Physicians and Other Healthcare Professionals with Addiction

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Background

Physicians and other healthcare professionals, like all people, are susceptible to developing addiction. In some, but not all cases, addiction may impair a healthcare professional’s ability to practice and present a risk to patient safety. The Federation of State Medical Boards (FSMB) defines impairment as the “inability of a licensee to practice medicine with reasonable skill and safety as a result of: (a) mental disorder… or (b) physical illness or condition… or (c) substance-related disorders…” Importantly, the FSMB definition goes on to clarify that:

Impairment is a functional classification which exists dynamically on a continuum of severity and can change over time rather than being a static phenomenon. Illness, per se, does not constitute impairment. When functional impairment exists, it is often the result of an illness in need of treatment. Therefore, with appropriate treatment, the issue of potential impairment may be resolved while the diagnosis of illness may remain.ⁱ  

Depending on the stage of their illness, many healthcare professionals who develop addiction are able to function effectively, but if their illness progresses to cause impairment, available evidence for physicians indicates that treatment usually results in remission of disease and restoration of functioning, particularly if appropriate monitoring and continuing care is put in place.ⁱⁱ  

The public, policymakers, regulatory agencies, and professional associations expect and deserve safe and competent care from all healthcare professionals. All parties involved should be assured that healthcare professionals with addiction have been appropriately evaluated, adequately treated, and have received or are receiving evidence-based continuing care and monitoring to ensure they are in sustained remission and unimpaired in practice. 

State laws and regulations vary in how they address potentially impaired healthcare professionals. Most states mandate that healthcare professionals report fellow healthcare professionals who are impaired by illness.  In some states, clinicians who have knowledge of a fellow clinician’s impairment because they are treating the impaired clinician may be exempt from such reporting.  Some states have statutes or rules that satisfy reporting requirements if a referral is made to a state’s Physician Health Program (PHP) in lieu of reporting to the regulatory agency (i.e. licensing board).    

Physician Health Programs (PHPs) are organizations whose purpose is to provide a therapeutic alternative to discipline for healthcare professionals with potentially impairing illnesses, including addiction.  While PHPs provide referrals for evaluation and treatment services, their key role is monitoring of health status. Based on the results of this monitoring, PHPs advocate for physicians with licensing boards, employers and other entities. Due to their knowledge of state regulations and experience in advocating for healthcare professionals, PHPs may offer advantages to those who are under investigation or have received actions from state licensing boards. 

Non-disciplinary referral tracks provide assistance for healthcare professionals without disciplinary action on the professional’s license.  ASAM encourages non-disciplinary referral to PHPs or clinicians with expertise in the treatment of addiction in healthcare professionals to facilitate early detection, evaluation, treatment and monitoring before potentially impairing illness progresses to actual impairment.  Non-disciplinary tracks also encourage self-referrals and more referrals by concerned colleagues, family members and patients.

ASAM recognizes that, for a variety of reasons, treatment of healthcare professionals with addiction may occur with or without oversight by a PHP.  PHPs have been established in many states to provide a non-disciplinary, confidential conduit for professionals to access comprehensive evaluation, any necessary treatment, and monitoring of health status. The reported outcomes for substance use disorders in physicians who are PHP participants are among the best in addiction medicine.ⁱⁱ These outcomes are described by retrospective studies of physicians; as with many retrospective studies, problems such as selection bias and limited characterization of illness severity need to be kept in mind when considering the reported outcomes. 

The interest and safety of the public are best served when state regulatory agencies, PHPs and, when involved, clinicians with expertise in the treatment of addiction in healthcare professionals work in concert to develop a confidential process allowing for early intervention, evaluation, treatment and return to practice with subsequent monitoring of the professional with addiction.  A non-disciplinary, confidential process results in more referrals and self-referrals for assistance with addiction.

Public regulatory agency disciplinary action often leads to unintended, onerous and permanent consequences for both recovering professionals and the public they serve. Inadvertently, these consequences can include constraints on healthcare professionals’ ability to practice effectively in the best interests of the public (e.g., restrictions on the practitioner’s ability to prescribe or dispense indicated medications and barriers to the practitioner’s ability to participate with provider panels or maintain active certification from a specialty certification board). Moreover, professional societies and specialty boards occasionally use the history of a publicly reportable disciplinary action by a regulatory agency to declare physicians unworthy of and ineligible for membership, certification, recertification, or continued participation in maintenance of certification programs. These reportable disciplinary actions and their consequences often have the unintended effect of leaving the professional unemployable and therefore unable to serve patients even when treatment has been successful, and the professional’s illness is in full remission.

This policy statement articulates the American Society of Addiction Medicine’s recommendations for promoting the health of healthcare professionals with addiction and thereby contributing to their safe practice.

Recommendations:

The American Society of Addiction Medicine recommends:

1. All relevant entities with an interest in healthcare professionals with addiction should recognize that while addiction is a potentially impairing illness, “impairment” is a functional classification and illness per se does not constitute impairment. Healthcare professionals who suffer from addiction may or may not be functionally impaired. The healthcare professional with addiction is a person with an illness, and that person may be impaired, may be in recovery, or may not be either.

2. The public health, safety and welfare are best served when an otherwise competent healthcare professional with a potentially impairing illness is identified early and receives appropriate evaluation and indicated treatment and, when ready, returned to the safe, monitored practice of their profession.  PHPs have demonstrated the capability to provide these component services; other clinicians with expertise in the treatment of healthcare professionals with addiction may be able do so as well. Clinicians who treat healthcare professionals outside of PHPs should thoughtfully appraise their ability to provide credible assurance of safety to practice for professionals in their care and understand their legal and ethical requirements for public safety within the context of the therapeutic relationship. Clinicians with expertise in the treatment of healthcare professionals with addiction should understand when participation in a PHP may offer an advantage to a patient and suggest this as an additional support.

3. Although specialized treatment programs for professionals may provide the benefit of extensive staff experience in working with this population, treatment for healthcare professionals should be individualized to the needs of each professional as well as to the available resources.

4. Healthcare professionals should be offered the full range of evidence-based treatments, including medication for addiction, in whatever setting they receive treatment.  Regulatory agencies (including state licensing boards), professional liability insurers, and credentialing bodies should not discriminate against the type of treatment an individual receives based on unjustified assumptions that certain treatments cause impairment.

5. Relapse, or a recurrence of symptoms, is a recognized characteristic of addiction. Once a healthcare professional fulfills all requirements for formal monitoring, ongoing chronic disease management provided by a clinician experienced in the treatment of addiction in healthcare professionals is recommended to maintain recovery and intervene clinically should active illness recur.

6. Diversion of controlled substances for personal use is not uncommon in healthcare professionals who develop addiction. The proper management of such cases should maximize early identification, proper treatment and monitored recovery. An episode of drug diversion should not result in automatic disciplinary action.  Rather, disciplinary responses to drug diversion should be proportionate to the harm caused by the episode of diversion.

7. Healthcare professionals should have the same rights of privacy and confidentiality of personal health information as other persons. Healthcare professionals should not be required to reveal their personal medical histories to patients, prospective patients or to the public.

8. Whenever possible, the reporting of healthcare professionals with potentially impairing conditions should result in efforts to restore health rather than disciplinary action. Therapeutic rather than disciplinary responses result in more self-reporting and peer reporting.  

9. Physicians and other health care professionals should not be discriminated against in the areas of professional licensure, clinical privileges, specialty certification or inclusion in managed care or health maintenance organization provider panels, solely due to a past diagnosis of addiction when that professional has demonstrated the disease is in sustained remission. Participation in and/or completion of a monitoring agreement with advocacy from a state PHP or other recognized monitoring agency may be especially valuable in the following circumstances: when a professional with a history of addiction or other potentially impairing illness is applying for licensure in a new state; for employment, privileges or credentialing by a healthcare organization or managed care entity; for certification or re-certification by a specialty board or other certifying organization; or for membership in a professional association.

10. Barring other substantive issues, successful completion by a healthcare professional of a regulatory agency’s administrative requirements and associated re-licensure - with or without license restrictions - should suffice for specialty boards and professional societies to affirm certification, eligibility for recertification, and/or membership.  When a professional is practicing within the boundaries of such a restriction, she or he is practicing safely. PHPs and other experts in the evaluation, treatment and continuing care of healthcare professionals should be consulted and input respected in all specialty society membership and/or board certification decisions related to appeals of adverse rulings on healthcare professionals recovering from addiction.

11. PHPs need further study to see if positive outcomes are replicated in more rigorous, prospective studies and to determine which factors are most important for producing good outcomes, whether such outcomes are sustained after PHP monitoring ends, and whether the PHP model of treatment and monitoring is feasible and effective for non-physician healthcare professionals.  Despite the need for more rigorous PHP outcomes research, states without PHPs and clinicians treating healthcare professionals outside of PHPs would do well to study PHP practices.ⁱⁱⁱ The study of healthcare professionals who are treated and monitored outside of PHPs to determine whether outcomes are comparable, including participant experience of the treatment and monitoring, would also be valuable.

12. Healthcare professionals should be educated about occupational risk factors for addiction given healthcare professionals’ unique access to controlled substances and legal authority to write prescriptions. They should also receive training in healthy self-care and stress management practices to promote health and prevent unhealthy use of medication or drugs such as alcohol.  Healthcare professionals should be able to recognize signs of addiction in colleagues and know how to help colleagues connect with non-disciplinary assistance. 

Adopted by the ASAM Board of Directors February 6, 2020.

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