A Call for National Standards and Oversight of State Physician Health Programs

Overall their lifetimes, 10-12% of physicians will develop a substance use disorder [1]. This rate is comparable to that of the general public. Physicians who are suspected of having substance use disorders or other mental health issues are often referred to their state physician health program (PHP) for evaluation. These referrals might come from chief medical officers, boards of medicine, or colleagues in a group practice. PHPs meet with, assess, and monitor physicians who have been referred to them for substance use or other mental and behavioral health problems. Once referred, physicians often have little choice but to comply with any and all recommendations by the PHP in order to continue practicing medicine, because they have often been told by the referral source that failure to comply with any and all recommendations of the PHP will result in termination of their ability to practice medicine. In most states, for example, boards of medicine rely completely on the PHPs for guidance about how to deal with impaired physicians. So even though PHPs don’t directly have the ability to prevent physicians from practicing medicine, since PHPs can’t themselves revoke medical licenses or hospital privileges, their determinations of physician compliance with their recommendations often result in exactly those actions. PHPs are therefore extremely powerful.

The prevalence rate of addiction among physicians is similar to the general population, with approximately 10% to 12% of U.S.-based physicians developing substance use disorders (SUDs) during their lifetimes. To address this public health concern, physician health programs (PHPs) have been created to facilitate the early identification, evaluation, treatment, and monitoring of physicians. Although a number of published studies provide outcome information from PHPs, there has been no comprehensive review of the related literature. The objective of this narrative review is to summarize the treatment outcomes, including treatment types, rates of relapse, rates of contract completion or extension, as well as licensure and work status rates of a nationally representative physician cohort and related subpopulations from a single dataset. Based on the studies included in this review, our findings reveal that physicians who completed their PHP contracts have more favorable treatment outcomes than members of the general population who receive mainstream treatment. In addition, our review describes unique features of physician rehabilitation facilitated by PHPs. However, further prospective research is needed to ensure a standardized and comparable dataset and facilitate performance improvement.

State Physician Health Programs (PHPs) assess, support, and monitor physicians with mental, behavioral, medical, and substance abuse problems. Since their formation in the 1970s, PHPs have offered support groups following the 12-step model for recovery from substance use disorders (SUDs). However, few programs have developed support groups for physicians without SUDs. This study at the Massachusetts PHP (Physician Health Services Inc.) represents the first effort to survey physician attitudes concerning a unique support group that goes beyond classic addiction models. The group was initiated because of the observation that physicians with problems other than SUDs did not fit easily into the 12-step framework. It was hypothesized that such a group would be effective in helping participants control workplace stress, improve professional and personal relationships, and manage medical and psychiatric difficulties. With a response rate of 43% (85 respondents), the survey identified a strong overall impact of the Physician Health Services Inc. support group, identifying positive effects in all areas of personal and professional life: family and friends, wellness, professional relationships, and career. Respondents identified the role of the facilitator as particularly important, underscoring the facilitator's capacity to welcome participants, manage interactions, set limits, and maintain a supportive emotional tone. The implications for physician health extend from supporting a broader application of this model to using a skilled facilitator to manage groups intended to reduce the stress and burnout of present-day medical practice. The results encourage PHPs, hospitals, medical practices, and physician groups to consider implementing facilitated support groups as an additional tool for maintaining physician health.

The objective of this study was to compare outcomes of psychiatrists and nonpsychiatrist physicians enrolled in state physician health programs for substance use disorders. The study used the data set from a five-year, longitudinal cohort study of 904 physicians, including 55 psychiatrists, with diagnoses of substance abuse or dependence consecutively admitted to one of 16 state physician health programs between 1995 and 2001. There was a higher proportion of women among psychiatrists than among other physicians, but there were no other significant differences between the cohorts. Five-year outcomes were similar between psychiatrists and the other physicians, with at least 75% of psychiatrists continuing their medical practice after five years of monitoring and treatment. Psychiatrists were not overrepresented compared with other physician groups and had similar clinical outcomes at the five-year follow-up. Physician health programs appeared to be effective treatment programs for psychiatrists with substance use disorders.

Stigma, Misunderstanding Among the Barriers to MAT Treatment

Tremendous strides have been made in the identification, treatment and monitoring of physicians who abuse alcohol or other drugs. Nevertheless, balancing the desire to help such physicians against the need to protect the public remains a perennial challenge for medical boards. This article offers suggestions for medical boards on establishing a positive working relationship with their state physician health programs (PHPs). Boards and PHPs have distinct yet complementary missions, and the facilitation of trust and communication between these two entities is critical. The article also reviews current trends in treatment and aftercare, including more individualized treatment planning and more extensive and sophisticated drug testing.

AMA to Work With APA, Other Groups on Integrated Care

A Comparative Analysis of Substance Use Disorder Programs Between Three Safety Sensitive Professions.

Perceived Effectiveness of Medications Among Mental Health Service Users With and Without Alcohol Dependence

Physician Health Committee of the Medical Society of the District of Columbia and Georgetown University Law Center, Washington, DC. ccohenp@aol.comThe recent editorial by Berge and colleagues1sends an extremely important message to the anesthesia community, and I agree with many of its thoughtful and incisive points. However, I must take issue with the authors’ proposed new default position of “one strike, you’re out.” I believe that the question of return to work is far too complex to be approached in a monolithic fashion that lumps all anesthesiologists who have manifested drug dependence into a single group that “should be directed toward lower-risk occupational environments, either within medicine or in a different field entirely.”A uniform prognosis cannot be assigned to every drug-dependent anesthesiologist. For example, Domino et al. 2suggest that dual diagnosis and family history are among the major factors that must be taken into account when predicting the risk of relapse in opioid-addicted physicians. My own experience supports an additional and extremely important variable that must be considered when deciding whether or not a drug-dependent anesthesiologist should return to his or her profession: The availability of long-term supervision, support, and monitoring. The Medical Society of the District of Columbia’s Physician Health Committee (PHC) intervenes on physicians whose colleagues (and sometimes themselves) believe them to be suffering from the disease of drug dependence. The PHC refers this physician to a specialist in addiction medicine and, if recommended, facilitates admission to treatment (usually residential). Immediately after discharge the physician, now in early recovery, enters into a five-year contract with the PHC. This contract mandates random drug testing (a daily phone call determines whether or not an observed urine sample must be furnished within the next 12 h), monitoring by a member of the PHC, participation in 12-step programs, and continuing aftercare under the supervision of an addictionologist. Some of our clients also submit hair samples for drug testing every two to three months. Our recommendation for a graduated return to work is made only after we receive a recommendation from the treating specialist that this would be appropriate. Aftercare of opioid-addicted anesthesiologists in recovery may include the use of depot naltrexone. At least one supervisory member of the department is made aware of the individual’s history at the time of return and is informed that the PHC will be responsible for monitoring.Approximately 90% of physicians (including anesthesiologists) enrolled in the Washington, DC Medical Society’s Physician Health Program have successfully completed their 5-yr contracts.3The PHC has monitored sufficient numbers of anesthesiologists in recovery whose return to work has been recommended to support my stance that “one strike” need not preclude reentry into anesthesiology. At the present time, although some of our clients do indeed voluntarily leave anesthesiology for another medical specialty, those who have returned to the practice of anesthesiology have been successful in their recovery. While the group of anesthesiologists with whom we have experience is small in comparison with the entire national cohort, our observations support my view that individual consideration, long-term close surveillance, and aftercare by specialists in addiction medicine may provide an alternative to the editorial’s default position.In contrast, the editorial1appears to base at least some of its argument on a “pragmatic review of our personal experience with our Mayo Clinic nurse anesthetists,” leading to the observation that “there has been nearly a 100% relapse rate” (relapse is not defined and could represent anything from a single “slip” to a full-fledged resumption of frequent drug use). It is significant that the authors do not provide evidence of long-term monitoring of these nurse anesthetists. Indeed, they state that “it is difficult to exactly quantify the relapse rate, because far too often affected individuals are simply lost to formal follow-up.”Finally, the editorial refers to Gastfriend’s statement that addiction is “a brain disease that subverts self-preservation”4to support its contention that “decision-making is damaged by addiction so that abstinence is not simply a choice.” However, Gastfriend also clearly emphasizes—quoting reports from several other Physician Health Programs—that “the vast majority of physicians who have substance use disorders seem to do surprisingly well in recovery.” While I certainly do not disregard the unmistakable threat that addiction poses to anesthesiologists and patients, my own personal experience, and that of other PHC chairs, suggests that the editorial’s pessimism is not justified. Documented sobriety is possible within the operating room environment. When complemented with vigilance,*including supportive and careful long-term monitoring, return to work can be successful for both the physician and society.Physician Health Committee of the Medical Society of the District of Columbia and Georgetown University Law Center, Washington, DC. ccohenp@aol.com

Physician Health Programs (PHPs) have been support-ing and advocating for health professionals for nearly four decades. Initially developed by state medical societies in the 1980s, PHPs recognized the need for therapeutic alterna-tives to disciplinary measures for physicians facing health issues that could impair their ability to practice safely. Originally focused on substance use disorders, PHPs have since expanded their services to encompass mental health and other co-occurring conditions.

Previous studies of interdisciplinarity and nursing responsibilities have mainly focused on outcomes such as patient safety, job satisfaction and organizational factors. Mental health nurses often describe role confusion in relation to other health professionals. Opportunities for interdisciplinary communication with other professionals may benefit health care. The current large-scale study is the first to investigate whether mental health and SUD nurses' perceptions of their opportunities to accommodate patients' needs are related to interdisciplinarity in the treatment unit and a nursing role with clearly defined responsibilities. Strong interdisciplinarity was associated with greater perceived opportunities to accommodate patients' psychosocial, somatic, and economic and legal needs, while strictly defined nursing roles/responsibilities were related to weaker opportunities to do so. The findings highlight the need to address how mental health and SUD nurses organize practice to meet patients' diverse needs Interdisciplinary teamwork could strengthen nurses' ability to address patient needs Finding the best possible balance of providing service in teams or individually could improve resource utilization at the same time as strengthening patient care, and making sure that the patients' various needs are met. INTRODUCTION: Nurses' roles in specialist mental health and substance use disorder (SUD) treatment services are multidimensional and complex. Their responsibility, autonomy and interdisciplinary collaboration may be of importance for their perceived opportunities to accommodate patients' health needs. Previous studies of interdisciplinarity and nursing responsibilities have mainly focused on outcomes such as patient safety, job satisfaction and organizational factors, and included relatively small samples. The studies have also mainly been conducted in other sectors than the mental health and SUD nursing sectors. The aim of this study is to examine the associations between nurses' roles, interdisciplinarity and their perceived opportunities to accommodate patients' psychosocial, somatic and economic/legal needs. A cross-sectional web-based questionnaire survey was conducted in a nationwide sample of Norwegian nurses in the mental health, SUD treatment and combined mental health and SUD treatment sectors. Of 5,501 contactable nurses (74% of the population), 1918 (35%) responded. The results revealed that interdisciplinarity was significantly associated with greater perceived opportunity to accommodate patient needs, whereas strictly defined nursing roles/responsibilities were associated with less opportunity to accommodate these needs. Facilitation of interdisciplinary collaboration may improve quality of care for patients in mental health and SUD treatment services.

To explore predictors of mental health and substance use treatment receipt in pregnant women in the USA. Secondary analysis of data from the 2008–2014 National Survey on Drug Use and Health was conducted. Two logistic regression models were run to identify predictors of mental health treatment receipt among pregnant women aged 18–44 years with mental health problems (N = 1106) and predictors of substance use treatment among pregnant women with substance use disorders (N = 521). Forty four percent of pregnant women with mental health problems received mental health treatment, and only 13% of pregnant women with substance use disorders received substance use treatment. Women with anxiety disorder (vs. no disorder) (adjusted odds ratio (AOR): 17.3, 95% Confidence Interval (CI): 8.6–34.8), major depression (vs. no depression) (AOR: 2.48, 95% CI: 1.44–4.27), higher level of serious psychological distress (AOR: 1.06, 95% CI: 1.003–1.12), college (vs. less than high school) education (AOR: 2.84, 95 %CI: 1.36–5.91), and health insurance coverage (vs. no coverage) (AOR: 2.34, 95% CI: 1.16–4.71) had higher odds of mental health treatment receipt. African American (AOR: .38, 95% CI: .20–.74) and Hispanic women (AOR: .17, 95% CI: .05–.59) had lower odds for mental health treatment relative to Whites. The best set of predictors of substance use treatment receipt included NonWhite (vs. White ethnicity) (AOR: .39, 95% CI: .19–.80), large (vs. small urban) residency (AOR: 4.38, 95% CI: 1.84–10.45), alcohol and illicit drug use disorders (vs. no disorder) (AOR: 2.92, 95% CI: 1.48–5.78; AOR: 8.70, 95% CI: 3.32–22.76; respectively), and comorbid anxiety/depression disorder (vs. no disorder) (AOR: 3.13, 95% CI: 1.40–7.02). The common barriers reported by pregnant women who perceived unmet need for mental health treatment included perceived cost, opposition to treatment, and stigma, regardless of their disorder. The majority of pregnant with mental health/substance use disorders do not receive treatment. More policy and treatment initiatives that address barriers to and predictors of treatment receipt are needed to help this vulnerable population of pregnant women to gain access to mental health and substance use treatment.

Purpose To compare trends in mental health and substance use disorders and treatment receipt of pregnant and nonpregnant women from 2008 to 2014. Methods Using data from the 2008–2014 National Survey on Drug Use and Health, logistic regression was used to compare trends in mental health and substance use disorders and treatment receipt for mental health and substance use disorders among propensity score-matched groups of pregnant (n = 5520) and nonpregnant women (n = 11,040). Among women in the matched sample who met criteria for at least one mental illness, trends in mental health treatment receipt of pregnant (n = 1003) and nonpregnant women (n = 2634) were compared. Results There were no differences in the trends by pregnancy status from 2008 to 2014. Past-year anxiety disorder, past-month psychological distress and illicit drug use disorder increased in the total sample from 2008 to 2014, yet trends in mental health treatment and unmet need for substance use treatment did not change over time. Pregnant women had lower odds of mental illness, but those who had mental illness were less likely to receive mental health treatment than their nonpregnant counterparts. Conclusions There is a need for preventive strategies addressing anxiety disorder, psychological distress and illicit drug use among women of childbearing age as well as initiatives to increase access to mental health treatment among pregnant women.

Prior research suggests that publicly funded substance use disorder (SUD) treatment programs lag behind privately funded programs in adoption of evidence-based practices, resulting in disparities in access to high-quality SUD treatment. These disparities highlight a critical public health concern because the majority of SUD patients in the United States are treated in the publicly funded treatment sector. This study uses recent data to examine disparities in access to physicians and availability of medications for the treatment of SUDs between publicly and privately funded SUD treatment programs. Data were collected from 595 specialty SUD treatment programs from 2007 to 2010 via face-to-face interviews, mailed surveys, and telephone interviews with treatment program administrators. Publicly funded programs were less likely than privately funded programs to have a physician on staff, even after controlling for several organizational characteristics that were associated with access to physicians. The results of negative binomial regression indicated that, even after taking into account physician access and other organizational variables, publicly funded programs prescribed fewer SUD medications than privately funded SUD treatment programs. Patients seeking treatment in publicly funded treatment programs continue to face disparities in access to high-quality SUD treatment that supports patients' choices among a range of medication options. However, implementation of the Affordable Care Act may facilitate greater access to physicians and use of medications in publicly funded SUD treatment programs.