From The Carlat Addiction Treatment Report, March 2020, Substance Use in Health Professionals

Issue Links: Learning Objectives | Editorial Information | PDF of Issue

Topics: Abstinence | Addiction Treatment | Alcohol use disorder | Legal issues | Opioid Use Disorder | Special populations

CATR: Tell us how your interest in addiction came about.
Dr. Earley: When I started working in the world of addiction treatment 35 years ago, there wasn’t much specific training. I was trained as a neurologist and always had an interest in patients with substance use disorders. Ultimately, I decided to shift my specialty and wound up cobbling together my own training over years of supervision with psychiatrists, mostly at larger not-for-profit psychiatric institutions, then running addiction programs that had a heavy interface with psychiatry. I stayed active with the American Society of Addiction Medicine (ASAM) so that I could keep up with the evidence base that was evolving at the time.

CATR: What drew you to your current role and to working with physicians in particular?
Dr. Earley: In my work, I saw that things were a little different in helping physicians get better. As a physician, I was drawn to their treatment and to the mission of returning our colleagues back to practice. I wound up working in centers that specialized in the treatment of health care professionals. This work, plus the work I did with the Federation of State Physician Health Programs (FSPHP), sparked my motivation for further development in the nuances of this safety-sensitive profession. Later, when Georgia started a physician health program (PHP), I left treatment work and moved to help start the Georgia PHP over 7-1/2 years ago. We built the program with knowledge base accrued from other programs across the US, fostered by our membership and meetings with the FSPHP. Most of the work we do at the Georgia PHP is with substance use, but we also support the assessment, treatment, and monitoring of physicians with bipolar and unipolar mood disorders and some physicians who have other conditions, such as burnout or difficulty in their personality structure.

CATR: What makes health professionals a unique population when it comes to addiction treatment?
Dr. Earley: I think the most important piece to understand is that health care professionals are on the one hand a vulnerable group, and on the other hand in safety-sensitive professions where their impairment could impact public safety. It’s important that the care be geared to not only maximizing the health of the physician, but also ensuring the public’s safety. And involved in that is a system. Health care professionals, especially physicians, are subject to oversight, whether through a credentialing process, a medical or specialty board, or insurance panels. Specific rules and regulations vary from state to state regarding safety to practice. This is one of the many reasons PHPs are critical. Understanding what PHPs do to help physicians with health problems is important to all addiction practitioners. You are going to run into physicians with addiction issues—in addition to physician assistants (PAs) or nurses with similar struggles. If you do not understand the context of safety requirements, you will be doing certain disservice to your patient or client.

CATR: Society doesn’t often think of physicians as, like you said, vulnerable.
Dr. Earley: One of the vulnerabilities comes from the fact that physicians have ready and sometimes constant access to substances with a high potential for causing addiction. Over the years, we’ve found all sorts of entry portals into addiction because physicians are used to dealing with medications. And at the same time, they may feel like their knowledge protects them from having problems. They tend to have less concern about the use of medications, so experimentation can occur—and that can lead them down a difficult path.

CATR: Do they approach treatment differently, too?
Dr. Earley: Their roles as physicians can impact their willingness to engage in treatment. Physicians feel an enormous amount of shame about how they obtain the substances that they use, and that shame can be a barrier to seeking or sticking with treatment. At the same time, for this population, we know that long-term relapse prevention strategies and monitoring ensure the best possible prognosis and maintain public safety (Domino K et al, JAMA 2005;293(12):1453–1460).

CATR: Let’s say we’re concerned about a colleague’s substance use. How does one learn about what is locally available?
Dr. Earley: The quickest way to learn more is to go to the FSPHP website at www.fsphp.org and look up your respective state’s program. Then call or email that program and say, “Hey, I need to know a little bit about what services you provide.” All PHPs are interested in teaching and helping people learn about what they do. So any practitioner—be it a family therapist, a primary care provider, or a colleague of someone whom they’re worried about—if they don’t know about their PHP in their state, they should search the FSPHP. We get calls all the time from people who say, “Tell me what you do,” and we’re happy to have that conversation.

CATR: Break down for us what services PHPs provide and to whom.
Dr. Earley: Most PHPs provide a confidential resource for the vast majority of their participants. PHPs work with physicians, but often they cover other health care professionals as well, working with those who have addiction or substance misuse issues, or psychiatric, medical, and behavioral problems (­DuPont RL et al, JSAT 2009;37(1):1–7). PHPs help with detection. They help steer people to proper evaluation. Physicians are bright, and that intelligence can make it more difficult for an evaluator to make the correct diagnosis. In general, PHPs don’t perform evaluations or provide treatment; instead they coordinate and provide oversight.

CATR: Interesting. How does the care coordination occur?
Dr. Earley: PHPs are really chronic disease management systems, much like a nurse in a health care system who works with a patient with diabetes to decrease complications and ensure the best outcome. So that’s a way of thinking about us: We coordinate care. We also help deal with the hospital medical staff, the physician’s professional liability carrier, and the medical board, if necessary. In doing so, we make sure the individual gets quality care and ensure that, when the time comes for the physician to reenter practice, the public is safe and the physician is ready to return. We are more like care managers, if you will. PHPs make sure that the I’s are dotted and the T’s are crossed, helping physicians get care with the least possible impact on their license and livelihood. Treatment is followed by long-term disease monitoring, which is critical for chronic mental health conditions like substance use disorders (DuPont RL et al, JSAT 2015;58:1–5).

CATR: Could you walk us through an example?
Dr. Earley: Sure. A hospital system someplace in Georgia may call me up and say, “I have a physician I’m worried about. What should I do next?” I would learn a little bit about that case, and if the level of concern is significant enough, I might say, “Maybe you should have this individual call us and we can talk over their options.” If an evaluation is needed, we help guide the physician to a facility that specializes in such evaluations. If treatment is indicated, we refer to facilities that have a specialty in caring for health care professionals. As we’ve discussed, physicians have different needs in terms of workplace access to substances, in terms of licensure issues, and in terms of dealing with the shame associated with their drug or alcohol use.

CATR: How does a PHP navigate the tension between public safety and patient privacy?
Dr. Earley: PHPs are set up in most states to allow for anonymity of the physician from licensure boards. Physicians have a right to privacy, but they also have a desire to ensure that they can practice and have gainful employment. We’re balancing not only public safety and the right to privacy, but also the opportunity to get care in a way that doesn’t threaten the future of a person’s medical career. So in most states, the PHP functions as an alternative to discipline. This is a vast improvement from the era before PHPs where, unfortunately, physicians who became ill were publicly sanctioned.

CATR: What would you say to someone who is concerned about a colleague but who is also concerned that that colleague may be disciplined if treatment is sought?
Dr. Earley: That question is at the crux of how this process works. For example, here in Georgia, if we have a physician who has a substance use disorder, in 95% of the cases, the medical board never knows. The other important point is, if you take a look at the outcomes of our work, they are very impressive for people who stay with us for a sufficient period of time (McLellan AT et al, BMJ 2008;337:a2038). When I have a physician who calls me up anonymously, I’ll say, “I will help with your anonymity from the medical board if possible, but let’s also talk about disease outcome. We provide wonderful opportunities for sustained long-term disease remission.” And in that case, the people whom we work with usually say, “Well, I’m a little anxious about you knowing about me, but the fact that you don’t have to tell the medical board is good, and the fact that I’m going to have a better prognosis makes me happy to work with you.”

CATR: Some PHPs have been criticized recently for not supporting the use of medications in addiction treatment, particularly opioid agonists in the treatment of opioid use disorder.
Dr. Earley: Actually, PHPs are among the earliest supporters of using medications to assist with addiction and looking at the full spectrum of a physician’s issues—whether it’s an anxiety disorder, depression, or a pain disorder, as well as recovery and prevention of relapse. PHPs have no categorical ban on the proper use of any FDA-approved medication for addiction treatment, but it’s an evolving issue for some programs.

CATR: Do we know much about addiction or substance use among health professionals who are not physicians?
Dr. Earley: We don’t know enough, actually. There is limited research about other health care professionals. One of the main reasons there is more research about physicians is because physicians tend to study themselves. The information on nurse practitioners and PAs is also smaller just because up until the last 10 years or so, they represented a smaller portion of health care providers, but their numbers are now growing rapidly. Among nurses who are not nurse practitioners, there are several fine research studies—but no meta-analysis is yet available. The consensus from health programs for nurses is that they do as well as physicians if they stay in a nurse program, but again that information doesn’t pass the muster of hard research, unfortunately. We hope to have research about other health care providers someday soon.

CATR: Do non-physician providers have their own programs?
Dr. Earley: Some states’ PHPs do have programs for nurses and/or other health professionals. Our state PHP covers PAs and respiratory therapists, for example. And among our PAs—this is retrospective analysis—our tracking system reports a recovery rate that’s very similar to what we see among physicians: maybe just a couple of percentage points lower. This is data from our tracking system, by the way; it is not published research. We think the similar recovery rate with different professions is related to the PHP model of chronic disease management—of looking at the illness as something to be followed over time and addressing a relapse with careful, measured responses rather than “hair on fire” kind of responses. We think it helps participants to know that they don’t have to be perfect and that if they have a return to use, we will manage it; we will work with them and we will make sure we can keep them healthy and in practice.

CATR: Can we reach out to PHPs for consultation or general advice?
Dr. Earley: While we are not self-promoters, we are happy to talk to anyone who has questions. I spend a lot of my day talking to partners in medical practices, chief medical officers, and members of medical and nursing boards. The FSPHP, as an organization, likes to teach. So don’t be shy—call your local PHP, ask questions, read about it. A good place to start is my chapter in the ASAM textbook on this topic (Earley P. Physicians health programs and addiction among physicians. In: Miller SC, Fiellin DA, Rosenthal RN, Saitz R, eds. The ASAM Principles of Addiction Medicine. 6th ed. Philadelphia: Wolters Kluwer; 2019:671–692).

CATR: It seems that the success of PHPs speaks to the need to consider addiction a chronic disease.
Dr. Earley: We have been and remain at the forefront of managing substance use disorders as a chronic illness. We manage people over years with tapering attention, with measured responses to loss of remission. And by doing so, we’ve learned a ton about the natural history of people who have addictive diseases and how to manage those diseases, so I think we have a lot to teach the field as well. It’s a wonderful population to treat. Most of my physicians are deeply grateful for the work I do. It’s extremely satisfying.

CATR: Thank you for your time, Dr. Earley.