This policy statement responds to concerns from numerous licensing authorities who note an increasing number of requests for professional licensure from applicants who are taking controlled medications. Suboxone and Adderall, in particular, are prescribed for opiate dependence, ADHD, and as alternatives to control a wide range of emotional conditions and behaviors including use of illegal substances. Other controlled medications found in a minority of those who apply for professional licensure include a wide range of Opiates, Benzodiazepines, Barbiturates, and Stimulants.
Palmetto does not recommend use of controlled medications in a professional population. We believe that such medications create side effects and physiological dependence incompatible with the practice of a profession.
Professionals have in common an increased fiduciary responsibility to the public by virtue of special training, special licensure, and possession of a specialized knowledge base. This is true of all professions, to include Law, Medicine, Nursing, Pharmacy, and Aviation. There is strong emphasis at every step of education and licensure on protecting the public from carelessness, incapacity, neglect or mistakes. The professional acts on behalf of the public using his professional knowledge for public benefit.
Controlled medications are controlled because they are dangerous, impairing and addictive. They have a long list of side effects incompatible with safe performance of a profession. These include dizziness, drowsiness, flushing, headache, insomnia, bloating, vomiting, allergic reactions, anxiety, blurred vision, confusion, decreased attention, fainting, loss of coordination, numbness, weakness, mood swings, slowed reflexes, slurred speech, edema, respiratory depression, mania, delirium, psychosis and jaundice. Many of these side effects have an adverse effect on the executive function crucial to performance of professional responsibilities. Moreover, the side effects are unpredictable and variable from patient to patient. Bitter experience teaches us that practice of a profession on controlled medications or alcohol results in mistakes which damage those entrusted to our care.
We find that the risk of an adverse event impairing performance of professional duty greatly outweighs any possible individual benefit from controlled medications. Maintenance therapy on controlled medications impairs the professional, creates tolerance to the medication, and increases the probability of polysubstance dependence. All controlled medications increase dopamine release, deplete dopamine stores and stimulate the limbic system, which is the seat of powerful survival drives. These drives tend to demand more stimulation and kindle craving for more controlled medication. Excess dopamine is also found in psychosis, and all antipsychotics block dopamine. It is understandable that all controlled substances therefore create the potential for irrational and even psychotic behavior.
We recommend abstinence based treatment for professionals with substance dependence using the Alcoholics Anonymous method. This method is research validated to work best over time with a combination of inpatient treatment (ideally about 3 months) followed by strict monitoring, accountability, and a clear understanding that continued abstinence is a condition for continued licensure. We now have decades of outcome studies at multiple facilities with multiple professions, all of which support this position. This method gives 80-95% recovery rates which are defined as drug-free at the one year point, and 85% continued sobriety over 5 years of strict monitoring after treatment. Standard recovery rates with a 3 month inpatient program and no monitoring run up to about 50%. Lower levels and intensity of treatment result in lower recovery rates. A 30 day inpatient program with limited monitoring gives an 80% relapse rate within 2 years. We find that professionals who are allowed to take any controlled medications or alcohol while being monitored can quickly rekindle the craving and impulsive behavior common to all addictions. Relapse on any number of controlled medications or alcohol then becomes much more likely, as does polysubstance dependence. Professionals who embrace the abstinence based method of AA consistently tell us that they are better adjusted, more competent, and much safer with the patient population than they were when they were practicing under the influence of controlled medications or alcohol.
We believe that a professional who wishes to take controlled medications should make a choice between the medications and the profession. Professional licensing boards in all professions understand that the risk of impairment and damage to the public greatly outweighs any possible individual benefits in specific cases where practice of a profession and concurrent use of controlled medications is at issue. The overwhelming majority of such organizations choose to take the safest course and prohibit use of controlled medications or alcohol while practicing a profession. We agree with this policy.Jay A. Weiss, MD, ASAM