State physician health programs (PHPs) play a key role in helping doctors with substance abuse problems. But the current PHP system is inconsistent and prone to potential conflicts of interest and ethical issues, according to a review available as publish ahead of print content from the December 2012 issue of Journal of Addiction Medicine, the official journal of the American Society of Addiction Medicine. The journal is published by Lippincott Williams & Wilkins, a part ofWolters Kluwer Health.

In the article, Drs J. Wesley Boyd and John R. Knight of Harvard Medical School point out “substantial variability in states’ PHP policies and practices, often raising serious ethical and managerial questions.” Collectively the authors served as PHP associate directors for more than 20 years; based on that experience they write, “We recommend that the broader medical community begin to reassess PHPs as a whole in an objective and thoughtful manner.”

‘Coercive’ Nature of PHP System Raises Ethical and Managerial Issues
Most states currently have PHPs, which help physicians with substance abuse disorders. State PHPs meet with, assess, and monitor doctors referred for substance abuse or other mental and behavioral health problems. hey also make provisions for follow-up and monitoring of treated physicians, including random drug testing.

The PHP system achieves good results in treating substance abuse disorders in physicians, with much higher success than reported for other groups of patients. However, Drs Boyd and Knight identify several ethical concerns related to the “coercive” nature of the system. They write, “Once a PHP recommends monitoring, physicians have little choice but to cooperate with any and all recommendations if they wish to continue practicing medicine.”

One issue is the high cost of evaluation and treatment. Insurance sometimes does not reimburse physicians for evaluations recommended by PHPs - a cost sometimes exceeding $4,500. If treatment is recommended, the cost may be prohibitive: as high as $39,000 for a “standard” 90-day length of treatment. That’s much longer than the 20- to 28-day stay typical for other patients undergoing substance abuse treatment - despite a lack of evidence that health care professionals need longer treatment.

Many centers who provide PHP-recommended evaluations also provide treatment, thus raising the potential for financial incentives for treatment recommendations. Drs Boyd and Knight note that close relationships between treatment centers and state PHPs are “replete with potential conflicts of interest.”

The authors also point out problems related to the practice of some PHPs that “any and all” positive test results be reported to the state licensing board - even if they don’t indicate substance abuse or relapse. Today’s highly sensitive tests can give a positive result even in a person who has used alcohol-based hand sanitizer, as well as some types of asthma inhalers and pain medications. PHPs may instruct doctors to avoid these exposures to simplify interpretation of test results, “rather than what might be in the best interests of the physician.”

Use of information about physicians in research by PHPs and their closely intertwined relationships with state licensing boards raise concerns as well. Because most doctors know little about them, PHPs “operate outside the scrutiny of the medical community at large,” the authors write. “Physicians referred to PHPs are often compromised to some degree, have very little power, and are therefore not in a position to voice what might be legitimate objections to a PHP’s practices.”

Drs Boyd and Knight outline recommendations to address the perceived problems. They believe that some form of independent ethical oversight of PHPs should be considered, along with a formal appeals process and a nationwide system for licensing and periodic auditing. They also call on specialty organizations such as the American Society of Addiction Medicine “to review PHP practices and recommend national standards that can be debated by all physicians, not just those who work within PHPs.”
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About Journal of Addiction Medicine
The mission of Journal of Addiction Medicine, the official journal of the American Society of Addiction Medicine, is to promote excellence in the practice of addiction medicine and in clinical research as well as to support Addiction Medicine as a mainstream medical specialty. Published quarterly, the Journal is designed for all physicians and other mental health professionals who need to keep up-to-date with the treatment of addiction disorders. Under the guidance of an esteemed Editorial Board, peer-reviewed articles published in the Journal focus on developments in addiction medicine as well as on treatment innovations and ethical, economic, forensic, and social topics.

About the American Society of Addiction Medicine
The American Society for Addiction Medicine is a professional society representing over 3,000 physicians dedicated to increasing access and improving quality of addiction treatment, educating physicians and the public, supporting research and prevention, and promoting the appropriate role of physicians in the care of patients with addictions.

About Lippincott Williams & Wilkins
Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes. LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

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Connie Hughes
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Wolters Kluwer Health