Dr. Wesley Boyd, an associate professor of psychiatry at Harvard, has spent years working with state programs that help doctors, nurses and other health care workers who have become addicted to opioids get back on their feet professionally.
He supports these non-disciplinary programs, in which doctors and nurses enroll for a number of years and are closely monitored by addiction specialists and state authorities as they seek to maintain or restore their medical licenses. But, he said, he is perplexed as to why these programs and other efforts to help health care providers generally do not stress a recovery method that has long been shown to be effective: the use of drugs like buprenorphine and methadone, known as opioid agonists, to relieve cravings.
“Obviously the data are clear that medication-assisted treatment is the best course of action,” said Boyd, who worked for Massachusetts’ Physician Health Services (previously known as the Society to Help Physicians) from 2004 to 2010. “Whether they’re doctors, nurses or anybody else, [they] can function perfectly well at work and in their lives generally while they’re using medication-assisted treatment.”
Furthermore, he said, “the odds that they’re going to stay clean and sober while using medications for treatment are better.”
Clinical studies show medication-assisted treatment significantly decreases the rate of relapse and overdose more than other interventions alone. Most advocates advise using it in conjunction with regular therapy or counseling. Legal and medical researchers also made this point in the New England Journal of Medicine last month, calling it “ironic that clinicians, who are better positioned than most people to acquire and afford opioid-agonist therapy, are often denied it.”
But some health care professionals believe opioid agonists are just a substitute for the drugs a doctor is addicted to, and, since they bind to the same brain receptors as opioids, may affect providers’ ability to do their jobs. The opioid agonists help reduce relapses and cravings by stimulating the same pathways opioids do, but in a controlled manner that prevents a person from feeling high.
Non-Disciplinary Treatment Programs For Addiction
Non-disciplinary treatment programs have been operating in most states since the 1970s to help health professionals overcome their addiction. Instead of revoking the license of an individual who is found to be impaired on the job, these peer-run programs try to get participants back to work with mandated treatment plans that include intensive therapy, monitoring their behavior in and out of the workplace and, of course, drug testing. Throughout treatment, participants are actively discouraged, if not outright banned from, using opioid agonists that could aid their recovery.
Members of the non-disciplinary program may advocate for a participant’s return to work when they believe the individual is ready, but, ultimately, it is the state board that determines when an individual is fit to care for patients.
California, however, is one of a handful of states that do not opt for such a program. In 2008, it let its program for doctors expire, meaning physicians reported to the licensing board are immediately disciplined. The board’s actions can include a public letter of reprimand, probation with various terms and conditions or license revocation.
When asked, Carlos Villatoro, a spokesman for the medical board, said “a physician cannot be impaired when practicing medicine whether they are using opioid agonists or any substance.”
Francine Farrell, director of the Pacific Assistance Group, which treats, monitors and serves as an advocate for California physicians hoping to return to work, said it’s unlikely any physicians in the program would be treated with opioid agonists.
“I don’t want to make a blanket statement, but generally speaking, we are 100% abstinence-based,” she said.
The California Board of Nursing still maintains its non-disciplinary program.
Bill Kinkle, a registered nurse in Pennsylvania, developed an addiction to opioids more than a decade ago and lost his license. He tried several recovery programs but relapsed and overdosed several times.
He has been working with the state’s Peer Nurse Assistance Program to get his license back. When he asked if he could use Suboxone, a brand name for a combination of buprenorphine and naloxone, he was told that unless he had a detailed plan for tapering off the drug, the nurse assistance program would not allow it.
So he is treating his addiction through the state program without the medication. He was required to participate in a 30-day inpatient program, undergo partial hospitalization (in which a participant is treated for several hours a day but can go home in the evenings) for an additional three weeks, receive three months of intensive outpatient therapy, attend Alcoholics Anonymous meetings three to five times a week and pay for expensive random urine screenings.
The Peer Nurse Assistance Program did not respond to requests for comment.
Some state officials are beginning to consider the use of drugs like methadone and buprenorphine. The North Carolina Medical Board, which handles physician licensing and discipline, is encouraging the state program for doctors with opioid addictions to consider introducing these medications.
Critics argue that the non-disciplinary programs can, in fact, feel more disciplinary than supportive and don’t help as many people as they could if opioid agonists were made available.
The programs “have no independent oversight and patients don’t have a recourse,” said Dr. Peter Grinspoon, an internist in Boston who had an opioid addiction and was both a participant in, and eventually a board member of, Massachusetts’ Physician Health Services program for addicted doctors.
Grinspoon, who also teaches at Harvard, said that although he was unaware of any formal state policy against medication-assisted treatments, none of the program’s participants with opioid addictions used opioid agonists while he served.
Impairment in Safety-Sensitive Positions
Scott Teitelbaum, medical director at the University of Florida Recovery Center, which treats health care professionals from all over the country, said he sometimes prescribes the medicines to the half of his patients who don’t work in “safety-sensitive positions.”
But, he said, it makes sense to have a different strategy for patients in those positions. When the programs ask him if a person should return to practice, they’re not asking what’s best for the individual; they’re asking whether it’s safe for the public. And when patients are using agonist therapies, Teitelbaum, who also was treated for cocaine and marijuana use, said he isn’t sure it is.
A review in Mayo Clinic Proceedings of several studies in 2012 showed small effects of both methadone and suboxone on performance in measures such as reaction time and memory. The review was criticized for weak evidence and a lack of appropriate control groups.
Grinspoon noted that doctors could be taking other medications that affect their performance but face no repercussions. For example, he said, they may take benzodiazepines for anxiety or Ambien to help them sleep.
“There are tons of pharmaceuticals that could affect our performance — all of which doctors are allowed to take,” he said. “And it’s just because of the stigma that they’re singling out addiction.”
Critics of medication-assisted treatment often point to the overwhelming five-year success rates reported by the non-disciplinary programs — generally between 70% and 90%.
But Boyd is wary of those rosy statistics. First, he noted, they rarely count people who dropped out of the program or died by suicide. He said some professionals who never suffered from substance use disorder are forced into the program by bad evaluations.
So far, Kinkle, the nurse in Pennsylvania, has stayed on track, “white-knuckling it” without Suboxone. If all goes according to plan, his license will be reinstated in another 13 months.
“My wife found me multiple times after an overdose lying on the floor unconscious,” said Kinkle. “All that could have been prevented had I been offered” Suboxone.
Clarification: This story was updated on Oct. 3 at 10:35 a.m. PT to make clear that the North Carolina Medical Board is not urging state health officials to endorse the use of drugs like methadone and buprenorphine but instead consider it.