Physician health program
Addressing the opioid epidemic
by Heidi Letko, LPC and Doris C. Gundersen MD
Much is known about the origins of the United States’ current opioid problem, with pharmaceutical companies and physician overprescribing widely to blame. It is important to remember that the pharmaceutical industry downplayed the risk for addiction with drugs such as Oxycontin, and the fifth vital sign was adopted in the 1990s, making pain treatment a priority for all patients. In 2000 the Joint Commission published a book citing studies suggesting that addiction was not a significant issue in patients prescribed opioids for pain control and that doctors’ concerns about addiction potential were inaccurate and exaggerated. (Note: The book was sponsored by Purdue Pharma). What has evolved in the last decade or more demonstrates that the concerns raised by physicians were indeed legitimate.
Media coverage of the current opioid epidemic is at an all-time high with drug overdose now the leading cause of death for those under age 50 and opioids driving the crisis. In 2015, of the over 52,000 drug overdose deaths, 33,000 were related to prescription opiates or heroin. That number has continued to rise in both 2016 and 2017.
In response to this crisis, pharmaceutical companies have begun to reformulate their drugs so as to make them less prone to abuse. State-legislated prescription drug monitoring programs were created and efforts were made to increase physician awareness with a new emphasis placed on alternative methods for the management of chronic pain, while restricting the use of narcotic analgesics for post-surgical and terminal pain. The Center for Disease Control’s recently disseminated guidelines for treating chronic pain will be helpful in stemming the tide of over prescribing narcotic analgesics.
The Colorado Physician Health Program (CPHP) has been addressing the crisis from two angles; helping the addicted physician and ensuring that those physicians who may be overprescribing are provided the education needed to responsibly treat their patients’ pain.
CPHP has been evaluating, monitoring and advocating for physician health for more than 30 years. CPHP evaluates, on average, 300 new clients each year and actively monitors approximately 500 physicians and physician assistants at any one time. Of those 500 clients, 10-15 percent are monitored for substance use disorders, with 26 percent of those being monitored for opiate abuse.
When CPHP identifies an active substance use disorder, recommendations for treatment include intensive outpatient or residential programs at facilities that specialize in treating physicians. Following successful completion of primary treatment, a physician’s aftercare typically includes 12 Step meetings, specialized physician support and treatment groups, individual treatment, and ongoing tissue testing so that relapses can be discovered early.
Anesthesiologists and emergency medicine physicians are known to be at higher risk of opioid addiction (versus alcohol or other drugs) due to ready access to their drug of choice. Following treatment, returning to practice poses unique challenges for these recovering physicians. Opioid users have the highest rates of relapse and proximity to their drug of choice places these physicians at significant risk. Additionally, the short half-life of certain opioids, such as fentanyl and sufentanil, can make urine drug screen testing alone inadequate. Therefore, physicians recovering from opioid use disorders also submit to quarterly hair or nail testing as these tests have a significantly longer, (three-month) window of detection. Additionally, most of these specialists are prescribed the opioid antagonist naltrexone which can prevent death if a relapse occurs. With these provisions in place, physicians in recovery can practice medicine safely.
Regardless of drug of choice, the recovering physician is monitored for approximately five years with an overall success rate of greater than 80 percent (successful program completion as well as continued ability to practice medicine). [Am J Addict 2012;21:327-334]. Recovery rates for the general population are considerably less favorable. Physicians in Colorado have the benefit of Safe Haven which allows physicians who are known to CPHP, and who are without legal history or adverse actions related to their health issue, to keep their health information private when applying or reapplying for licensure. This provision encourages individuals to proactively seek and receive the healthcare they need while receiving enough oversight from CPHP that the Colorado Medical Board (CMB) can be confident that the public is safe in the absence of knowing the monitored physician’s personal health history.
As a result of the opioid crisis, CPHP has also seen an increase in the number of physicians mandatorily referred for evaluation due to excessive prescribing. CPHP evaluates these physicians to rule out any health related problem. CPHP also makes recommendations for prescribing classes and other educational resources and guidelines. We conduct research, provide presentations about physicians who develop substance use disorders and also consult with workplaces contending with an ill or impaired physician. You can learn more about our program at www.cphp.org.
Posted in: Colorado Medicine | Initiatives | Prescription Drug Abuse