The opioid‐impaired provider: A call for national guidance to maximize rehabilitation while protecting patient safety

Opioid use disorder (OUD), which includes opioid abuse and addiction, has been at epidemic levels for over a decade. According to the Centers for Disease Control and Prevention (CDC), “In 2017, more than 70,000 people died from drug overdoses, making it a leading cause of injury-related death in the United States. Of those deaths, almost 68% involved a prescription or illicit opioid.” Many organizations, including the CDC, the National Institute on Drug Abuse (NIDA), the Department of Health and Human Services (HHS), the Food and Drug Administration (FDA), the American Medical Association (AMA), and the American Dental Association (ADA), have generated guidelines to help reverse the course of this epidemic. Despite providers who abuse or are addicted to opioids (OIPs) being a contributing factor in this multifaceted and enduring epidemic, none of the guidelines specifically address OIP behavior. Meanwhile, the HHS Secretary recently joined with the Attorney General of the United States Department of Justice (DOJ) to announce expansion of DOJ's Opioid Strike Task Force whose mission is to target and permanently remove from practice providers who abuse their prescription authority. In the absence of explicit guidance about fostering rehabilitation of OIPs, HHS' recent cooperation with the DOJ is noteworthy.

have generated guidelines to help reverse the course of this epidemic.
Despite providers who abuse or are addicted to opioids (OIPs) being a contributing factor in this multifaceted and enduring epidemic, none of the guidelines specifically address OIP behavior.

Meanwhile, the HHS Secretary recently joined with the Attorney
General of the United States Department of Justice (DOJ) to announce expansion of DOJ's Opioid Strike Task Force whose mission is to target and permanently remove from practice providers who abuse their prescription authority. 2 In the absence of explicit guidance about fostering rehabilitation of OIPs, HHS' recent cooperation with the DOJ is noteworthy.

| A CRITICAL ETHICAL DIVIDE
Unlike national opioid guidelines, both the ADA and the AMA have explicit ethical standards regarding doctors' responsibility to protect impaired providers (exact verbiage contained in Table 1). 3,4 Similarly, the American College of Physicians Ethics Manual includes: "Every physician is responsible for protecting patients from an impaired physician and for assisting an impaired colleague. Fear of mistake, embarrassment, or possible litigation should not deter or delay identification of an impaired colleague." 5 Its related position paper states, "The physician should be rehabilitated and reintegrated into medical practice whenever possible without compromising patient safety." 6 In contrast, the United States Supreme Court has repeatedly affirmed that police and other law enforcement professionals and government employees, including Drug Enforcement Administration (DEA) and DOJ employees, have no constitutional duty to protect citizens unless they are in custody. 7 When the directive of an agency is to gather enough evidence to obtain a conviction, sometimes law enforcement professionals find it necessary to knowingly keep citizens, including patients and impaired providers, at risk of medical harm.
An example of the contrasting ethos of protecting patients and providers from harm vs punishing providers who harm patients is the case of Gary Hartman. An endodontist by trade, Dr Hartman's practice in Virginia Beach was quite successful, earning him up to $500 000 USD per year. 8  All dentists have an ethical obligation to urge chemically impaired colleagues to seek treatment. Dentists with first-hand knowledge that a colleague is practicing dentistry when so impaired have an ethical responsibility to report such evidence to the professional assistance committee of a dental society. Anyone who believes that a member-dentist has acted unethically should bring the matter to the attention of the appropriate constituent (state) or component (local) dental society. Whenever possible, problems involving questions of ethics should be resolved at the state or local level Protect society The medical professional should safeguard the public and itself against physicians deficient in moral character or professional competence. Physicians should observe all laws, uphold the dignity and honor of the profession and accept its self-imposed disciplines. They should expose, without hesitation, illegal, or unethical conduct of fellow members of the profession The dental profession holds a special position of trust within society. As a consequence, society affords the profession certain privileges that are not available to members of the public-atlarge. In return, the profession makes a commitment to society that its members will adhere to high ethical standards of conduct Hartman also tested positive for opioids, stimulants, and marijuana.
He was neither arrested nor was charges filed. His practice continued, and his local medical community did nothing. In 2017, during the same year a pharmacist anonymously reported him to the DEA, one of his patients died from a drug overdose. 11  By then its only option was to revoke his license. The next year, when Hartman was formally indicted, the court's representative stated that the Hartman case should "stand as a warning to other medical professionals" and "we will not cease our efforts in bringing these types of pill-pushers to justice." 9 A situation should never again progress to the point that a pharmacist must contact law enforcement in the hope of stopping an impaired provider from putting patients at risk.

| Opioid abuse and diversion among healthcare providers
A 2019 literature review indicates that substance use disorders affect approximately 8% to 15% of American healthcare professionals, a rate that is on par with the general public. 12 This means in the United States alone, 1.3 to 2.3 million healthcare professionals are either abusing and/or addicted to drugs and/or alcohol. Doctors and other providers with prescription authority face unique addiction risks because they have easy access to addictive drugs, tend to work under chronically stressful conditions, and personally use opioids at a rate five to eight times higher than the lay public. [13][14][15] This is not a new concern. Among physicians hospitalized between 1986 and 1991 due to current substance-related impairment, opioid addiction was diagnosed in 36% of cases. 16 Because the opioid epidemic exploded only after this study was completed, OUD may now comprise a greater proportion of substance-related impairment cases than ever before.
According to figures partially generated prior to the explosion of the opioid epidemic, at a minimum, nearly half a million to over one mil- Maine require veterinarians to look at a pet owner's past medication history before dispensing opioids or writing an opioid prescription." However, even this guide avoids the topic of addiction among veterinarians themselves. 24

| Provider monitoring programs
Almost every state has a program that coordinates confidential, therapeutic, and nonpunitive intervention for doctors and other healthcare professionals with a history of substance abuse. These provider monitoring programs stem from a 1973 AMA Council on Mental Health report that "recognized the significant scope of problems affecting physicians, the failure of physicians to seek help, and the 'conspiracy of silence' surrounding alcoholism and drug dependence." 25 The landmark report "helped to reorient physician impairment from a disciplinary issue to an illness requiring rehabilitation." 26 These programs are predicated on the view that it is possible to suffer from the problem of addiction without the condition causing permanent impairment. Namely, people can "recover" or go into "remission." The programs coordinate assessment, treatment, and treatment compliance monitoring services. They offer a "collaborative process that leads to restored lives for the affected physician as well as patient safety." 26 Whenever possible, they avoid bringing participants to the attention of either medical boards or law enforcement agencies. Although the Federation of State Physician Health Programs (FSPHP) that advocates for use of these monitoring programs includes the word "physician" in the its title, most programs also serve dentists and allied health professionals.
An anonymous survey of physicians who had been referred to a state monitoring program indicated over 90% would recommend the program to others. 27 Another study involving over 800 physicians who participated in such programs in 16 different states found that over 80% successfully completed the program. During the monitoring phase, 19% tested positive for drug or alcohol use. However, among program completers who returned to practice under monitoring conditions, almost 80% were still in practice 5 years later. Another 11% had had their licenses revoked, 3 % had retired, 3 % had died, and 3 % were of unknown status. Such findings suggest provider monitoring programs "provide an appropriate combination of treatment, support, and sanctions to manage addiction among physicians effectively," and yield markedly better outcomes than observed among the general population. 28 With evidence of high satisfaction and success among participants, particularly among those with substance use disorders, linkages have grown even stronger between monitoring programs and licensing boards. To be most effective, however, such programs must operate independently of medical and healthcare licensing boards regardless of whether they receive any funding from these boards and/or related professional societies. Indeed, FSPHP has taken strong steps to guard against conflicts of interest related to funding sources. 29

| Healthcare's hidden curriculum
Though ethical credos and standards of professionalism direct physicians to protect patients from impaired colleagues, a 2010 survey of 2038 physicians reported that almost a third of the 17% of responders with knowledge of an impaired colleague did not report that colleague to relevant authorities. 6 Over a third of all respondents in this survey did not agree that physicians should report impaired colleagues at all, citing fear of retribution, belief that someone else would or should report, or that either no action or excessive punishment would result. 6 This gap between what physicians know and how they actually behave may be attributed to the hidden curriculum, an unintended learning and socialization process in professional training that strongly influences beliefs, attitudes and behaviors. 26 With federal funding, a large healthcare system piloted and refined a program to promote full disclosure-a commitment to communicating openly and honestly with patients and families about unexpected medical errors (a long-established but often ignored ethical standard). Before final program rollout, teams of experts held meetings to introduce it in all local facilities. The program's protocol used highly scripted language to foster a high rates of provider compliance, consistency, and success The event The scripted response Potential medical error "We are sorry that this event occurred and want you to know it is being reviewed carefully to determine the cause. As soon as this assessment is completed, we will meet with you to let you know the findings" Error-free adverse event "We are very sorry that this event has occurred. We have completed the review and the event was not preventable for the following reasons" Healthcareinduced harm "We are very sorry that our actions led to this very disappointing outcome. We would like to explain what happened and what changes we have made so this will not happen again. We will work with you to try to make you whole and earn back your trust" a Ascension health's full disclosure protocol. 32 problem could affect the medical profession for years to come. Medical education, including continuing medical education, must change if we hope to optimize help for OIPs.  Table 2).

| Systematically overcoming denial in healthcare
Research has shown that the practice of full disclosure can substantially decrease the number of claims, lawsuits, and time from reporting to resolution as well as liability, compensation, and administrative costs. 34 Full disclosure also guards against the costly second victim phenomenon "whereby health care workers are also traumatized by the same events that harm patients." 35 The success of this well-coordinated effort to address one of healthcare's thorniest issues-an issue that providers have historically resisted addressing proactively-provides both inspiration and practical guidance for designing a framework and interventions to address the equally thorny and uncomfortable issue of helping OIPs. Building community-based networks (ie, coalitions) represents a proven and cost-efficient way to meaningfully engage diverse stakeholders in creating workable, local-level solutions to vexing healthcare issues. 32 Rather than relying on individual organizations to solve seemingly intractable problems, coalitions pool community resources to better tackle the factors underlying complex problems. The resulting synergy makes it possible to accomplish goals that no single organization could achieve on its own. 40 Such collaboration will be necessary to adequately tackle the opioid crisis but may not occur without encouragement and guidance from national and state agencies.
Because a local/regional medical center is usually the largest healthcare entity in any given community, it is most likely to have the appropriate staff with which to coordinate a network that represents all types of licensed providers. While not every impaired provider will be formally affiliated with their respective local/regional medical centers, these centers will presumably serve every impaired provider's patients.

| CONCLUSION
The number of OIPs abusing their prescription privileges to support personal drug addictions is likely to comprise only a tiny fraction of the 10 million adults with OUD; however, that tiny fraction could amount to at least 10 000 OIPs engaging in unethical and unsafe opioid prescribing practices. This arguably conservative estimate equates to at least 200 providers per state, leaving few, if any, communities totally immune. The United States needs a national-level healthcare policy that directs communities to develop and implement "how-to" guidance to ensure healthcare professionals can effectively meet their ethical obligation to encourage the rehabilitation of OIPs without compromising patient safety or requiring criminal prosecution. Such guidance must be customizable to local needs and capacities. It should include clear action steps healthcare professionals can employ regardless of their professional disciplines or employing organizations and specific strategies for connecting with state-level provider monitoring programs. As the nation reflects on longstanding racial biases within the law enforcement community, the health profession must also face aspects of its own hidden curriculum. Meanwhile, healthcare leaders should continue to support the DOJ initiative to prosecute all unimpaired providers who willfully abuse their prescription privileges. Both healthcare and law enforcement strategies are necessary to most effectively combat the societal-level opioid crisis.