needed, physicians should work to educate
patients about the precipitants of cravings and
relapse and help them to cope adaptively with
the associated psychological and environmental
risk factors.
Case Management ......................................................................................................
Many of the activities involved in chronic
disease management and oversight can be
performed by professionally-trained case
managers working in a variety of settings such
as physicians’ offices, hospital or out-patient
addiction treatment programs, justice facilities
or social service agencies. They should,
however, work under the supervision of a
trained physician and other medical
professionals.^343Professional case managers can help to navigate
and coordinate resources within the fragmented
health care system and ensure that patients
receive the services they need to keep addiction
symptoms in check.^347 The role of the case
manager is to link patients to the health and
social services appropriate to their specific
needs, ensure that patients follow through with
referrals, help patients identify and access aThe Physician Health ProgramAn addiction treatment model that provides
effective long-term disease management is the
Physician Health Program (PHP) established by
state medical societies and licensing boards to treat
physicians who have addiction.^330 Today, all 50
states and the District of Columbia have a PHP.^331
The PHP assists the participating physician in
finding clinical treatment services,^332 provides case
management of individuals undergoing treatment
and maintains relationships with the authorized
treatment facilities that evaluate and treat referred
physicians.^333 Contingency management in the
form of negative consequences for violating its
terms (e.g., losing one’s license to practice
medicine, malpractice suits, disciplinary actions
from hospital boards) is a critical part of the
program.^334 PHPs must have the oversight of a
medical director; some have an MD on staff who
serves as a medical consultant.^335Treatment managed by a PHP is more intense and
lasts longer than that for the general population,
with three to six months spent in structured therapy
followed by five years of contingency management,
and it includes pharmaceutical therapy,
psychosocial interventions and nutrition and
exercise counseling.^336 PHPs also typically have a
mutual support program component.^337 Long-term
monitoring is employed to reduce relapse: when
relapse or signs of possible relapse occur, the
reaction is therapeutic, not punitive.^338 Physicians
who relapse tend to improve again after a treatment
adjustment.^339More than 80 percent of physicians who participate
in PHPs return to work and remain substance free
for a minimum of five years after receiving
treatment.^340 Seventy-one percent of participating
physicians retain their medical license and are
employed after five years.^341Key elements of the PHP program that appear to
contribute to its success and that are replicable in
the general population include high intensity care
for an extended duration and the inclusion of long-
term monitoring and disease management.^342A Case Management Approach:
Recovery Management CheckupsRecovery Management Checkups (RMC)--in
which patients are contacted, evaluated and
linked to additional support services including
those that address co-occurring conditions--have
been shown to be an effective approach to
chronic disease management by helping patients
engage in and stay in treatment.^344Research finds that adolescents and adults in
addiction treatment who receive RMCs--based
on a method that involves locating individuals
for checkup, assessing eligibility for
intervention, linking individuals to treatment
services, engaging participants in treatment and
retaining participation for at least 14 days in
residential treatment or seven days in intensive
or regular outpatient treatment--demonstrate
higher levels of treatment participation and
abstinence rates and reduced time to
readmission for treatment following relapse.^345
Patients receiving such checkups were
significantly likelier than patients receiving
usual care to return to treatment (55 percent vs.
37 percent), do so sooner (384 days earlier) and
to be abstinent (480 days vs. 430 days) over a
two-year follow-up.^346