitoring period (which could be up to five years or longer).
Cannabis is still an ongoing issue. We do not have a precise way of determining if someone is currently intoxicated, or if their use is far enough in the past to have minimal effect on the present but is still detectable. Unless these questions get resolved requiring abstinence is likely to remain the only sensible option.
Other substances are either illegal or legal substances (prescription medications) used illegally (not as prescribed). In these cases, requiring abstinence is also likely to remain the only sensible option.
But don’t people need treatment to change their substance problems? NO. A substantial portion of those who have resolved a substance problem have done so with no or minimal outside help. The National Recovery Study found that 46% of those who resolved alcohol problems got no outside assistance, and of the 54% who “got help,” mutual help groups (which are non-professional—not treatment, and free) were the most common approach used (https://www.practicalrecovery.com/prblog/national-recovery-study/).
The message that the public should be getting about substance problems is not “treatment works” or “get help.” What the alternative slogans should be I will leave to others, but alternative slogans need to capture the ideas that change can come from within when we realize our values are being compromised, that outside assistance is available and might be helpful, that others who have made these changes can be especially helpful (if they are not trying to push their ideas on you), and that even though the process of change can be challenging and is typically not smooth, these changes are worth the effort.
Back to our physicians: An expert evaluation could determine how long a leave of absence to require. During that leave monitored abstinence should be required. If the leave is long enough there should be another evaluation at the end of it. Someone exhibiting major problems needs to demonstrate that their new course of action is stable, which might require more than a few weeks. An expert also needs to set up a rigorous monitoring plan, one that is timely, cross-validating, complete, and (in later stages) as non-onerous as possible while still assuring safety. The physician would probably be on a “last chance” agreement. That dire consequence will likely be very effective.
In addition to a much lower level of disruption when treatment is not required, the physician is much less likely to be distracted by anger at whatever organization is imposing the abstinence requirement. Resolving a substance problem is hard enough without increasing the emotional burden of it. Most physicians will likely understand that, regardless of how their problems began (which will likely include some poor decisions on their part) 1) assurance of public safety is now in order, and 2) it is ultimately up to the physician themselves to solve these problems (even if they use a powerlessness-based approach).
The physician can then focus on whatever changes are needed. We could study what percentage of these physicians seek treatment, and their reactions to it. Given the recovery capital that many physicians have, I predict that treatment seeking would be minimal (perhaps some outpatient sessions for most). If a physician cannot accept responsibility for change and the need for monitoring, they may not accomplish the initial abstinence required before returning to practice.
Back to the general idea: Those wanting to assist others should focus on ends not means. If you are concerned about someone’s substance problems, focus on the changes in their behavior you want to see, not on how those changes are to be made. In so doing you will not be stirring up counterproductive anger (most of which would be reasonable). The changer’s efforts can then be focused on change and not on anger at you.
Liked this article on physicians with substance problems? You might also be interested in: Infantilizing Addiction.
