Further, the physicians had significantly lower odds of lifetime use, but higher odds of lifetime abuse/dependence, for cocaine/crack cocaine and cannabis vs. the comparison group, as well as lower lifetime amphetamine use (OR, 0.21) with no difference in abuse/dependence vs. the comparison group, and lower odds of psychiatric disorders, including obsessive-compulsive disorder, major depression, and specific phobias.
While Dr. Gold and his colleagues concluded that more research is needed to understand psychiatric morbidity in physicians, and while physicians in certain specialties may have an increased likelihood of addiction in relation to exposure to drugs in the operating room setting, most physicians “get addicted in ways that are similar to others in the population,” Dr. Angres said: They have a pain problem, they get a drug like hydrocodone or other narcotic, they have a particular kind of experience that “goes above and beyond the pain management” (some individuals have a paradoxical effect in which they feel connected and energized, for example), and they become addicted.
The main drug of choice, even among physicians, is alcohol, he noted, explaining that stress is another common precipitating factor.
There is a definite relationship between stress and addiction; alcohol may be used to cope with stress, and those who are vulnerable to addiction can become dependent.
“Physicians are more stressed today than ever. The whole landscape of medicine, the economics of medicine means physicians have to see more patients and spend less time with patients,” Dr. Angres said, adding that factors like electronic medical records requirements and concerns about malpractice all contribute to increasing stress levels and are likely also increasing the rate of addiction and other forms of physician impairment or distress, including cognitive difficulties, depression, and anxiety.
Affected physicians, sometimes referred to as “disruptive physicians,” are increasingly a focus of programs and protocols to promote physician wellness.*
Northwestern and other high-level academic centers are “gearing up” for the problem. It is becoming more common for physicians to undergo screening when they are hired, and to undergo random screening to make sure they aren’t under the influence, he explained.
“And I also think that the medical community is much more attuned to detecting this and helping people gain access to proper assessment, rehabilitation, and reentry,” he added.
Treatment and outcomes
Treatment for physicians is often provided through state PHPs, some of which are under the umbrella of a licensing board or are part of a diversion program involving an autonomous entity.
“PHPs are really critical,” Dr. Angres said, explaining that they provide education, conduct research to help reduce malpractice claims, and ensure proper assessment of physicians, and they do long-term monitoring involving wellness checks.
While there is some controversy about the role of PHPs – some physicians have resented the monitoring, say they have felt coerced into participating, and have demanded more choice regarding treatment options – these programs are highly successful and data driven, Dr. Angres said.
“When the outcomes are clearly very good with a certain kind of protocol, you want to stick with that, particularly if public safety is involved,” he said, adding that these programs work because they are more supportive than punitive, they treat affected physicians for their disease, and they help physicians do what they need to do to safely reenter the practice of medicine.
Punitive programs would drive substance abuse/dependence problems underground, making them more dangerous, he said.
There is a great deal of debate about the appropriate duration of treatment, but most importantly, physicians should be with other physicians.
“What gets people sober is really being with other people who are sober,” he said, adding that a peer group of others with similar experiences and a similar life path is critical.
Twelve-step programs, which employ this principle as part of treatment and aftercare, result in better outcomes, and it is also crucial that physicians be treated by personnel who are experienced and conversant with working with physicians, because there are important factors necessary for successful reentry and engagement in the workplace.
Medications also are an important part of care, in many cases.
Dr. Gold’s research has long focused on the evaluation and treatment of impaired health professionals.
“After the discovery of the antiopiate withdrawal efficacy of clonidine, we tried an experimental medication – naltrexone – as a treatment for impaired health professional opiate addicts. … Naltrexone was both safe and effective. Injectable naltrexone is now widely recognized as a safe and effective treatment to prevent opiate relapse,” he said in an interview.
Naltrexone is particularly important for the treatment of addicted anesthesiologists, as they are at high risk of relapse when they return to work; their relapses are often overdoses after detoxification, he said.