For Health Workers Struggling With Addiction, Why Are Treatment Options Limited?
Friday, September 6, 2019
Peter Grinspoon got addicted to Vicodin in medical school, and still had an opioid addiction five years into practice as a primary care physician.
Then, in February 2005, he got caught.
"In my addicted mindframe, I was writing prescriptions for a nanny who had since returned back to another country," he says. "It didn't take the pharmacist long to figure out that I was not a 19-year-old nanny from New Zealand."
One day, during lunch, the state police and the DEA showed up at his medical office in Boston.
"I start going all, 'I'm glad you're here. How can I help you?' " he says. "And they're like, 'Doc, cut the crap. We know you're writing bad scripts.' "
He was fingerprinted the next day and charged with three felony counts of fraudulently obtaining a controlled substance.
He also was immediately referred to a Physician Health Program, one of the state-run specialty treatment programs developed in the 1970s by physicians to help fellow physicians beat addiction. Known to doctors as PHPs, these programs now cover other sorts of health providers, too.
The programs work with state medical licensing boards — if you follow the treatment and monitoring plan they set up for you, they'll recommend to the board that you get your medical license back, Grinspoon explains. It's a significant incentive.
"The PHPs basically say, 'Do whatever we say or we won't give you a letter that will help you get back to work,' " Grinspoon says. "They put a gun to your head."
But the problem, he and other critics say, is that, for various reasons, most PHPs don't allow medical professionals access to the same evidence-based, "gold standard" treatment that addiction specialists today recommend for most patients addicted to opioids: medication-assisted treatment.
Grinspoon was told that to avoid a criminal record he would need to spend 90-days at an inpatient center in Virginia; there, he was not allowed access to the most common MAT prescription of counseling plus buprenorphine or methadone. These drugs are particular members of the opioid family that have been shown to suppress cravings for heroin, fentanyl and other frequently abused opioids. (Another drug, naltrexone, works by blocking opioids' action, and is also sometimes prescribed as a component of medication-assisted treatment.)
"Why would you send this Jewish atheist to a religious, Christian rehab place in Virginia?" Grinspoon says. "It didn't make any sense. I was just sitting there listening to people recite the Lord's Prayer and hold hands. And I'm not against the Lord's Prayer, but it just didn't help me."
At the same time, Grinspoon was forced off all the drugs he'd been taking "cold turkey," without the medical support that would have eased withdrawal pangs and cravings. "It was completely insane," he says.
"Why on earth," Grinspoon adds, "would you deny physicians — who are under so much stress and who have a higher access and a higher addiction rate — why would you deny them the one lifesaving treatment for this deadly disease that's killing more people in this country every year than died in the entire Vietnam War? There's no reason for it."
Grinspoon eventually recovered, but only, he says, after going through several "awful" rehab experiences. "I recovered despite going to rehab not because I went to rehab," he says.
Addiction specialists call for an end to the medication 'ban'
While there is some variation in the particular rules and policies that each state's physician health program follows, Dr. Sarah Wakeman of Harvard and the Massachusetts General Hospital Substance Use Disorder Initiative, says most PHPs don't refer patients to addiction programs that include medication as part of their treatment. And that's a problem, she says.
"I think the underlying issue is stigma and a misunderstanding of the role of medication," Wakeman says, "and this idea that a non-medication-based approach is somehow better than someone taking the medication to control their illness."
She co-authored a recent opinion piece in the New England Journal of Medicine titled "Practicing What We Preach — Ending Physician Health Program Bans on Opioid-Agonist Therapy," along with collaborators Leo Beletsky and Dr. Kevin Fiscella.
"Systematically denying clinicians access to effective therapy is bad medicine, bad policy and discriminatory," they write in NEJM. "We call on the health care sector to practice what it preaches, by discarding this antiquated norm."
"It's the peak of hypocrisy and absurdity," Beletsky, a professor of law at Northeastern University tells NPR.
"I work with a lot of folks who are health professionals themselves, who are on the front lines advocating and fighting against stigma, trying to get policies and practices to align more closely with the science," he says. "If those very same people were themselves struggling with addiction they would not have access to those medications."
The strict policies of PHPs might have a chilling effect on health professionals who have opioid use disorder and need help, Beletsky and Wakeman believe.
A proven record, and reasons for caution
So what do the institutions getting blamed here — Physician Health Programs — have to say about all this?
Dr. Christopher Bundy is the executive medical director of Washington state's PHP and the president-elect of the Federation of State Physician Health Programs.
He wants to make clear, first of all, that there is no systematic ban against the use of medication-assisted treatment, and no health care provider should avoid seeking help.
"There are doctors today across the country who are being monitored on buprenorphine," he says. "And not just physicians. Nurses and other health professionals — certainly nurses in our state are able to work on buprenorphine."
Bundy acknowledges, though, that those cases are not the norm.
There are "rational and understandable reasons," he says, why such medications are often not used in rehab programs aimed at health professionals.
For example, he cites concerns that medications like buprenorphine can affect cognition. PHPs also get pressure from other stakeholders, such as regulators and licensing boards not to use medication. And, he points out, the in-patient, non-medication treatment model has been proven to work with many health professionals across several decades, and he worries that changing it could open PHPs up to unnecessary risk.
"Our tendency is to err on the side of caution," Bundy says, "especially when implementing therapies that have the potential to impair somebody's ability to practice safely. Despite the fact that there are many who would like us all to believe that the jury is in [on medications like buprenorphine], more remains unknown than known, especially when it comes to how to appropriately use these medications in safety-sensitive professionals." That includes some other professions, such as pilots, he says — not just health workers.
Bundy notes that the public trusts PHPs to help health workers get healthy enough to be able to work with patients again — and that trust is fragile.
"We only need to have a case of one physician who is on buprenorphine where there's a bad patient outcome," he says, "to potentially have a whole other source of criticism being levied against the PHP for putting that physician back to work on a medication that may have played a role in that bad outcome."
An overwhelming process
Bill Kinkle, a nurse in recovery from opioid use disorder, is right now going through the laborious process of getting his nursing license back. He lives outside of Philadelphia and is very public about his past drug use — he even has a podcast called "Health Professionals in Recovery."
He's working through an extensive treatment and monitoring program to get his nursing license back. Kinkle hopes to complete his third year of documented sobriety next fall; if so, he'll then be eligible to practice nursing again.
When he was in the throes of his addiction and desperate to get into recovery, Kinkle says he was scared to do anything that might jeopardize his chance to get his career back.
"In the nursing community, there is a ton of fear about the PHPs," he says. "Everybody always told me, 'You can't be on Suboxone [a form of buprenorphine] — you can't be on anything.'"
But he wanted to check for himself. So he called his state's PHP to ask what their policy actually was.
" 'The Board of Nursing will send you for some type of extensive cognitive testing,' " he says he was told. " 'Number one, the testing is very expensive. And it's very difficult to find someone that will do the testing that we require.' "
Daunted by that response, Kinkle says he instead "white knuckled it." He went to abstinence-based programs — over and over again, and over and over. Many, many times, as soon as the rehab ended, Kinkle would relapse and turn to opioids again.
"A lot of those, I overdosed," he says. "And had my wife not found me on the floor and been able to take care of me, I very well may have died."
Kinkle believes "all that possibly could have been mitigated, had I gotten the gold standard of treatment, which is either buprenorphine or methadone."
He doesn't fault PHPs or licensing boards for their problematic policies, even though he thinks those policies put his life at risk. He says the stigma associated with addiction is ingrained in our culture; there's no single institution to blame.
Both sides of the table
Peter Grinspoon was monitored in his recovery from opioid dependence by a PHP for seven years; and then later went to work for that very program.
"I've seen this issue from both sides," he says. "I actually sat at the same table — in 2005 looking like something the cat dragged in, and then from 2013 to 2015 as a physician in recovery, helping other doctors."
Grinspoon says in his experience, there was a de facto ban on medication-assisted treatment. In his state the ban was based, he says, on the assumption that the licensing board would reject any doctor-applicant who was taking a medication like buprenorphine. He says the feeling among staff at the PHP was "why bother to set someone up for failure?"
He believes such a policy needs to change, and that any cited concerns about cognitive impairment associated with medication-assisted treatment are unproven — and hypocritical.
"Why do they make medical students, interns and residents work 28-hour shifts then?" he points out. "I'd rather have someone on Suboxone [treat me] than someone who's been up all night. And doctors are allowed to drink the night before [they go to work] — they're allowed to take Ambien for sleep. That totally impairs you the next day."
"This is pure stigma," Grinspoon says. "It's harming doctors. They need to reevaluate this completely."
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