Dr. Willenbring is right that bad and/or inadequate rehab is dangerous. HOWEVER, this is true of a lot of treatments. For example, an inadequate course of antibiotics is dangerous.
So, what does good treatment look like? He suggests it comes in the form of medication.
Another way to identify what good treatment looks like is to ask one question can cut through a lot of confusion about treatment options—“What kind of treatment do addicted doctors get?” This question avoids arguments about treatment models, evidence-based practices and the effectiveness of 12 step groups. It moves past what physicians recommend for people like you (or your loved one) and what they actually do for people like themselves.
Fortunately, a few days after Dr. Willenbring’s comments were published, the NY Times published an article on a doctor with addiction who was arrested for diverting medication. What kind of treatment did she get?
She was allowed to attend a rehabilitation program while still seeing patients.
Rehab? It doesn’t say what kind of rehab but, rehab? Really?
She didn’t want to go to the New York Health Committee for Physician Health, a program funded by the American Medical Association to identify and treat doctors with mental health or drug problems, she says, “because I didn’t want anybody to find out.”
Nobody wants to admit defeat or weakness; but only doctors (and airline pilots) thought to have drug problems have such rigorous drug-testing programs, according to Terrance M. Bedient, the director of the Committee for Physician Health. Some lose their livelihoods temporarily, some permanently.
. . .
“I saw people with less privilege, less education, treated the same way I was,” she says. “The judge in my case understood addiction so well. It’s a disease.”
And that is what many in the addiction field think we should remember: not that Dr. Karcher didn’t have advantages — she did — but that she got the kind of treatment that more substance abusers should get. Physicians in New York State have some of the best outcomes in the country, according to Brad Lamm.
“It’s not that they’re better people or better addicts,” he says.
They don’t get specific about the kind of rehab Dr. Karcher got, but what kind of rehab do doctors usually get?
Physicians’ Health Programs (PHPs) do not provide substance abuse treatment. Under authority from state licensing boards, state laws, and contractual agreements, they promote early detection, assessment, evaluation, and referral to abstinence-oriented (usually) residential treatment for 60 to 90 days. This is followed by 12-step-oriented outpatient treatment. Physicians then receive randomly scheduled urine monitoring, with status reports issued to employers, insurers, and state licensing boards for (usually) 5 or more years.
A sample of 904 physicians consecutively admitted to 16 state Physicians’ Health Programs (PHPs) was studied for 5 years or longer to characterize the outcomes of this episode of care and to explore the elements of these programs that could improve the care of other addicted populations. The study consisted of two phases: the first characterized the PHPs and their system of care management, while the second described the outcomes of the study sample as revealed in the PHP records. The programs were abstinence-based, requiring physicians to abstain from any use of alcohol or other drugs of abuse as assessed by frequent random tests typically lasting for 5 years. Tests rapidly identified any return to substance use, leading to swift and significant consequences. Remarkably, 78% of participants had no positive test for either alcohol or drugs over the 5-year period of intensive monitoring. At post-treatment follow-up 72% of the physicians were continuing to practice medicine. The unique PHP care management included close linkages to the 12-step programs of Alcoholics Anonymous and Narcotics Anonymous and the use of residential and outpatient treatment programs that were selected for their excellence.
It’s worth noting that there is other evidence for the use of residential. (See here, here and here.) But, let’s stay focused on the PHP approach.
Is there another approach that rivals the outcomes found in PHPs?
Back to Willenbring:
. . . adding that the model for the 28-day rehab, Minnesota’s Hazelden Foundation, began offering buprenorphine maintenance itself in 2012 after a series of patient deaths immediately after treatment. Hazelden’s medical director, Dr. Marvin Seppala, told me when the rehab announced the change that using these medications is “the responsible thing to do” because of their potential to save lives.
That was 4 years ago. A year in, they were teasing pretty impressive early outcomes and promised more outcomes studies were to come. 4 years is a long time to keep the world waiting. However, they just posted that they expect to publish their outcomes next year. We’ll have to wait and see what they end up reporting.
To be sure, some people have good outcomes with medication assisted treatment. At the same time, it’s not as simple and obvious as the article suggests. First, the evidence doesn’t match the hype. (See here, here, here, here and here.) Second, while the inadequacy of many residential/inpatient treatment programs has gotten a lot of attention, medication assisted treatment has its share of problems. (See this recent photo essay on Boston’s “methadone mile” and this recent article on problems with buprenorphine in northeast Tennessee.)
One thought on “Does rehab kill?”
I find the double standard breathtaking, yet, I believe there is a true cognitive dissonance in many cases – they don’t get the discriminatory nature of the what’s best for our patients is not what we want for ourselves.
The other issue is client choice. If ‘doctor knows best’ is all that is available (and as you have shown, the results from ORT are not universally convincing) then that’s simply not good enough. Patients don’t want to be on medication lifelong; or at least many of them don’t. Do we simply ignore what their aims and goals are, or do we raise the bar, and give them the best evidenced treatment at the right dose for the right time?
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