Over the past three decades, there has been a growing interest in the understanding and investigation of substance use disorders (SUDs) in physicians. Much of the literature has been based on clinical experience and anecdotal reports with only a small portion of the articles predicated on the systematic analysis of data. In recognition of this lack of data, representatives from various organizations concerned with physician health met in 1996 at the Physician Health Research Conference to define problem areas and set standards for research into this topic (Dilts et al., 1999). The organizations included the American Medical Association, American Academy of Addiction Psychiatry, American Society of Addiction Medicine and Federation of State Physician Health Programs (FSPHP), as well as centers that treat SUDs in physicians, groups of academic physicians and medical licensure boards. This effort has been continued by the FSPHP, an organization that has grown dramatically in the past 10 years.
Physician Health Programs
Physician health programs (PHPs) now exist in all states and most are members of the FSPHP (FSPHP, 2002). In 1974, the AMA encouraged states to develop programs in which physicians provide confidential support for their colleagues who suffer from an SUD and to increase patient safety (Goldman et al., 2000). Initially, the programs were peer networks of physicians suffering from an active SUD who were supported by physicians who were, themselves, in recovery. Today, most of the programs are run by professionals and address stress and other psychiatric illnesses of "disruptive physicians." Consequently, many of the programs have recruited psychiatrists with a subspecialty in addiction psychiatry to function as medical directors. Most importantly, PHPs provide the hope of successful recovery for participating physicians and their families.
Beginning in January 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) required hospitals to handle physician health separately from physician discipline. This mandate required hospitals to educate physicians and staff about physician impairment and to develop procedures to identify impaired physicians who should be referred for evaluation and treatment (Physician Health Services Inc., 2001). Many hospitals have received help from PHPs in enacting these requirements.
In 1992, one study utilized a mailed questionnaire to obtain the self-report of substance use and SUDs in a sample of 9,600 physicians, 8% of whom reported having an SUD during their lifetime, 2% during the past year (Hughes et al., 1992). This percentage appears low as compared to the prevalence of SUDs in the general population reported by the Epidemiologic Catchment Area study and the National Comorbidity Survey (Narrow et al., 2002). The latter two studies were conducted using structured objective interviews based on the symptomatology of SUDs as opposed to self-reporting the diagnosis or treatment. Recently, re-analysis of the structured studies discriminating for clinical significance to the subjects indicated a prevalence of SUDs in the general population more closely reflecting the prevalence in physicians found by Hughes et al. in 1992 (Narrow et al., 2002). In general, it is considered that the incidence of alcoholism in physicians is equal to that of the general population and that other SUDs may equally or slightly more frequently occur in physicians (Centrella, 1994).
The most common specialty participating in PHPs is internal medicine. Nearly 20% of reported state PHP participants are internists (Mansky, 1996). Anesthesiologists, family practitioners and psychiatrists each account for approximately 10% of the participants and emergency medicine physicians account for about 4%. The percentage of each specialty in PHPs does not indicate the risk for developing an SUD. This risk can best be obtained by comparing the percentage of the specialty in the PHP to the percentage of the specialty practicing in the state. This comparison has shown anesthesiology and emergency medicine to be the highest-risk specialties (Mansky, 1996). Note in the Table that physicians specializing in internal medicine make up 18.10% of the program's participants but have a low risk of only 0.74, whereas anesthesiologists make up 10.70% of the program but have a risk factor of 3.04, indicating that they are at high risk (Mansky, 1993).
The substance of choice used by most physicians is alcohol, followed by opiates and then cocaine. This hierarchy of choice is based on several studies, including Knisely and co-investigators' report of 1,601 physicians in four state PHPs over a three year period (2002), Mansky's analysis of 550 subjects in a PHP over seven years (1996), and Galanter and colleagues' study of 100 physicians successfully treated at a national center (1990). It is interesting to note that anesthesiologists differed in their drug-of-choice hierarchy: opioids were followed by alcohol and cocaine use. Physicians who were addicted to opioids most commonly used pharmaceutical opioids, with very few using heroin.
Angres DH, Talbott GD, Bettinardi-Angres K (1998), Healing the Healer: The Addicted Physician. Madison, Conn.: Psychosocial Press.
Centrella MC (1994), Physician addiction and impairment--current thinking: a review. J Addict Dis 13(1):91-105.
Dilts S, Goldman L, Shore J (1999), Physician Health Research Conference (Estes Park, Colorado--September 15-17, 1996): progress report one year later. Psychiatr Q 70(2):93-106.
Fayne M, Silvan M (1999), Treatment issues in the group psychotherapy of addicted physicians. Psychiatr Q 70(2):123-135.
FSPHP (2002), State program listing. Available at: www.ama-assn.org/ama/pub/category/6020.html. Accessed Nov. 24.
Galanter M, Talbott D, Gallegos K, Rubenstone E (1990), Combined Alcoholics Anonymous and professional care for addicted physicians. Am J Psychiatry 147(1):64-68 [see comment].
Goldman LS, Myers M, Dickstein LJ (2000), Evolution of the physician health field. In: The Handbook of Physician Health: The Essential Guide to Understanding the Health Care Needs of Physicians, Goldman LS, Myers M, Dickstein LJ, eds. Chicago: American Medical Association.
Hughes PH, Brandenburg N, Baldwin DC Jr et al. (1992), Prevalence of substance use among US physicians. [Published erratum JAMA 268(18):2518.] JAMA 267(17):2333-2339 [see comments].
IDAA (2002), International Doctors in Alcoholics Anonymous. Available at: www.idaa.org. Accessed Dec. 8.
Knisely JS, Campbell ED, Dawson KS, Schnoll SH (2002), Tramadol post-marketing surveillance in health care professionals. Drug Alcohol Depend 68(1):15-22.
Mansky PA (1993), A large established impaired physician program. Presented at the American Academy of Psychiatrists in Alcoholism and Addictions Fourth Annual Symposium. Palm Beach, Fla.
Mansky PA (1996), Physician health programs and the potentially impaired physician with a substance use disorder. Psychiatr Serv 47(5):465-467.
Merrill JO, Marlatt GA (2002), Health care workers and addiction. N Engl J Med 347(13):1044-1045 [letter].
Morse RM, Martin MA, Swenson WM, Niven RG (1984), Prognosis of physicians treated for alcoholism and drug dependence. JAMA 251(6):743-746.
Narrow WE, Rae DS, Robins LN, Regier DA (2002), Revised prevalence estimates of mental disorders in the United States: using a clinical significance criterion to reconcile 2 surveys' estimates. Arch Gen Psychiatry 59(2):115-123 [see comment].
Pakull B (2002), The federal aviation administration's role in evaluation of pilots and others with alcoholism or drug addiction. Occup Med 17(2):221-226, iv.
Physician Health Services Inc. (2001), JCAHO Requirement--MS.2.6 Physician Health. Available at: www2.mms.org/phs/jcaho-requirements.html. Accessed Dec. 27, 2002.
Reading EG (1992), Nine years experience with chemically dependent physicians: the New Jersey experience. Md Med J 41(4):325-329.
Shore JH (1987), The Oregon experience with impaired physicians on probation. An eight-year follow-up. JAMA 257(21):2931-2934.
Verghese A (2002), Physicians and addiction. N Engl J Med 346(20):1510-1511.