Our PHP program and many like it are led by recovering physicians certified in addiction psychiatry or addiction medicine. For treatment to be most successful, the initial evaluation should focus on assessing drug and alcohol abuse, as well as getting the physician into a facility that can evaluate him over time and throughout detoxification and early recovery. Although suicidal ideation and suicide planning should be assessed, the initial psychiatric evaluation is often complicated by drug intoxication or withdrawal effects, shame, and guilt. Subsequent evaluations should include postdetoxification assessment for comorbid psychiatric conditions.30 The prevalence rate of comorbidity is estimated to be 25% to 75% among physicians with addictions,31,32 and comorbidity may affect treatment planning and prognosis.
Following the assessment, the addiction specialist/team makes recommendations regarding the setting and conditions of treatment. Since physicians with a substance use disorder are not typical of addicts in general, it is not useful to apply standard professional guidelines (eg, the American Society of Addiction Medicine dimensional assessment guidelines33). Rather, because of the public health consequences of relapse, most physicians who are addicted are treated more aggressively and for longer periods than are nonphysicians. Ideal evaluation and treatment most often occur in a specialized program for professionals. For some, detoxification is needed, but it is not sufficient for treatment and recovery.
Physicians will lobby for a level of care that minimizes the disruption of their daily life. However, it is generally not advisable to grant the physician’s request for treatment in the least restrictive environment, but rather to maximize the treatment dose and duration to improve effectiveness and reduce the likelihood of relapse and further damage to health, family, and the ability to practice. Depending on the response to treatment, physicians typically undergo 3 to 6 months of intensive treatment in a structured program and 5 years of urine testing with controlled, contingency-managed outpatient follow-up.
While in treatment, physicians participate in a number of therapeutic activities designed to help them understand and accept their addiction, implement and maintain sobriety, repair relationships, prevent relapse, and facilitate their return to productivity. Sobriety, while essential, is not in any way synonymous with recovery. Typically, attendance at educational lectures is complemented by participation in both individual and group cognitive-behavioral therapy sessions. Group dynamics can be a powerful component of treatment by providing the physician with additional opportunities to confront denial and learn from the experiences of others.
In addition, it is beneficial for physicians to participate in a regular “professionals” meeting, which is moderated by an addiction specialist and is attended by professionals living in the community who have successfully completed treatment and are in recovery. This experience provides those in treatment with encouragement and hope as well as role models who can be mentors in the recovery process. Family programs and family therapy are typically considered essential to treatment as well.35 In fact, psychological treatment may also be recommended for the children of physicians with addiction.36
Introduction to a 12-step recovery program such as Alcoholics Anonymous or Narcotics Anonymous is important to the maintenance of sobriety in the future, and it helps the recovering physician to develop a support network. Research has repeatedly demonstrated the effectiveness of this approach.36-38 However, it should be noted that referral to Alcoholics Anonymous is less effective than intensive treatment, even if participation in the intensive program is forced.39 As a result, participation in a 12-step program should be viewed as part of a more comprehensive treatment plan.
In order to successfully return to practice after the intensive treatment program, it is imperative that the physician undergo a full performance-based assessment of his competency to complete job-related tasks in his specialty. The evaluators should feel confident that the physician has the ability to practice with “reasonable skill and safety” before the physician is allowed to return to work. In addition, the physician and treatment providers should collaborate with their state’s PHP to develop a contract specifying the conditions for retaining his medical license. Research has demonstrated that the medical license may be useful as a bargaining chip in helping the physician to maintain sobriety.40Table 3 lists several key components that should be included in a PHP “return-to-work” contract.
Most physician treatment programs use time in treatment, residential care, contingency management, Caduceus meetings, urine testing, cognitive-behavioral therapy, life skills, and stress management; however, they generally do not use medications. Medications can be helpful and added to contracts in cases of recidivism. We have used acamprosate, naltrexone, and buprenorphine in some physicians to facilitate treatment. However, while naltrexone may prevent relapse in opioid-dependent physicians, it does not replace learning how and why to say no.41 Methadone treatment is not generally recommended by PHPs for physicians who have an addiction disorder.42
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