The Delicate Path of Treating Addiction Among Doctors
The darkest moment in Courtney Barrows McKeown’s path to recovery came when she considered driving over a bridge. As she tells it, she had been drinking from a bottle of wine and contending with feelings of hopelessness and shame; a routine test had come back positive for alcohol, and she had just learned she’d been fired from her surgical fellowship as a result. After half an hour, she decided to call her psychiatrist, who set in motion a series of supports that brought McKeown back from the edge. She said it was a relief.
McKeown, a surgeon who had trained at a prestigious program in Boston, had been connected to her psychiatrist through a Physician Health Program, or PHP, an organization that supports practitioners whose medical licenses hang in the balance after substance use disorders and other serious problems affecting their work come to light. PHPs walk the line of offering support while monitoring behavior and may give evidence to state medical boards when a practitioner applies to return to practice.
For McKeown, her contact with PHPs helped, she said, because without their oversight, she would not have been seeing a psychiatrist: “My life was sort of saved by a PHP.”
But not everyone has a positive experience with their PHP. In recent years, some doctors have criticized the organizations for being overly punitive, and say they felt obliged to work with one for fear of losing their license. Others argue that PHPs trail best practices in addiction medicine by prioritizing abstinence-based models and hesitating to prescribe synthetic opioids to doctors with substance use disorder.
Melissa Freeman, a former neurologist, lost her medical license when she refused to comply with PHP treatment in 2019. In an article she wrote in the journal Qualitative Research in Medicine & Healthcare that same year, she described the treatment as triggering and counterproductive. In an email to Undark, she wrote that, “My experience with them left me so absolutely wrecked that it destroyed my faith in the entire medical system,” adding that she would rather die than be in a room with a physician. “I highly doubt that PHPs have improved since my experience.”
Complicating the issue: For doctors who are reported to their medical board because of worries about their mental health or behavior, cooperating with such programs may be mandatory if they want to keep their license. Doctors, like nurses and pilots, are bound by stricter rules than other workers because errors can put others at risk. In some states, a doctor who receives a DUI may be obliged to report it to the licensing board; their employer can also make such a report if there is evidence of inappropriate substance use or the doctor’s behavior is concerning.
Physicians can also voluntarily decide to enroll in a PHP, in which case their participation is supposed to be confidential. But if the program feels the doctor is not adhering to a PHP’s recommendations and the public may be at risk, the PHP can report matters to the licensing board, which makes disciplinary actions public.
“It’s all about patient safety,” Michael Baron, the president of the Federation of State Physician Health Programs (FSPHP) and medical director of Tennessee’s Physician’s Health Program, told Undark.
“I highly doubt that PHPs have improved since my experience.”
For some physicians, though, the fear of losing their license or job may leave them unwilling to seek the help they need, said Francis Mei Hardin, a head and neck surgeon who writes a blog about residents and mental health called “Rethinking Residency.” Doctors afflicted by mental illness or addiction often struggle to prioritize their own treatment and care. And they may be a particularly vulnerable population due to their high risk for burnout and mental health struggles, which can facilitate the misuse of substances: While the number of doctors experiencing addiction broadly mirrors the general population, a 2022 review found that self-reported problem alcohol use among doctors increased in recent years. And a recent BMJ meta-analysis found that female surgeons are 76 percent more likely than the general population to consider suicide.
For patients who are mandated to participate, many initially balk at the program, Baron said, but they often come to appreciate the PHP’s role. “Almost all of our long-term participants are exceedingly grateful because, like, really, their life was in chaos. They weren’t happy, they might have been suicidal,” he said. “We get them the help they need.”
Physician Health Programs emerged in the 1970s after the American Medical Association recognized that doctors struggling with addiction needed therapeutic support. Conceived as an alternative to disciplinary action, PHPs usually operate independently of state medical boards, with 47 now distributed across the U.S. Today, they manage a wide range of issues, including mental health problems, substance use disorders, and cognitive decline, as well as sexual misconduct. Medical boards “approach physician health from a punitive approach, whereas physician health programs approach physician health as a reparative approach,” Baron said.
For McKeown, the trouble began during her residency, when she began to take Adderall and other stimulants to improve her focus and then self-medicated her anxiety and insomnia with alcohol, precipitating a mental health crisis. Her manager advised her to check in with the PHP in Massachusetts for an evaluation. The directors were stern, recalled McKeown, who cycled through four PHPs as her career led her to move states. But the PHP in Massachusetts required her to see the psychiatrist who she says helped save her life.
Doctors may be a particularly vulnerable population due to their high risk for burnout and mental health struggles, which can facilitate the misuse of substances.
After six weeks in an outpatient program and a commitment to undergo regular monitoring and drug tests, McKeown returned to practice and excelled in the final years of residency. But after beginning a competitive fellowship in Ohio after graduation, her feelings of stress reappeared, and she began drinking alcohol in the evenings after work to cope. When she tested positive for alcohol metabolites — substances that can stick around long after a person has had a drink — during routine monitoring, it triggered disciplinary action from the State Medical Board of Ohio. It was devastating, McKeown said, and it led to that moment in her car when she considered ending her life. “For me, the only thing I identified with is being a surgeon,” she told Undark. “So it’s like, well, if I can’t be this, then what am I?”
A core principle of PHPs is that the support they offer is tailored to physicians and informed by understanding the pressures they endure. A couple of PHP leaders Undark interviewed had experienced addiction themselves, including Baron, of FSPHP and Tennessee PHP. McKeown, who now lives in Tennessee, said Baron spoke on her behalf before the state medical board when she got her license to practice in the state: “He just cares a lot about what he does,” she said.
Michael Baron is the president of the Federation of State Physician Health Programs (FSPHP) and medical director of Tennessee’s Physician’s Health Program. “It’s all about patient safety,” Baron said of PHPs.
Chris Bundy, a psychiatrist who is executive medical director of Washington state’s PHP, as well as chief medical officer of the FSPHP, can also relate: “I run the program that I was once part of as a monitoring participant, so I have the lived experience,” he said. “I do this work because I believe in the model, and I believe in what we’re doing.”
There is data to back up the programs’ success, according to practitioners who lead PHPs. A 2022 study surveyed just over 130 doctors who had completed a PHP monitoring agreement at least five years prior; more than three-quarters of respondents reported zero alcohol use in that time. A 2011 study, meanwhile, found that most doctors who completed the program (about 67 percent of surgeons and 75 percent of non-surgeons) were still practicing five years on.
But Lisa McGiffert, a patient safety activist, questioned the independence of some research carried out by PHP practitioners in an interview with Undark. The 2022 study, for example, was led by a researcher at the University of Florida who is also the director of research of the state’s PHP. Meanwhile, the 2011 study was funded by the Washington Physicians Health Program, and other assessments of PHP effectiveness involve the support of PHP organizations and access to their data.
Linda Bresnahan, the executive director and CEO of FSPHP, said that the researchers conducting these studies are experts in the field and included individuals not affiliated with a PHP, adding that studies are peer reviewed and subject to regulatory and ethical oversight. The organization is seeking funding for further research, she noted in an email. “More investment is needed in FSPHP, state PHPs and our healthcare professionals for this purpose,” she added.
“I do this work because I believe in the model, and I believe in what we’re doing.”
But critics of the PHP system from within the medical community voice a litany of complaints: Doctors with more severe diagnoses may be sent to rehab centers far away and out of state and have to pay high fees. (The 2022 survey found the average personal cost to participants to be more than $30,000.) In some rare cases, treatment centers deploy polygraphs — which FSPHP has no official position on — to assess whether or not the physicians in their care are telling the truth. Pamela Wible, who advocates for doctors’ mental health and suicide prevention, said she has encountered doctors who say they were anonymously reported, or that diagnoses may be unfounded or based on false-positive drug tests. Other critics say that opportunities to appeal are inadequate, and that, once in the system, doctors who disagree with a diagnosis face the threat of losing their license, placing them in a situation where they are forced to comply. If a doctor wants an opportunity to retest, it may be at their own expense. (In response to these criticisms, Bresnahan emphasized in an email that PHPs often have no choice but to refer physicians to out of state programs, as they are not available everywhere. She also noted that only state medical boards can remove physician licenses. FSPHP guidelines, she wrote, “recommend that PHPs provide a process whereby participants may request reconsideration of recommendations with which they disagree,” while noting the organization “cannot speak to the specific experiences of individuals and does not have data summarizing the process of reconsideration across member programs.”)
In a recent Reddit thread, anonymous posters complained of being sent to a PHP for missing work after a parent died, and for what they considered to be harmless recreational alcohol or cannabis use. Sam, a doctor just about to finish residency in family medicine who did not want to provide his full name for fear of professional consequences, told Undark that a malicious colleague reported him to his program director for smoking pot on his days off. He was deemed not safe to practice and sent to a rehab center in Florida for three months, which cost roughly $46,000, he said. He’s now being monitored, and said he spends $130 per week on obligatory therapy, hundreds of dollars a month for frequent tests, and $150 per month to the PHP.
He described the situation as anxiety-inducing and said it had harmed his career: “I have to disclose it to every job I apply to and they are essentially holding my license hostage,” he said, adding: “I have been turned down from certain jobs because of this.”
Freeman told Undark that the PHP asked her to stop taking clonazepam, which she was prescribed for anxiety, because of its potential for abuse. Since she did not want to continue being screened for drug and alcohol use, she wrote in her article that “I lost my job, my medical license, and shortly thereafter, my board certification from the American Board of Psychiatry and Neurology.” Freeman, who said she now works in data management, said the in-patient rehab center the PHP sent her to cost $7,000 out of pocket for a brief stay. The process and subsequent termination of her license additionally deprived her of millions in earnings, she said. Her future job prospects dimmed, and in her article, she wrote, “I also lost my health and wellbeing.”
One hotly contested recent issue for PHPs is whether physicians addicted to opioids should have access to opioid replacement therapies, including methadone or buprenorphine — a topic addressed in a series of commentaries and letters to the editor published last year. Because mental health disorders, alcoholism, and substance use disorders can be viewed as disabilities, some experts say PHPs are vulnerable to claims that they violate the Americans with Disabilities Act. In 2022, for instance, the Justice Department found that the Indiana State Nursing Board violated the ADA by preventing nurses on methadone and buprenorphine from participating in a supportive program that may be required for their licenses to be reinstated so that they could return to work.
A commentary piece in the Journal of Addiction Medicine last year urged that buprenorphine should be the “standard of care for physicians in state monitoring programs.” Stephanie Klipp, an addiction nurse in Pennsylvania who co-authored the article, told Undark in September she was about to engage in legal action against the PHP in Pennsylvania. “These are peer reviewed, are a gold standard of care, but they are not accessible to nurses and providers that are in these programs,” she said. (Klipp passed away last month at the age of 37.)
One doctor described his experience with a PHP as anxiety-inducing and said it had harmed his career: “I have to disclose it to every job I apply to and they are essentially holding my license hostage.”
Michael Baron, the FSPHP president, stressed that as a physician, he prefers to treat “safety-sensitive occupational workers” with naltrexone — which is used to treat both opioid use disorder and alcohol use disorder, but is not an opioid — out of concern about potential adverse effects that buprenorphine could have on cognitive function, citing a protocol published by the Substance Abuse and Mental Health Services Administration and another study co-authored by researchers at the University of Florida and the state PHP. There is also a possibility that those prescribed buprenorphine could increase the dose, Baron told Undark. “It’s an easy drug to abuse.”
Not everyone agrees though: “I haven’t seen convincing evidence that buprenorphine causes cognitive impacts which would limit a physician’s ability to practice,” Sarah Wakeman, the medical director for the Massachusetts General Hospital Substance Use Disorder Initiative and an assistant professor at Harvard Medical School wrote in an email.
Wakeman routinely prescribes the drug in her clinic, she said, without any indication of cognitive harm to patients, though she acknowledged more research is needed to put the issue to rest. She said: “Only buprenorphine and methadone have shown mortality benefit. So of all the treatments we have for opioid use disorder, only methadone and buprenorphine save lives, and that’s been shown again and again.”
Sarah Wakeman, the medical director for the Massachusetts General Hospital Substance Use Disorder Initiative, said she routinely prescribes buprenorphine in her clinic without seeing cognitive harm to patients.
Visual: Courtesy of Sarah Wakeman
Both sides of the debate are aware that the stakes are high. In 2022, Bundy wrote in a newsletter published by the Washington Medical Commission that “with fentanyl replacing the U.S. heroin supply, resulting in record high opioid overdose deaths, now is the time to get help and treatment for opioid addiction.” But PHPs remain hesitant. In its most recent policy statement on the issue, the FSPHP maintained that there is mixed data on how drugs like buprenorphine affect cognitive function. “Given this uncertainty,” the document continued, “a judicious approach that errs on the side of public safety is indicated when considering the special needs of this population.”
Much of the criticism of PHPs comes from a few very loud voices, Bundy suggested. “Not everybody is entitled to practice medicine,” he told Undark, and explained that hospitals and medical boards all play a role when decisions are made to end a person’s medical career. “Those people can end up very disgruntled on the way out. And I feel like we are sometimes collateral damage along that pathway.”
He added: “We can’t help everyone. Just like an ER can’t save everybody that comes through the door.”
Some critics of PHPs aren’t against their existence altogether, but rather how they function. But Bundy says the programs remain a better alternative to having state medical boards discipline doctors directly when misuse comes to light. In states without PHPs, like California, the number of physicians being monitored is relatively low — meaning that those grappling with earlier stage problems are not seeking help, according to PHP leaders.
Still, inconsistency in the nature and quality of care offered by PHPs in different states is also a significant issue, Baron acknowledged. A few programs, like Utah’s, are directly affiliated with the state medical board, which could discourage doctors from seeking help, he said. “It makes it worrisome to me,” Baron said. The variability “is there. We know it’s there, but we’re working to change it, to improve it.”
“Not everybody is entitled to practice medicine.”
The Federation of State Physician Health Programs has recently developed an initiative to assess PHPs, which will roll out soon. Bundy told Undark the program aims to assess how well PHPs adhere to best practices. “Going back to that opacity versus transparency, you’ve got to make the rules of the game apparent to everyone, right, so that we can all sing from the same choir book, so to speak. And that’s what we’re trying to do.” (J. Wesley Boyd, a former PHP associate director turned critic of the organizations, said he did not believe past audits of the programs were objective because they are conducted by individuals already involved in this field.)
After the conversation with her psychiatrist, McKeown went into treatment, this time overseen by the State Medical Board of Ohio rather than the PHP. Her license was suspended for 90 days, and she spent four weeks in inpatient therapy, two months in outpatient, and acquired a sponsor, whose role it was to support her in her recovery. Before she returned to practice, three separate psychiatrists, two of whom specialized in addiction, evaluated her mental state. They all agreed that she should continue in medicine. She’s now partway through a five-year monitoring process managed by the PHP, and just started a new job in Tennessee, where her monitoring is done by the Tennessee PHP.
She has developed a healthier attitude to her work, she told Undark, and now volunteers for the Dr. Lorna Breen Heroes’ Foundation, which seeks to reduce physician burnout and support mental health, in addition to her job as a surgeon. “I love to operate. I love to be able to take care of patients in times where it’s probably the scariest moment in their life,” she said. But she added, “I also knew that if I got my hand cut off in an accident tomorrow, I would find I have another purpose too, which is doing a lot of this advocacy work.”
For McKeown, even though participating in the PHP was difficult, it was also, in the end, lifesaving. She wants to speak out about it because when she was at her lowest point, she only found negative critiques of the programs. “There’s been a lot of bad stories, a lot of scary stories out there,” she said, “Some of them might very well be true, but I think it’s sort of creating a little bit of a poisoning the well for people who really do probably need the help.”
“Because I think if you really embrace it,” she added, “there are people who do want you to get better.”
If you or someone you know needs help, the national Suicide and Crisis Lifeline in the U.S. is available by calling or texting 988. There is also an online chat at 988lifeline.org.