By Gregory Skipper, MD, Medical Director, Promises Professionals Treatment Program Why do we physicians become addicted? And, once addicted, why are we likely to deny a problem exists and unlikely to seek help … until colleagues or the medical board step in? The answers to these questions are important because they are directly related to determining the most effective length of treatment for addicted physicians.
How Addiction Patterns in Physicians Inform Addiction Treatment
Doctors become addicted for some of the same reasons as everyone else — hereditary factors and high stress levels on the job and at home, without adequate coping skills, lead to chronic anxiety and depression that motivate us to drink or use substances to find some relief. Unfortunately, we physicians (and other health care professionals) have a few additional risk factors for addiction:
- Many physicians have easy access to highly addictive substances.
- We have a tendency toward high-achievement and self-sufficiency — traits that make us good at our jobs, but also make us more likely to deny a problem or to try and treat the problem ourselves.
- We are in positions of authority and are held in such high regard that any criticism or confrontation about observed signs of addiction are less likely to occur. (So denial is not limited to the addict, but is “contagious” and extends to colleagues, family and friends.)
- We risk losing our license to practice medicine — and, therefore, our reputation and our livelihood — if it is discovered we have an addiction, so we are very highly motivated to hide it.
These additional factors can contribute to addiction continuing for a long time before being recognized or treated. This is why, in part, longer treatment durations, and treatment programs that address contributing attitudes and behaviors, are recommended for physicians.
Longstanding Habits Take Time to Break
It takes time and effort to unlearn long-term and deeply ingrained, habitual behaviors. This may be especially true for those with control-oriented and reward-driven personalities, which can be prevalent among medical professionals. Further, long-term substance abuse can require a longer time for the body to detoxify and for the brain’s reward center or neurotransmitter system to return to normal. Studies of brain imaging have shown gradual resolution of abnormalities associated with alcohol and drug use. The DSM-5 specifies “Early Remission” from substance use disorders is achieved only after at least 3 months of abstinence, and “Sustained Remission” is achieved only after a year. Therefore, longer treatment durations are advisable for best outcomes. This is especially true for physicians. Physicians must show proof of stability, successful completion of treatment and that we can safely provide care to patients before being allowed to return to work. It simply takes time to break addictive thought patterns and behaviors, learn new ways to cope with the pressures of work and healthier ways to navigate the challenges of a doctor’s life. Doctors need excellent cognitive function for work, and executive functioning in particular, so taking the necessary time to heal before returning to practice is particularly important.
Learning From Well-Established Physician Treatment Programs
As discussed in a recent presentation by my colleagues, addiction specialists Daniel H. Angres, MD, and Paul H. Earley, MD, DFASAM, at the 2017 annual Federation of State Physician Health Programs meeting, studies by Tom McLellan, MD, director of the Treatment Research Institute and others have consistently shown that longer duration treatment — typically 90 days or more — delivers better results for everyone. For physicians, the “ante is upped” because of the intense focus on imperative high success rates needed to justify a physician returning to work. The Talbott Recovery Campus, which is named for G. Douglas Talbott, MD, the co-founder and original medical director, was the first program in the world that focused specifically on the treatment needs of physicians. The Talbott Recovery Model for physicians and other addicted health care professionals set the standard for physician treatment in the 1970s. From the beginning, the “Talbott Model” specified that physicians spend one month in residential addiction treatment for detoxification and stabilization, one month undergoing partial hospitalization with independent living to extend treatment and gain basic recovery skills, and another two months continuing to live in a sober living setting while undergoing reduced direct treatment. This last phase required physicians to be placed at a site doing “Mirror Imaging,” which involved working, but not as a physician. It required the physician in recovery to perform housekeeping duties, talk with patients, give lectures, and do other tasks at one of several indigent facilities. Longer treatment plans that utilize a Physician Treatment Model based on The Talbott Model have helped many physicians achieve long-term addiction recovery, even after returning to the work environment. Based on the largest study of outcomes for physician health programs (McLellan, Skipper, Campbell and DuPont, 2008), we know that this Physician Treatment Model delivers excellent results. In the study, which involved 904 physicians consecutively admitted to one of 16 state physician health programs (lasting 60, 90 or 120+ days, followed by aftercare and/or drug monitoring) between 1995 and 2001, 78% of the physicians demonstrated successful recovery without relapse over an average period of 7.2 years. There have been numerous other smaller studies, mostly involving individual states assessing their own data, that have shown similar excellent outcomes.
Treatment Program Essentials for Addicted Physicians
An analysis of study results and the more successful treatment models tells us that for these physician treatment programs to work, they need to have the capability for long-term treatment of 90 days or more. To ensure active engagement, commitment and successful outcomes, a few essential program elements must also be included, such as:
- Physician-driven program (led by a physician and medical director who have extensive expertise and history in treating physicians, and are directly involved in treatment and care of the physician patients)
- Expert staff capable of dealing with doctors with extensive schooling and big egos
- Peer group or treatment milieu of other physician patients for increased empathy, confrontation and shame reduction
- 12-step focus
- Intensive family involvement
- Assessment and treatment of dual diagnosis and Addictive Interactive Disorders (AID)
- Support in addressing work/re-entry and legal issues: learning about who to tell what upon return; what to indicate on forms, such as credentialing or re-credentialing; how to handle questions related to psychiatric or substance-related problems; regulatory boards and how they work, and many other issues that will be faced
- Compulsory, long-term aftercare drug testing/monitoring, usually provided by the respective State Physician Health Program and communication with that program to arrange seamless handoff following treatment
When programs include these essential elements, and also provide behavior retraining and consistent recovery support during aftercare, the majority of participants stay abstinent for an average of five years.
What We Have Learned From Cases of Relapse, Length of Treatment
While we know that the risk of relapse is greatest during the first year of recovery, this risk decreases as physicians progress through recovery — roughly 50% who relapse in these programs have done so for only brief periods in early recovery and eventually achieved extended abstinence. We also have learned that certain physicians enrolled in these programs have higher risk factors for relapse, including dual diagnosis (i.e., co-occurring mental disorders) and co-morbidities (i.e., chronic pain), lack of family or workplace support, and riskier work environments (i.e., anesthesiologists have direct access to opioids like fentanyl, which complicates recovery). Physicians with these additional risk factors have sometimes returned to work soon after treatment and relapsed, indicating that longer treatment periods and more robust aftercare plans were warranted in these cases. There is something to be said for matching the duration of treatment to each individual’s needs and risk factors — not every addict will need to complete a 90- or 120-day program — but I would argue that all physicians struggling with addiction need to be treated for a minimum of 60 days to establish a foundation for recovery, and a rigorous post-treatment aftercare plan with support and monitoring is imperative.
Challenges to Treatment Efficacy Extend Beyond Duration
There are additional challenges we must overcome, beyond duration, in order to make physician treatment programs more effective. In addressing these challenges it is helpful to circle back to the reasons why physicians who become addicted deny the problem or are unlikely to seek help — reasons that also can make us less likely to comply with long treatment programs or respond to traditional treatment approaches. The medical profession tends to attract people who are hardworking, high-achieving, perfectionist, self-sufficient and who like to be in control. These personality traits may challenge our ability to accurately self-examine — to recognize our negative behavior patterns and correct them — which is necessary to addiction recovery. Unless we can do this, we will be thwarted in our attempts to acquire healthier problem-solving skills and new coping strategies during treatment — especially if we are focusing more on getting back to work as soon as possible. As addiction specialists serving this population, we must not only ensure that each physician undergoes a minimum of 60 days of treatment — individualized according to their risk factors and specific needs — we must also make sure that the treatment approaches and behavior training modalities we use are tailored to this unique client population. Additionally, because addiction within the medical community engenders feelings of injured pride and deep shame, we must incorporate therapeutic strategies that help clients address and resolve these feelings as they heal. Sources: Parts of this article were adapted from a presentation by Daniel H. Angres, MD, and Paul H. Earley, MD, called “Treatment Length of Stay for the Addicted Physician.”