Physicians generally display better health and have lower rates of all-cause mortality than the general population.1 However, their education, nutrition, and lifestyle do not offer similar protection from substance abuse and dependence. Prevalence rates of alcohol abuse and dependence among physicians are about equal to those seen in the population as a whole, while prescription drug misuse and dependence rates are far higher.2,3 Addiction impairs more physicians than any other disease.4
Defined as “a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. . . . [Addiction] is characterized by impaired control over drinking and/or drug use, preoccupation with the drug or alcohol, use of drugs or alcohol despite adverse consequences, and distortions in thinking, most notably denial.”5 The recognition that addiction is a disease, rather than a character flaw or failure of willpower, has led to the development of effective treatments and has helped reduce the stigma associated with rehabilitation and recovery. This model promotes the acceptance of treatment in persons with addiction disorder and results in increased satisfaction with care and improved prognosis.
This article briefly reviews the factors that contribute to physician addiction, why the need for treatment is so important, and what the barriers to treatment are. It concludes with the presentation of a model for successful treatment.
The causes of physician addiction are not fully understood, although it appears that many factors can contribute to the development of this disorder. For example, the ready access that physicians have to drugs and their ability to self-prescribe have been suggested as potential pathways to addiction. Indeed, despite the fact that physicians are less likely than the general population6 to smoke cigarettes7 or use alcohol or illicit drugs,3,8 rates of prescription drug abuse are higher among physicians.9 Currently, more attention is being paid to this important issue, particularly within the field of anesthesiology.10,11 Yet, not all physicians who have an addiction disorder abuse prescription drugs. Work-related stress has been pinpointed as an another contributor to physician addiction, but physicians with addictions typically deny using substances to self-medicate and describe using them for euphoric effects.12
Building on research involving the role of reward neurocircuitry in addiction,13,14 recent studies have provided support for the hypothesis that some physicians may be neurobiologically sensitized to develop addiction as a result of chronic exposure to small amounts of addictive substances that are aerosolized and can be inhaled or absorbed through the skin.15 This hypothesis can help explain why opioid abuse and dependence occurs most commonly among anesthesiologists and surgeons.
While numerous pathways to abuse and dependence exist, this hypothesis has been useful because it can be tested and may explain why some physicians become addicted.15-17 Physician addiction reminds us of the limitations of education as a protective factor against drug abuse. Finally, factors contributing to addiction in the general public, such as family history of addiction, comorbid psychiatric diagnosis, or early drug experimentation, may also influence the development of addiction among physicians.
Need for treatment
Regardless of the contributing factors, the importance of obtaining treatment for addicted physicians cannot be overstated. The potential consequences of neglecting substance use disorders extend beyond the physician to his or her patients, coworkers, and family members. Indeed, clinical experience suggests that disruption or discord in the physician’s primary relationship (eg, spouse) is virtually always present in cases of addiction. The lives of family members are negatively affected, and children are at increased risk for psychological problems and substance use.18
1. Torre DM, Wang NY, Meoni LA, et al. Suicide compared to other causes of mortality in physicians. Suicide Life Threat Behav. 2005;35:146-153.
2. O'Connor PG, Spickard A Jr. Physician impairment by substance abuse. Med Clin North Am. 1997;81:1037-1052.
3. Hughes PH, Brandenburg N, Baldwin DC Jr, et al. Prevalence of substance use among US Physicians. JAMA. 1992;267:2333-2339.
4. Talbott GD, Wright C. Chemical dependency in health care professionals. Occup Med. 1987;2:581-591.
5. Morse RM, Flavin DK. The definition of alcoholism. The Joint Committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine to Study the Definition and Criteria for the Diagnosis of Alcoholism. JAMA. 1992;268:1012-1014.
6. SAMHSA. Results from the 2005 National Survey on Drug Use and Health: national findings. Rockville, MD: Office of Applied Studies NSDUH Series H-30 2006; US Dept of Health and Human Services; 2006. DHHS publication SMA 06-4194.
7. Nelson DE, Giovino GA, Emont SL, et al. Trends in cigarette smoking among US physicians and nurses. JAMA. 1994;271:1273-1275.
8. Kenna GA, Wood MD. Alcohol use by healthcare professionals. Drug Alcohol Depend. 2004;75:107-116.
9. Hughes PH, Storr C, Baldwin DC Jr, et al. Patterns of substance use in the medical profession. Md Med J. 1992;41:311-314.
10. Luck S, Hedrick J. The alarming trend of substance abuse in anesthesia providers. J Perianesth Nurs. 2004;19:308-311.
11. Merlo LJ, Gold MS. Prescription opioid abuse and dependence among physicians: hypotheses and treatment. Harv Rev Psychiatry. 2008;16:181-194.
12. Kleber HD. The impaired physician: changes from the traditional view. J Subst Abuse Treat. 1984;1:137-140.
13. Koob GF, Le Moal M. Plasticity of reward neurocircuitry and the “dark side” of drug addiction. Nat Neurosci. 2005;8:1442-1444.
14. Le Moal M, Koob GF. Drug addiction: pathways to the disease and pathophysiological perspectives. Euro Neuropsychopharm. 2007;17:377-393.
15. Gold MS, Byars JA, Frost-Pineda K. Occupational exposure and addictions for physicians: case studies and theoretical implications. Psych Clin North Am. 2004;27:745-753.
16. Gold MS, et al. Fentanyl is present in the air and operating room surfaces. J Addict Dis. 2006;25:141-144.
17. McAuliffe PF, Gold MS, Bajpai L, et al. Second-hand exposure to aerosolized intravenous anesthetics propofol and fentanyl may cause sensitization and subsequent opiate addiction among anesthesiologists and surgeons. Med Hypotheses. 2006;66:874-882.
18. Emshoff JG, Price AW. Prevention and intervention strategies with children of alcoholics. Pediatrics. 1999; 103:1112-1121.
19. Roy A. Suicide in doctors. Psychiatr Clin North Am. 1985;8:377-387.
20. Graham C. Poland wrestles with the problem of drunken doctors. Lancet. 2006;368:190-191.
21. Taub S, Morin K, Goldrich MS, et al. Physician health and wellness. Occup Med (Lond). 2006;56:77-82.
22. Pomm RM, Harmon L. Evaluation and posttreatment monitoring of the impaired physician. Psychiatr Ann. 2004;34:786-789.
23. Council on Ethical and Judicial Affairs of the American Medical Association. Reporting Impaired, Incompetent, or Unethical Colleagues, in Reports of the Council on Ethical and Judicial Affairs. Chicago: American Medical Association; January 1992.
24. Angres D, Busch K. The Chemically-dependent physician: clinical and legal considerations. In: Miller RD, ed. Legal Implications of Hospital Policies and Procedures. San Francisco: Jossey-Bass; 1989:21-32.
25. Breiner SJ. The impaired physician. J Med Educ. 1979;54:673.
26. Vaillant GE, Clark W, Cyrus C, et al. Prospective study of alcohol treatment. Eight year follow-up. Am J Med. 1983;75:455-463.
27. Farber NJ, Gilibert SG, Aboff BM, et al. Physicians’ willingness to report impaired colleagues. Soc Sci Med. 2005;61:1772-1775.
28. Skipper GE. Treating the chemically dependent health professional. J Addict Dis. 1997;16:67-73.
29. Roback HB, Moore RF, Waterhouse GJ, Martin PR. Confidentiality dilemmas in group psychotherapy with substance-dependent physicians. Am J Psychiatry. 1996;153:1250-1260.
30. McGovern MP, Angres DH, Leon S. Differential therapeutics and the impaired physician: patient-treatment matching by specificity and intensity. J Addict Dis. 1998;17:93-107.
31. Angres DH, McGovern MP, Shaw MF, Rawal P. Psychiatric comorbidity and physicians with substance use disorders: a comparison between the 1980s and 1990s. J Addict Dis. 2003;22:79-87.
32. Wijesinghe CP, Dunne F. Substance use and other psychiatric disorders in impaired practitioners. Psychiatr Q. 2001;72:181-189.
33. American Society of Addiction Medicine. Patient Placement Criteria. Chevy Chase, MD: American Society of Addiction Medicine; 2000.
34. Enders LE, Mercier JM. Treating chemical dependency: the need for including the family. Int J Addict. 1993;28:507-519.
35. Eells MA. Interventions with alcoholics and their families. Nurs Clin North Am. 1986;21:493-504.
36. Gallegos KV, Lubin BH, Bowers C, et al. Relapse and recovery: five to ten year follow-up study of chemically dependent physicians—the Georgia experience. Md Med J. 1992;41:315-319.
37. Galanter M, Talbott D, Gallegos K, Rubenstone E. Combined Alcoholics Anonymous and professional care for addicted physicians. Am J Psychiatry. 1990;147:64-68.
38. Moos RH, Moos BS. Paths of entry into Alcoholics Anonymous: consequences for participation and remission. Alcohol Clin Exp Res. 2005;29:1858-1868.
39. Walsh DC, Hingson RW, Merrigan DM, et al. A randomized trial of treatment options for alcohol-abusing workers. N Engl J Med. 1991;325:775-782.
40. Crowley TJ. Doctors’ drug abuse reduced during contingency-contracting treatment. Alcohol Drug Res. 1985-1986;6:299-307.
41. Washton AM, Gold MS, Pottash AC. Naltrexone in addicted physicians and business executives. NIDA Res Monogr. 1984;55:185-190.
42. Vinson S, Graham NA, Gold MS. Socioeconomic inequities often translate into health inequalities. J Natl Med Assoc. 2006;98:816-817.
43. Gold MS, Pomm R, Frost-Pineda K. Urine testing confirmed, 5-year outcomes of impaired physicians. World Psychiatric Association; November 2004; Florence, Italy.
44. Gold MS, Frost-Pineda K. Problem doctors: is there a system level solution? Ann Intern Med. 2006;144:861-862.
45. Jacobs WS, Repetto M, Vinson S, et al. Random urine testing as an intervention for drug addiction. Psychiatr Ann. 2004;34:781-784.
46. Shore JH. The Oregon experience with impaired physicians on probation. An eight year follow-up. JAMA. 1987;257:2931-2934.
47. Domino KB, Hornbein TF, Polissar NL, et al. Risk factors for relapse in health care professionals with substance use disorders. JAMA. 2005;293:1453-1460.
48. Gossop M, Stephens S, Stewart D, et al. Health care professionals referred for treatment of alcohol and drug problems. Alcohol Alcohol. 2001;36:160-164.
49. Gold MS, Frost-Pineda K, Melker RJ. Physician suicide and drug abuse. Am J Psychiatry. 2005;162:1390.
50. Talbott GD, Martin CA. Relapse and recovery: special issues for chemically dependent physicians. J Med Assoc Ga. 1984;73:763-769.
51. Gallegos KV, Keppler JP, Wilson PO. Returning to work after rehabilitation: aftercare, follow-up, and workplace reliability. Occup Med. 1989;4:357-371.
52. Morse RM, Martin MA, Swenson WM, Niven RG. Prognosis of physicians treated for alcoholism and drug dependence. JAMA. 1984;251:743-746.
53. Femino J, Nirenberg TD. Treatment outcome studies on physician impairment: a review of the literature. R I Med. 1994;77:345-350.
54. Herrington RE, Benzer DG, Jacobson GR, Hawkins MK. Treating substance-use disorders among physicians. JAMA. 1982;247:2253-2257.
55. Alpern F, Correnti CE, Dolan TE, et al. A survey of recovering Maryland physicians. Md Med J. 1992;41:301-303.
56. Boisaubin EV, Levine RE. Identifying and assisting the impaired physician. Am J Med Sci. 2001;322:31-36.
57. Gold MS, Frost-Pineda K, Goldberger BA, DuPont RL. Physicians and drug screening. J Adolesc Health. 2006;39:154-155.
DuPont RL, McLellan AT, White WL, et al. Setting the standard for recovery: Physicians’ Health Programs. J Subst Abuse Treat. 2009;36:159-171.
Gallegos KV, Lubin BH, Bowers C, et al. Relapse and recovery: five to ten year follow-up study of chemically dependent physicians—the Georgia experience. Md Med J. 1992;41:315-319.
White WL, DuPont RL, Skipper GE. Physicians health programs: what counselors can learn from these remarkable programs. Counselor: Mag Addict Prof. 2007; 8:42-47.