Impaired Physicians And Medicalworkers

Impaired Physicians And Medicalworkers

Concern about impairment from alcohol and drugs in health-care professionals in the United States and in other countries has waxed and waned during the twentieth century. Until the 1960s, ALCOHOL, the OPIATES, and other PRESCRIPTION DRUGS were the primary concerns. More recently, the concern was extended to MARIJUANA and COCAINE.

Although there are many estimates of addiction rates among physicians, the prevalence of alcohol and other drug problems within the entire health-care profession is unknown. Brewster (1986) reviewed published estimates of U.S. addiction rates among physicians and found that available reports were not adequate to support firm conclusions about the prevalence rates. Adding to the difficulty is the physician's ability of self-medication, and the fact that much of the detection of abuse to begin rehabilitation can come only after a voluntary confession.

Physicians (since we do have data on them) are as likely as their age and gender peers to have experimented with drugs—both licit and illicit. They are, however, less likely to be current users of illicit substances (Hughes et al., 1992). Self-medication by physicians has changed little since the 1960s, whereas the use of cocaine and marijuana has greatly increased (McAuliffe et al., 1986).

Figure 1 shows the results of three surveys of drug use among U.S. medical students. Substantial numbers of medical students come to medical training having had some experience with illicit drugs.

Disciplinary or diversion actions by health professionals' licensing boards and studies of health professionals who receive treatment for alcohol or drug dependency are additional sources of information about the kinds of problems caused by drugs and alcohol and their relative frequency.

It is widely believed that health-care professionals are especially vulnerable to problems of alcohol and drug abuse because of familiarity with and ready access to drugs, the high STRESS associated with patient-care responsibilities, and their own family problems may also contribute. Many physicians self-prescribe medications for relief of PAIN and ANXIETY. A 1989/90 survey of U.S. physicians found that 11.4 percent had used BENZODIAZEPINES and 17.5 percent had used minor opiates during the preceding year without medical supervision (Hughes et al., 1992a).

While the problem of drug addiction among health-care professionals is now widely acknowledged, such awareness has not always been the case. Impaired physicians and other health-care workers have been fearful of seeking help because they have not known how patients and colleagues might respond, which has become even more complicated since courts in numerous states have determined that physicians are not obligated to reveal their drug and alcohol practices to patients. Doctors also do not reveal their difficulties because they fear loss of practice privileges and licenses. Like many other professionals, physicians often feel uncomfortable about confronting drug or alcohol abuse in a colleague. They want to believe that a colleague in trouble will know when to seek help and will voluntarily seek it. The reluctance of physicians to report colleagues has been called a conspiracy of silence.

In 1972, the American Medical Association (AMA) Board of Trustees accepted the report of its Council on Mental Health and officially ended the conspiracy of silence by making physicians ethically responsible to recognize colleagues' inability to adequately practice medicine—an inadequacy that includes difficulties caused by drug or alcohol abuse. The council recommended a series of steps that should be taken if the impaired physician does not curtail practice: referral of the problem to the medical staff of hospitals in which the physician practices; referral to the state or county medical association; or, if other steps fail, referral to the licensing agency. In 1974, the AMA drafted model legislation allowing states' licensing agencies to require treatment and rehabilitation of impaired physicians as a condition of maintaining licensure. Before that time, the only possible response of the licensing agency was to discipline the physician. Since then, many state medical societies and licensing bodies have established programs for health professionals with alcohol or drug addiction.

In response to increasing malpractice, the U.S. Department of Health and Human Services established the National Practitioner Data Bank to collect information about malpractice and state-board licensing actions, hospital restrictions, revocation or denial of privileges, or denial of membership by a professional society. The purpose of the data bank is to prevent physicians from moving from state to state and continuing to practice without disclosing previous adverse actions against them. Hospitals must request information from the data bank when a physician applies for clinical privileges. The data bank prevents physicians with untreated alcohol or drug dependencies who have been disciplined in one state from practicing without restrictions in another state.

As a means of detecting drug and alcohol abuse, random urine testing is sometimes proposed for physicians and other health-care professionals. The AMA opposes routine urine testing because it intrudes on personal privacy and because a positive test does not establish impairment. Furthermore, drug- and alcohol-induced impairments are complex psychosocial and neurobehavioral problems that require a comprehensive clinical assessment, and neurobehavioral testing may better reflect the degree of impairment. Urine testing is useful for other purposes, though It is, for example, one of the best ways to document abstinence, which is an indicator of treatment progress.

DIFFERENCES IN PREVALENCE BY SPECIALTY

The choice of a particular drug and route of administration is influenced by accessibility and familiarity. Among anesthesiologists, for example, injectable fentanyl and its analogs are the most frequently abused opioids (see Table 1).

Although opioid addiction—and addiction treatment—among anesthesiologists has received frequent notice, the addiction rate among anesthesiologists may not be higher than among other physicians. Opiate abuse among anesthesiologists may be discovered more frequently because of the hospital environment in which they must practice. Interpersonal stress and the isolation of an office practice are believed to make psychiatrists particularly vulnerable to alcohol and drug abuse. The privacy of a solo office practice also makes detection difficult.

DETECTION OF ADDICTION

In hospitals, drug use by health-care professionals is often uncovered during inventory audits of medications, and the concealment efforts of impaired health-care professionals are often reflected in their treatment of or attitude toward patients. Some physicians who abuse prescription medications routinely overprescribe opiates or other drugs to patients in an effort to hide their self-prescription; others may prescribe unusually conservatively to avoid drawing attention to themselves.

TREATMENT

Many health professionals are pessimistic about the treatability of substance abuse, and if they develop an alcohol or drug problem, they may discount the value of treatment for themselves. Those who train or work in public-sector hospitals or clinics often observe that the treatment of their patients is rarely successful. Their perception is unduly pessimistic, however, because such clinics often treat recalcitrant, end-stage substance abusers. Furthermore, recent observation has seen medical care givers surpass all other professions as the most successful with intervention programs. This is possibly attributable to the ability of doctors to notice the difficulties in colleagues and the consequential early response.

The resistance to seeking treatment on their own often necessitates some form of coercion to force health professionals into treatment. One method of breaking down denial and forcing a person to seek treatment is called an intervention. The process consists of a group confrontation of the drug-abusing professional by concerned friends, family, and colleagues. A peer professional experienced in conducting interventions often assists in setting up the confrontation. The interventionist rehearses those who will be involved. When the stage is set, participants each tell the abuser what they have observed concerning the drug abuse and how it has adversely affected them. The confrontation, which may include threats to notify the abuser's employer, hospital, or state licensing board, may motivate an abuser to go for treatment. Such motivation is often fleeting, so it is important for the addict to go immediately into a treatment setting.

TREATMENT MODALITIES

Most treatment for impaired health professionals is drug-free and recovery-oriented, emphasizing follow-up participation in ALCOHOLICS ANONYMOUS (AA), COCAINE ANONYMOUS (CA), or other peer-led groups. Recovering physicians rate participation in AA, for example, as an important factor in their recovery. In most respects, treatment of addiction for health professionals differs little from that used for other middle- and upper-class patients. Health-care professionals who abuse prescription drugs often see themselves as being different from street-drug users. Some programs deal with this form of resistance by insisting on a uniform treatment for all patients. There are, however, special problems that must be addressed. For example, addicted physicians, unlike street addicts, often underreport their degree of PHYSICAL DEPENDENCE on a substance in an effort to project a false sense of being in control. A period of inpatient treatment is often required.

METHADONE MAINTENANCE, which has been employed successfully for some HEROIN (and other OPIOID) addicts, is generally not an option for practicing health professionals, since most licensing boards will not allow them to practice while taking methadone. NALTREXONE has been particularly successful with health-care professionals and is the only medication for treatment of opioid dependency acceptable to most licensing boards. The ingestion of naltrexone reassures licensing boards and hospitals that the recovering health professional is not impaired from abuse of opioids. Its lack of mood-altering effect also fits well with the drug-free treatment philosophy.

WORK REENTRY

Work reentry can be difficult for recovering health professionals. Those who have abused prescription medication face reexposure to their drugs of abuse, which could lead to relapse. Hospital and other professional privileges are not easily regained. Licensing boards often opt to revoke or restrict the impaired health professional's license to practice, and insurance companies often refuse malpractice coverage to recovering addicts.

Some of these obstacles can be overcome with planning and peer support. For example, a nurse may find employment in a blood bank or other setting in which there is no access to drugs. Also, a physician may make arrangements to have a colleague see all the patients that require a NARCOTIC, thus avoiding having to write narcotic-containing prescriptions. Reentry may involve redirecting the health-care practitioner's professional activities to a different location or area of treatment, restricting the recovering health professional's scope of practice, or removing him or her from the previous practice environment altogether. For many health professionals, return to full practice after a period of monitored abstinence and compliance with treatment is possible.

One matter that remains unnegotiable, however, is the safety of the public. Medical boards do find it is their responsibility to aid the physician in reentering the workforce, but not at the expense of the health of patients.

RESPONSE TO TREATMENT

Prognosis for physicians treated for ALCOHOLISM or drug dependency is generally favorable. A study comparing physicians with other middle-class patients similarly treated in an inpatient program showed that physicians did better. The California Physicians' Diversion Program reported a 69 percent success rate for anesthesiologists and an overall success rate of 73 percent. This success is attributed to regular attendance at group meetings, regular testing for sobriety, and immediate corrective action whenever a slip or relapse occurs.

Such high rates of success are not uniformly attained. In a survey of training programs for anesthesiologists, it was found that of the seventy-nine anesthesiology residents who returned to their specialty following treatment, only twenty-seven (34%) did not relapse—and of the fifty-two who relapsed, thirteen (25%) died of drug overdose (Menk et al., 1990).

Some medical specialties are more stringent than others in allowing recovering trainees to return. Minor slips that are often dealt with by additional treatment in some specialties are usually not acceptable in anesthesiology training programs. Therefore, comparison of recovery rates between treatment programs and different subgroups of physicians is difficult to impossible.

BIBLIOGRAPHY

AMA COUNCIL ON MENTAL HEALTH. (1973). The sick physician: Impairment by psychiatric disorders, including alcoholism and drug dependence, Journal of the American Medical Association, 223(6), 684-687.

BALDWIN, D. C., JR., ET AL. (1991). Substance use among senior medical students. Journal of the American Medical Association, 265(16), 2074-2078.

BREWSTER, J. M. (1986). Prevalence of alcohol and other drug problems among physicians. Journal of the American Medical Association, 255(14), 1913-1920.

FOUBISTER, V. (2000) Treatment alleviates impairments-if doctors get it. American Medical News, 43 (I) 13, 10.

GA. DOCTORS NOT REQUIRED TO REVEAL DRUG USE. Alcoholism & Drug Abuse Weekly April 17, 2000.

GALANTER, M., ET AL. (1990). Combined Alcoholics Anonymous and professional care for addicted physicians. American Journal of Psychiatry, 147(1), 64-68.

HANKES, L., & BISSELL, L. (1992). Health professionals. In J. H. Lowinson et al. (Eds.), Substance abuse: A comprehensive textbook. Baltimore: Williams & Wilkins.

HUGHES, P. H., ET AL. (1992a). Prevalence of substance use among U.S. physicians. Journal of the American Medical Association, 267(17), 2333-2339.

HUGHES, P. H., ET AL. (1992b). Resident physician substance use by specialty. American Journal of Psychiatry, 149, 1348-1354.

IKEDA, R. M., & PELTON, C. (1990). Diversion programs for impaired physicians. Western Journal of Medicine, 152, 617-621.

LING, W., & WESSON, D. R. (1984). Naltrexone treatment for addicted health-care professionals: A collaborative private practice experience. Journal of Clinical Psychiatry, 45(9), 46-48.

MC AULIFFE, W. E., ET AL. (1986). Psychoactive drug use among practicing physicians and medical students. New England Journal of Medicine, 315(13), 805-810.

MENK, E. J., ET AL. (1990). Success of reentry into anesthesiology training programs by residents with a history of substance abuse. Journal of the American Medical Association, 263(22), 3060-3062.

MORSE, R. M., ET. AL. (1984). Prognosis of physicians treated for alcoholism and drug dependence. Journal of the American Medical Association, 251(6), 743-746.

ORENTLICHER, D. (1990). Drug testing of physicians. Journal of the American Medical Association, 264(8), 1039-1040.

PELTON, C., & IKEDA, R. M. (1991). The California physicians diversion program's experience with recovering anesthesiologists. Journal of Psychoactive Drugs, 23(4), 427-431.

SWEARINGEN, C. (1990). The impaired psychiatrist. Psychiatric Clinology in North America, 13(1), 1-11.

TALBOTT, G. D., ET. AL. (1987). The Medical Association of Georgia's Impaired Physician Program, review of the first 1000 physicians: Analysis of specialty. Journal of the American Medical Association, 257(21), 2927-2930.

VAILLANT, G. E., BRIGHTON, J. R., & MC ARTHUR, C. (1970). Physicians' use of mood-altering drugs: A 20-year follow-up report. New England Journal of Medicine, 282, 365-370.

WESSON, D. R., & SMITH, D. E. (1990). Prescription drug abuse—patient, physician and cultural responsibilities. Western Journal of Medicine, 152(2), 613-616.

WESTERMEYER, J. (1988). Substance abuse among medical trainees: Current problems and evolving resources. American Journal of Drug and Alcohol Abuse, 14(3), 393-404.

DONALD R. WESSON

WALTER LING

REVISED BY ANDREW J. HOMBURG