Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States

Treatment Research Institute, 600 Public Ledger Building, 150 S Independence Mall, Philadelphia, PA 19106, USA.
BMJ (online) (Impact Factor: 17.45). 02/2008; 337(nov04 1):a2038. DOI: 10.1136/bmj.a2038
Source: PubMed


To evaluate the effectiveness of US state physician health programmes in treating physicians with substance use disorders.
Five year, longitudinal, cohort study.
Purposive sample of 16 state physician health programmes in the United States.
904 physicians consecutively admitted to one of the 16 programmes from September 1995 to September 2001.
Completion of the programme, continued alcohol and drug misuse (regular urine tests), and occupational status at five years.
155 of 802 physicians (19.3%) with known outcomes failed the programme, usually early during treatment. Of the 647 (80.7%) who completed treatment and resumed practice under supervision and monitoring, alcohol or drug misuse was detected by urine testing in 126 (19%) over five years; 33 (26%) of these had a repeat positive test result. At five year follow-up, 631 (78.7%) physicians were licensed and working, 87 (10.8%) had their licences revoked, 28 (3.5%) had retired, 30 (3.7%) had died, and 26 (3.2%) had unknown status.
About three quarters of US physicians with substance use disorders managed in this subset of physician health programmes had favourable outcomes at five years. Such programmes seem to provide an appropriate combination of treatment, support, and sanctions to manage addiction among physicians effectively.

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    • "Knowledge about and access to effective suicide methods may explain the higher rates among doctors [3]. Although there is now evidence [4] [5] [6] [7] [8] that appropriate treatment for substance use disorders in physicians often results in return to safe and successful practice, little data exist on the identification of physicians at risk for suicide. "
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    ABSTRACT: Objective: We compared fitness-for-duty assessment findings of physicians who subsequently engaged in suicidal behavior and those who did not. Method: Assessments of 141 physicians evaluated at the Vanderbilt Comprehensive Assessment Program were retrospectively compared between those who later either attempted (n = 2) or completed (n = 5) suicide versus the remainder of the sample. Results: Subsequent suicidal behaviors were associated with being found unfit to practice (86% vs. 31%, P < .05), being in solo practice (71% vs. 33%) and chronically using benzodiazepines (57% vs. 11%, Fisher's Exact Test, P < .05). Conclusion: Being found unfit for practice may trigger a cascade of adverse social and financial consequences. Those engaged in solo practice may be particularly vulnerable due to isolation and lack of oversight by supportive colleagues. Finally, chronic benzodiazepine use may impair resilience due to associated brain dysfunction. Although these characteristics must be investigated prospectively, our observations suggest that they may be important signals of increased risk for suicidal behavior in physicians. The intense stress associated with medical practice and the relatively high rates of suicidal behavior among physicians make it important to be able to identify physicians who are at risk, so that appropriate preventive actions can be taken.
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    • "An estimated 10% to 14% of physicians may experience substance use disorder at some point in their careers (Hughes, 1992; Flaherty & Richman, 1993), which is similar to the prevalence of substance use disorder in the general population (McLellan, Skipper, Campbell, & DuPont, 2008; DuPont et al., 2009). Physicians are less likely to experiment with illicit substances, but they do tend to use alcohol and selfprescribed controlled medications such as benzodiazepine tranquilizers, minor opiates, and/or stimulants (Flaherty & Richman, 1993; McGovern et al., 2000; Hughes, Baldwin, Sheehan, Conard, & Storr, 1992; Mansky, 2003; McLellan et al., 2008; Skipper, Campbell, & DuPont, 2009). However, researchers recently compared 99 physicians referred to a Physicians' Health Program with an age-, gender-, and education status–matched comparison group from the National Epidemiologic Survey on Alcohol and Related Conditions and found that doctors had significantly higher odds of substance use disorders involving cannabinoids, cocaine/crack, opiates, sedatives, and alcohol (Cottler et al., 2013). "
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    ABSTRACT: Co-occurrence of mental disorders and substance use disorders (dual diagnosis) among doctors is a cause of serious concern due to its negative personal, professional, and social consequences. This work provides an overview of the prevalence of dual diagnosis among physicians, suggests a clinical etiological model to explain the development of dual diagnosis in doctors, and recommends some treatment strategies specifically for doctors. The most common presentation of dual diagnosis among doctors is the combination of alcohol use disorders and affective disorders. There are also high rates of self-medication with benzodiazepines, legal opiates, and amphetamines compared to the general population, and cannabis use disorders are increasing, mainly in young doctors. The prevalence of nicotine dependence varies from one country to another depending on the nature of public health policies. Emergency medicine physicians, psychiatrists, and anaesthesiologists are at higher risk for developing a substance use disorder compared with other doctors, perhaps because of their knowledge of and access to certain legal drugs. Two main pathways may lead doctors toward dual diagnosis: (a) the use of substances (often alcohol or self-prescribed drugs) as an unhealthy strategy to cope with their emotional or mental distress and (b) the use of substances for recreational or other purposes. In both cases, doctors tend to delay seeking help once a problem has been established, often for many years. Denial, minimization, and rationalization are common defense mechanisms, maybe because of the social stigma associated with mental or substance use disorders, the risk of losing employment/medical license, and a professional culture of perfectionism and denial of emotional needs or failures. Personal vulnerability interacts with these factors to increase the risk of a dual diagnosis developing in some individuals. When doctors with substance use disorders accept treatment in programs specifically designed for them (Physicians’ Health Programs), they show better outcomes than the general population. However, physicians with dual diagnosis have more psychological distress and worse clinical prognosis than those with substance use disorders only. Future studies should contribute to a better comprehension of the risk and protective factors and the evidence-based treatment strategies for doctors with dual diagnosis.
    No preview · Article · Aug 2014 · Journal of Dual Diagnosis
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    • "The largest evaluation conducted to date regarding the effectiveness of this intensive and extended continuing care treatment approach involved a 5-year retrospective, intent-to-treat analysis of 904 physicians consecutively admitted to 16 state-level PHPs [84, 85]. Nearly all (88%) of the patients met diagnostic criteria for substance dependence and the remaining patients met criteria for substance abuse. "
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    ABSTRACT: There is little disagreement in the substance use treatment literature regarding the conceptualization of substance dependence as a cyclic, chronic condition consisting of alternating episodes of treatment and subsequent relapse. Likewise, substance use treatment efforts are increasingly being contextualized within a similar disease management framework, much like that of other chronic medical conditions (diabetes, hypertension, etc.). As such, substance use treatment has generally been viewed as a process comprised of two phases. Theoretically, the incorporation of some form of lower intensity continuing care services delivered in the context of outpatient treatment after the primary treatment phase (e.g., residential) appears to be a likely requisite if all stakeholders aspire to successful long-term clinical outcomes. Thus, the overarching objective of any continuing care model should be to sustain treatment gains attained in the primary phase in an effort to ultimately prevent relapse. Given the extant treatment literature clearly supports the contention that treatment is superior to no treatment, and longer lengths of stay is associated with a variety of positive outcomes, the more prudent question appears to be not whether treatment works, but rather what are the specific programmatic elements (e.g., duration, intensity) that comprise an adequate continuing care model. Generally speaking, it appears that the duration of continuing care should extend for a minimum of 3 to 6 months. However, continuing care over a protracted period of up to 12 months appears to be essential if a reasonable expectation of robust recovery is desired. Limitations of prior work and implications for routine clinical practice are also discussed.
    Full-text · Article · Mar 2014
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