Public Policy Statement on Healthcare and Other Licensed Professionals with Addictive Illness - An Overview
Healthcare professionals, like all individuals, are human, fallible and subject to medical illnesses, including addiction. The public—and too often the healthcare community itself—views addiction and its prognosis for remission in a negative light. This view represents an antiquated but long standing stigma about addiction, a lack of sufficient longitudinal addiction care, sparse treatment outcome data, and inadequate dissemination of evidence-based treatment into the healthcare community and the public at large. Healthcare professionals are a unique cohort, with distinctive characteristics that come into play in the development of the illness, the course of treatment, legal and ethical ramifications and eventual outcomes. Our best data regarding licensed professionals comes from research on over three decades of physician-specific addiction treatment and monitoring. These programs were initially recommended by the American Medical Association and the Federation of State Medical Boards. Nationally, the membership organization for the majority of Physicians Health Programs (PHPs) is the Federation of State Physician Health Programs (FSPHP). These programs have continued to evolve and mature; the majority of such programs now provide assistance for other licensed healthcare professionals in addition to physicians, and some address other professionals with addictive disease such as attorneys, judges, or healthcare administrators.
Physicians treated for addiction have recently become the focus of high quality, evidence based outcome research published in peer-reviewed journals (see Domino et al1 McLellan et al2, DuPont et al3). The results of this research indicate the treatment of physicians is profoundly effective when properly executed. ASAM has adopted a serof public policy statements addressing knowledge gained from such research and three decades of experience on physician-specific treatment, post-treatment monitoring and continuing care. This evidence-based research, over a period of decades, has implications for care and policy development in the future. Throughout these documentthe authors use the term “Healthcare and other licensed professionals” as aterm of applicability. While these public polices, by definition, address physicians, ASAM believes the overarching principles communicated through these policies are equally applicable to all healthcare professionals, other licensed professionals, and non-licensed professionals in safety sensitive positions. The breadth of the collection ostatements reflects this orientation. The eleven public policy statements surrounding this topic are as follows:
1) Healthcare and other Licensed Professionals with Addictive Illness - An Overview
2) Illness versus Impairment in Healthcare and other Licensed Professionals
3) Discrimination and the Addicted Professional
4) Coordination between Treatment Providers, Professionals Health Programs and Regulatory Agencies
5) The Evaluation, Treatment and Continuing Care of Addiction in Healthcare and Other Licensed Professionals
6) Credentialing in Healthcare and Other Licensed Professionals with Addictive Illness
7) Confidentiality in Healthcare and Other Licensed Professionals with Potentially Impairing Illness
8) Public Action by State Medical Licensure Boards and Comparable Regulatory Agencies Regarding Healthcare and Other Licensed Professionals with Addictive Illness
9) Public Safety and the Healthcare and Other Licensed Professional with Addictive Illness
10) Recovering Physicians, Medical Licensure Boards, Specialty Board Certification and Professional Society Membership
11) Relapse in Healthcare and Other Licensed Professionals
Although healthcare and other licensed professionals have the potential to develop many types of psychiatric, psychological and behavioral illnesses, this group of policies focuses on substance use disorders (SUDs), especially addiction. This collection of public policy statements is not intended to be a complete compendium on the subject of addiction in healthcare and other licensed professionals. There are many research papers, review articles and textbooks on the topic of addiction and even on addiction among physicians. These public policies focus on three important areas of addiction among healthcare and other licensed professionals, including issues related to stigma (see Public Policies 2 and 3), the effective response to the problem of addiction among professionals (See Public Policies 4, 5 and 11), and the interrelation and integration of medical, legal, and sociologic issues regarding addiction in this particular population (see Public Policies 6, 7, 8, 9 and 10).
Several factors are involved in the etiological differences of addiction as it manifests in the “special populations” of healthcare and other licensed professionals. First, one group of professionals—healthcare providers—have greater access to addictive drugs in their workplace, which can accelerate and complicate the onset and progression of the disease. Secondly, healthcare professional training creates a level of comfort and an associated false sense of immunity to the dangers of drug use. Having technical knowledge about the pharmacology of drugs does not protect susceptible individuals from becoming addicted to such drugs and, in fact, may actually predispose susceptibility. Thirdly, all healthcare and other licensed professionals with addictive illness face tremendous prejudice based on stigma and fear which make them hesitant to admit a problem or seek assistance. Lastly and importantly, as with other safety-sensitive occupations, healthcare and other licensed professionals with untreated, potentially impairing conditions have the potential to place the public at risk.
Many individuals and agencies play a role in the care and coordination of the addicted healthcare and other licensed professionals. For the purposes of these policy statements, we have focused on four critical entities: the population of healthcare and other licensed professionals with the disease of addiction; the specialty treatment programs where these persons receive clinical care; the various Physicians / Professionals Health Programs (PHPs) which provide continuing care monitoring and earned advocacy; and state-specific licensure and other comparable regulatory agencies. These entities, as defined, have an interrelated and often symbiotic role in both the successful rehabilitation and recovery of the addicted professional, and the safety and welfare of the public.
The Addicted Professional
The disease of addiction produces characteristic behaviors. The characteristics and circumstances of the patient who is, himself or herself, a professional are unique. These issues must be considered and managed during treatment and post-treatment recovery. These policies address physician patients who are part of a professional cohort; but include other licensed professionals including, but not limited to, nurses, physician assistants, pharmacists, psychologists, commercial pilots, attorneys, law enforcement officials, as well as any cohort which provides a public service that could impact the public health, safety, and welfare. Each of these groups is unique in the perception of their disease, their experience of addiction-induced shame, and the necessary coping skills to ensure successful long-term recovery. Some of these professional groups share strong similarities; however, each specific group should be treated by providers knowledgeable, skilled and experienced in understanding the distinctive educational background, psychological characteristics, work environment, professional culture, social factors, and specific licensure and regulatory agency processes related to each particular cohort of addiction treatment recipients.
Addiction Treatment Programs for Healthcare and Other Licensed Professionals (ATPs)
Addiction Treatment Programs for healthcare and other licensed professionals specialize in the diagnosis and treatment of addictive and/or mental illnesses in healthcare and other licensed professionals. These clinical programs possess expertise in dealing with issues specific to these populations of ill individuals; some ATPs have expertise in one or more subsets of professionals. ATPs provide a multi-disciplinary spectrum of therapeutic services, addressing the biologic, psychosocial, family, and spiritual components of these disease states. One important element in specialized Addiction Treatment Programs is the presence of a cohort of like-professionals. This “peer relating” during treatment decreases the isolation and enhances the interdependent learning necessary for effective treatment. ATPs for professionals have extensive experience with and knowledge of the stressors and triggers in the work and home environment specific to the professional cohort being treated. This information is used to focus the treatment on cohort-specific issues, encourages reintegration into a healthy home and work environment, and ultimately promotes a sustained successful recovery. The most comprehensive programs manage multiple psychiatric diseases, complex medical conditions, psychological co-morbidities along with a broad spectrum of addictive disorders.
Many facilities that treat addicted professionals provide comprehensive evaluation services as well. Some evaluation programs are organized as separate entities from ATPs, while others are integrated with treatment facilities. Evaluation centers must exhibit a proven track record in understanding the complex multifactorial and insidious nature of addiction among healthcare and other licensed professionals. They should utilize a multi-disciplinary team of individuals with specific expertise in distinct but interrelated specialties. The multi-disciplinary evaluation process is essential to a truly thorough and comprehensive evaluation. They collect outside data and collateral information, investigate the workplace environment and associated risks, complete psychological and neurocognitive testing and perform intricate drug screen testing tailored to the specific individual. These centers communicate regularly with and release reports (with appropriate consent) to referral sources such as the Professionals Health Programs, regulatory agencies and/or other need-to-know entities.
Professionals Health Programs (PHPs)
A Professionals Health Program has mutually symbiotic dual roles of enhancing public safety and facilitating the successful rehabilitation and practice re-entry of healthcare and other licensed professionals with potentially impairing medical conditions. Professionals Health Programs (PHPs) provide a confidential conduit for ill professionals to access a comprehensive evaluation and any necessary subsequent treatment. When a professional with a potentially impairing illness becomes involved with a Professionals Health Program (PHP) and no harm to the public has been identified, he or she is ideally enrolled in an alternative pathway to professional discipline. PHPs provide the availability of a non-disciplinary alternative with rehabilitation and accountability being emphasized, facilitated, and carefully documented over time. The PHPs continuous, skilled and documented monitoring of the professionals recovery status and associated earned advocacy further promotes the public safety (see Public Policy 9). PHPs are exceptionally distinct in their ability to provide early identification, intervention, and referral for evaluation and/or treatment. They also conduct three types of post-treatment monitoring: behavioral, chemical, and worksite evaluations. Their success is largely attributable to this tri-partite model of recovery monitoring. The intervention, referral and post-treatment monitoring services offered by PHP’s are generally conceptualized as being distinct from the clinical services offered by ATPs. PHPs educate the medical community about addiction among professionals, the risks of addiction in professionals and the recognition of the subtle signs and symptoms of addiction in the workplace. Such education and prevention services further enhance public safety by encouraging earlier detection and referral to treatment when appropriate. PHPs are uniquely qualified to advocate for program enrollees with potential employers and regulatory agencies when enrollees have successfully engaged in an ATP and are compliant with PHP monitoring requirements.
Regulatory Agencies (RAs)
These are agencies of state government charged with credentialing and granting licenses to professionals and assuring to the public at large that the conduct of the professional meets professional and statutory standards. State statutes mandate the regulation of selected professions to ensure the delivery of quality healthcare or other services necessary to the public health, safety, and welfare. They investigate the practice of licensees and have authority to address those who violate the state’s professional practice acts or comparable legislation. Their primary mission is to protect the public. Regulatory agencies, through the charge given them by the state legislature, focus on public safety, while Professionals Health Programs focus simultaneously on public safety and the health of the licensed professional. This is complementary to the focus of Addiction Treatment Programs, which attend to the health of the addicted professionals under their care and the fitness for duty of such professionals. Addiction rehabilitation requires an understanding of the inter-organizational complexities along with associated expertise in the interrelated management of addicted professionals to the benefit of the public we serve. This understanding of addiction rehabilitation among professionals facilitates the interaction by and between Addiction Treatment Programs, Regulatory Agencies, and the Professionals Health Programs. (See Public Policy 4).
Accordingly, ASAM Recommends the following, aligned with this Overview of issues related to Physicians and Other Licensed Professionals with Addictive Illness:
a) The healthcare community, general public, and public policy makers be assisted in the understanding of the reality that addiction occurs in healthcare and other licensed professionals like any other group of human beings. The addicted professional deserves the same professional, compassionate, respectful and confidential care as is offered to any other person in need of addiction treatment.
b) The recommendations set forth in this interrelated set of policies become the basis for standards of care for all healthcare and other licensed professionals promulgated by Professional Health Programs, Regulatory Agencies and others. Addicted professionals warrant compassionate care, state of the art disease management, safe reentry into the workplace, skilled long-term monitoring and appropriate advocacy on their behalf. Addicted professionals, appropriately managed, should retain the ability to engage in the professional activities for which they have been trained without unnecessary restrictions on their licensure. Such professionals deserve the earned advocacy of competent Professionals Health Programs (PHPs) upon successful and cooperative treatment by qualified Addiction Treatment Programs (ATPs).
c) Treatment providers who treat addicted professionals have a strong working knowledge of the professionals’ educational background, psychological, social, work and environmental issues. These treatment providers have extensive experience in the regulatory issues, subtleties of the presentation and clinical management of addiction in the populations specific to the professional cohorts of patients they serve.
Furthermore, ASAM Recommends the following which comprise a Summary of the major Recommendations of the other ten public policy statements on Healthcare and Other Licensed Professionals with Addictive Illness:
Policy 2) All relevant entities with an interest in healthcare and other licensed professionals with addictive illness should recognize addiction is a potentially impairing illness, while “impairment” is a functional classification. Professionals diagnosed with addictive illness may or may not evidence “impairment”. The term “impaired professional” used to signify professionals in recovery is pejorative, and should be replaced with the term “recovering professional”. An addicted professional is a person diagnosed with an illness. That person may be impaired, may be in recovery, or may not be either. Individuals with addictive illness, their families and the community at large are best served when addicted professionals are identified early, referred to treatment and appropriate post treatment monitoring before their illness becomes an impairment.
Policy 3) All parties involved, including regulatory agencies, should assiduously avoid direct or indirect discrimination against any and all healthcare and other licensed professionals who develop an addictive illness. Any restriction of access to the rights and privileges of membership in a professional organization or serving in a professional role should be based on just cause only, not solely on the presence of a particular diagnosis. Those in remission who have had appropriate evaluation, treatment and are being monitored or have successfully completed such monitoring should not be unnecessarily scrutinized or discriminated against.
Policy 4) Addiction Treatment Programs (ATPs), Professionals Health Programs (PHPs) and Regulatory Agencies (RAs) should coordinate their efforts and work in concert to enhance the health and safety of healthcare and other licensed professionals with an addictive illness to the benefit of the health and safety of the public they serve.
Policy 5) The evaluation and treatment of addicted and recovering healthcare and other licensed professionals is best performed by a PHP-approved multi-disciplinary team of clinicians with extensive knowledge and experience regarding the unique manifestations of illness and recovery within the framework of the licensee’s professional cohort. Continuing care should be conducted by competent PHP Professionals.
Policy 6) Credentialing processes must be fair, reasonable, unbiased, and performed in good faith, and should utilize accurate, current documentation that reflects the current state of active disease or disease remission and an accurate assessment of current impairment. When a recovering healthcare or other licensed professional in sustained remission from an addictive illness is credentialed, the credentialing body should not discriminate against such professionals for any reason, and specifically as it relates solely to a past history of addictive illness.
Policy 7) Healthcare and Other Licensed professional’s who have health problems, including addictive illness, should have the same rights to privacy as do other patients in clinician-patient relationships. Professionals with addictive illness should be afforded confidential and compassionate care. Health status information, per se, about licensed professionals, should not be publicly disclosed. Addiction Treatment Providers, Professional Health Programs and Regulatory Agencies must work together to ensure confidential quality care is balanced with the imperative for public safety.
Policy 8) Automatic and publicly-disclosed adverse disciplinary actions by Regulatory Agencies in response to potentially-impairing illnesses in professional licensees are not beneficial to the recovering professional and are not necessarily in the best interest of the professional or the public. Regulatory agencies should have extensive knowledge of the addictive behaviors that occur in healthcare and other licensed professionals – typically via interface with their PHP. Public Action should be limited whenever possible to actions clearly indicated for the enhancement of public safety.
Policy 9) When considering healthcare and other licensed professionals with addictive illness, the public health, safety and welfare are paramount. The public health, safety and welfare are best served when an otherwise competent professional with a potentially impairing illness is managed with a cohesive effort among all involved entities. Such management leads to earlier identification, appropriate evaluation, any indicated treatment, competent monitoring through a Professionals Health Program (PHP) and the safe return to the active practice of their profession. Barriers to these goals must be removed.
Policy 10) Professional and Specialty Societies, Specialty Certification Boards, and State Regulatory Agencies should support recovering healthcare and other licensed professionals. Unjustifiable impediments to society membership, specialty certification, and board certification, on the basis of recovery from addictive illness alone, is counterproductive, pejorative, and should not occur.
Policy 11) Relapse is not indicative of willful misconduct but a reality of the illness indicating the need for further evaluation, treatment, and monitoring. A subset of healthcare and other licensed professionals with addictive illness will experience relapse. When relapse does occur, decisions regarding response to and management of the relapse should be clinically driven and guided by the PHP.
1 Domino, KB, Hornbein TF, Polissar NL, et al. Risk factors for relapse in healthcare professionals with
substance use disorders. JAMA. 2005;293(12):1453-60.
2 McLellan AT, Skipper GS, Campbell M, et al. Five year outcomes in a cohort study of physicians treated
for substance use disorders in the United States. BMJ. 2008;337:a2038 doi: 0.1136/bmj.a2038.
3 DuPont RL, McLellan AT, White WL, Merlo LJ, Gold MS. Setting the standard for recovery: Physicians’
Health Programs. Journal of Substance Abuse Treatment 2009;36:159-171