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When physicians struggle with substance use disorders, physician health programs are an important source of information and support. Certain medical specialties are at higher risk for substance use disorders than are others, and drugs of choice vary by specialty. Physician health and patient safety must be considered, but colleagues can help.
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.
As an SUD develops in a physician, difficulties are manifested in social, marital, financial and legal functioning before they occur in the practice setting (Centrella, 1994). Personality changes occur relatively rapidly in opiate and cocaine addiction and much slower with alcohol dependence, which develops over many years. The physician may become increasingly irritable and moody and may argue with staff and colleagues. As the disease progresses, patients are also included in the altercations. Absences from work or canceling office hours occur more frequently, especially after a major holiday weekend. Excuses include illness and financial or social crisis; however, the SUD is most likely the cause of the absence. The physician may be periodically unreachable during the day and then make rounds at unusual hours. Record-keeping may deteriorate. Problems may progress to obvious impairment at the work site including the odor of alcohol on the breath and obvious signs of intoxication. The physician may be intoxicated at social events or arrested either for a drinking and driving offense or as a consequence of drinking behavior. Eventually, the physician becomes socially isolated from colleagues and support systems.
It is considered best to confront the physician with a group of concerned colleagues, friends and family (Angres et al., 1998; Centrella, 1994; Verghese, 2002). Solo confrontation is rarely effective, and the physician may just disqualify that person's contention. Hospital committees or state PHPs may also prove helpful in the intervention. Techniques of motivation and persuasion have also been very promising (Merrill and Marlatt, 2002), although there is some disagreement as to which method is best.
Several clinical centers that specialize in treating physicians may be available locally. If not, there are national programs dedicated to the treatment of health care professionals. National centers provide increased confidentiality and increased objectivity that decrease the effects upon the physician's local reputation and professional relationships. These centers are experienced in working with a PHP in advocating for the physician with medical boards, other regulatory agencies, managed care and physician-employers. Some physicians, however, may respond better to local outpatient evaluation and treatment.
Physicians tend to respond well to SUD treatment. The recovery rate for physicians participating in PHPs with support and monitoring has been reported to be over 90% if allowance is made for a slip or a single brief relapse, usually at a time when the physician is not practicing. The recovery rate reported from a number of PHPs has been shown to be 70% or higher with abstinence as the criteria, and over 90% if persistent recovery and a return to premorbid functioning by returning to practice are used as the criteria to measure recovery (Mansky, 1993; Reading, 1992; Shore, 1987).
It seems obvious that physicians' motivation to maintain their license and lifestyle is a key to recovery. This may be a factor, but published data indicate that other independent variables may account for the high recovery.
Monitoring for drugs in the urine has been shown to increase the recovery rate of physicians compared to control groups of unmonitored physicians (Shore, 1987) and unmonitored middle-class patients (Morse et al., 1984). A program run by the Federal Aviation Administration for pilots with substance use issues, which utilizes monitoring and the ability to return to active professional activities (analogous to PHPs), also has reported a recovery rate above 90% (Pakull, 2002). Confidential treatment and the ability to continue or resume practice encourage physicians to accept the support of PHPs. These factors motivate physicians to seek treatment earlier and permit colleagues to refer with assurance that they are not destroying but preserving a fellow physician's career.
Mutual Support Groups
In addition to mutual support through traditional 12-step programs, physicians are encouraged to attend Caduceus groups and International Doctors in Alcoholics Anonymous (IDAA) groups. Caduceus groups allow for confidential mutual support, especially for discussion of professional, career and recovery factors (Angres et al., 1998). With both local meetings and annual international gatherings, IDAA is an organization of doctoral-level recovering health care professionals (IDAA, 2002).
Treatment and Advocacy
Advocacy is an important part of recovery in physicians and includes relating to medical boards, other regulatory agencies, managed care companies, malpractice insurance carriers, employers--even to civil and criminal court proceedings. Treating physicians with SUDs usually involves advocacy in various settings as well as in traditional clinical activities. The clinician must often report the physician's response to therapy to a PHP or a state medical board (Fayne and Silvan, 1999). The treating clinician may also be asked to testify before regulatory agencies or boards.
Physicians recovering from SUDs and returning to practice tend to do best with abstinence-based treatment (Centrella, 1994). At the present time, medical licensing boards, other regulatory systems, employers and insurance-related organizations do not have a positive valence in dealing with non-abstinent physicians who are recovering from SUDs. Consequently, harm-reduction approaches are utilized only for the nonpracticing physician. The positive results of abstinence-based opioid-addiction treatment in physicians contrast with the relative ineffectiveness of this approach with the general population of opioid addicts. There are only very rareincidences of physicians being treated for opiate addiction with methadone maintenance.
The prognosis of a physician treated for an SUD is excellent. The issue of physician recovery from an SUD introduces factors related to the interaction of the illness with the workplace as well as organizations and institutions related to the workplace.
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