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My colleagues and I thank Ms Wilson and Dr Skipper for their correspondence, along with the many others who contacted us outside of the pages of Mayo Clinic Proceedings to express their interest in our article on physician addiction. For us, these interactions have highlighted the many unknowns and complexities that arise when dealing with health care professionals who abuse drugs. Specifically, contemporary prevention and treatment of addiction in these individuals are clearly hindered by an inadequate understanding of the following: (1) the magnitude of the problem; (2) optimal detection of substance abusers; (3) factors that initially contribute to drug diversion and abuse; (4) treatment, aftercare, and monitoring factors needed for optimal long-term maintenance of sobriety; and (5) the best way to institutionalize such optimal programs to supplant inferior programs.
Consistent with these views, Wilson highlights the potential importance of triggers and cues that develop during addictive use of a substance. These, in turn, contribute to the perpetuation of abuse and may harm successful return to work. Her unpublished research has determined that visual, tactile, and olfactory cues (as generated by such mundane and unavoidable tasks as bathroom use or putting on gloves) may provide potent triggers to relapse. Such observations emphasize the enormity of the task the addict encounters in premature attempts to return to the workplace, yet remain sober. We applaud Wilson's efforts to explore reliable methods that might help extinguish, over time, such potent cues. It appears likely that an overly rapid return to the work environment where drug diversion and abuse occurred, before such cues can be extinguished, almost certainly contributes to the high relapse rate seen with addicted health care professionals.
In contrast to the complexities and nuance inherent in Wilson's correspondence, we were surprised by some of the statements by Skipper. He took exception to our comment that “the problem of physician addiction has largely escaped the public's attention” by offering a uniquely American perspective of the media coverage this issue has received. In response, we hasten to point out that physician addiction is not unique to the United States. When I spoke on the topic several years ago in New Delhi, India, a television interviewer told me that, to the best of her knowledge, this was the first time the topic had ever been broached publicly in India, a country of more than a billion people. Given that the problem is relatively unknown in one of the most populous countries in the world and because our article was published in a medical journal with a worldwide audience, we differ with Skipper when he calls our statement an “inaccuracy.”
Furthermore, Skipper says that our section on intervention is “misinformed,” stating that the style of intervention that he prefers and claims to “have performed thousands of” is superior. This appears to simply be his opinion. He offers nothing from the indexed literature to support this contention, and we are unable to identify anything in the indexed literature that would confirm or refute his belief. Additionally, Skipper refers to good outcomes in a series (apparently unpublished data) in which interventions are conducted by telephone. Although such an intervention method might indeed have its place, we think that, in the setting of the acutely intoxicated caregiver who is actively involved in hands-on patient care, such a response would clearly be inappropriate. Such a caregiver must be immediately removed from the patient-care environment.
Finally, Skipper takes exception to our citing the study by Menk et al1 and for not including several other studies whose results he prefers.2-4 In fact, we did reference the study by Domino et al,4 although we drew a different conclusion than did Skipper, in that we focused on those who failed to remain abstinent while he focused on those who did. In that study, 17 of 22 fentanyl-addicted anesthesiologists relapsed to fentanyl use, with Menk et al1 having earlier documented that even one relapse can have fatal consequences. These data allow more than one conclusion to be drawn. Failing to have drawn the same conclusion from different parts of the data set does not constitute providing “misinformation” on our part, any more than it does on his.
We agree with Skipper's statement that the literature identifies established model programs in several states that are achieving better results than were documented by earlier studies such as that of Menk et al.1 We applaud the recent contribution to the literature by Skipper et al,5 which shows that an optimally designed PHP can provide better than average outcomes for those who seek to reenter the workplace. We firmly believe that the most successful rehabilitation programs (for patient outcomes) need to be replicated and required nationwide. Access to programs that have designs of proven efficacy is especially crucial for anesthesia care professionals (whether physicians, nurse anesthetists, or others) who have previously diverted drugs from the workplace and are now seeking to return to an operating room practice. Currently, there is no uniformity among state's PHPs that monitor these individuals, nor do all states have such programs. We firmly believe that all anesthesia care professionals should adhere to a uniform program of the highest demonstrated quality of aftercare and monitoring supported by the indexed literature because they all share the same risk of relapse and death.
My colleagues and I applaud Wilson for pursuing a research path that might ultimately result in beneficial changes in treatment and aftercare. Although Skipper's opinions on some of these matters differ from ours, we hardly think that this constitutes our having provided, as Skipper suggests, “misinformation.” Well-intentioned people can disagree on what conclusions should be drawn from ambiguous literature without such base accusations arising.