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 EthicsOpinion 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 EthicsOpinion 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 EthicsOpinion 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 EthicsOpinion 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