Physician Impairment due to Substance Use Disorders

Discussion

Physician impairment is an important issue because of the potential negative impact on themselves, their family, other physicians and staff, and their patients. If impaired physicians undergo appropriate treatment and aftercare, most can successfully return to work. However, many doctors do not get the help that they need. They may deny that they have a problem, may not know how to get assistance, or are afraid of the consequences. According to the Council on Ethical and Judicial Affairs of the American Medical Association (AMA), as physicians, we have an ethical responsibility to act proactively with regard to our impaired colleagues in order to help them and to protect patients.^[1] Impairment has been defined by the AMA as "any physical, mental or behavioral disorder that interferes with the ability to engage safely in professional activities.^[2]" Impairment may result from substance use disorders, mental health issues, or physical health problems. Recent evidence even suggests that sleep deprivation may have an effect on performance that is equivalent to alcohol intoxication.^[3]

Epidemiology of Substance Abuse and Dependence Among Physicians

No large-scale studies have been performed in the United States in regard to the frequency of substance abuse and dependence among physicians since the early 1990s. The last study, conducted in conjunction with the AMA almost 20 years ago, was a national survey of a sample of over 5000 physicians across various specialties.^[4] At that time, the self-reported lifetime prevalence of substance abuse or dependence was 7.9%, which was lower than the estimated 16% prevalence for the general population. The rate for physicians may have been low because it was based on self-report; therefore, whether substance abuse and dependence are more or less common for doctors than for others remains an unanswered question. Currently, it is reasonable to assume that the overall rates are probably similar. However, the drugs used are not. The survey found that physicians were more likely to drink alcohol than the general population, but not more likely to drink excessively, and were much less likely to smoke cigarettes. Physicians were also less likely to use illicit drugs and much more likely to use prescription medications, especially narcotics and benzodiazepines, than the general population. Minor opiates had been used by 17.6% of physicians in the past year -- 92% of the time for the self-treatment of symptoms. The use of these medications, especially opiates, has remained common among physicians. Of note, the use for these drugs is now increasing among the general population as well. During the 3-year period from 2004 to 2006, 4.98% of individuals over the age of 12 years in the United States used nonprescribed pain medication, second only to marijuana.^[5]

Data from state physician health programs have shown that alcohol or opioids are the drugs of choice for physicians enrolled for substance use disorders. Among 2429 physicians followed by the Georgia Program from 1975 to 1995, alcohol was the drug of choice for 47%, opioids for 30%, cocaine for 7%, and 16% for all others.^[6] The drugs of choice were similar among 292 healthcare professionals followed by the Washington Program from 1991 to 2001, including 232 physicians: alcohol, 56%; opioids, 32%; cocaine, 3%; and all others, 9%.^[7]

Most of the studies of substance use disorders in physicians include few women. However, women now outnumber men in many medical schools, and determining the differences, if any, between male and female physicians with substance abuse and dependence is important. A recent study of 125 women and 844 men in 4 state physician health programs found that the female participants were younger (40 vs 44 years old), more likely to abuse sedative-hypnotics (11% vs 6%), and more likely to have a comorbid psychiatric disorder (42% vs 27%).^[8] How these and other differences may affect the course of treatment and ultimate outcome remains to be determined, but will be a crucial area for future research as the number of women physicians continues to increase.

Factors Contributing to Substance Abuse

Physicians frequently begin using alcohol and other drugs to self-medicate their own stress. They often have compulsive personality traits, marked by a triad of self-doubt, guilt over perceived deficiencies, and an excessive sense of responsibility.^[9] These traits are often combined with a low intrinsic sense of self-worth because physicians typically identify their self-worth with what they do rather than who they are. This combination of factors often leads to overwork, or what has been referred to as the "if I work more, I will be loved" syndrome. Even when they work hard, however, physicians tend to be self-critical, especially when things do not turn out as planned, which can affect both their work and home lives: "I should have ordered that test; I should have thought of that diagnosis; I should have gotten home for my daughter's soccer game or the dinner my spouse planned." As their guilt increases, they may work even harder. If they already use alcohol, they may find that they drink more to dull the tension. Or, as in the case presented, they are given narcotics initially and legitimately for pain and find that they feel better emotionally as well as physically. Once the legitimate reason no longer applies and their doctor stops providing narcotics, if they have become dependent -- as in the case under discussion -- they may find other sources, such as the Internet, forged prescriptions, or the hospital or office stock. At varying rates, they may find that they continue to lose control as their lives become even more unmanageable.

Many physicians come from families with a history of alcoholism or drug dependence, which increases their risk as well.

Other factors that may contribute include the pressure to use drugs, especially alcohol in social settings, easy access to prescription drugs, and "pharmacologic optimism.^[10]" The social use of drugs often begins in college and continues in medical school and beyond. Physicians have access to drugs through their own ability to prescribe and knowledge about the process that can lead to effective diversion and availability at work. Finally, because physicians are knowledgeable about the effects of medications, they may believe that the answer to their problems lies in just being able to find the right pill.

Impact of Physician Substance Abuse

Typically, for physicians with substance abuse, family life deteriorates before work does.^[11] Often there is marital or family discord and financial difficulties before anyone at work recognizes that there is a problem. Ultimately, substance misuse affects work as well. The physician with alcohol dependency may not come into work intoxicated but may have a hangover. With narcotic or sedative abuse, these drugs may have been prescribed legitimately at first, so it is easy for the dependent physician to rationalize just taking 1 or 2 pills because "my doctor prescribed it that way before." However, once control becomes an issue, escalation to use at work becomes more likely and direct patient harm may result.

Identifying Impairment and Intervening

There is often no easy way to identify a physician impaired by chemical dependency at work until the problem is quite advanced. Although work is often the last area to be affected, there may be clues. By definition, impairment must affect an individual's ability to care for patients. (Some physicians can drink heavily outside of work without being impaired.) A physician may also Illicitly use controlled prescription medications without impairment, but because this behavior is illegal and considered unethical, it is inappropriate under any circumstance. A variety of behaviors may provide clues of a problem^[10,12]:

Marital or family problems (often occur first).
Changes in behavior, including outbursts of anger and increased irritability. At work, there may be unexplained or unexpected work absences, rounding at unusual hours, or missed deadlines.
Consistent heavy drinking at social functions, especially if it is out of the norm for the rest of the group.
Driving under the influence (DUI): This is a red flag. In general, driving after drinking has become less socially acceptable, so a DUI often signals a loss of control. A single DUI may just be due to poor judgment, but more than 1 DUI is almost always a sign of a significant problem.

Physicians, like others with substance dependence, suffer from denial and often downplay the importance of substance misuse when confronted. This requires a high index of suspicion if there are numerous clues for substance abuse, and referral to the local physician wellness program or committee or employee assistance program should be considered. If the physician is in a setting where "for cause" drug testing is in force, obtaining a urine drug screen or a blood alcohol level can be very helpful. In situations where there is an impact on work but the underlying cause is unclear, it may be necessary to refer the physician for a comprehensive evaluation at a facility specializing in these problems. These evaluations may take 3 days or more, but are likely to determine whether a substance use disorder exists. Once a physician is identified as being impaired, he or she should immediately be removed from clinical duties and referred for appropriate treatment.

These actions will often increase the stress for an individual already feeling out of control; therefore, emotional and psychological support should also be provided by his or her supervisor and the services provided.

As outlined in the 2002 mandate from the Joint Commission on Accreditation of Healthcare Organizations, all hospitals should have physician wellness programs that are separate from the disciplinary process. These programs should address education of the medical staff as well as evaluating and monitoring affected physicians.^[1] They are often the best resources for helping impaired physicians.

Because of the fear that someone's career might be jeopardized, physicians are often reluctant to report potentially impaired colleagues. However, failure to act may have even greater consequences. Most states allow doctors to seek treatment for substance use disorders without being reported to the Board of Medicine if there is no evidence of patient harm. However, waiting for a bad outcome before acting not only places patients at risk, but also greatly increases the likelihood that the impaired physician will face disciplinary action as well. Because of the need to protect patients, colleagues and other staff members who suspect a physician of substance abuse have an ethical obligation to act if they believe that clinical care is being compromised,^[1] and in most cases, early action will prevent future problems. It should be noted that some states impose legal obligations to report impaired physicians. Although most physicians (95%) agreed that they have an ethical obligation to intervene with an impaired colleague, only two thirds indicated that they would do anything more than talk to them privately.^[13]

When we are confronted by colleagues who need our help, it can be useful to remember the words of Martin Luther King, Jr.: "In the end, we will remember not the words of our enemies, but the silence of our friends.^[14]"

Strategies to Address Impairment

A number of programs around the country specialize in the treatment of addictions among physicians and other professionals. They may also provide acute services, such as detoxification, if needed, and then enroll participants in an intensive residential treatment program that may last 3 months or more. Many of these programs offer an intensive evaluation both to determine the nature of the addiction as well as to assess for other comorbid psychiatric conditions that may affect both treatment and outcomes.

In addition to undergoing appropriate treatment, physicians should enroll in their states' impaired physicians programs, which are usually separate from the states' medical boards and allow physicians to be monitored long term without any board action or public notification. The outcomes for physicians with substance dependence are usually excellent, at least for those who agree to intensive treatment and enroll in their state physicians' health programs. Most of the outcome data for physicians come from evaluation of participants in these programs. On average, 75%-90% of physicians completing treatment and signing contracts with their state programs (usually for 5 years) achieve long-term abstinence.^[6,15,16] Of concern, following a period of general acceptance of role and availability of these programs in all 50 states, their future is now somewhat less certain. For instance, the Wisconsin program closed in 2007 after 30 years due to reduced referrals and inadequate funding.^[17] Some programs have come under increased scrutiny because they allow physicians with substance use disorders to continue to practice without their patients' knowledge. As an example of this, the program in California was recently discontinued due to concerns about patients' rights and safety.^[18] Currently, 42 state programs are members of the Federation of State Physician Health Programs, which maintains a directory that is available online.^[19]

Aftercare under the supervision of the state physician health program, usually guided by a signed contract of 5 years or longer, often includes the following:

Required attendance at 12-step meetings and other support groups, such as Caduceus;
A worksite monitor who regularly works with the physician and makes regular reports to the oversight program;
Regular appointments with a primary care physician;
Follow-up with a therapist or psychiatrist if indicated; and
Random drug and alcohol screening.

The majority of doctors with substance dependence who follow this path will remain abstinent, but relapse does occur. A recent study from the Washington Physicians Health Program identified 3 factors that significantly increased the risk for relapse among 292 program participants: a family history of a substance use disorder, a psychiatric diagnosis in addition to a substance use disorder (dual diagnosis), and use of a major opioid (but only if a dual diagnosis was also present).^[7] If all 3 factors were present (family history, dual diagnosis, and major opioid use), the risk for relapse was increased 13-fold.

Returning to Work

Once they have completed treatment and begun aftercare, physicians with substance use disorders need to address their return to work. Both the state physician health program and local hospital wellness committees can help with this transition. After initial treatment, most physicians can return to their prior specialties. Of note, anesthesiology residents, especially those who are addicted to medications available at work, may be at particular risk for relapse, and their likelihood of prolonged abstinence may be higher if they return to another specialty, although this remains controversial.^[20] Some studies have found no difference in relapse rates for practicing anesthesiologists.^[21] For all physicians with substance use impairment, work hours may need to be restricted to allow a gradual return to work that coincides with establishing a steady recovery program. Many physicians gain great satisfaction from their work, and although comprehensive addiction treatment programs can help them achieve a more balanced approach to life, the pull of work often remains. Without mandated work limitations, the physician may not take the time needed for 12-step meetings and other pursuits that are crucial for successful recovery. Although many physicians initially believe that their professional lives are over and that being confronted with their addiction is the worst thing that has ever happened to them, most come to believe that the intervention and treatment that have allowed them to regain control of their lives is one of the best things to ever happen to them.

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