We should re-examine policies for opioid addicted physicians?

can of wormsThis is interesting.

A physician posted a message to an ASAM discussion board about his dissonance related to working in a treatment facility that does not use opioid maintenance treatments. Specifically, buprenorphine.

ASAM turned the message board post into a magazine article and summarizes responses to the message.

There’s a lot that one could respond to. However, there’s one point I’d like to draw your attention to. Among the solutions highlighted in the article is this:

Restrictive policies on MAT also affect physicians who themselves may have opioid use disorder. This should be re-examined as a part of advocacy and future work[2-8].

If you don’t know a lot about this, this might seem like a pretty uncontroversial proposal.

Let’s step back and consider this for a moment.

  • The doctor is frustrated that his non-physician colleagues and decision makers do not support his preferred approach.
  • He posts a message on a board for other addiction physicians and seeks some guidance.
  • They cite evidence (We could ask, “evidence for what?“) and suggest that ignorance, fuzzy thinking, greed and ideology are preventing the advancement of their preferred approach . . .
  • AND, they note that the model of care for addicted physicians, Physician Health Programs (PHPs), also rejects their preferred approach.
  • Because of this, they suggest re-examining the PHP approach to include their preferred approach.

Now, a little about PHPs:

Now, a little about their preferred approach:

  • The alternative that they are proposing doesn’t quite live up to their hype. (For a few examples, look here, here and here.)
  • The evidence base for the alternative they are proposing focuses on different outcomes–like reduced drug use, reduced disease transmission, reduced overdose and reduced criminal activity–rather than stable recovery.

So, let’s review:

  • Some addiction docs are frustrated about the lack of acceptance of opioid maintenance medications and are engaged to advocacy to legitimize them.
  • However, they do not use them with their peers. They’ve found a better way. The PHP approach is viewed as the gold standard because of its outstanding outcomes for addicted physicians and patient safety.
  • Now, they suggest that the field should re-examine the gold standard, to replace it or integrate their preferred approach (which has poor outcomes relative to the PHP model) with the goal of conferring legitimacy on their preferred approach.
  • This should be done to overcome the ignorance, fuzzy-thinking, greed and ideology preventing the legitimization of their preferred approach.

This isn’t to suggest that abstinence-based providers are good while other providers are bad. Or, that there’s no place for these medications in the treatment of addictions. I just want patients to have full informed consent and access to quality care of an appropriate duration and intensity.

However, the suggestion that addiction docs should tinker with the gold standard (that produces outstanding outcomes and protects patients) so that they can promote an approach with shaky outcomes is cause for skepticism of their efforts and risks de-legitimizing both approaches.


Filed under Uncategorized

3 responses to “We should re-examine policies for opioid addicted physicians?

  1. Well said Jason. Linda Kurtz

  2. Do they have to discontinue one program to have another? It sounds like this should be seen as more of a “pilot project” to see outcomes and hopefully enhance the PHP rather than to replace the PHP.

  3. Jason: there is one “civilian” program that emulates the PHP model, with the same success rates. It’s the Hawaii HOPE program (Hawaii’s Opportunity Probation with Enforcement) that uses intensive monitoring, graded response, and rapid response for felons on probation for drug related offenses. Their website is http://hopehawaii.net.
    That’s the good news. The bad news is that this program, like the PHP programs, rely on “negative reinforcement” external to their drug use; i.e. loss of job or loss of freedom. These programs, unfortunately, won’t work with those who voluntarily seek care and can simply walk away from their treatment, whatever level.
    The abstinence based position of the PHPs is based on (1) its 12 step orientation and (2) its success rate. Michigan does allow the use of buprenorphine “off label” for chronic pain, but not for opioid dependency. It does allow the use of naltrexone (Vivitrol®), which is non-narcotic. It does not allow the use of methadone for either chronic pain or for dependency.
    You can review the data on PHPs at: http://www.fsphp.org/Hambleton%20et%20al%20Blue%20Print%20Study%20Handout.pdf. By the way, in this study of about 900 participants around the country, none of them were on MAT.

    Carl Christensen
    Medical Director, Michigan Health Profession Recovery Program