Doctors are as vulnerable to addiction as anyone. California grapples with a response.

Ariella Morrow, an internal medicine doctor, gradually slid from healthy self-esteem and professional success into the depths of depression.

Beginning in 2015, she suffered a string of personal troubles, including a shattering family trauma, marital strife, and a major professional setback. At first, sheer grit and determination kept her going, but eventually she was unable to keep her troubles at bay and took refuge in heavy drinking. By late 2020, Morrow could barely get out of bed and didn't shower or brush her teeth for weeks on end. She was up to two bottles of wine a day, alternating it with Scotch whisky.

Sitting in her well-appointed home on a recent autumn afternoon, adorned in a bright lavender dress, matching lipstick, and a large pearl necklace, Morrow traced the arc of her surrender to alcohol: "I'm not going to drink before 5 p.m. I'm not going to drink before 2. I'm not going to drink while the kids are home. And then, it was 10 o'clock, 9 o'clock, wake up and drink."

As addiction and overdose deaths command headlines across the nation, the Medical Board of California, which licenses MDs, is developing a new program to treat and monitor doctors with alcohol and drug problems. But a fault line has appeared over whether those who join the new program without being ordered to by the board should be subject to public disclosure.

Patient advocates note that the medical board's primary mission is "to protect healthcare consumers and prevent harm," which they say trumps physician privacy.

The names of those required by the board to undergo treatment and monitoring under a disciplinary order are already made public. But addiction medicine professionals say that if the state wants troubled doctors to come forward without a board order, confidentiality is crucial.

Public disclosure would be "a powerful disincentive for anybody to get help" and would impede early intervention, which is key to avoiding impairment on the job that could harm patients, said Scott Hambleton, president of the Federation of State Physician Health Programs, whose core members help arrange care and monitoring of doctors for substance use disorders and mental health conditions as an alternative to discipline.

But consumer advocates argue that patients have a right to know if their doctor has an addiction. "Doctors are supposed to talk to their patients about all the risks and benefits of any treatment or procedure, yet the risk of an addicted doctor is expected to remain a secret?" Marian Hollingsworth, a volunteer advocate with the Patient Safety Action Network, told the medical board at a Nov. 14 hearing on the new program.

Doctors are as vulnerable to addiction as anyone else. People who work to help rehabilitate physicians say the rate of substance use disorders among them is at least as high as the rate for the general public, which the federal Substance Abuse and Mental Health Services Administration put at 17.3% in a Nov. 13 report.

Alcohol is a very common drug of choice among doctors, but their ready access to pain meds is also a particular risk.

"If you have an opioid use disorder and are working in an operating room with medications like fentanyl staring you down, it's a challenge and can be a trigger," said Chwen-Yuen Angie Chen, an addiction medicine doctor who chairs the Well-Being of Physicians and Physicians-in-Training Committee at Stanford Health Care. "It's like someone with an alcohol use disorder working at a bar."

From pioneer to lagger

California was once at the forefront of physician treatment and monitoring. In 1981, the medical board launched a program for the evaluation, treatment, and monitoring of physicians with mental illness or substance use problems. Participants were often required to take random drug tests, attend multiple group meetings a week, submit to work-site surveillance by colleagues, and stay in the program for at least five years. Doctors who voluntarily entered the program generally enjoyed confidentiality, but those ordered into it by the board as part of a disciplinary action were on the public record.

The program was terminated in 2008 after several audits found serious flaws. One such audit, conducted by Julianne D'Angelo Fellmeth, a consumer interest lawyer who was chosen as an outside monitor for the board, found that doctors in the program were often able to evade the random drug tests, attendance at mandatory group therapy sessions was not accurately tracked, and participants were not properly monitored at work sites.

Today, MDs who want help with addiction can seek private treatment on their own or in many cases are referred by hospitals and other health care employers to third parties that organize treatment and surveillance. The medical board can order a doctor on probation to get treatment.

In contrast, the California licensing boards of eight other health-related professions, including osteopathic physicians, registered nurses, dentists, and pharmacists, have treatment and monitoring programs administered under one master contract by a publicly traded company called Maximus Inc. California paid Maximus about $1.6 million last fiscal year to administer those programs.

When and if the final medical board regulations are adopted, the next step would be for the board to open bidding to find a program administrator.

Fall from grace

Morrow's troubles started long after the original California program had been shut down.

The daughter of a prominent cosmetic surgeon, Morrow grew up in Palm Springs in circumstances she describes as "beyond privileged." Her father, David Morrow, later became her most trusted mentor.

But her charmed life began to fall apart in 2015, when her father and mother, Linda Morrow, were indicted on federal insurance fraud charges in a well-publicized case. In 2017, the couple fled to Israel in an attempt to escape criminal prosecution, but later they were both arrested and returned to the United States to face prison sentences.

The legal woes of Morrow's parents, later compounded by marital problems related to the failure of her husband's business, took a heavy toll on Morrow. She was in her early 30s when the trouble with her parents started, and she was working 16-hour days to build a private medical practice, with two small children at home. By the end of 2019, she was severely depressed and turning increasingly to alcohol. Then, the loss of her admitting privileges at a large Los Angeles hospital due to inadequate medical record-keeping shattered what remained of her self-confidence.

Morrow, reflecting on her experience, said the very strengths that propel doctors through medical school and keep them going in their careers can foster a sense of denial. "We are so strong that our strength is our greatest threat. Our power is our powerlessness," she said. Morrow ignored all the flashing yellow lights and even the red light beyond which serious trouble lay: "I blew through all of it, and I fell off the cliff."

By late 2020, no longer working, bedridden by depression, and drinking to excess, she realized she could no longer will her way through: "I finally said to my husband, 'I need help.' He said, 'I know you do.'"

Ultimately, she packed herself off to a private residential treatment center in Texas. Now sober for 21 months, Morrow said the privacy of the addiction treatment she chose was invaluable because it shielded her from professional scrutiny.

"I didn't have to feel naked and judged," she said.

Morrow said her privacy concerns would make her reluctant to join a state program like the one being considered by the medical board.

Physician privacy vs. patient protection

The proposed regulations would spare doctors in the program who were not under board discipline from public disclosure as long as they stayed sober and complied with all the requirements, generally including random drug tests, attendance at group sessions, and work-site monitoring. If the program put a restriction on a doctor's medical license, it would be posted on the medical board's website, but without mentioning the doctor's participation in the program.

Yet even that might compromise a doctor's career since "having a restricted license for unspecified reasons could have many enduring personal and professional implications, none positive," said Tracy Zemansky, a clinical psychologist and president of the Southern California division of Pacific Assistance Group, which provides support and monitoring for physicians.

Zemansky and others say doctors, just like anyone else, are entitled to medical privacy under federal law, as long as they haven't caused harm.

Many who work in addiction medicine also criticized the proposed new program for not including mental health problems, which often go hand in hand with addiction and are covered by physician health programs in other states.

"To forgo mental health treatment, I think, is a grave mistake," Morrow said. For her, depression and alcoholism were inseparable, and the residential program she attended treated her for both.

Another point of contention is money. Under the current proposal, doctors would bear all the costs of the program.

The initial clinical evaluation, plus the regular random drug tests, group sessions, and monitoring at their work sites could cost participants over $27,000 a year on average, according to estimates posted by the medical board. And if they were required to go for 30-day inpatient treatment, that would add an additional $40,000 — plus nearly $36,000 in lost wages.

People who work in the field of addiction medicine believe that is an unfair burden. They note that most programs for physicians in other states have outside funding to reduce the cost to participants.

"The cost should not be fully borne by the doctors, because there are many other people that are benefiting from this, including the board, malpractice insurers, hospitals, the medical association," said Greg Skipper, a semi-retired addiction medicine doctor who ran Alabama's state physician health program for 12 years. In Alabama, he said, those institutions contribute to the program, significantly cutting the amount doctors have to pay.

The treatment program that Morrow attended in spring of 2021, at The Menninger Clinic in Houston, cost $80,000 for a six-week stay, which was covered by a concerned family member. "It saved my life," she said.

Though Morrow had difficulty maintaining her sobriety in the first year after treatment, she has now been sober since April 2, 2022. These days, Morrow regularly attends therapy and Alcoholics Anonymous and has pivoted to become an addiction medicine doctor.

"I am a better doctor today because of my experience — no question," Morrow said. "I am proud to be a doctor who's an alcoholic in recovery."

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.