Commentary: A New Paradigm for Substance Abuse Treatment
Substance abuse treatment is committed to abstinence from nonmedical drug use. Yet, continued nonmedical drug and alcohol use and relapse are so common that they are often defined as part of the disease itself.
A “new paradigm” for care management has been pioneered over the past four decades by the state Physician Health Programs (PHPs).1 PHPs provide diagnostic evaluation, treatment referral, close monitoring and support services to health care professionals who have conditions, including in particular substance use disorders, which can impair their ability to practice medicine with reasonable skill and safety. In dealing with substance use disorders, PHPs use a zero tolerance standard for any alcohol or other drug use, enforced by intensive random testing and close linkage to the 12-step programs of Alcoholics Anonymous and Narcotics Anonymous to produce remarkable long-term outcomes. These outcomes set a far higher standard for success in treatment and they cast doubt on the definition of addiction as being characterized by relapse. They demonstrate that the environment in which the decision to use or not to use alcohol and drugs is a powerful determinant of outcomes.
PHPs use frequent random drug tests with panels covering 20+ substances often including advanced alcohol tests which can detect recent use up to six days after alcohol consumption. Each day, physicians call a telephone number to learn if they are required to be drug tested that day. There are immediate and serious consequences for a positive test or for any other noncompliance with the program, including skipping tests. Noncompliant physicians are typically removed from medical practice and are admitted to more intensive treatment under even more intense monitoring.
The first national study of the physicians in 16 state PHPs showed that over the course of five years of monitoring, 64 percent completed their monitoring contracts, 16 percent signed new contracts or extended their contracts and 28 percent did not complete their contract.2 Among the physicians who completed or extended their contracts, 81 percent had no relapse during the five years of monitoring. Among the physicians who had at least one positive drug test, 74 percent never had a second positive. The overall positive rate was about one half of one percent, meaning on average, one in 200 tests were positive for any alcohol or drug use.
The lessons learned from the PHP experience are widely applicable in many other settings including drug-free workplace programs. Physicians in PHPs have a lot on the line, including their careers. It is in the interest of these physicians to become drug- and alcohol-free and resume their medical practices. The same can be said for employees who participate in workplace recovery programs.
While some may dismiss the PHP results because physicians are a uniquely advantaged patient population, a similar approach has produced outstanding results in a dramatically different population of addicted people — convicted felons on probation. A randomized control study of the pioneering HOPE Program showed that compared to a control group of standard probationers, HOPE participants were 55 percent less likely to be arrested for new crimes, 72 percent less likely to use drugs, 61 percent less likely to miss appointments with probation officers and 53 percent less likely to have their probation revoked.3 HOPE probationers were sentenced to 48 percent fewer days of incarceration.
The new paradigm of long-term monitoring with swift, certain and serious consequences for any detection of drug or alcohol has the potential to substantially improve long-term outcomes for substance abuse treatment.
Robert L. DuPont, MD
President, Institute for Behavior and Health, Inc.
1DuPont, R. L. & Humphreys, K. (2011). A new paradigm for long-term recovery. Substance Abuse, 32(1), 1-6.
2McLellan, A. T., Skipper, G. E., Campbell, M. G. & DuPont, R. L. (2008). Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. British Medical Journal, 337:a2038.
3Hawken, A. & Kleiman, M. (2009). Managing Drug Involved Probationers With Swift and Certain Sanctions: Evaluating Hawaii’s HOPE. Washington, DC: National Institute of Justice, Office of Justice Programs, U.S. Department of Justice.