When the addict is a doctor

The first time Dr. Peter Grinspoon experimented with Vicodin was with a fellow medical student at Harvard.

“It said, 'Careful: Causes extreme euphoria,' ” Grinspoon said. “And once we read that we were sort of destined to try it.”

Then, as a primary-care physician based in Boston, Grinspoon tried to replicate the euphoria the drug indeed delivered, at first, during nine years of regular drug use. He ultimately resorted to writing prescriptions under a false name to feed his habit. It all came to a head in February 2005 when law enforcement agents came to his office and arrested him for fraudulently obtaining a controlled substance.

Grinspoon spent the next two years on probation and out of work. His medical license was suspended and only reinstated after he completed a 90-day treatment program under the oversight of a state physician health program.

The growing number of Americans with a friend, family member or neighbor affected by heroin or prescription opioid abuse has inspired lawmakers and law enforcement officials to move toward treatment and away from punitive measures such as incarceration. It is an approach some are concerned healthcare providers have not fully embraced when they deal with substance abuse in their ranks.

Although Grinspoon credits the treatment program for his recovery, he said state programs still unnecessarily punish physicians while they're trying to get help. In his case, the medical board took disciplinary action against him when he failed two drug tests in the gap between enrolling in the program and starting treatment.

“The problem is you don't go immediately from addiction to recovery,” said Grinspoon, who now counsels other doctors about their substance abuse.

Grinspoon wrote about his experience with drug addiction in the new book Free Refills: A Doctor Confronts His Addiction.

“Of all the people you would expect to understand addiction as a disease and not some moral failing that needs to be punished, you would think the medical boards would understand.”

But others would say understanding must be tempered with the very real risk of a patient being hurt or killed by an impaired healthcare practitioner. There are those both in and outside the industry who want to maintain a higher, more rigorous standard given the safety implications.

“Some healthcare systems, unfortunately, have drifted more toward criminalizing substance use in the workplace,” said Dr. Marc Myer, director of the Addiction Treatment for Health Care Professionals program at the Hazelden Betty Ford Foundation.

News reports have chronicled the harm patients face at the hands of clinicians who use drugs.

Perhaps the most notorious example is David Kwiatkowski, a traveling medical technician who was sentenced in 2013 to 39 years in prison for causing a multistate outbreak of hepatitis C. Kwiatkowski would inject himself with fentanyl and then leave the syringes, refilled with saline, to be used on patients.

Late last year the New Jersey State Board of Medical Examiners suspended the medical license of Dr. Vijay Vaswani, finding that his admitted cocaine abuse demonstrated he was “incapable of safely performing the responsibilities of a physician.” Sensational reports in the New Jersey media recounted that Vaswani, who had been vice president of the medical staff at Robert Wood Johnson University Hospital at Hamilton, had a documented history of drug problems dating back to his residency 15 years before.

The fear of harm at the hands of impaired clinicians has prompted calls for them to undergo mandatory drug testing. In 2014, voters in California—which abandoned its addiction assistance program for doctors after concluding it wasn't effectively addressing the problem—narrowly rejected a malpractice proposal that included a provision requiring physicians to undergo random testing. Proponents of testing include HHS Inspector General Daniel Levinson. In 2014 Levinson co-wrote an editorial for the New York Times urging hospitals to screen all healthcare workers with access to drugs and in support of requiring hospitals to call the cops if they suspect a physician or worker is stealing drugs.

Some say such talk has worsened fears among providers that they'll face punitive actions if they seek help for addiction—actually making it more, not less, likely that patients will be harmed.

“The issue with physicians or anyone involved with public safety is that addiction is so stigmatized that the risk of losing your job or your practice is very great,” said Dr. Michael Lowenstein, medical director of the Waismann Method Medical Group, an opioid rapid detox center in Orange County, Calif.

Others, however, say such fears reflect a lack of awareness of the resources available.

“Most physicians are not very familiar with the role of the state licensing board,” said Dr. Humayun Chaudhry, president and CEO of the Federation of State Medical Boards, the organization that represents the country's 70 state medical and osteopathic regulatory boards. “But the system is actually designed to be supportive of physicians when they seek help, and that's not always perceived that way.”

Chaudhry points to the success of what are known as physician health programs, such as the one in Massachusetts that helped Grinspoon, that provide help to medical professionals with substance use disorders.

All but three states—California, Nebraska and Wisconsin—have PHPs, which refer doctors to a treatment program, where they can spend up to 90 days in an inpatient facility without fear of disciplinary action from a state medical board.

A 2009 study published in the Journal of Substance Abuse Treatment found more than three-quarters of doctors who entered a PHP remained drug-free after five years, with 71% retaining their license and employment after five years.

“The PHPs provide a safe haven for physicians with substance abuse and other problems,” said study co-author

Dr. Robert DuPont, a drug treatment expert who in 1973 became the country's first director of the National Institute on Drug Abuse. “A common mistake people make is to think PHPs have a hammer or a guillotine over the heads of doctors, and they don't.”

But such programs have critics. A 2015 article in the American Medical Association's Journal of Ethics alleged some of the programs wield too much power over the treatment that doctors receive when they disclose a drug problem under fear of being reported and punished.

Though voluntary admission into an addiction assistance program shields physicians from disciplinary actions and promises anonymity, they typically must sign a consent order with a state medical board that stipulates their intent to stay sober to keep their license. The consent order remains on a doctor's record for an average of five years, said Dr. Scott Balogh, assistant professor of addiction medicine at University of Tennessee Health Science Center.

“It absolutely impairs a person's ability to find employment,” Balogh said. “If you have one of those on your record some places won't even interview you.”

The organization that represents state PHPs, the Federation of State Physician Health Programs, said it did not have an estimate of the number of clinicians participating in such programs.

Grinspoon and others said improving the way the healthcare system addresses drug addiction would require more than what these types of programs normally provide. They said it would call for a culture change that begins with more training about addiction in medical school.

That now seems to be underway. Last October, the American Board of Medical Specialties officially recognized addiction medicine as a subspecialty that will allow physicians to get certification and offer the opportunity for more comprehensive education.

Balogh said a greater understanding of the science around addiction has helped to reduce stigma often associated with the disorder, a trend he expects to continue.

“It's been looked at as a moral character issue for so long that it's probably going to take a generation of providers for addiction to be truly accepted as a disease and not as a choice,” Balogh said.

An estimated 10% to 14% of medical professionals will develop a problem with substance use at some point in their careers, according to a 2014 study published in the Western Journal of Emergency Medicine.

Myer of the Hazelden Betty Ford Foundation said there's no evidence to suggest there's been an increase in substance abuse among medical professionals that parallels the troubling rise in opioid use and overdoses among the general population. But the stress, long hours and easy access to medications make clinicians uniquely vulnerable. And familiarity with opioids can give clinicians a false sense that they can use them without developing a problem.

“The whole medical field is about being self-reliant, being confident and inspiring confidence,” said Dr. Timothy Huckaby, medical director for the Orlando (Fla.) Recovery Center. “Everything that works to make you a really great doctor also works to make you a really bad addict.”

Huckaby was an addict himself. As a young anesthesiologist in 1996, he was injured in a serious car crash and was prescribed painkillers after foot surgery. When the pain continued after he ran out of meds, he started to occasionally use fentanyl, a synthetic opiate more potent than morphine that was readily available to him at work. “You always had extra,” Huckaby said. “You always had it in your pocket.”

He didn't get help until his colleagues intervened. “I had no control over it because I didn't understand it,” Huckaby said. “In medical school they really never taught us anything about addiction.”