President's Blog

How To Achieve an 80 Percent Recovery Rate

by Stuart Gitlow | October 16, 2012

The September issue of our Journal of Addiction Medicine features an article by JW Boyd and JR Knight discussing ethical dilemmas confronting state physician health programs (PHP's). Within the article, the authors show concern regarding the coercive nature of the system, specifically indicating that "physicians have little choice but to cooperate with any and all recommendations if they wish to continue practicing medicine." There is also concern that when such treatment is recommended, cost may be prohibitive for the standard 90 day length of rehabilitation, notably longer than the 20-28 day stay typical for other patients undergoing substance abuse treatment, despite what they describe as a lack of evidence that healthcare professionals require longer treatment.

The Federal Aviation Administration has similar rules applying to aircraft pilots identified as having addictive illness. These pilots have little choice but to cooperate with FAA standards and regulations if they wish to obtain a special issuance medical certificate, under which they may continue to fly either privately or commercially. They too have to pay sometimes prohibitive amounts for their treatment, which as it happens is also a 90 day length of rehabilitation as a starting point. The questions which Boyd and Knight pose for physicians could therefore also be posed for pilots. A quick literature search reveals there to be no evidence that pilots require longer treatment.

But there's a problem with this line of thinking. Both pilots and physicians have been demonstrated to do well with these treatment programs. Recovery rates over 80% appear to be rather consistently identified both by PHPs and by studies of pilots conducted by the FAA and by independent airlines. These long term recovery rates appear dramatically superior to the recovery rates obtained within the general population, which, depending on what literature you believe, seems to lie somewhere in the 40-50% area. Further, one could easily argue that many of our patients have little choice but to cooperate with recovery programs if they are to regain their physical health, their financial status, custody of their children and their legal freedom. It would seem that these measures of coercion would often be at least equal to one's desire to simply regain access to one's chosen occupation or avocation.

Given that recovery rates are demonstrably higher with pilots and physicians going through these well-defined recovery programs, I would flip the question as posed by Boyd and Knight: is there any evidence that the general public requires less treatment than do healthcare professionals and pilots? I would further ask, given the excellent outcomes generally obtained by PHPs and pilot recovery programs, why there have been no studies in which members of the lay public go through identical programs to determine what their long term outcome would be. Indeed, what happens when a non-healthcare professional or non-pilot goes through 90 days of rehab, and is then followed regularly by an addiction specialist physician while simultaneously attending twelve-step or similar self-help groups and being subject to random urine drug testing, all as the FAA requires of pilots requesting a special issuance medical, and as state medical boards generally require of physicians wanting to return to practice? Would they too have an 80-90% recovery rate?

Before we go after a successful set of programs, perhaps we should first ask the question as to whether we should direct our attention toward less successful approaches. This is not meant in any way to undermine the ethical dilemmas addressed by Boyd and Knight; such dilemmas are legitimate and deserving of focus and attention so as to ameliorate the inherent conflicts of interest as best we can. The authors have done an expert job at pointing out the major issues to be considered. But as with all ethical dilemmas, there are valid arguments on both sides that need to be considered closely, and each argument needs to be considered from an opposing direction to determine if the stage is set properly for any investigation to follow.

20 Comments

  1. 20 Susan T. Haney, MD, FACEP, FAAEM 18 Jun

    The claim of an 80-90% success/recovery rate in physicians from a single poorly designed study (Setting the standard for recovery: Physicians' Health Programs. DuPont RL, McLellan AT, White WL, Merlo LJ, Gold MS. J Subst Abuse Treat. 2009 Mar;36(2):159-71. doi: 10.1016/j.jsat.2008.01.004) using a single data set (a sample of 904 physician patients consecutively admitted to 16 state PHP's) is misleading on many levels.  First, the study was neither randomized nor controlled (nor blinded) -- making quality of evidence for effectiveness of the PHP treatment model over any other treatment model (including no treatment) poor from a scientific perspective.  Second, the study contains multiple flaws in both reasoning (type I and type II errors) and statistical analysis that render its conclusions invalid.  Third, the impact of undeclared but substantial financial conflicts-of-interest (including funding by drug testing and addiction treatment industries) and personal ideological biases (including personal 12-step recovery from addictions) in the authors of this study should not be underestimated.

     

    At most, DuPont et al.'s  study represents the consensus opinion of its authors.  If they had found a way to use the same methodology for identifying ("diagnosing") addiction in the general population as was used on these physicians (for example, by blinding the investigators to subjects' occupations), they may have discovered that physicians were twice as likely to be successful in coerced PHP's because they were half as likely to be actually "addicted" in the first place.  Misdiagnosis/overdiagnosis in this paradigm -- incentivized by lucrative self-referral dollars for expensive 90-day treatment programs -- is both widespread and completely unethical.

  2. 19 Activist 30 May

    If we were to apply the real scientific method to this opinion piece, as with a peer-reviewed journal article, this would not pass muster.

     The 80%-50% comparion is useless - how can one possibly compare professional doctors and pilots to the general population?  These are two of the most highly competitive professions we have - the practitioners of each must be highly disciplined, extremely intelligent, physically skilled, and will have beat out many other contenders who did not make the cut.

    We're comparing that to the folks that work at McDonalds.  Great science buddy!  

  3. 18 Why stop at 80%? 30 May
    Why stop at 80%? If you can get them to give you the right to shoot in the head any non-compliant addicts I bet you could ratchet it up to 90%+, why not? It seems to work in Singapore. You folks are on the right track! ;) Shoot them in the head! Kill them, dont just take away their livlihood, slow, soft death gets 80% imagine what we could do with a direct shot to the head?
  4. 17 August West 29 May

    In the 21st Century there is no valid excuse for the refusal of transparency and accountability.  The only reason one would take this stance would be if there was something to hide.  Secrecy among the FSPHP creates a powerful impression that there is something to hide.  This pithy "if it ain't broke don't fix it"  non sequitur logical fallacy argument claiming an 80% "success rate"  implies no need for improvement.  Of course from the catbird seat there is no need--it is all backslapping, polemical, holier than though euphoria--police warden cuz I said so mentality--schoolyard bullies brandishing self appointed powers--reduced to the lowest denominator--mental midgets with a big stick with the ability to remain invisible.  Looking good Billy Ray! Feeling Good , Louis!  Positively 4th Street.

     

     

    The bottles stand as empty, as they were filled before.

    Time there was and plenty, but from that cup no more.
    Though I could not caution all, I still might warn a few:
    Don't lend your hand to raise no flag atop no ship of fools.

    Ship of fools on a cruel sea, ship of fools sail away from me.
    It was later than I thought, when I first believed you,
    Now I cannot share your laughter, ship of fools.

    It was later than I thought when I first believed you,

    Now I cannot share your laughter, ship of fools.--Hunter/Garcia


    http://www.drugwarrant.com/2013/05/reefer-madness-redux/http://www.youtube.com/watch?v=HbNuuKJEwEAhttp://www.drugwarrant.com/2013/05/robert-l-dupont-vies-for-stupid-oped-award-but-loses/ http://health.dir.groups.yahoo.com/group/wmdp/message/1752 http://releaf.co/?tag=dr-steve-adelman-medical-marijuana

     

     

  5. 16 Warren Mullaney 25 May
    https://docs.google.com/file/d/0B4v41Wac6BvScDBDUVkxNkhON2s/edit?usp=sharing

     

    Just wondering why no one has commented on the above URL.  How about you Skipper. Care to justify what this evidence shows?   You can't can you?  Give it a go now will you? please comment on what this shows and try to defend it.    Below is from the comments section of another blog:

     

    The Physician Health Services, FSPHP agenda is clear if one looks at the major players behind the scenes. Robert DuPont (White House drug Chief 1973-1977) runs a corporate drug testing business (Besinger, DuPont and Associates) along with Dr. Gregory Skipper who runs the Alabama Physicians Health Program. An ex-felon who had his licensed revoked in Oregon, Dr. Skipper introduced EtG testing as a means to test for alcohol and successfully partnered with a drug testing company to screen for alcohol use. Using an arbitrary cutoff point of 100 ng/ml it quickly became apparent that the test was flawed as it was introduced into professional monitoring programs and the criminal justice system. The flawed test was exposed in a Wall Street Journal article and has largely been abandoned. It is now known that hand sanitizer, cosmetics, sauerkraut, bananas, and myriad other substances can cause a positive EtG test. Hand sanitizer can produce a level of 2000. Thousands of people have been harmed by this test (did not get jobs, lost jobs, lost licenses, went to prison) and Dr. Skipper, somewhat like Mrs. Winchester and her mystery house adding room for the ghosts of victims of the Winchester rifle, has set up a website where people can leave their tragic stories of how they were harmed by the EtG. He takes no responsibility however and the conflicts of interest are again staggering. Although he is a Physicians Health Service director her runs Promises Treatment Center and has ties to the drug testing industry. PHS still uses EtG and Dr. Skipper has introduced another test (PEth) which they are claiming can confirm ant EtG. Junk science with scant data it is being used by USDTL.
    Skipper and DuPont work together with a concerted goal of applying Physicians Health Programs as a model for everyone else as well as further impacting medical progress by identifying “disruptive physicians” who they can then remove from practice.http://gregskippermd.homestead.com/http://online.wsj.com/article/SB115534928148134109.htmlhttp://www.promises.com/news/physician-impairment-focus-of-jama-article-co-authored-by-director-of-professionals-treatment-at-promises/http://en.wikipedia.org/wiki/Robert_DuPonthttp://gregskippermd.weebly.com/uploads/7/4/7/5/74751/php_article_counselor_mag._2010.12.pdfhttp://www.wvmphp.org/php.phasei.how_are_addicted_phys_treated.pdfhttp://www.williamwhitepapers.com/pr/2007PhysicianHealthPrograms.pdfhttp://www.usnews.com/news/blogs/washington-whispers/2013/03/08/former-dea-chiefs-may-profit-from-illegal-pot-critics-sayhttp://www.medscape.com/viewarticle/773544

  6. 15 Go to Singapore 13 May
    80% recovery rate, that's nothing, why not look to Singapore or China for models that get higher results. Stone them to death if they fail a test. Surely that will get you to 90%+?!!!!!
  7. 14 Warren 04 May

    Regarding the need for regulation, oversight, quality control, and accountability here is a picture that speaks a thousand words.  Incompetence, duplicity, stupidity, and malice can thrive in situations where there is absolute power without accountability. History has shown that this fosters corruption.   How does one defend what these documents reveal?   Inexcusable, egregious, unethical, and criminal--transparency and accountability should be priority number one--once that is done perhaps  some instruction in evidence based medicine is in order.   It is not 1955 anymore fellas--logical fallacy, pseudoscience,  junk science, and 12-step fanaticism are not contributing to medical progress and certainly not helping the physicians in the programs.  

     

    https://docs.google.com/file/d/0B4v41Wac6BvScDBDUVkxNkhON2s/edit?usp=sharing

  8. 13 Jonathan Barlow 30 Apr

    I applaud the discussion and the questions posed.  Rather than affirm the many excellent discussions, perhaps I start by sharing my bias in siding with the comments of John Lawrence, Andrea and John.  At a practical reality, the findings discussed are not particularly "amazing" and would fit rather well into the traditional concept of "the pain of addiction outweighing the pleasure of addiction" which is foundational to lasting recovery.  I hope, however, to move to the broader theme: that being the idea of coercion and recovery. 

     

    It may be said that 'coercion' is in many ways the only way in which an individual establishes recovery.  As said, without sustained "pain" overcoming the sustained "pleasure" then recovery is extremely difficult, if not inconceivable regardless of treatment approach or supposed contingencies.

     

    I wonder whether there is a meaningful distinction between "natural" coercion (realities such as near death experiences, imprisonment, liver failure, loss of marriage, or inability to achieve a "high") and "manufactured" coercion (realities such as occupational mandates, employee stipulations or even stipulations set forth by loved ones).  Perhaps our distinction between natural and manufactured coercion are not germane.  

     

    Perhaps the origin of coercion is less important than the sustained quality of the effect of coercion.  If this is true, then its implications are meaningful for both impaired professionals and the lay public/families who feel powerless to addiction.   

     

    I am reminded of a simple metaphor based on the Goldilocks fairy tale.  Perhaps recovery has little to do with the specifics of what is in the "porridge."  Perhaps the formula for success is in establishing a "porridge" that is neither too hot or too cold for the individual considering recovery.  If this were true then establishing the right "temperature" of a porridge should be our focus, as compared to exactly who does the temperature regulating.  In other words, the success of the impaired professional programming may have little to do with its formula for treatment and far more to do with the sustained coercion over time.  (It would be interesting to compare the "success" of the programs discussed above with drug court programs that also report "success".  (Certainly potentially contaminating variables -- would need to be controlled.)

     

    To be very specific, it is the family that carries the greatest capacity to offer sustained "coercion" in a manner that could establish an optimal temperature of the "porridge" over an extended period of time.  Far too often families instinctively establish a porridge that is far too "hot" or far too "cold."  What has been most intriguing to me has been to establish sustained guidance to a motivate family on how to achieve a "coercion" that is neither too hot or too cold. If implemented properly at the family level, perhaps the idea of occupational, employee or even legal "coercion" would be only discussed as a last resort rather than as an idea of a progressive treatment intervention.

  9. 12 Roy D Clark Jr MD 25 Dec

    For those veterans of "The Sick Physician" ... "The Impaired Physician" - I go back to the beginning of my Fellowship training at Mayo Rochester  in the 1970s - these dilemmas and issues are not new.

    Before these programs, most state medical licensing boards had no alternative to permanent revocation when such a physician came to their knowledge.

    As formal programs began to evolve, we admittedly used the principle of “reciprocal thievery,” agreeing we would meet regularly, talk frequently and steal from each other “what worked.”  There was a close exchange with the FAA, ATA, and ALPA HIMS program for pilots and flight crew as both were in development and the few physicians experienced in addiction usually were involved at some level in both programs.

    I can only speak specifically from the my perspective (1983-2002) during the development of the Washington Physicians Health Program.

    The WPHP program, including the “coercive nature” and recommendation for a 90-day period of initial intensive treatment, beginning with a 30-day inpatient or IOP at  one of a few carefully-selected independent treatment facilities, reflected the success of similar experiences and new standards around the country. All too often theose new standards had been written with pens of sorrow dipped in the blood of a tragic event.

  10. 11 Greg Skipper 11 Nov

    Programs such as HOPE probation in Hawaii and 24/7 in the Dakotas (and elsewhere) are examples of programs with designs similar to Physician Health Programs involving offenders, not professionals, that have been shown to be very effective. The basic idea is 1, a clear expectation of total abstinence, 2. a contingency agreement that spells out positive and negative reinforcers for continuing to have negative drug tests or failure to continue. Contingency monitoring can be used in most patients. We have been leveraging such things as: return to live at home, payment for college, utilization of car, and other creative contingencies and we're finding when these things are held as contingencies based on monitoring and clean testing that outcomes are greatly enhanced. The entire field of "contingency management" in which incentives are given for negative drug test monitoring has considerable evidence of efficacy. Therefore it does not appear that physicians do better just because they have more to loose or a different form or severity of addiction.

  11. 10 John Lawrence 25 Oct
       Anyone employed in the field of addiction recovery knows that there is no more powerfu al factor in motivating an alcoholic and/or addict than an ultimatum from an employer making clear that the alcoholic/addicts continued employment is contingent upon sobriety. The same fellow who has resisted the earnest and tearful pleas from family members that he seek out recovery has a far more open mind when the singlemost important method he has to measure his self-worth is under threat. It stands to reason that the investment that a physician (or airline pilot) has made in time, money and labor under grueling conditions to earn credentials as a physician, will gravitate toward recovery when his only alternative is to sacrifice that lifetime of effort for the privilege of further indulging a behavior he is already prepared to admit is problematic. Anyone busy congratulating him or her self for acting in the role of monitor for a colleague attempting to retain licensure is wasting time better devoted to some meaningful contribution elsewhere. These coercive agencies are neither protecting the public from errant physicians nor safeguarding the profession from rogue agents acting under the influence. It would make far more sense for random screenings to be mandatory for any practitioner who relies on a trusting public to ply his or her trade. The weekly samples these agents demand from those physicians who have been identified, fairly or not, as risks to the profession and/or to their patients, do nothing to identify nor do they seek to identify, those physicians who are in fact addicted and flying comfortably under the radar. It is clear that many, if not most of the professionals acting under the auspices of one of these "health programs" are do-gooders who are awaiting the chance they are certain will come, to come up with a sample that appears tainted enough to justify the vigilance they are able to convince themselves is necessary and a public service. Anyone sober, and living a program of recovery, sees agencies like these as examples of usefulness similar to the efforts put forth carrying pails of water to a flood. You're pushing paper but you are the only ones believing you are providing a service that accomplishes anything other than making yourselves nuisances to some poor soul who has real issues to contend with.
  12. 9 Rehan Memon MD 23 Oct
     I recently received an email detailing the MOC requirements for ASAM certified physicians. I have to say that the MOC requirements are pretty extensive and lengthy and I wanted to voice my opinion/concern about them. 
    First- 12 self assessment activity requirement by reading articles and answering 3/4 questions correctly every yr and receiving 12 credits for it every yr should have been an optional NOT mandatory requirement. There should be total CME hours requirement and how one chooses to full fill it, should be left at physician discretion.
    Second- 26 CME credits every 2 yrs (that would have to be ASAM annual meeting or a review course). The total 10 yr requirement is coming around 250 hours of CME (including 120 hrs of journal articles) is simply too much.
    I believe these are very aggressive MOC requirements. My primary board certification is in Anesthesiology with added qualification in Pain medicine and even my primary board has easier MOC requirements than this. In addition, fee of $425 every year ($4250 in 10 yrs) will become a mandatory NOT optional fee if its tied to MOC requirements. In addition, the fact that it covers fees for re certification is actually not an incentive since the fee for re certification is around $1800 (in contrast to $4250).
    In summary, I would like to say that these requirements should be re evaluated and possibly made easier (with less CME) since most of the physicians (including myself) have Addiction Medicine as secondary or tertiary certification and NOT the primary certification and it is going to be very difficult to keep the certification status active if the MOC requirements are kept as is. I hope that these concerns will be given due thought and consideration and will help shape the future ASAM procedures and policies in regards to MOC.
    ThanksRehan Memon, MD
  13. 8 J. Wesley Boyd, MD, PhD 20 Oct

    As i said in an email to the editors , given the press around this piece it should be available to everyone, not just those who are ASAM members.  I myself (not an ASAM member) just saw the actual piece  5 minutes ago . . . .  I have blogged about it and also will be on national call in radio for an hour this Tuesday about  the piece.

  14. 7 ASAM Staff 19 Oct
  15. 6 Penny Ziegler 17 Oct
    While there are no national regulations governing the operation of Physician Health Programs, the comment that they have no accountability or external oversight is not accurate across the board. Some programs are directly affiliated with licensng Boards and/or other agencies that provide oversight and auditing of program practices, staffing, relationships with treatment providers, etc. Even when there is no formal affiliation with a regulatory agency, a PHP would have difficulty developing a trusting relationship with Boards, employers, etc. if it was not adhering to appropriate standards of operation, including use of criteria for assessment and treatment referral, offering choices and options to participants, and responding to participant complaints and dissatisfaction. The utility and credibility of any advocacy program depends on its maintaining the highest ethical standards, addressing any appearance of conflict of interest, and conducting its own continuous quality improvement activities.
  16. 5 Andrea 17 Oct

    When have any type of overseer group requiring people to comply with their standards, i.e. 90 day porgrams, UA's, meeting participation and their very livelihood depends on successful completion, yeah you're going to have a higher percentage of "success" simply because failure means losing their licenses and no longer able to work in their profession. The general public does not have that, even someon of equal SES and similar education/intelligence level, if they relapse and fail to complete treatment, they could quit one job and go to another without ever having to address their addiction problem. Healthcare professionals and pilots don't have that "luxury".

     

    Even people on probation or parole can/do "successfully" complete treatment when being required to report to someone about their participation and require drug screens, then once they are done with probation/parole could and often do go back to using if the change wasn't sincere.

     

  17. 4 Warren 17 Oct

    The principles of respect for persons, autonomy, compassion, truth telling, nonmaleficence, and beneficence form a necessary foundation for treating patents with substance abuse disorders.  Although initially created to help doctors with drug and alcohol problems, many Physician Health Programs have degenerated into little more than urine drug testing programs that serve not to promote the health of,  but to monitor and police the physician in recovery.  Physicians Health  Programs are currently unregulated and have no accountability or external oversight in place.  The have absolute power over the physician,  low public visibility, peer group and managerial secrecy, and operate outside the usual constraints of regulation and accountability.

    This organizational structure is one that can facilitate and foster substandard care, misconduct, and corruption.  History past and present (i.e state crime labs, police, forensic experts) is replete with examples of this inevitability.


    Federal employees, DOT, the FAA and many other organizations respect the rights of those who develop substance abuse disorders.  Rules are followed such as documentation of chain of custody, split samples, autonomy in choice of treatment, and the right to appeal to an external agency if those rules are breached.


    Physicians Health Programs, on the other hand, can essentially do whatever they want. I have witnessed incompetence in MROs who simply rubber stamp positive tests stating "a positive is a positive," confirmatory distortion on psychological tests, and even the manipulation of a specimen to show a positive drug test.  When individuals in a group believe that ethical and legal rules don't apply to them and when the thoughtful academic members of the group leave or are forced out it is a red flag.


    Skipper states that because doctors and pilots are in safety sensitive positions they forfeit some freedoms to continue to work.  Be that as it may, they don't forfeit the right to fair and honest testing and treatment.  The "ever present opportunity for civil action"  if ethics are violated is absurd.  If a member of a Physicians Health Program violates the civil rights of, abuses, or even commits a crime against a physician in the program there is not only no appeal process but no one to even report it to.  Even the most egregious abuse of power remains unseen and unheard.  How do you file a civil suit without accountability.  And like John says, the success rates are comparing apples and oranges--there are many reasons why physicians would have a higher success rate than the general population.  Claiming credit for this success would only be valid if it compared physicians who developed substance abuse problems and joined a Physicians Health Program with those who did not.  And comparing this organization to the rest of medicine is also like comparing apples to oranges.


    The unfortunate fact is that corruption flourishes in the absence of institutions to expose and punish it.

  18. 3 John 16 Oct

    Apples and oranges.  Physicians have higher incomes (deep credit cards), are usually not homeless, have higher baseline intelligence and social status than the "average" rehab patient.  Many physicians are plunked into a 90 day program without a single outpatient treatment program and thus may represent "easy" cases compared to others.  Motivation is artificially high (it is said that the only opiate addicts who agree to injected naltrexone are doctors and paroled felons).

    Put your random set of people accepted to a 30 day rehab into a 90 day rehab and see if they really do better than 40-50 percent. 

  19. 2 Greg L. Jones 16 Oct
    Thank you Dr. Gitlow. Thank you for your clarity of thought and leadership. It is certainly needed at this moment.
  20. 1 Greg Skipper 16 Oct

    Stuart: I agree with you. The success rates for professional health programs, including health professionals, attorneys, and pilots, utilizing the system of care that has evolved for them (which includes thorough evaluations, adequate treatment and long-term monitoring) is nothing less than amazing  (80% total abstinence over 7 years compared to the dismal success rates of 40-50% abstinence for average folks over 1 year or less or the high dropout rates with buprenorphine) and should be expanded to allow others to utilize a similar approach. We are attempting to do this with all our patients by finding a leverage point and developing aftercare agreements that include contingency monitoring wherein the patient is allowed to return home, drive, go to college, or return to work only if they remain in monitoring and remain sober. The spouse, parent or boss is included in the agreement. Preliminary results are good and acceptance seems high. So where is the conflict? It benefits the patient when those around them set limits and hold them to a high standard of health for any chronic illness. Boyd and Knight mention that evaluation and treatment are sometimes offered by the same program. Is that not the standard in all of medicine? Cardiologists that do evaluations also do treatment. We expect them to be ethical and we should do the same for evaluation and treatment programs. Costs for treatment of substance related disorders are high but successful treatment is worth it as shown in CALDATA and other studies. Compared with costs for regular hospital stays for other health issues treatment of substance use disorders is a bargain. Because doctors and pilots are in safety sensitive positions they forfeit some freedoms to continue to work. As for a watchdog agency, I say we should let the systems continue to work as they are with the ever present opportunity for civil action if ethics are violated. That is how the rest of medicine works and it should continue to work in our field as well. 

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