Lisa J. Merlo, PhD, MPE

[[{"type":"media","view_mode":"media_crop","fid":"29558","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_9372358328473","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3061","media_crop_rotate":"0","media_crop_scale_h":"94","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]The recent focus on physician well-being has highlighted the prevalence of burnout, psychological distress, and “disruptive behavior.” However, the prevention and treatment of disruptive physician behavior has been limited by lack of empirical data. Disruptive behavior is a complex construct with no consistent definition. The AMA describes it as “personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care,” and the Joint Commission definition includes all “behaviors that undermine a culture of safety.”

Rather than a single incident, disruption generally refers to a pattern of negative behaviors that creates a hostile work environment and impedes patient safety. The most commonly reported behaviors include degrading comments, yelling, and refusing to work with other members of a health care team.

, disruptive behavior may fall along a continuum ranging from overly passive to overly aggressive. It is noteworthy that the label of “disruptive behavior” is not typically applied to expressions of concern or constructive criticism when expressed through appropriate channels.

 lists common consequences of disruptive behavior, including negative patient outcomes and problems for staff in their work environment.

 Disruptive behavior may contribute to patient consequences by interfering with necessary communication. One study documented that 64% of pharmacists would simply fill a questionable medication order rather than call to confirm it, to avoid interacting with a disruptive physician.

 Another study reported that 40% of health care professionals have been intimidated into silence regarding questionable medical practice or a potential error because the “offending” physician was disruptive.

 Unfortunately, although the prevalence of physician disruptive behavior is low (3% to 5%), the overall impact is significant, with up to 97% of physicians and nurses experiencing disruptive behavior in their workplace.

 As a result, there has been a call to examine and improve the identification and rehabilitation of distressed/disruptive physicians.

Identifying key risk factors associated with disruptive behavior may improve access to prevention programs or interventions. Clinical experience suggests that many factors contribute to disruptive behavior, including lack of emotional intelligence, lack of awareness, lack of clear boundaries, burnout, unhealthy conflict resolution strategies, substance abuse, poor social skills, medical conditions, and psychiatric distress. However, there is limited information in the literature about the prevalence of psychiatric disorders among physicians referred for disruptive behavior. Our study sought to examine the prevalence of psychiatric disorders among physicians referred to a state monitoring program because of disruptive behavior.

Following appropriate Institutional Review Board approval, charts for past and current participants in the state monitoring program were reviewed by the monitoring program staff to identify individuals referred for disruptive behavior. Information about the professionals’ demographics, professional specialty, and psychiatric diagnoses was collected, recorded, and shared with the research team. DSM-IV Axis I and Axis II diagnostic information was collected from evaluations conducted by board-certified psychiatrists or licensed psychologists approved by the monitoring program. Reports were based on inpatient or outpatient assessments that included diagnostic interview, psychological testing, and collateral reports. Frequency counts were completed for Axis I and Axis II diagnoses. V codes were not included in the analyses. Because of significant comorbidity and overlap, Axis II diagnoses were grouped by personality disorder clusters for analysis.

Although the monitoring program covers professionals from 28 licensing categories (eg, pharmacists, dentists, psychologists), 53 of the 54 professionals referred for disruptive behavior were physicians (52 MDs, 1 DO, 1 massage therapist). The professionals ranged from 29 to 65 years of age (mean, 47.0 years; SD = 8.2), and the majority were men (92.6%). Racial/ethnic background was not reliably reported for 31 (57.4%). However, 18 individuals (33.3%) were described as white, 3 (5.6%) were described as Asian, 1 (1.9%) was described as black, and 1 (1.9%) was described as Latino. The specialties of the physicians included primary care (n = 11, 20.8%), surgeon (n = 13, 24.5%), non-surgical specialist (n = 24, 45.3%), and unspecified (n = 5, 9.4%).

Thirteen subjects (24.1%) had no Axis I diagnosis. Thirty (55.5%) had one Axis I diagnosis, and 11 (20.4%) had multiple Axis I diagnoses. Fifteen (27.8%) had no Axis II diagnoses, traits, or features noted. Eighteen (33.3%) had a diagnosis, traits, or features from one personality disorder cluster noted, and 21 (38.9%) had multiple Axis II diagnostic clusters noted. The personality disorder clusters represented in the study population are presented in 

Across both Axis I and Axis II diagnoses, only 2 physicians (3.7%) had no diagnosis noted on either Axis I or Axis II. Conversely, 27 physicians (50%) had both Axis I and Axis II diagnoses, traits, and/or features noted. Thirteen physicians (24.1%) had only Axis I diagnoses, whereas 12 physicians (22.2%) had only Axis II diagnoses, traits, and/or features.

Most studies that have examined disruptive physician behavior have focused on its incidence and consequences. There are limited data on specific characteristics of physicians referred for disruptive behaviors. A study of physicians referred for boundary violations found that several met criteria for psychiatric diagnoses, such as mood disorders, adjustment disorders, personality disorders, and anxiety disorders.

 The current study demonstrates similar results among physicians referred for disruptive behavior. Specifically, it revealed high comorbidity of psychiatric disorders and disruptive behavior, with 96.2% of the participants in this study obtaining an Axis I and/or Axis II diagnosis, based on a comprehensive assessment by a qualified psychiatrist or psychologist.

Some important limitations should be considered. First, the retrospective nature of the study precludes meaningful conclusions regarding directionality of the link between psychiatric disorders and disruptive behavior. This is particularly a limitation for the diagnosis of adjustment disorder. It is unknown whether this diagnosis was a factor contributing to the disruptive behavior or a consequence of disruptive behavior. Another limitation was the restricted sample, which included participants from only one state’s monitoring program and consisted primarily of male physicians. Finally, because of the nature of the chart review, there was a lack of data regarding the reliability of the psychiatric diagnoses. Although the evaluators are all qualified professionals with expertise in assessment and diagnosis of psychiatric conditions, diagnostic classification is not completely objective.

Many barriers may prevent staff from referring a disruptive physician for intervention (

). Yet failure to do so compromises patient safety and does a disservice to the disruptive colleague who could benefit from appropriate intervention. This issue is particularly important for psychiatrists, since they may be able to suggest mental health treatment to a disruptive colleague before an adverse event occurs and they may be called on to intervene or evaluate a physician outside their own work environment in cases of disruptive behavior. Recognizing the association between psychiatric disorders and disruptive behavior may assist psychiatrists in identifying appropriate options for treatment and advocating for the disruptive physician to receive appropriate intervention.

When a physician is identified as potentially disruptive, a series of steps should be followed. First, the individual who is intervening (usually a supervisor) must confirm the facts of any concerning incidents. Second, the supervisor should discuss the event with the physician and explain that the behavior was not professional. Third, the supervisor should obtain assurances that the behavior will not recur. Fourth, it is extremely important to document the incident and follow-up conversation in the physician’s personnel file. Finally, the supervisor should closely monitor the physician’s behavior and follow up with observations.

There are 3 levels of disruptive behavior:

• Initial “mild” offenses, such as problems with attendance or charting

• A pattern of repeated low-level offenses or a single egregious behavior, such as throwing objects or inappropriate physical contact

• Behavior(s) that create imminent risk of harm to patients or staff, such as refusal to heed a clear warning that a medical error is about to occur

If a pattern of mild disruptive behavior develops, the physician may benefit from referral to a live continuing medical education workshop for distressed physicians and his or her behavior should be closely monitored. In more severe cases, referral to a physician health program (ie, state monitoring program) is indicated. The physician health program will be able to assist with the appropriate next steps to ensure patient safety and rehabilitation of the physician.

This study highlights the need to consider a holistic approach when discussing the problem of disruptive behavior in health care settings. Given the high prevalence of comorbid psychiatric diagnoses, it is likely that more attention to physician health and wellness could decrease disruptive behavior and its negative impact on quality and patient safety.

Psychiatrists may be in the best position to act as champions in this cause and to help colleagues recognize options for improved mental health. Disruptive behavior prevention programs should assess psychiatric distress and provide referral to treatment to reduce the overall incidence of physician disruptive behavior. Intervention programs include referral for psychiatric evaluation and treatment whenever physicians are referred for disruptive behavior. Finally, all physicians should be encouraged to seek professional care when their physical or mental health is compromised.

Funding for this study was provided by the Professionals Resource Network, Inc, an integral arm of the Florida Medical Association.

Dr Merlo is Assistant Professor in the department of psychiatry, University of Florida, and Director of Research at the Professionals Resource Network, Inc. Ms Sutton is a psychology resident in the department of psychiatry, University of Florida. Ms Conwell is the Chief Administrative Officer at the Professionals Resource Network, Inc. Dr Brown is an Associate Professor in the department of psychiatry, University of Florida, and Assistant Medical Director at the Professionals Resource Network, Inc. The authors report no conflicts of interest concerning the subject matter of this article.

 American Medical Association. Opinion 9.045-Physicians with disruptive behavior. 2000. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion9045.page. Accessed October 23, 2014.

 The Joint Commission. Leadership standard clarified to address behaviors that undermine a safety culture. 2012. http://www.jointcommission.org/assets/1/6/Leadership_standard_behaviors.pdf. Accessed October 23, 2014.

 Reynolds NT. Disruptive physician behavior: use and misuse of the label. 

 Stecker M, Epstein N, Stecker MM. Analysis of inter-provider conflicts among healthcare providers. 

 Rosenstein AH, O’Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. August 2008. http://www.mc.vanderbilt.edu/root/pdfs/nursing/ppb_article_on_disruptive.pdf. Accessed October 24, 2014.

 Saxton R, Hines T, Enriquez M. The negative impact of nurse-physician disruptive behavior on patient safety: a review of the literature. 

 Rosenstein AH, O’Daniel M. Impact and implications of disruptive behavior in the perioperative arena. 

 Felps W, Mitchell TR, Byington E. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. 

 Brooks E, Gendel MH, Early SR, et al. Physician boundary violations in a physician’s health program: a 19-year review. 

Articles

This study highlights the need to consider a holistic approach when discussing the problem of disruptive behavior in health care settings.

Psychiatric Conditions Affecting Physicians With Disruptive Behavior

Many barriers can prevent physicians who have a substance use disorder from obtaining the help they need. Here, signs, symptoms, and intervention steps. The Tipsheet below can apply to anyone struggling with addiction but is especially sensitive to physicians in the workplace. For intervention strategies, 

TIPSHEET: SIGNS OF PHYSICIAN SUBSTANCE ABUSE IN THE WORKPLACE

â  Tardiness or absenteeism; frequent breaks; missed appointments

â  Charting mistakes, medical mishaps

â  Rounding at inconsistent times; volunteering for extra shifts

â  Missing or broken vials; failure to document wastage, or have wastage witnessed

â  Paying extra attention to patients receiving mood-altering drugs

â  Volunteering to give medications to patients

â  Asking peers to prescribe for them; obtaining prescriptions for family members

â  Obtaining prescriptions "for family members

â  Recurrent nonspecific health problems; flu-like symptoms

â  Changes in sleep or eating patterns; weight loss or gain

â  Appearance of oversedation; bloodshot or watery eyes

Lack of coordination; hand tremors; stumbling

Alcohol detectable on breath; long sleeves in hot climate (to hide injection sites)

â  Changes in appearance; decreased hygiene

â  Decreased social interaction with colleagues; isolation

â  Conflicts with staff, patients, peers

â  Excessive drinking/intoxication at social events; embarrassing or inappropriate behavior

â  Depression; pessimism; hopelessness; suicidal ideation

â  Over-emotional; appearing overwhelmed

Any warning signs listed in the above Tipsheet should be considered sufficient evidence to warrant an immediate intervention. For intervention techniques, 

Typically, the first step in the successful treatment of a physician with a substance use disorder is diagnosis and referral to a Physician Health Program (PHP). Cooperation with the PHP generally prevents the physician from experiencing punitive measures. In addition, many states protect the confidentiality of physicians who willingly participate in the PHP and do not require that a report be made to the Board of Medicine.

Guidelines for making such a referral are outlined in the following Tipsheet. The physician with a substance use disorder is most likely to be successful in a treatment program in which the staff members are familiar with treating health care professionals.

TIPSHEET: INTERVENTION STEPS IN THE CASE OF SUSPECTED PHYSICIAN ADDICTION

â  Contact the state physician health program (PHP)

â  Avoid confronting the physician alone; recruit others to assist you

â  Acknowledge the physician's abilities and demonstrate your respect for the individual

Describe specific, observable problem behaviors of concern; consider using a script to assist with this step

Avoid accusation or blame; be kind and empathic

â  Avoid negotiating, arguing, or bargaining

â  Do not engage the individual in attempts to avoid the intervention

â  Present a specific plan of action for assessment and treatment; consider working with the state PHP to develop a plan first

â  Indicate clearly the consequences of not following through with the plan

â  Do not be afraid to use coercion. It works!

â  Insist on immediate action. Do not consider requests for "one more chance"

â  Provide for safe transition and transportation to the next step in the plan

â  Typically, assist the physician in attending a professional assessment

Successful Treatment of Physicians With Addictions

," by Lisa J. Merlo, PhD, and Mark S. Gold, MD, from which this Tipsheet was adapted.

Tragic Trends in the Treatment of Addictive Illness

The Neurobiological Development of Addiction

Many barriers can prevent physicians who have a substance use disorder from obtaining the help they need. However, in many states, all is not lost for physicians who willingly participate in treatment. Here, signs, symptoms, and intervention steps.

Tipsheet: Physician Substance Abuse in the Workplace

Physicians generally display better health and have lower rates of all-cause mortality than the general population.

 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.

 Addiction impairs more physicians than any other disease.

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.”

 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 cigarettes

 rates of prescription drug abuse are higher among physicians.

 Currently, more attention is being paid to this important issue, particularly within the field of anesthesiology.

 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.

Building on research involving the role of reward neurocircuitry in addiction,

 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.

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.

 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.

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.

In addition, drug abuse has been directly associated with physician suicide,

and accidental death may occur during periods of intoxication. The physician may also encounter legal difficulties secondary to substance use (eg, for driving under the influence or for domestic violence)

 or risk the loss of his job or medical license.

Hospitals and clinics are put at risk because intoxication is likely to compromise the physician’s ability to provide competent care. Further, colleagues may provide substandard care as the result of incomplete or inaccurate charting by the impaired physician. Because patient safety must always be considered paramount, co-workers must take responsibility for the identification of physicians with addiction.

 Identification of the problem represents the first step toward recovery.

Despite the many reasons to seek or encourage treatment, however, many barriers can prevent physicians who have a substance use disorder from obtaining the help they need.

 First, a hallmark symptom of addiction is denial, which may be magnified in physicians, because they typically use sophisticated methods of rationalization and may develop elaborate justifications for their behavior. Many physicians have received little education regarding the nature of addiction and may falsely believe that they can manage the disease on their own. Personality traits, such as self-reliance, independence, and perseverance-which contribute to physicians’ occupational success-may lead either to dismissal of the problem or to attempts at self-treatment.

Many physicians with an addiction disorder are adept at hiding their addiction, and the problem can be difficult to identify. Unfortunately, even physicians who recognize their impairment may be reluctant to seek treatment because of concerns about the negative consequences of being identified. The perceived risks of seeking treatment may outweigh the perceived benefits for some, particularly when the physician feels as though he is still able to practice competently.

Physician colleagues have moral, ethical, and legal obligations to report any coworker whose impairment threatens patient safety,

 but the disease is progressive and typically does not impair work performance until the more advanced stages.

 Thus, impairment observed in the workplace suggests a serious problem. Workplace warning signs listed in 

 should be considered sufficient evidence to warrant an immediate intervention.

Colleagues and family members may be hesitant to report a physician in whom they suspect drug or alcohol addiction because of concerns about the ramifications of making such a report.

 Physician colleagues should note that it is not necessary to be certain of the exact DSM-IV diagnosis before making a referral; attempts at diagnostic certainty may delay treatment and can put the physician’s colleague in the uncomfortable role of detective.

The avoidance of “punishment” and the promotion of “treatment” is critical to the success of programs for physicians who have an addiction disorder. Most states now have a Physician Health Program (PHP) to assist with the treatment of drug and/or alcohol abuse in physicians, and cooperation with the PHP generally prevents the physician from experiencing punitive measures. In addition, many states protect the confidentiality of physicians who willingly participate in the PHP and do not require that a report be made to the Board of Medicine.

Typically, the first step in the successful treatment of a physician with a substance use disorder is diagnosis and referral to a PHP. Guidelines for making such a referral are outlined in 

. The physician with a substance use disorder is most likely to be successful in a treatment program in which the staff members are familiar with treating health care professionals. These environments foster acceptance of the diagnosis and are helpful in reducing shame because of the presence of peers. However, it is not advisable to attempt treatment for a physician with an addiction within his own medical community. Transference issues, concerns about limits of confidentiality, and personal bias can interfere with disclosure and limit-setting or can create professional conflicts.

Dr X is a 45-year-old anesthesiologist with no family history of addiction. He denied smoking, but endorsed occasional drinking (typically fine wines) as well as experimentation with marijuana during college. An honors student throughout high school and college, Dr X went on to medical school and was selected for a very competitive anesthesiology residency program. During residency, he was routinely evaluated as one of the top trainees and went on to join a major anesthesiology group. Ten years into practice, he first self-administered sufentanil intranasally. Within 3 days, Dr X had progressed to self-injecting up to 30 mL of sufentanil per day. As a result, he would awaken with symptoms of withdrawal at 3 am every day. After injecting, he would go to work. After more than 6 months of daily use, he overdosed in the hospital. He was stabilized and admitted to a center specializing in the treatment of chemically dependent professionals. After 3 months of inpatient treatment, Dr X was discharged; he continued to be monitored by a state PHP under a 5-year contract. The contract included agreement to frequent random urine testing (results of all tests were negative) and participation in outpatient support groups. Dr X has been in recovery for more than 5 years and is currently practicing addiction medicine.

Our PHP program and many like it are led by recovering physicians certified in addiction psychiatry or addiction medicine. For treatment to be most successful, the initial evaluation should focus on assessing drug and alcohol abuse, as well as getting the physician into a facility that can evaluate him over time and throughout detoxification and early recovery. Although suicidal ideation and suicide planning should be assessed, the initial psychiatric evaluation is often complicated by drug intoxication or withdrawal effects, shame, and guilt. Subsequent evaluations should include postdetoxification assessment for comorbid psychiatric conditions.

 The prevalence rate of comorbidity is estimated to be 25% to 75% among physicians with addictions,

and comorbidity may affect treatment planning and prognosis.

Following the assessment, the addiction specialist/team makes recommendations regarding the setting and conditions of treatment. Since physicians with a substance use disorder are not typical of addicts in general, it is not useful to apply standard professional guidelines (eg, the American Society of Addiction Medicine dimensional assessment guidelines

). Rather, because of the public health consequences of relapse, most physicians who are addicted are treated more aggressively and for longer periods than are nonphysicians. Ideal evaluation and treatment most often occur in a specialized program for professionals. For some, detoxification is needed, but it is not sufficient for treatment and recovery.

Physicians will lobby for a level of care that minimizes the disruption of their daily life. However, it is generally not advisable to grant the physician’s request for treatment in the least restrictive environment, but rather to maximize the treatment dose and duration to improve effectiveness and reduce the likelihood of relapse and further damage to health, family, and the ability to practice. Depending on the response to treatment, physicians typically undergo 3 to 6 months of intensive treatment in a structured program and 5 years of urine testing with controlled, contingency-managed outpatient follow-up.

While in treatment, physicians participate in a number of therapeutic activities designed to help them understand and accept their addiction, implement and maintain sobriety, repair relationships, prevent relapse, and facilitate their return to productivity. Sobriety, while essential, is not in any way synonymous with recovery. Typically, attendance at educational lectures is complemented by participation in both individual and group cognitive-behavioral therapy sessions. Group dynamics can be a powerful component of treatment by providing the physician with additional opportunities to confront denial and learn from the experiences of others.

In addition, it is beneficial for physicians to participate in a regular “professionals” meeting, which is moderated by an addiction specialist and is attended by professionals living in the community who have successfully completed treatment and are in recovery. This experience provides those in treatment with encouragement and hope as well as role models who can be mentors in the recovery process. Family programs and family therapy are typically considered essential to treatment as well.

 In fact, psychological treatment may also be recommended for the children of physicians with addiction.

Introduction to a 12-step recovery program such as Alcoholics Anonymous or Narcotics Anonymous is important to the maintenance of sobriety in the future, and it helps the recovering physician to develop a support network. Research has repeatedly demonstrated the effectiveness of this approach.

 However, it should be noted that referral to Alcoholics Anonymous is less effective than intensive treatment, even if participation in the intensive program is forced.

 As a result, participation in a 12-step program should be viewed as part of a more comprehensive treatment plan.

In order to successfully return to practice after the intensive treatment program, it is imperative that the physician undergo a full performance-based assessment of his competency to complete job-related tasks in his specialty. The evaluators should feel confident that the physician has the ability to practice with “reasonable skill and safety” before the physician is allowed to return to work. In addition, the physician and treatment providers should collaborate with their state’s PHP to develop a contract specifying the conditions for retaining his medical license. Research has demonstrated that the medical license may be useful as a bargaining chip in helping the physician to maintain sobriety.

 lists several key components that should be included in a PHP “return-to-work” contract.

Most physician treatment programs use time in treatment, residential care, contingency management, Caduceus meetings, urine testing, cognitive-behavioral therapy, life skills, and stress management; however, they generally do not use medications. Medications can be helpful and added to contracts in cases of recidivism. We have used acamprosate, naltrexone, and buprenorphine in some physicians to facilitate treatment. However, while naltrexone may prevent relapse in opioid-dependent physicians, it does not replace learning how and why to say no.

 Methadone treatment is not generally recommended by PHPs for physicians who have an addiction disorder.

Finally, with the addition of 5 years of treatment and urine testing, most addiction-treatment programs for physicians report 5-year sobriety, return to work, and return to function of greater than 70%, even for physicians who are addicted to crack cocaine or opioids.

 Outcomes are defined over a 5-year period and confirmed by random drug screening. A program without random drug testing may not even exist in the United States. We see testing as an essential component of continued treatment for the recovering physician

 and the earliest warning sign that the physician is in need of more or different treatment.

Urine testing, coordinated by treatment contract with contingency management, is supervised by the PHP. In many states, the physician calls an 800 number daily and is randomized to urine test or no test but given at least 1 urine test weekly. This behavioral intervention is a powerful tool in keeping the disease and the consequences of use in the present.

 Research has shown that 96% of physicians who undergo urine testing remain drug-free, while only 64% of those who are not subject to testing maintain their sobriety.

 Drug screening should include personalized testing for the drugs most commonly used by the physician. In addition, blood tests or hair testing may prove beneficial.

Fortunately, with appropriate treatment and adequate monitoring, the prognosis for physicians recovering from addiction is quite good. Sustained recovery may be negatively affected in physicians with comorbid psychiatric disorders, and prognosis is worse for those who have a family history of addiction, abuse opioids, or use multiple drugs.

 Environmental exposure to potent opioids may be a factor in determining relapse.

 Additional factors that contribute to relapse include inadequate coping skills, interpersonal skill deficits, family dysfunction, continued denial regarding the nature and severity of addiction, overconfidence, and shame and/or guilt.

Research repeatedly has shown that physicians generally fare much better than the general public following addiction treatment.

 Although accommodations may be needed (eg, decreasing hours or eliminating night shifts),

 approximately 75% to 85% are able to return to work,

 do not use drugs, and lead a productive life.

 As a result, it has been suggested that this PHP treatment approach (including drug screening

) should be implemented as the standard of care for all individuals with suspected addiction, not just physicians.

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Physicians generally display better health and have lower rates of all-cause mortality than the general population. However, their education, nutrition, and lifestyle do not offer similar protection from substance abuse and dependence.

The nation's leading causes of death are related to alcohol and drug use, tobacco smoke exposure, and behavioral addictions. Each year, more than 400,000 Americans die as a result of smoking, overeating, substance use, and related accidents and suicide. In addition, the comorbidity of addictions and psychiatric illnesses (ie, dual diagnosis) is quite common. Approximately 29% of those with a psychiatric disorder and almost half of those with severe mental illness (eg, schizophrenia) have a lifetime history of addiction.

 As a result, addiction-related prevention, research, and treatment have remained important areas of concentration in the field of psychiatry.

There are significant individual differences in drug experimentation, drug(s) of choice, susceptibility to addiction, prognosis following intervention, and likelihood of relapse. Over the past few decades, there have been notable advances in the identification, prevention, and treatment of addiction disorders. For example, it was not until DSM-III-R that cocaine was listed as a potential substance of abuse, but this discovery expanded the focus of addiction research and treatment beyond specific physical withdrawal symptoms. More recently, animal models have improved and research is currently under way with addicted rats.

 In addition, advances in neurobiology and imaging, proteomics, nanotechnology, pharmacology, and behavioral research have impacted the addiction field. This article highlights many of the latest developments in addiction research and focuses on those with a clear application to psychiatric practice.

Influence of neurobiology and neurotransmitters

Several components of the neurological reward system (eg, the nucleus accumbens, the ventral tegmental area, and the neurotransmitters [particularly dopamine]) have been implicated in addiction. For example, release of dopamine in the nucleus accumbens is associated with craving for cocaine and drug-seeking behavior.

 Similarly, morphine, cannabis, nicotine, and ethanol administration result in increased dopamine release in the nucleus accumbens.

 They are also associated with molecular adaptations in dopamine transporters, as well as opioid, g-aminobutyric acid (GABA), and nicotinic cholinergic receptors throughout the brain.

 In addition, the brain's endogenous opioid and cannabinoid systems, within the pathway connecting the ventral tegmental area and the nucleus accumbens, are activated by several drugs of abuse.

 Increased glutamate release in the pathway connecting the prelimbic cortex to the accumbens is associated with drug-seeking behavior.

 With regard to tobacco, findings from recent research indicate that patients with damage to the insula (an area associated with consciously experiencing an urge) were able to immediately quit smoking, without the typical urges and relapses that usually characterize smoking cessation.

Research findings indicate that individual differences in sensitivity to substances of abuse may be affected by genetic factors and early environmental factors, and strong interactions between the cannabinoid and opioid systems within the brain may produce cross-sensitization of neurons following exposure to substances of abuse.

 Several pharmacological interventions for the treatment of addiction and the prevention of relapse target these neurotransmitters and their receptors.

When considering the possibility that all addictions represent 1 disease, one would expect a common neurobiology, as well as transposable treatments that might work for multiple addictions. For example, naltrexone was used in the 1970s for opioid relapse prevention and has been subsequently used to treat alcohol dependence, gambling, compulsive eating, and other addictions. Drug self-administration represents an acquired drive that results in use despite pain and suffering; it appears to be caused, in part, by pathological learning and preoccupation with the substance. This may help to explain the mechanisms of action in complete blockers such as naltrexone, partial agonists such as buprenorphine, and agonists such as methadone. Research continues to identify brain events associated with pleasure, which may shape behavior and the development of addiction.

Neuroimaging with MRI, magnetic resonance spectroscopy, positron emission tomography (PET), single photon emission CT (SPECT), and functional MRI scanning has helped to confirm that addiction is a disease marked by changes in brain structure and functioning, as well as behavioral correlates. In their review of the literature, Fowler and colleagues

 noted that structural abnormalities in the frontal cortex, prefrontal cortex, basal ganglia, and amygdala have been associated with abuse of various substances. Similarly, they reviewed functional imaging studies, which have demonstrated that the caudate nucleus, cingulate, and prefrontal cortex become activated during a drug "rush," whereas the nucleus accumbens becomes activated during periods of craving. PET and SPECT studies have highlighted the role of striatal dopamine in drug-related reward and addiction.

The dopamine spike that causes the pleasurable drug-related "high" is believed to attenuate drug users' ability to experience pleasure in other activities.

 In addition, findings from recent studies indicate that drug effects are long-lasting and recovery is slow and difficult. Imaging may also be useful in determining the likelihood of relapse in patients, which may have implications for treatment recommendations.

Risk factors for alcohol dependence have been well studied, and many scientists expect that genes for alcoholism risk will be identified in the near future. However, early alcohol exposure and binge drinking appear to play a critical role in the development of alcohol dependence. Similarly, early brain exposure to drugs of abuse (whether in utero or through secondhand exposure) may sensitize the brain, making abuse and dependence more likely. For example, parents who drink alcohol inadvertently teach their children to identify the smell of their favorite alcoholic beverage. Mothers who smoke frequently have children who smoke, which may be associated with early secondhand smoke exposure.

In an animal model, rats that were exposed to tetrahydrocannabinol during adolescence showed higher levels of opioid self-administration during adulthood than rats that had not been exposed.

 In humans, correlational twin studies have shown that regular use of marijuana during adolescence is associated with use of other illicit drugs in the future.

Drugs of abuse cause specific interactions within the brain's most primitive and salience-provoking systems. They change the brain and can produce disease where none would have been without early use or exposure. Although the "gateway hypothesis" describes the progression from tobacco/marijuana use in adolescence to later abuse of "hard" drugs via attitude changes, it is possible that the earlier tobacco or marijuana use actually sensitizes the brain, making it remember the effects of drug use, and making it more susceptible to abuse of other drugs in the future. Indeed, preliminary research shows that anesthesiologists who experience long-term secondhand exposure to extremely low doses of opioids in the air of the operating room are at increased risk for opioid addiction.

Addiction-related prevention, research, and treatment have remained important areas of concentration in the field of psychiatry.

Lisa J. Merlo, PhD, MPE

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