Addressing Substance Use Disorders in Physicians to Sustain Wellness
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SPECIAL REPORT: CLINICIAN WELLNESS
Clinicians are having a difficult time addressing the unreasonable demands of an increasingly broken health care system. Even before the COVID-19 pandemic, our rates of burnout were steadily rising to the point that more than half of physicians were reported to have at least 1 symptom of burnout.1 Physicians have one of the highest suicide rates of any profession, with female physicians being particularly vulnerable. A quarter to one-third of our students and trainees are reported to be suffering from clinical depression.
The pandemic exacerbated all these stressors, causing many doctors to quit, cut down, or “quietly quit,” yet this process has been gaining momentum for decades. Physician shortages are looming. As corporations buy up primary care practices, and as hospitals increasingly act just like avaricious corporations, doctors are increasingly feeling like cogs in someone else’s machine.
A related issue is that of physicians and addiction. Physicians become addicted to drugs or alcohol at least as often as members of the general population. It is thought that 10% to 14% of physicians suffer from addiction to drugs or alcohol during their careers.2 It is quite possible that the rates are even higher, as our current system of addressing this problem is punitive and dehumanizing, which, of course, incentivizes physicians to hide their addiction and to avoid any unwanted attention from the medical boards that often comes from seeking help.
I am a primary care doctor who is 15 years into recovery from a severe and life-threatening addiction to prescription opioids. During my addiction and my halting steps toward recovery, I learned about the challenges and obstacles that physicians face as they struggle with substance use disorders (SUDs). It was a nightmare. I had the state police and the US Drug Enforcement Administration (DEA) visit me in my office; I was booked and fingerprinted; I was saddled with 3 felony drug charges; and I lost my medical license for 3 years.
Once I was deemed to be in stable recovery, I was invited to become an associate director of our state’s physician health program (PHP). In this role, I sat at the exact same table where I sat 8 years previously—except this time I was sitting on the other side, helping other doctors who were struggling as I had struggled. Having participated in this issue from both sides, I have gained insight into how physicians become addicted, how they are treated, and how they try to heal and recover.
Who is Afflicted?
Are all types of physicians afflicted to the same extent? According to a 2014 article from the Journal of Dual Diagnosis3:
“Emergency medicine physicians, psychiatrists, and anesthesiologists are at higher risk for developing a substance use disorder compared with other doctors, perhaps because of their knowledge of and access to certain legal drugs.”
Other research suggests that anesthesiology residents have a particularly high risk of developing SUDs—often to injectable fentanyl—as well as a higher risk of subsequent relapse during their professional careers.4 However, it is important to note that addiction can affect any physician regardless of specialty, gender, race, or life circumstances due to the common stressors to which we are all exposed.
What Predisposes Doctors to Addiction?
In addition to the usual conditions that can predispose all individuals to addiction—family history, trauma history, undertreated anxiety and depression, poor distress tolerance—physicians have extra stressors that enhance our risk. For example, we have the added stress of trying to be good doctors in a profoundly broken system. Many of us face moral injury daily as we try to do what is right for our patients in the face of hospital and insurance policies that hamstring us. At the same time, we still have the same aggravating circumstances as non-physicians, such as depression, divorces, caring for older family members, illnesses, financial problems, and troubles with our children.
When these factors are added to our ready knowledge about and access to easily abusable prescription opioids and sedatives (not to mention alcohol), it creates a “perfect storm.” It starts slowly, and before you know it, you are withdrawing, afraid to get help, jonesing for more drugs, and feeling trapped. To ask for help is to risk bringing the medical board crashing down on your head.
How to Recognize Addiction in a Colleague
Doctors are great at hiding their addictions, especially from themselves. Usually there is no “smoking gun” (ie, someone smelling of alcohol, slurring words, nodding off, or getting caught injecting in a bathroom or swigging on a flask between patients). However, there are signs that something is wrong, be it addiction, depression, psychosis, or some other problem.
One might notice a relatively rapid decrease in a colleague’s competence at work, newfound tardiness, irritability, and/or deteriorating personal hygiene. A once-affable colleague might be isolating themselves, pushing others away, being quarrelsome, and/or keeping odd hours in the hospital. When I was addicted, I would return to my office to snort oxycodone by myself. In retrospect, it was lonely and miserable, but I could not stop.
What Do You Do if You Suspect Addiction in a Colleague?
According to the letter of the law, we are mandated reporters: We must report a colleague who is impaired to the medical board of our state or to the PHP (reporting to the PHP also discharges our mandated reporter duties). Many PHPs have “diversionary” programs in which, if there are no criminal charges or allegations of patient harm, physicians can get treatment without the board necessarily finding out about it.
There are other pathways. I truly believe it is in the spirit of the law to confront a colleague, with empathy, and to tell them, “I suspect you are impaired, and if you do not get help, I will have to report you. Let’s work on getting you help.” If your colleague truly will not get help, you may be forced to take the nuclear option, which is then to actually report them.
What are the Consequences of Addiction in Physicians?
Addictions tend to get worse as they progress, and this is almost universally true for physicians who are afraid to acknowledge that they have a problem and accept help. If untreated, an addiction may cost doctors their job, family, finances, and health. Addicted physicians can also harm patients—something that is exceedingly difficult to live with and can result in a devastating lawsuit. They can get into criminal difficulty, usually via illegal diversion of medications.
If you are struggling, the best thing you can do is find a trusted colleague or manager and confide in them, ask for help, and arrange to get the help you need.
How are Addicted Physicians Treated?
PHPs generally monitor and oversee treatment, and the treatment preferences are evolving. It used to be that everyone was sent to rehab for 90 days, in addition to a longitudinal program of support group meetings, drug testing, therapy, and work with an addiction psychiatrist. Doctors are “monitored” for 3 to 5 years and are eventually allowed to work again if the medical board feels they are in stable recovery and pose no threat to patient care. These days, there is less emphasis on rehab and more focus on intensive outpatient programs, in which one can receive plenty of group therapy, counseling, and care from addiction and other specialists.
Physicians who work with their PHPs and successfully compete their contracts generally have a good outcome, with 70% to 80% of doctors achieving stable recovery and being able to go back to work.5 Part of this is due to the leverage that is used against doctors like a blunt instrument. I was essentially told, “If you keep flunking drug tests, you will not go back to practicing medicine.” The success also has to do with the resources doctors have to throw at their problems and the long-term, coherent follow-up. According to 1 study, “Over the course of 5 years of care, 78% never had a single positive drug or alcohol test result and 72% were able to return to practice.”6 Not all doctors make it. Two of my colleagues overdosed and died lonely deaths, locked in bathrooms—both were anesthesiologists, as it happens.
How Can We Prevent Addiction in Physicians?
Doctors have to be recognized as individuals who struggle with the same challenges and problems as everyone else. We need all the institutions that we deal with to take this into account. For example, the medical boards snoop for mental illness and often include in their periodic renewal forms questions such as, “Have you taken a leave of absence in the last several years?” If a doctor can practice safely, this is none of the board’s business.
Next, the entire ecosystem of physician health has to become more supportive and nurturing and less punitive. Doctors need to be empowered to ask for help and have reasonable assurances that, by doing so, they 1) will get good help and 2) will not damage their careers beyond repair. A physician who is getting help and is being carefully monitored by their PHP is much safer for patient care than is someone who is afraid to get help.
Finally, we need to address the mental health challenges of our entire profession. If medical students and residents need time for therapy appointments, of course we need to grant this. If individuals need time off to deal with crises, this must be granted. We need to encourage individuals to ask for help—no more “physician, heal thyself.”
Most of all, we need to support our brothers and sisters in medicine, especially when they are faltering. There is no reason for us to buy into the stigma or judgment—we know better. We need to lift each other up, treat each other with compassion, and work together so that, once again, our profession will be a healthy, safe, and sane place in which doctors can flourish.
Dr Grinspoon is a primary care physician, educator, and cannabis specialist at Massachusetts General Hospital in Boston; an instructor at Harvard Medical School in Boston, Massachusetts; and a certified health and wellness coach. He is the author of the recent book, Seeing Through the Smoke: A Cannabis Expert Untangles the Truth About Marijuana , as well as the groundbreaking memoir Free Refills: A Doctor Confronts His Addiction. He is a board member of the advocacy group Doctors for Cannabis Regulation. He is also a TedX speaker and commonly lectures on the topics of cannabis, psychedelics, addiction, opioids, and physician health.
References
1. Loren D. Therapists in the patients’ chair. Psychiatric Times. August 15, 2022. Accessed November 27, 2023. https://www.psychiatrictimes.com/view/therapists-in-the-patient-s-chair
2. Flaherty JA, Richman JA. Substance use and addiction among medical students, residents, and physicians. Psychiatr Clin North Am. 1993;16(1):189-197.
3. Braquehais MD, Lusilla P, Bel MJ, et al. Dual diagnosis among physicians: a clinical perspective. J Dual Diagn. 2014;10(3):148-155.
4. Warner DO, Berge K, Sun H, et al. Substance use disorder among anesthesiology residents, 1975-2009. JAMA. 2013;310(21):2289-2296.
5. Buhl A, Oreskovich MR, Meridith CW, et al. Prognosis for the recovery of surgeons from chemical dependency: a 5-year outcome study. Arch Surg. 2011:46(11):1286-1291.
6. McLellan AT, Skipper GS, Campbell M, DuPont RL. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ. 2008;337:a2038.
