Dialogue with Dr. Dan Angres
The following is an interview with Dr. Angres, led by Dr. Mark Gold, world renowned addiction expert.
Substance Abuse Q and A, Positive Sobriety Institute
Q: You were one of the earliest pioneers in physician evaluation and treatment, what has changed since you began?
A: Many things. For instance, early on there was an expectation that all physicians received three to four months of treatment no matter what their presentation and circumstances were. This was based on the Talbott model. Actually, in part due to the work Doug and I did in the early 80’s that led to our publishing joint outcome data in our book “Healing the Healer”, we demonstrated that individualizing treatment made sense. We showed that, carefully selected, physicians treated in our evening program had similar 80% long term abstinence rates as did our extended treatment folks. Now, this was a smaller group as they were primarily alcoholic, no co-morbidity, and no work impairment and had a supportive family. This is an atypical presentation but it happens. More important it shows the importance of individualizing treatment plans. Most physicians need some time away from work but treatment “dose” including length of stay should be on the higher end (we average 7 weeks although some may need longer). In other words, we need to avoid “cookie cutter” approaches. On the other hand, we need to avoid “quick fixes” as well that include generic outpatient programs or worse, individual therapy alone. The best way to determine treatment needs is to do a comprehensive assessment that is multidisciplinary with appropriate collaterals. This is another change in that this is now the typical Physician Health Program point of contact referral as opposed to direct referral into treatment. Finally, more physicians than ever are employed by hospitals. This often puts physicians in need under hospital legal and H.R. This can edge out PHP’s which is overall detrimental to people getting the help, support and advocacy they need.
Q: On your last point, what is being done to help PHP’s not lose their influence?
A: We need to lobby on behalf of the PHP’s and this includes research on outcomes. Bob DuPont’s and your work, for example, has been critical in demonstrating the outstanding five-year abstinence outcomes with PHP involvement. We also need to expand the work that Dr. Gunderson has done in Colorado demonstrating the reduction of malpractice claims in those physicians that are involved with PHP’s. This includes impairments other than addictions like the disruptive physician as well. In Illinois, we are working with the Illinois Professional Health Program and the Illinois State Medical Insurance Exchange (ISMIE) researching malpractice claims here in Illinois. This is building on the work Dr. Marty Doot pioneered years ago. This is a powerful message in both demonstrating the PHP’s role in promoting a culture of safety as well as reducing cost.
Q: Why are recovery rates so high for physician addicts, even intravenous addicts, and so poor for everyone else?
A: There are many factors that contribute to the excellent outcomes for properly treated and monitored addicted physicians. Some people think these outcomes are a product of accountability alone. Although the possibility of losing one’s ability to practice plays a role, it is not the only factor. In my article published in Substance Abuse Research and Treatment 2013:7 49 “A Two Year Longitudinal Outcome Study of Addicted Health Care Professionals: An Investigation of the Role of Personality Variables” we pointed to a number of contributing factors that play out in a professionals treatment setting. This includes a strong therapeutic community of peers, a staff with expertise in the treatment and re-entry of professionals like physicians and in no small way personality variables.
Q: I know you have done a lot of work on personality and addiction. What are the variables you have found?
A: Previous research by Gabbard and others have shown that physicians as a group have pretty positive personality structures. This includes a high level of persistence and conscientiousness as well as a need to be seen by others in a positive light. In addition, physicians tend to be altruistic; this is what attracts most people to medicine. We found that this was the case in our sample as well utilizing the Temperament and Character Inventory that I had used in my work with Dr. Robert Cloninger from Wash. University. and cross checking it with the Millon. These profiles seem to contribute to the near 80% outcomes we have.
Q: I understand you are continuing this research?
A: We are. At PSI, I have put together a very sophisticated research team in conjunction with Northwestern that is expanding on the work I have previously done in this area. I was very excited to see that Nora Volkow and others have published a review that suggests that personality traits may be the single best window into understanding the genetic variations in addiction (they call this endophenotyping–using indirect ways to understand the very complex contributions of genetics–in this case personality traits). Their work centered on vulnerability and susceptibility to getting addicted by looking at traits associated with brain states and specific genetic/neurotransmitter pathways. We are applying a similar approach to people already diagnosed with addiction and in treatment. We hope to come up with addiction sub-types that are badly needed in our field. To date we really have only Types 1 and 2 (late and early onset respectively) and need more refined subtypes. Our research involves the NEO-PR (the big five) inventory. We hope to be able to not only begin the subtyping process but, by repeating these tests in interval throughout recovery, see how targeted therapies can positively modulate personality.
Q: How do you envision replicating the treatment and monitoring for physicians to the general population?
A: This is a necessary but daunting effort; one that at Positive Sobriety Institute we are fully committed to. I don’t believe it is as simple as providing the same treatment structure such as longer residential or boarded partial treatment as well as longer monitoring. The rule of thumb is that the higher the accountability, the greater the compliance. In a recent webinar sponsored by Bluff Plantation in Augusta, Georgia, Dr. Mike Sucher made a very important point on this. He said that everyone has at least one thing they would not want to lose. It may be maintaining the ability to be a parent or something else and our job is to explore and facilitate that accountability factor and build it in to any treatment approach. Additionally, the average age of the addict in treatment is much younger as it reflects the heroin/opioid epidemic in particular. This average age for most professionals program is much older so maturity levels and marital/family support may be factors as well. Finally, the overall personality profiles may be less favorable in the general population as well. All these challenges need to be factored in to applying the professional’s model to the general addicted population. One thing that can level this playing field is extended sober living. This can facilitate the most important process of recovery: time in solid recovery that allows for the necessary healing of the brain and what Paul Early so aptly describes as the establishment and maintenance of “recovery mind”.