Transcript SUBSTANCE ABUSE IN HEALTHCARE PROFESSIONALS

SUBSTANCE USE
DISORDERS IN
PHYSICIANS
Christopher Welsh M.D.
University of Maryland
School of Medicine
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“WHY SHOULD I
STAY AWAKE?”
It might be my colleague
 It might be my patient
 It might be me

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KEY POINTS
 SUDs similar to the general population
 Benzodiazepines and opioids higher
 Identification is often difficult and delayed
 Treatment outcomes are often better
 Impaired Physician Programs are helpful
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DEFINITIONS
Substance Use Disorders(SUDs)
 DEPENDENCE

Tolerance
Withdrawal

Inability to cut down/control use

Considerable time spent using/obtaining/recovering
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Important activities given up/reduced
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Use despite negative consequences
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 ABUSE (less severe)

Failure to fulfill role obligations
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Use in hazardous situations

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EPIDEMIOLOGY
 VERY VARIABLE!!!!

Population studied

Methods used

Terminology

Diagnostic criteria

Changes over time?

Concern about anonymity
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EPIDEMIOLOGY
General
 Similar rates of SUDs to general population

8-14%
 Less SUDs compared to other occupations

Roofers, painters
 Increased rates of use & SUDs with:

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Benzodiazepines
Prescription opioids
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EPIDEMIOLOGY
Medical Students
 Use begins prior to medical school
 Types of drugs same as general pop.
 Alcohol use & dependence variable
 Drug use and dependence less
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EPIDEMIOLOGY
Residents

Rates of dependence:10-14%
 Alcohol & illicit drug use begins prior
 Benzo & opioid use begins during


Self-treatment
Self-prescribed
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EPIDEMIOLOGY
Practicing Physicians
 Prevalence of dependence: 8-14%

Still means 60-75,000 affected M.D.s in U.S.!!!!
 Use & misuse of prescription opioids
& benzodiazepines up to 5Xs higher
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EPIDEMIOLOGY
By Specialty

HIGHEST
 LOWEST

Emergency Medicine

OB-GYN

Psychiatry

Pathology

Anesthesiology

Radiology

Pediatrics
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REASONS FOR USE
 Recreational
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Seen more in medical students
 Performance Enhancement

Seen more in Emergency Medicine
 Self-medication (pain, anxiety, “stress”)

Seen more in residents & attendings
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PROGRESSION
 Family
 Community
 Finances
 Spiritual/emotional
 Physical health
 Job performance

Often one of the last things affected
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CONTRIBUTING
FACTORS

Family History
 Personality characteristics
 Health/lifestyle
 Stress???
 Availability???
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IDENTIFICATION
 Urine drug screening
 Employment/school application
 Physician screening
 Impaired Physicians Programs
 Reporting
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“WARNING SIGNS”







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Isolation
Friction with colleagues
Disorganization
Inaccessibility
Frequent absences
Rounding on patients at odd hours
Inappropriate or forgotten orders
Slurred speech during off-hours calls
Prescriptions for family members
OD or suicide attempt
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WHY THE DELAY
IN DETECTION?
 Independence
 “Malignant denial”
 “I can take care of myself”
 “Knowledge is protective”
 Fear of consequences
 “Conspiracy of silence”
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“CONSPIRACY OF
SILENCE”
 Reputation
 Financial
 Fear & intimidation
 Professional pride
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REPORTING
 Ethical obligation
 Disabled Doctors Act
 Federal law
 Requirements vary by state
 Protection from law suit varies
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TREATMENT
THE GOOD NEWS!!!
 Variable data
 Most show better outcomes
 70-90% “success rate”
• little correlation with substance
• little correlation with specialty
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TREATMENT
Goals
 Abstinence
 Acceptance of chronic disease concept
 Identification of triggers
 Development of non-chemical coping
skills
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TREATMENT
Key Factors For Success
 Duration of aftercare
 Physician’s Health Program involvement
 Family involvement
 12-Step involvement
 Witnessed urinalysis
 Contingency contract
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TREATMENT
Stumbling Blocks
 Uniqueness
 Role-reversal
 Over-identification w/ performance
 Identification (by treatment provider)
 Medical knowledge
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TREATMENT
Physician-specific
 In-Patient

Talbott, Farley
 12-Step

“Caduceus meetings”
 Pros & Cons
 Combined approaches
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“RE-ENTRY”
 Most return to practicing medicine
 Change to a less high-risk specialty
 Imposed prescribing restrictions
 Altered work schedule
 Specialization in addictions
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“PREVENTION”
 Medical school policies
 Medical school education
 State Impaired Physicians Programs
• Protect the public
• Provide “rehabilitation” (vs punishment)
 JCAHO-mandated hospital programs
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KEY POINTS
A Review
 SUDs similar to the general population
 Benzodiazepines and opioids higher
 Identification is often difficult and delayed
 Treatment outcomes are often better
 Physician Rehab Programs are our friends
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WHERE TO GET HELP
State Agency
#
School Resources
#
Your email address
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NURSES
 Rates similar to general population
 Higher use of benzodiazepines & opioids

more parenteral use
 Higher in emergency room & critical care
 Especially difficult to monitor
 Watch for diversion
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DENTISTS
 Less good data
 More use of inhaled anesthetics
 Possibly higher opioid use and SUDs
 Related to higher suicide rate?
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PHARMACISTS
 Estimates of dependence: 10-18%
 Less parenteral use
 @ 50% have used CS w/o script


@ 20% on regular basis
primarily self-medication
 @ 60% of students have used CS w/o script
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@ 40% on regular basis
primarily recreational
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VETERINARIANS
 Little good data
 More Ketamine use
 Other higher-potency opioids
 Inhaled anesthetics
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