Relapse following treatment for substance use disorders (SUDs) is so common that it is frequently cited as a hallmark of the disorder. Recent evidence from several extremely disparate patient populations suggests that far better outcomes can be achieved with contingency contracts and long-term monitoring. This article describes three populations, starting with the physician health model, that validate this new paradigm. It also encourages wider use of contingency contracts with long-term monitoring for all patients.
Four decades of evolution in the way states handle addicted physicians have set a new standard for treatment of SUDs as chronic illnesses. In this new paradigm, close and prolonged monitoring following acute treatment is employed. The monitoring includes intensive random drug and alcohol testing linked to swift and certain, but moderate, consequences for any use of alcohol or drugs.
Efforts with physicians
Physician Health Programs (PHPs) were established four decades ago, driven by a growing awareness of the frequency and poor outcomes of SUDs among physicians. Unlike typical managed care initiatives, PHPs were not focused on achieving the lowest cost; their overarching priority was to do whatever was necessary to achieve the best outcomes. They set a new standard for long-term care management, achieving truly revolutionary outcomes for biological SUDs. 1
The goal of PHPs is early identification of physicians with SUDs, prior to overt impairment and the attendant disasters that can harm patients and destroy careers. PHPs provide confidential care for physicians referred to their programs as long as they are compliant. In return, physicians sign long-term contingency monitoring contracts, typically for five years, stipulating that they will adhere to the PHP's care management plan and submit to random monitoring to ensure that they remain abstinent from any use of addictive drugs as well as any alcohol use. Abstinence is monitored with frequent random drug testing using test panels of 20 drugs or more.
When physicians relapse to any use of drugs or alcohol or by noncompliance with program requirements, immediate intervention occurs and the physician is typically removed from medical practice and referred to additional evaluation and/or treatment, followed by even more intensive monitoring. The PHPs do not themselves provide treatment-they select and supervise treatment as care managers. The PHPs select treatment providers who they believe can provide the best services.
In a study of 904 physicians admitted to 16 PHPs, 88 percent met diagnostic criteria for substance dependence while 10 percent met criteria for alcohol or substance abuse; the remaining 2 percent were physicians who previously had completed one PHP contract and volunteered to sign another to extend monitoring.2 Overall, 79 percent of the physicians had no relapse and abstained from drugs and alcohol for the full length of monitoring. Of the 19 percent who had at least one positive drug test, only 26 percent had a second positive test over the five-year duration.
Not only were the majority of physicians drug- and alcohol-free at five-year follow-up, but 78 percent of all physicians were licensed or working. Only 11 percent had had their licenses revoked. PHPs treat SUDs like the chronic disorders they are, offering physicians the opportunity, motivation and support to achieve long-term recovery.
Critics of the PHP experience might argue that physicians make up an utterly unrepresentative patient population (highly educated and with the most resources, including the best health insurance). In response, the programs described below have adopted intensive zero-tolerance monitoring strategies with success in criminal justice system populations. The justice populations have some of the heaviest drug users, traditionally with the poorest prognoses and highest societal costs. These programs have dramatically reduced recidivism and incarceration. Unlike PHPs, however, these programs are severely constrained in their funding.
Unlike PHPs, Hawaii's Opportunity Probation with Enforcement (HOPE) addresses probationers with a history of SUDs who also have extremely serious social and economic problems.3 In the HOPE program, probationers initially meet with a judge regarding the rules. Participants are typically subject to intensive random drug testing for up to six years. They are advised that any detected violation of probation, particularly any drug use, is met with clear, swift, short-term incarceration. Violators are arrested and hearings are typically held within 72 hours of a violation.
Unlike PHPs, HOPE does not automatically refer to treatment but rather uses behavioral triage. Upon entering HOPE, probationers are simply asked if they wish to receive treatment to help them meet the zero-tolerance requirement of abstinence from any use of alcohol or drugs. They are again advised that any use will be met with immediate incarceration. Most HOPE probationers have had prior treatment and only a small percentage choose to participate in treatment again. Most are monitored without treatment.
If these individuals fail to maintain total abstinence, they are then often referred to treatment. About 85 percent of HOPE probationers complete the program without treatment.
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