Physician Impairment and Substance Use Disorder

UNMC Psychiatry presentation

 

Physician Impairment

“The inability to practice medicine with reasonable skill and safety to patients by reason of physical or mental illness,
including deterioration through the aging process, the loss of motor skills, or the excessive use or abuse of drugs, including alcohol.”

 

AMA Code of Medical Ethics.

 

““…physical or mental health conditions that interfere with a physician’s ability to engage safely in professional activities...”

 

AMA Code of Medical Ethics.

 

AMA’s Code of Medical Ethics
Opinion 8.15

 

“It is unethical for a physician to practice medicine while under the influence of a controlled substance, alcohol, or other chemical agents which impair the ability to practice medicine.”

AMA Code of Medical Ethics.

  

AMA’s Code of Medical Ethics
Opinion 9.3.1 (b)

“Take appropriate action when their health or wellness is compromised, including:

(iv) seeking appropriate help as needed, including help in addressing substance misuse or substance use disorders. Physicians should not practice if their ability to do so safely is impaired by use of a controlled substance, alcohol, other chemical agent or a health condition”

AMA Code of Medical Ethics.

 

Alcohol Misuse

Alcohol misuse is a common response to unmanageable stress

Alcohol increases impulsivity and the risk of a suicide attempt

 

US Public Health Service, The Surgeon General's Call to Action to Prevent. Suicide. Washington, DC: 1999.

 

15-20% (1,2) of health care professionals will misuse substances at one point in their career

Alcohol – Most commonly used

Opioids & stimulants – Next most common

Recreational drugs (cannabis, cocaine) use is less than the general population

Men > women likely to misuse substances

Women have higher prevalence of alcohol use and choose alcohol over other substances

Female physicians have higher alcohol misuse rates than general population

 

Oreskovich MR, Kaups KL, Balch CM, Hanks JB, Satele D, Sloan J, Meredith C, Buhl A, Dyrbye LN, Shanafelt TD. Prevalence of alcohol use disorders among American surgeons. Arch Surg. 2012 Feb;147(2):168-74. doi: 10.1001/archsurg.2011.1481. PMID: 22351913.

 

Female Impaired Physicians

More likely to report past (51.8% vs. 29.9%; OR = 2.51) or current (11.4% vs. 4.8%; OR = 2.54) suicidal ideation

More likely to have made a suicide attempt whether under the influence or not

More likely to misuse sedative hypnotics than men (11.4 vs. 6.4; OR = 1.87)

Less likely to have family problems, specifically in the marital realm (OR 0.50; 0.32-0.76) and with their children (OR 0.52; 0.28-0.97)

Less likely to have a mandatory referral as a presenting problem at treatment (OR 0.61; 0.39-0.95) and less likely to have had loss of staff privileges (OR 0.46; 0.26-0.83)

No gender differences in employment problems (65.3% vs. 67.5%) or legal problems

 

By Specialty

Most studies have reported a consistently higher rate of drug and alcohol use in emergency room physicians, psychiatrists, anesthesiologists and physicians in solo practice

ER physicians – Cannabis (10.5 vs. 4.6%) and cocaine

Psychiatrists – Benzodiazepines (26 vs. 11%)

Anesthesiologists – Major opioids (although more have alcohol use disorders than opioid use disorders)

Pediatricians, pathologists, radiologists, and obstetricians and gynecologists have the lowest rates of substance use among physicians

 

Easy Access Creates Risk

Physicians have easy access to medications that can be misused:

When administering to patients

By self-prescription

Alcohol is available to physicians as it is to anyone in our society

 

Identifying Impairment

Family and marital problems (often occur first)

Financial issues, legal issues (DUI)

Work performance is typically not impaired until the more advanced stages (Can be 6-7 years from diagnosable SUD to treatment)

Physicians are likely to protect their work performance until the disease has neared the end stage

43% of opioid-using doctors had been using opioids for more than 2 years before detection

 

The physician with substance use disorder often retains the ability to protect his/her practice performance at the expense of other dimensions of life

Social, family, and emotional problems will often occur prior to practice impairment

No one sign signifies impairment

Collectively, however, they may define a pattern and provide warning that a potential problem exists

Early identification can help remediation and assure patient safety

 

Burden and Implications

Substance use disorder is very disabling among physicians

Addiction has been directly associated with physician suicide

Accidental death may occur while intoxicated

Patient safety

Substandard care by physicians also affects colleagues

Legal ramifications

Loss of job – Difficulty finding other jobs

Loss of medical license

Loss of DEA Registration Number

 

The Conspiracy of Silence Related to Stigma

The key barrier to intervention is denial:

By the impaired physician

By colleagues 

By family

By associates

Shame –

Physician as weak, selfish, bad person

Fear of Reprisal

Loss of prestige and livelihood

  

The Need for Intervention

Intervention may be necessary when an individual is either unaware of her/his addiction or, because of shame, fear, or denial, is psychologically unable to recognize the seriousness of the disease or the need to seek treatment.

Physical or mental illnesses often co-occur with  substance use disorders and requires intervention in their own right – Have to treat the whole person

 

Code of Medical Ethics
Opinion 9.3.1

When physician health or wellness is compromised, so may the safety and effectiveness of the medical care provided. To preserve the quality of their performance, physicians have a responsibility to maintain their health and wellness, broadly construed as preventing or treating acute or chronic diseases, including mental illness, disabilities, and occupational stress.

 

Collectively, physicians have an obligation to ensure that colleagues are able to provide safe and effective care, which includes promoting health and wellness among physicians.

 

State laws that require reporting of specified physician conduct to state agencies vary considerably by jurisdiction

 

AMA’s Code of Medical Ethics
Opinion 9.3.2

Providing safe, high-quality care is fundamental to physicians’ fiduciary obligation to promote patient welfare. Yet a variety of physical and mental health conditions—including physical disability, medical illness, and substance use—can undermine physicians’ ability to fulfill that obligation. These conditions in turn can put patients at risk, compromise physicians’ relationships with patients, as well as colleagues, and undermine public trust in the profession.

 

In carrying out their responsibilities to colleagues, patients, and the public, physicians should strive to employ a process that distinguishes conditions that are permanently incompatible with the safe practice of medicine from those that are not and respond accordingly. 

 

Steps for Intervening if Physician Addiction is Suspected
(Physicians Helping Physicians)

Contact the state  physician health program (PHP) Nebraska Does Not Have a PHP – Consider LAP or EAP

Recruit others to assist you (avoid having a conversation with the physician alone – Should not be a confrontation)

Express positive regard for the physician’s abilities (demonstrate respect for the individual)

Describe specific, observable problem behaviors of concern

Avoid accusation or blame; be kind and empathetic

Avoid negotiating, arguing, or bargaining (do not engage the individual in attempts to avoid the intervention)

Present a specific plan of action for assessment and treatment (consider working with the state PHP to develop a plan first)

Indicate clearly the consequences of not following through with the plan

Insist on immediate action; do not consider requests for “one more chance”

Provide for safe transition and transportation to the next step in the plan (typically, assist the physician in attending a professional assessment )

Activities of PHP for Physicians with Substance Use Disorders

Usually Required

Abstinence from all substances, including alcohol

Group therapy with other physicians with a professional facilitator

Individual psychotherapy

Mutual help meetings (Multiple times per week)

Body fluid screening, random as well as for cause (Multiple times per month)

 

Possibly Required

Psychiatry Care

PCP (No self prescribing and ask advice on OTC medications)

Family Therapy

Workplace limitations (No opioids or procedures with opioids)

Prescribing limitations

Work hours limited

Neurocognitive testing

Return to work evaluation, if disability requires several months’ absence