“If you tell a lie big enough and keep repeating it, people will eventually come to believe it.” –Joseph Goebbels
Physician Health Programs (PHP) claimed “gold standard” for addiction treatment. “80% success rate” being used to promote “new paradigm” to other populations.
PHPs are essentially Employee Assistance Programs (EAPs) for doctors. The vast majority of people know little or nothing about Physician Health Programs (PHPs).
Physician Health Programs (PHPs) are being called the “gold-standard” for EAPs. Claims of unparalleled success are being used to promote PHPs to other populations as a “replicable model of recovery.”
Drs. Robert Dupont and Gregory Skipper are promoting PHPs as “A New Paradigm for Long-Term Recovery” claiming an 80% success rate in doctors.
An article entitled “What Might Have Saved Philip Seymour Hoffman,” claims PHPs “ought to be considered models for our citizenry” and the “best evidence-based addiction treatment system we have going.” The author repeats the 80% success rate for doctors and claims Philip Seymour Hoffman might still be alive if he had been treated using the PHP model.
The basis for these claims is a 2009 study published in the Journal of Substance Abuse Treatment entitled Setting the Standard for Recovery: Physicians’ Health Programs and authored by Robert Dupont, A. Thomas McLellan, William White, Lisa Merlo and Mark Gold.
This study is the cornerstone of the “PHP-blueprint.” It is the very foundation on which everything else is based, a Magnum opus used to lay claim to supremacy that has been endlessly repeated and rehashed in a plethora of self-promotion and treatment community blandishment.
To date there has been no academic analysis of the “PHP-Blueprint.” There has been no Cochrane type analysis or critical review. There has been no opposition to its findings or conclusions which are paraded as fact and truth without challenge or question and there is a general lack of concern from those both within and outside the medical profession.
The Expansion of Physician Health Programs (PHPs) to Other Populations
1. Although these programs claim to help doctors they may actually be harming many and contributing to suicide.
2. The plan is to greatly expand these programs to other populations and you could be next.
In 2012 Robert Dupont delivered the keynote speech at the Drug and Alcohol Testing Industry Association annual conference and described a “new paradigm” for addiction and substance abuse treatment and proposed expansion of this paradigm to other populations including workplace, healthcare, and schools.
It is therefore critical that the “PHP-blueprint” be examined using critical reasoning and evidence base. All of this needs to be assessed in terms of legitimacy and intent.
Lack of Evidence-Base and Conflicts of Interest
A cursory analysis of the study on which this success rate is based reveals very little evidence base.
The claim of 80% success rate in physicians is based on Setting the Standard for Recovery: Physicians’ Health Programs is unfounded. The study is a poorly designed using a single data set (a sample of 904 physician patients consecutively admitted to 16 state PHP’s).
It is non-randomized and non-blinded rendering the evidence for effectiveness of the PHP treatment model over any other treatment model (including no treatment) poor from a scientific perspective. The study contains multiple flaws in both reasoning (type I and type II errors) and statistical analysis that render its conclusions invalid.
In addition the impact of undeclared but substantial financial conflicts-of-interest (including funding by drug testing and addiction treatment industries) and personal ideological biases (including personal 12-step recovery from addictions) in the authors of this study also needs to be considered.
Moreover the misdiagnosis and over-diagnosis of addiction in physicians in this paradigm incentivized by lucrative self-referral dollars for expensive 90-day treatment programs is a significant factor.
False Endpoints and High Mortality Rate
The mean age of the 904 physicians was 44.1 years. They report that 24 of 102 physicians were transferred and lost to follow “left care with no apparent referral.”
What happened to them? These are physicians with multiple identifiers (state license, DEA, UPIN, etc) not transient drifters.
Of the 802 left in the program they report 155 failed to complete the contract. Of these, 48 involuntarily stopped or had their license revoked and 22 died with 6 of those being suicides. This study is looking at defined endpoints while being monitored so 6 killed themselves while being actively monitored by the program. But what about the 24 that left with no apparent referral? It is unlikely the just left on a whim. There must have been some precipitant event.
More importantly what happened to those 48 who were reported to the Medical Board for noncompliance and had their licenses revoked–that would be the critical time when this population would be at most risk for completing a suicide. That would be when hope was lost and the coerced physician, knowing that the fight was over, would take that step.
The outcomes they used were the last reported status of the PHP participant enrolled in the program. Measuring success of program completion in doctors compared to the general population is meaningless as the short-term outcomes are quite different in terms of the external consequences imposed. The consequence of not completing a PHP is the invariably career ending. So what happened to the 24 of who “left care with no apparent referral,” the 85 who “voluntarily stopped or retired,” and the 48 who “involuntarily stopped or license revoked.”
Whether you leave a PHP voluntarily, involuntarily, or with no apparent referral it is the end game and your career is over. Comparing this to other populations where the consequences of failing to complete the program are not so final is inappropriate. Claiming superiority over programs with a 40% success rate is unfounded because for most of those people the consequences are not so final and may mean nothing more than an increase in testing frequency.
The big question is what happened to the 157 physicians who left or stopped? How many of them killed themselves. With an average age of 44 there were 6 reported suicides 22 deaths, and another 157 no longer doctors. I would venture to say the number of suicides is a lot higher than they claim. But using the last recorded PHP status as the final outcome obfuscates this.
Due to the severity of the consequences a 20% failure rate is quite concerning. This is of particular concern because many doctors (if not most) monitored by PHPs are not addicts.
Imposed 12-step ideology and use of non-FDA Approved Drug and Alcohol Testing
As noted above, PHPs are essentially Employee Assistance Programs (EAPs) for doctors. Most EAPs, however, were developed in the presence of trade unions and other organizations working on behalf of the best interests of the employee. This collaborative effort led to EAPs that were more or less “organizationally just” with procedural fairness and transparency.
No such organizations exist for doctors. Due to the absence of oversight and accountability PHPs have been able to use non-FDA approved laboratory developed tests of unknown validity on doctors without any opposition.
The distinction between professional and private life as a fundamental value of our society and the importance of this boundary was also upheld by these groups.
In the PHP paradigm no procedural fairness or transparency exists and the boundary between professional and private life has eroded.
PHPs impose 12-step ideology on all doctors referred to these programs. State Medical Boards enforce this in violation of the Establishment Clause of the 1st Amendment yet there is little recourse for doctors as they are threatened with non-compliance and loss of licensure.
Selling the PHP Paradigm
The use of 12-step is most likely not ideologically driven but profit driven. Abstinence based 12-step programs justify the use of frequent drug and alcohol testing with ongoing lifelong assessment and treatment. As with drug-courts, PHPs provide a lucrative model to the drug and alcohol testing, assessment and treatment industry.
The plan to expand this to other populations is outlined in the ASAM White Paper.
This concerns all of us. The first step needs to be a critical appraisal of Setting the Standard for Recovery: Physicians’ Health Programs, the foundation of their claims of an 80% success rate and a conflict-of-interest analysis of its authors. The legitimacy of the study and its claims needs to be questioned.
It does not take a Cochrane review to see that the emperor has no clothes. This is not difficult. It is straightforward and simple.
As an illegitimate and irrational authority it is necessary that this opinion remain unchallenged. We need to challenge it.
Historical, political, economic and social analysis reveals that the “PHP-blueprint” is a false-construct built on circumnavigation and obfuscation. An evidence-based scrutiny of the literature would reveal it to be invalid and of little probative value.
But if nobody speaks up it is inevitable that they will expand the “PHP blueprint” to other employee assistance programs and schools.
This is not just about doctors. You too are at risk for coercion, control, conformity and forced adherence to a lifetime of abstinence and 12-step indoctrination and if you do not speak up now it won’t be a risk but a certainty.