Five year outcomes in a cohort study of physicians treated
for substance use disorders in the United States
A Thomas McLellan, chief executive officer,1Gregory S Skipper, medical director,2Michael Campbell,
research scientist,3Robert L DuPont, president3
Objective To evaluate the effectiveness of US state
physician health programmes in treating physicians with
substance use disorders.
Design Five year, longitudinal, cohort study.
Setting Purposive sample of 16 state physician health
programmes in the United States.
Participants 904 physicians consecutively admitted to
one of the 16 programmes from September 1995 to
Main outcome measures Completion of the programme,
continued alcohol and drug misuse (regular urine tests),
and occupational status at five years.
Results 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
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.
Conclusion 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
About 10-12% of physicians in the United States
develop a substance use disorder.1Those whose
condition is detected and who are confronted—
typically by their colleagues—are usually referred to
the state physician health programmes for inter-
vention, treatment, professional support, and long
term monitoring. These programmes began in the
United States in the 1970s as volunteer groups of
physicians to assist colleagues with alcohol, drug, and
mental health problems. The groups evolved into
formal agencies operating under the authority of state
physician licensing boards. The aim was to reduce
public health problems caused by “impaired
physicians” through early detection, treatment, and
that cause impairment.
Affected physicians typically are referred to one of
these programmes by colleagues or regulatory agen-
under the allegation or formal charge of “impaired
performance” due to problems with substance use or
mental health. Once a formal evaluation has deter-
is arrangedunder which no further reporting or action
occurs pending satisfactory completion of formal
physicians to complete treatment and monitoring to
enable them to continue practising medicine.3
It is important to emphasise that the physician health
programmes do not treat physicians. They provide
evaluation and diagnosis, develop a contract detailing
treatment and ongoing professional support, and carry
out regular monitoring through random visits to places
of work and regular screenings for alcohol and drugs—
typically for five years.2The programmes also act as
intermediaries between the physician and various
regulatory parties (for example, licensing boards,
insurers, hospital practice boards). Although variability
state programmes (5 to 180 physicians) is considerable,
the average programme manages about 65-75 physi-
cians, at an operating annual cost of about $521000
(£301000; €381000)—paid for primarily through a
charge appended to all physicians’ licensing fees (about
$23 for each physician in most states). These operating
the physicians. Such costs range from about $5000 to $
40000 (depending on the mix of outpatient and
residential care) and are typically paid for by a
combination of the physician’s health insurance and
in a companion article.2
Given the potential public health and safety pro-
blems caused by addiction among physicians, evalua-
tion of the effectiveness of care and supervision
1Treatment Research Institute,
600 Public Ledger Building, 150 S
Independence Mall, Philadelphia,
PA 19106, USA
2Alabama Physician Assistance
Program, Montgomery, AL, USA
3Institute for Behavior and Health,
Rockville, MD, USA
Correspondence to: A T McLellan
Cite this as: BMJ 2008;337:a2038
BMJ | ONLINE FIRST | bmj.compage 1 of 6
provided by physician health programmes is impor-
tant. This is made more important by the fact that
studies of these programmes have been short term self
evaluations of individual programmes.4-7Although
most of the results from these studies have been
provided longer term results.57These are important
it is prudent to refer a physician to one of these
programmes. Licensing boards, insurers, and patients
have the right to know the effectiveness of these
programmes. Outcomes from mainstream addiction
treatment in the general population have consistently
shown poor compliance rates during treatment, and
relapse rates of 40-60% within six months of complet-
We carriedout atwo stageindependent evaluation of
first study we surveyed 42 of 49 active programmes,
describing the personal and professional histories,
substance use, and other health problems of the
physicians, as well as the intervention, evaluation,
referral for treatment, and monitoring activities after
longitudinal cohort study reports the outcomes in 904
of 16 of those programmes and followed for five years.
We focused on three outcomes, measured through
audited medical records and laboratory tests: comple-
tion of the programme, continued alcohol and drug
misuse, and occupational status at five years.
We carried out a retrospective, longitudinal, cohort
study over five years from 1 September 1995 to 1
September 2001 of all physicians consecutively
sampled. We examined the laboratory and medical
records of the physicians during the five years.
Setting, participants, and outcomes
The 42 programmes that participated in the first study
were eligible to participate in this second study.
Requirements were the availability of records on
alcohol and drug testing in a computer analysable
outcomes of the physicians from their records (n=16).
All eligible programmes were included in the study.
The programmes that did and did not participate in
the follow-up study were not statistically or clinically
significantly different for evaluation, referral, treat-
ment, supervision, support, and monitoring practices.
The 16 participating programmes tended to be large:
31% were in the largest quarter of programmes. The
(range 11-119).2Although these 16 programmes may
not be considered nationally representative, they
showed no obvious clinical, administrative, or organi-
sational differences from those not participating.
All 904 physicians with a diagnosis of substance
from 1 September 1995 to 1 September 2001 met the
inclusion criteria. We restricted the evaluation to
objective data from official records (for example,
treatment services, attendance, sanctions by the
programme, reports to licensing boards) and from
laboratory records (urine tests and other specimens).
Review of medical records
To protect the confidentiality of the physicians, data
were collected by members of each programme’s
medical records department. Data were collected
between November 2006 and January 2007 under
training, supervision, and monitoring by the authors.
Lost to follow-up
During the study 102 of the 904 (11.3%) participants
had no access to any continuing records for those
on the remaining 802 physicians.
As we used official records there were few instances of
missing data (<4%). We report simple descriptive
statistics with no substitution procedures for missing
The participants were predominantly men (87%). The
average age was 44 years. Sixty three per cent were
were single.Fivemedical specialties represented more
than 50% of physicians: family medicine (20.0%),
internal medicine (13.1%), anaesthesiology (10.9%),
emergency medicine (7.1%), and psychiatry (6.9%).
The primary drug problems were alcohol (50.3%),
opiates (35.9%), stimulants (7.9%), or other substances
substanceand 13.9% reported a history of intravenous
drug use. The average duration of substance misuse
Failed to complete contract
Voluntarily stopped or
Involuntarily stopped or
licence revoked (n=48)
Died (n=22; 6 suicides)
Contract extenders (n=132):
Still being monitored (n=132)
Completed contract (n=515):
No longer being monitored
Completed contract but being
monitored voluntarily (n=67)
Physicians consecutively enrolled into 16 state physician health programmes (n=904)
Transferred and lost to follow-up (n=102):
Transferred in good standing (n=78)
Left care with no referral (n=24)
Followed by record checks (n=802)
Flow of physicians through trial
page 2 of 6
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an alcohol or drug related offence and 17.0% reported
previous treatment for substance misuse.
Fifty five per cent of participants were formally
a licensing board, hospital, insurer, or other agency.
The remaining 45% were informally mandated by
Clinical and monitoring procedures
by supervision after treatment.2
Overall, 78% of physicians entered residential treat-
ment (mean 72 days, range 30-90), always followed by
outpatient treatment (1-3 nights a week) for a recom-
to outpatient treatment. With good compliance and
positive progress, physicians were eligible to return to
Regardless of setting or duration, most treatment
(95%) comprised 12 steps, with the goal of total
abstinence from alcohol and other drugs of
misuse.1314The physicians were expected to attend
Most were encouraged to attend meetings of the
Caduceus Society (support group for healthcare
providers’ recovery) throughout the remaining years
of their contract.
Use of addiction pharmacotherapy as a component
prescribed methadone for an opiate misuse problem;
46 (6%) were prescribed naltrexone for treatment of
were prescribed an antidepressant for comorbid
depression or anxiety disorders.
Supervision after treatment
After completion of formal treatment the physicians
received coordinated monitoring in several forms.
Alcohol and drug testing
A key component of monitoring was random drug
testing. Urine was tested in 99.2% of physicians, with
Participants were required to phone their programme
each workday to find out whether they should report
for testing that day, on the basis of random selection.
Testing was carried out four times a month early in
care, tapering to one or two times a month throughout
the monitoring period. The frequency of monitoring
compliance with other elements of the care plan.
observed by staff responsible for collection. In other
cases dry room collection procedures were used.
Testing included more than the usual five substance
test panel. A typical panel covered 20 substances,
including amphetamines, barbiturates, benzodiaze-
pines, opiates, several opioids, cocaine, cannabinoids,
and ethyl alcohol.
Additional monitoring and response to problems
Participants were expected to attend scheduled
appointments for clinical evaluation. They also
received random, unannounced visits at their place of
work from programme monitors.
from any other source, almost all the programmes
reacted clinically, with combinations of re-evaluation
(54%), increased monitoring (43%), and intensified
treatment (46%). Forty two per cent of programmes
or other entity, and an additional 16% started
confidential probationary periods without referral to
the licensing board or other agency.
The same increases in monitoring occurred for
physicians with more than one incident of substance
misuse, but almost always with a formal report to the
licensing board. In turn, licensing boards did one or
more of the following: limited practice (n=129),
temporarily suspended the licence (n=94), revoked
the licence (n=32), placed the physician’s name in the
opioids and benzodiazepines (n=56).
Overall, 102 of 904 physicians (11.3%) moved out of
their physician health programme’s jurisdiction and
anotherstate programmeandthesephysicianswere of
generally good status at the time of transfer. The
remaining 24 moved away without contacting the
programme and with no record of referral. This
As a result of the lack of records for five years on these
participants they were lost to follow-up.
Of the remaining 802 physicians with known
outcomes, 155 (19.3%) failed to complete their
Table 1 |Occupational status of physicians at five year follow-up of being in a state physician
health programme for substance use disorders. Values are numbers (percentages) of
Licensed or practising
477 (92) 97 (73) 15 (10)589 (73)
Licensed or working
13 (3) 12 (9)17 (11)42 (5)
Retired or left practice
7 (1) 3 (2) 18 (12)28 (4)
Licence revoked9 (2) 14 (11)64 (41)87 (11)
Died3 (1) 0 (0)27 (17) 30 (4)
Unknown 6 (1)6 (5) 14 (9) 26 (3)
BMJ | ONLINE FIRST | bmj.compage 3 of 6
licences during monitoring owing to factors such as
advanced age, financial problems, or psychiatric or
other health problems. An additional 48 physicians
revoked owing to significant relapse, usually accom-
panied by a failure to accept treatment or monitoring.
Twenty two physicians died (six from suicide) during
participation and another eight died by the five year
follow-up (table 1).
In total, 515 physicians (64.2%) completed their
contracted period. Sixty seven of these physicians
voluntarily elected to continue being monitored after
One hundred and thirty two physicians (16.5%) had
their contracts extended beyond the monitoring
relapse (low severity of relapse that did not endanger
patients); failure to comply with requirements, such as
of previous relapse.
Alcohol and other drug use during supervision
After formal treatment the physicians were permitted
to return to practice under monitoring. Table
summarises the results of drug testing for the 647
physicians who completed their contract or had their
contractsextended;81% of thetotalgroup.Fifty seven
of 132 physicians with extended contracts had a
a mean of 56 months, with testing twice a month.
Across both groups 33 of the 126 with a positive test
result retested positive.
Of 159 documented incidents of substance misuse
(126 initial positive test results and 33 repeat positive
of medical practice, such as on duty or on call. One
episode of patient harm (over-prescribing drugs) was
consequences of substance use not recorded in the
Occupational status after supervision
Records showed that five years after the start of the
contracts 631 of the 802 physicians (78.7%) were
licensed without restriction and either practising
An additional 28 physicians (4%) had retired or
voluntarily left practice, 87 (11%) had their licence
revoked, 30 (4%) had died (7 substance misuse, 6
suicides, 17 other), and 26 (3%) had missing data.
The status of the physicians at five year follow-up
varied as a function of their completion status of the
physician health programme. For example, 95% of
physicians who had completed their contract and 82%
less than 1% had died. In contrast, 21% of the
physicians who did not complete their contract were
still licensed and 17% had died.
About three quarters of US physicians treated for
substance use disorders in physician health pro-
grammes had favourable outcomes throughout five
years. Such programmes seem to provide an appro-
priate combination of treatment, support, and sanc-
tions to manage addiction among physicians
Physician health programmes share the dual role of
helping addicted physicians attain sobriety and perso-
nal recovery as well as providing assurance to
colleagues, hospitals, insurers, licensing boards, and
the general public that these physicians can practise
safe care. The processes used by these programmes
include clinical assessment, referral for treatment, and
years. Many questions have been raised about the
effectiveness of these programmes—one was stopped
owing to allegations of poor monitoring.1516
We carried out a longitudinal, retrospective cohort
study of 904 physicians consecutively admitted to 16
state physician health programmes. Objective out-
comes were derived exclusively from laboratory
results of urine testing and audit of official records.
All the participants entered some period of profes-
sional, specialty treatment, typically 60-90 days in a
residential setting, followed by continuing outpatient
care. Formal treatment was followed by a return to
support groups, formal meetings with the programme
no comparably intensive or protracted form of treat-
ment and monitoring provided to any other group of
addicted people in the United States.8-1012
At five year follow-up 14% of the physicians had
a result of their identification by and participation in a
of close monitoring andtough sanctionsorinadequate
monitoring and lax standards. The urine test results in
the 647 physicians who completed their contract with
the programme and those whose contract was
extended may provide the best evidence.
Table 2 |Resultsof drug tests throughout monitoring period for 647physicianswho completed
their contract with a physician health programme or had it extended
(n=132) Both groups (n=647)
Average duration of contract (months)54 6456
Mean No of drug tests per physician82121 94
No (%) with at least one positive drug test
57 (11) 69 (52)126 (19)
No (%) with a repeat positive result* 8 (16)25 (38) 33 (26)
*Percentage of those with one positive test result.
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Over the average course of 56 months of random
identified substance misuse at any time. Nineteen per
cent, however, had at least one incident of substance
misuse during the five years of monitoring. Ten of these
of alcohol or other misuse of drugs would result in
the case only when there had been a period of non-
compliance or if the circumstances of the relapse were
dangerous. Instead, most of the programmes in this
with reports to the licensing board. The more serious
sanctions included restrictions on, or suspensions of, the
licence or prescription privileges. Evidence suggests that
this may be a sensible approach as only 26% of the 126
physicians who tested positive retested positive.
Our study has several limitations. Firstly, the sample
cannot be considered nationally representative of
physician health programmes in the United States.
Becauseof financial andtimeconstraintsweneededto
audit primary, objective outcome measures rapidly
and efficiently, and only 16 of the 42 programmes that
volunteered had electronic clinical and laboratory
records continuously available from 2001 to 2007; we
selected all of these programmes. That these 16
programmes started to keep electronic records seven
yearsago suggeststhat theymay have beenamongthe
best funded or best led programmes at that time. Data
from the phase one survey indicated that the pro-
grammes included larger samples (mean census 76 v
68), with correspondingly larger budgets; but, impor-
tantly, the duration of the programmes, their clinical,
administrative, and sanctioning approaches, and the
procedural elements of care did not differ.
A second limitation is that we recorded only
objective, verifiable information from records, such
as drug testing, sanctions, and modifications to
licences. We are confident of the validity of these
records, and our results are consistent with most other
published studies of physicians with substance use
a limited picture of the broader functional status and
personal health of these physicians. A prospective
study is needed to enrich these data, with additional
information on clinical and administrative processes
and a broader range of measures for functional status.
Finally, the focus on official records made it
impossible to track 102 physicians who moved out of
their programmes’ jurisdiction during the course of
cannot be inferred. It is a concern that 24 of these
physicians moved away without contacting their
programme and with no formal referral for continued
monitoring. This suggests an effort to avoid detection
and is thus a potential danger to patients.
evidence that the combination of identification, inter-
vention, formal treatment, professional support, and
monitoring by physician health programmes is effec-
could not or would not stop their misuse of substances
were detected early during the course of formal
treatment and this usually resulted in voluntary or
involuntary cessation of practice. From a policy
perspective we conclude that affected physicians are
well advised to enter the supervision of a physician
health programme voluntarily, and that regulatory
boards are well advised to continue supporting these
It is not possible from the evidence here to prove
whether this form of support and monitoring for
use in the context of patient care has the potential for
considerable harm. Thus it will always feel more
powerful to invoke sanctions alone in a “get tough”
policy. But sanctions without the prospect of help in
achieving recovery could simply reduce colleagues’
willingness to refer affected physicians—or licensing
boards to exercise harsh sanctions—potentially
increasing the true prevalence of the problem. On the
basis of these data, and considering available alter-
the best available measures for protecting patients and
for recovering physicians’ careers.
We thank the Robert Wood Johnson Foundation for unrestricted career
cooperation and access to the data.
Contributors:ATMcL oversaw data collection and audits, participated in
writing of the paper. GSS and RLDuP liaised and communicated with the
WHAT IS ALREADY KNOWN ON THIS TOPIC
to alcohol and other drugs
Addicted physicians receive treatment through physician
health programmes, operating under jurisdiction of state
WHAT THIS STUDY ADDS
in physician health programmes had favourable outcomes
at five years
During monitoring 81% had negative urine test results
Most (95%) who completed monitoring were licensed and
working as physicians at five years
BMJ | ONLINE FIRST | bmj.com page 5 of 6
Federation of State Physician Health Programs. MC was responsible for
the preparation and storage of the data and analyses and participated in
instrument, oversaw audits of data, and participated in the analyses and
writing of the paper.
Funding:This study was supported by the Robert Wood Johnson
Competinginterests:GSS is the director of the Alabama State Physician
Health Program. His contribution to the work was invaluable in securing
cooperation from the Federation of State Physician Health Programs and
not direct or influence the data analyses.
Ethicalapproval:This study was approved by the institutional review
board of the Treatment Research Institute, Philadelphia.
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