Physicians appear to have much greater odds of substance abuse and dependence disorders related to alcohol, opiates, and sedatives than their nonphysician counterparts, some estimates showed.
The good news is that physicians with substance abuse and addiction respond particularly well to treatment – so much so that experts have recommended that the treatment methods employed in specialized programs for impaired health professionals be disseminated and used in programs for the general public.
“In a nutshell, for a physician with addiction who goes to an appropriate program that has expertise working with physicians and then follows up with 5-year monitoring, the average rate of abstinence of about 80% is the polar opposite of that in the general population, Dr. Daniel H. Angres of Northwestern University in Chicago said in an interview.
At best, the abstinence rate after treatment is about 20% for the general population, said Dr. Angres, an addiction psychiatrist and medical director of the Positive Sobriety Institute in Chicago, who has spent more than 3 decades working with physicians and other health care professionals struggling with drug abuse and dependence.
The key is proper treatment in a setting with other health professionals and long-term monitoring; without both, the outcomes won’t be as good, he stressed. But Dr. Angres added that there is more to it than that. Often, the very factors that drive a person to become a physician and help that person succeed in the endeavor are the factors that can improve the odds of beating addiction, he explained.
Scope of the problem
Substance abuse and dependence in general are on the rise. This is true among physicians as well as the general public. Opioid use has been a particular problem. A 2008 review by Dr. Mark S. Gold , former chair of the psychiatry department at the University of Florida, Gainesville, and Lisa J. Merlo, Ph.D. , also of the university, noted that 12%-23% of physicians admit to prescription opioid use, compared with 1%-4% of nonphysicians ( Harv Rev Psychiatry. 2008;16[3]:181-94 ).
However, Dr. Angres said there are few data to suggest that physicians are at substantially increased risk of addiction.
“The rule of thumb is that addiction affects probably 1 in 10 people. We can comfortably say about 10% will have an addiction problem at some point in their lives,” he said.
But addiction is a disease with genetic underpinnings, and while there was a time when it was thought that perhaps physicians had greater risk because they had greater access, the playing field with respect to access has been leveled over time. There are no good data to suggest that more than 15% of physicians are affected, Dr. Angres noted.
That’s not to say certain specialties aren’t overrepresented among addicts, he added.
Anesthesiologists, for example, have been shown to have a greater risk of addiction – perhaps as a result of their having access to, and/or excess exposure to, drugs like fentanyl and propofol. In fact, the review by Dr. Gold and Dr. Merlo also noted an increasing trend for abuse of sublingual and intravenously administered analgesics among health care professionals. Not far behind anesthesiologists are surgeons, pain doctors, and emergency physicians, Dr. Gold said in an interview. “We have proposed a number of theories to explain this, from self-selection bias to selecting anesthesia because of student drug use to second- and third-hand occupational exposure risks.”
Meanwhile, another 2008 study by Dr. Gold, Dr. Merlo, and their colleagues demonstrated that chronic secondhand exposure to low doses of drugs such as fentanyl and propofol among health care professionals in the operating room might sensitize vulnerable individuals to the “rewarding effects of these drugs, placing them at higher risk for developing an addiction.” The authors concluded that the findings, while they served only as “preliminary support for an unproven hypothesis,” suggest a need for workplace protections ( J Addict Dis. 2008;27[3]:67-75 ).
Dr. Gold also led a more recent study comparing psychiatric and substance use disorders among physicians in a state Physician’s Health Program (PHP) with those in a general treatment population. He and his colleagues found that 99 physicians referred to the PHP for suspected impairment had similar lifetime use of alcohol, opiates, and sedatives as a group of age, sex, and education status–matched persons in a general treatment population.
However, the physicians had significantly higher odds of meeting DSM-IV criteria for abuse/dependence disorders related to alcohol (odds ratio, 2.56), opiates (OR, 86.58), and sedatives (OR, 54.76), the authors reported ( J Addic Med. 2013 Mar-Apr;7[2]:108-12 ).
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 “disrupted 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.
Five-year outcomes studies suggest that with appropriate treatment, outcomes are indeed excellent among physicians, compared with their peers. Two such studies, led by researchers from the Institute of Behavior and Health in Rockville, Md., respectively showed that 102 anesthesiologists treated and monitored under PHP supervision had excellent outcomes similar to those of other impaired physicians ( Anesth Analg. 2009;109[3]:891-6 ), and that 144 surgeons treated under PHP supervision had positive outcomes similar to those of nonsurgeons ( Arch Surg. 2011;146[11]:1286-91 ).
In their review article, Dr. Gold and Dr. Merlo concluded that for physicians overall, “appropriate intervention (e.g., typically in with the state PHP), methods of evaluation and treatment for addicted physicians are extremely effective. The combination of medical, psychosocial, and support group interventions, combined with extensive posttreatment monitoring and drug testing, generally results in sustained recovery among the physicians who attend specialized treatment programs. These outcomes are typically obtained even when physicians did not enter treatment voluntarily. Thus, it is likely that impaired professional programs represent the best treatment available for opioid use disorders, and nonphysician addicts would likely experience a similar benefit from participating in such a program.”
Dr. Angres agreed that physicians in general are “a good outcome group.”
“If treated and monitored appropriately, these are some of the best outcomes we see in addiction treatment,” he said.
Many factors are involved in the superior results among physicians vs. their nonphysician counterparts, he said, explaining that physicians tend to be particularly conscientious, hard-working individuals with good support systems and personality variables that allow them to persevere under difficult circumstances. They also have a great deal riding on recovery in terms of reentering the practice of medicine.
“So motivation is a big issue. … All of these things come together,” he said.
Changing trends
In addition to the stress-related factors that appear to be contributing to increased substance abuse and dependence, concerning cultural trends are emerging.
“We have an epidemic among young adults,” Dr. Angres said.
Heroin, prescription opiates, psychostimulants, binge drinking – all are occurring in epidemic proportions throughout our culture, including among the new generation of medical students and young physicians, he added.
“We are seeing for the first time, even in the last year or so, medical students, residents, and young adults who are addicted to drugs like heroin because it is so ubiquitous. So this is a new phenomenon. This is just a new reality. It’s not a massive problem [in medicine], but it is something that we’re seeing that we didn’t see before. … These are emerging issues that are disconcerting,” he said.
Dr. Gold also noted the changing trends, explaining that over the course of his career, substance misuse and dependence have emerged and changed.
“In the ’70s and ’80s, medical students rarely presented in need of treatment, but when they did, they had alcohol, tobacco, and benzodiazepine problems. Residents … had problems with prescription opiates, and many programs reported overdoses. More recently, medical students no longer smoke cigarettes. … Now it is marijuana,” he said, adding that binge drinking, club drugs, and psychostimulant abuse also are on the rise.
Students now are more like their peers and unlike their mentors with respect to drug misuse, use, and dependence, and there is an emerging concern that the most heavily involved students in terms of drug abuse and addiction will select one specialty or another based on drug access, said Dr. Gold, now professor (adjunct) at the University of Southern California, Los Angeles, and at Washington University in St. Louis.
“They often are surprised that the college of medicine, their patients, and professors do not accept as appropriate behavior the taking of another person’s [attention-deficit/hyperactivity disorder] medication, or smoking cannabis, or taking drugs for their mentees,” he said.
As for treatment in this new era of substance abuse and dependence, the approach remains much the same, Dr. Angres said, noting that medication-assisted treatment may be necessary for heroin addiction. A concern, however, is that the relapse rate may be higher.
“We don’t know what that will mean,” he said. “It will be years before we can see how it plays out with physicians with [heroin], but you do the same things, with perhaps some extra support above and beyond [the standard approach].”
Dr. Angres disclosed that he is part owner of the Positive Sobriety Institute, which treats addicted professionals, including physicians. Dr. Gold reported having no relevant financial disclosures.
