• Comment on the Emergence of Addiction Medicine as a Challenging Field
• Define the terms Addictive Disease and Impaired Physician
• Describe Studies of Prevalence of Addiction in Physicians and Medical Students
• Mention Variable in Outcome Studies
• Present Outcome Studies from 5 Hospitals
• Describe Physician Health Committees and Studies from 6 PHCs
• Describe Work of UH PHC from 1994-2000

• Like much of modern medicine, this talk couldn’t and wouldn’t have been given three decades ago
• No one I knew from Bellevue wanted to treat drunks
• Reputedly, only dry drunks treated drunks
• Drunks rarely got better (neither did diabetics or cystic fibrosis pts)

• Disease Concept of Addictions takes hold
• Insurance started to cover addictions
• Addictions Industry begins 1970s
• American Society of Addiction Medicine
• American Academy of Psychiatrists in Addictions, 1984

• American Society for Addictive Medicine
• Impaired Control over Use
• Preoccupation with Use
• Continued Use Despite Known Adverse Consequences
• Distortion of Thinking, notably Denial

• Landmark Report by AMA in 1973 on "The Sick Physician"
• Followed by development of

• Physicians Health Committees in all states
• Associated with State Medical Societies
• Federation of state-wide PHCs

• The term "impaired physician" has changed meaning over time
  
• Olden Times: you were not impaired if…
  You could come to work every day
  Your hangover didn’t interfere with work
  No evidence of withdrawal
  No evidence of Laennec’s Cirrhosis
  
• Olden Times (1960s – 1970s):
  Residents might send medical students out for beer and pizza on a slow evening on call
  Faculty could have a glass of Chardonnay at lunch
  
• Now: such behavior is inappropriate
  
• Physicians were not their brothers’ keeper
  Helplessness – no easy way to intervene
  Minimization – don’t think about it
  
• Unless there was gross, continued dereliction of duty, choices were
  Do nothing
  Terminate
  Report to Medical Board
  

• Standards have now been raised
• "Impaired implies an enduring condition which, without effective treatment, is not amendable to remission"
  SUBSTANCE ABUSE
  MENTAL ILLNESS
  OTHER MEDICAL CONDITIONS
  -- JAMA 281:1889, 1999

• Severe Cases of Impairment easy to identify (addiction, dementias)
• More Subtle Cases Require Complex, Professional Judgments
• Use Outside Experts When Unclear

• Colleagues rarely "turn in" Substance –Using Physicians to get Treatment
• Drug Abusing Physicians are in Denial
• Accused Non-Abusing Physicians Deny They have Any Problem
• Careful, Confidential, Evaluation Needed

• Substance Abuse is a Chronic Relapsing Brain Disease that is responsive to comprehensive treatment and careful follow up
• Substance Abuse is the most common form of impairment of MDs disciplined by State Medical Boards

• Abandoning Patient to get a "fix"
• Preoccupation with Withdrawal
• Constant Potential for Poor judgements: immoral/illegal activities
• Possible poor occupational performance & outcomes
• Loss of control can lead to overuse and intoxication

• Best Estimate of Impairment from Substance Abuse: => 8%

• Stratified Randomized National Sample of 1785 PGY IIIs, graduating in 1984:
• Use within past 30 days
• 87% use alcohol, 5% daily
• 7% use marijuana, 5% daily
• 1.4% use cocaine, not daily
• 3.7% use benzodiazepines, not daily

JAMA 265:2074-8, 1991:

• A year longitudinal study of one Midwestern medical school class

• 11% meet criteria for excessive drinking during a six month period
• 18% met criteria for alcohol abuse during first two years

• 23 medical schools, 30 day self-reports
• 87.5% alcohol
• 10% cigarettes
• 10% marijuana
• 2.8% cocaine
• 2.3% tranquilizers
• 1.1% opiates
• <1% chemically dependent (except cigarettes)

• Types of Available Data
• Mailed follow-up questionnaire
• Interview
• Self report plus secondary sources
• GTT & other LFTs
• Blood alcohol levels
• Random drug screen

• How did the MD get into treatment?
• Voluntary Self-Referral
• Coerced (Court, Employer, Medical Board)
• Mandatory
• Information Sources:
• MDs Seeking Treatment in hospitals
• Families of MDs in treatment
• Physicians Health Committees
• State Licensing Authorities
• Survey Results from General Population
• Coroners Office
• AMA data files
• Defining Treatment Variables

Long Term In-Patient
Thirty Day In-Patient
Short or No In-Patient, primarily Residential
Naltrexone or Other Endorphin Blockers
AA, NA, CA with or without
Psychotherapy for physician and family

• Without Random Urine Screen (earlier)
• With Random Urine Screens (later)

• Alive and Well
• Practicing with a License
• Recovery Components: AA, etc
• Remaining Sober:
• All the time
• Most of the time
• Some of the time

• Very few Studies Have Collected Comparable Data
• But, it is possible to develop useful impressions

• Five In-Patient Hospital Studies:
• Lutheran Hospital
• Hazelden Foundation, Minnesota
• Menninger Foundation
• DePaul Rehabilitation Hospital
• Mayo Clinic

• 10,000 pts admitted for substance abuse
• 51 MDs identified
• 80% of MDs had pretreatment job and family problems
• 30% had tried counseling and/or AA

• 44% of MDs had complete abstinence
• 30% had infrequent or non-problematic use
• 80% significantly improved (2 sources)
• 14% required rehospitalization
• Follow up averaged 42 months

• MDs constitute 2% of all admissions
• 85 MDs treated, 67 were contacted
• Of those MDs contacted:
• 76% abstinent for at least 1 year
• 16% reported light/moderate drinking
• 7% reported problematic relapse

• MD population compared to other pts there:
• 76% of contacted MDs report abstinence at 1 year
• 61% of contacted other pts report abstinence at 1 year
• MDs use more narcotics and sedatives; otherwise quite similar demographics

• 50 MDs studied
• 60% Coerced
• 24% Job-Related Problems
• 64% Continuous Sobriety
• 20% Problems with Sobriety
• 16% Dead of Lost to Follow up

• 40 MDs in 2 year program
• 77% of Sample Back in Practice
• 94% of Completers Back in Practice
• 67% Continuous Sobriety
• 15% Brief Relapse
• 17% Problematic Relapse, Treatment Drop-out
• Problematic Relapses within 1^st 90 days
• Brief Relapses occur in latter part of 1^st year of recovery
• Factors Associated with Good Outcomes:
• Long duration of treatment
• Family involvement
• Self-help participation
• On-going psychotherapy
• Physician-specific group involvement
• Urine drug monitoring

• MDs get better results than non-MDs, due to higher degree of coercion
• Intensity of Treatment, motivational factors related to extent of loss
  

• MDs are at least as likely as a population to have problems with addictions; there is considerable amount among MDs
• Physicians, when coerced, get better outcomes than treatment population
• Public demands more accountability for medical practices
• Federal Drug-Free Policies (DOT)

• Medical Board of Practice: to protect the public
• Physicians Health Committees: to protect the public AND to protect the health and careers of physicians
• PHCs have both responsibility and authority; can report to Medical Board
• PHC is strictly confidential
• Medical Board proceedings are public
• PHC does NOT report National Practitioner Data Bank
• Medical Board does report to Data Bank
  

• New Jersey PHC
• Maryland Rehabilitation Program
• Oregon Board of Medical Examiners
• Georgia Impaired MDs Treatment Program
• California Medical Board Diversion
• Missouri Physicians Health Program

• 85% of cases from colleagues, family, self referral; very few from State Board
• 601 intakes from 1982-1990
• 1/3 alcohol-related
• ¼ psychiatrically-related
• 5/12 dementia and other health problems
• 308 cases of Substance Abusing MDs
• excludes serious dual diagnosis cases
• excludes drop outs and deaths
• favorable outcome means abstinence or one relapse
• data from self-report, urine screens, two sources
• 98% of MDs have favorable outcomes at 2 years
• 86% of MDs have favorable outcomes at 9 years

• 92 MDs in program
• 78 MDs responded to follow-up
• 85% respond to one-time questionnaire at 88 months
• 87% report excellent family functioning
• 89% practicing medicine full time

• Rate of Recovery for MDs Without Psychiatric or Physical Disorders
• For Alcoholism: 86%
• For Drug Addiction: 90%
• For Total Sample: 75%

• 77% of completers abstinent 5 – 10 years
• 22% had relapses, most back in treatment
• All relapsers stopped participating in recovery programs prior to relapse
• 68% of relapses within 2 years of initial treatment
• RELAPSES
• Early:
• Lack of Belief in Disease Concept
• In Denial
• Reject Treatment Recommendations
• Second Year:
• Family or Emotional Triggers
• Later Relapses
  Stress + increasing denial
• Slacking Off Treatment Activities
• Protective Factors
• Participation in AA
• Espousing Spiritual Pathway
• Dealing Effectively with Over-Work
• Improved Family/Interpersonal Relations
• Survey of sub-sample of 550 PHC Alumni, 100 respondents at Annual Retreat
• 5.5 self-help meetings per week
• 70% spoke to sponsor previous week
• 54% still I psychotherapy
• 95% practicing medicine (38 hrs/week)
• 84% complete abstinence
• 16% only brief slip

• Comprehensive treatment and close monitoring after treatment have proven successful with 75 – 85% of physicians who enter treatment to return to their professional positions (Medical Clinics of North America 81:1037-52, 1997)

• Membership from 1994 – 2000
• Internal Medicine: Robert Lavender
• Family Practice: Forrest "Bernie" Miller
• Surgery Kent Westbrook
• Emergency Medicine: pending
• Pathology: James Waldron
• Anesthesia: Sorin Brull
• Psychiatry: Fred Guggenheim
• Assistant Dean for GME: Jeanne Heard MD PhD
• UH General Counsel: Bob Bishop, esp
• Employees Assistant Program: Jim Pfeiffer
• Liaison to ACH: Chris Smith, MD

• All Clinical Departments, save three, have had at least one faculty or resident as a case with UH PHC;  one Basic Science Department faculty served by PHC

• 21 Non-Addictive Medical Disorders
• 19 Addictive Disorders
• 12 Simple DWIs

• Dementias (self-detected)
• Other Neurological Conditions
• Hematology-Oncology Disorders
• Bipolar, Unipolar Affective Disorders
• Personality Disorders

• Intoxication/Coma at Work
• Report of Spouse to Program Director
• Report to Dean by Student About Erratic Lecturer
• DEA Review of Prescriptions Written
• Colleagues/RN Staff

William Osler in "Inner History of the Johns Hopkins Hospital" re  William S. Halstad:  "The proneness to seclusion, the slight peculiarities amounting to eccentricities at times (which to his old friends in New York seemed more strange than to us) were the only outward traces of the daily battle through which this brave fellow lived for years. When we recommended him as full surgeon to the hospital in 1890, I believed, and Welch did too, that he was no longer addicted to morphia. He had worked so well and so energetically that it did not seem possible that he could take the drug and done so much."......."About six months after the full position had been given, I saw him in severe chills, and this was the first information I had that he was still taking morphia. Subsequently, I had many talks about it and gained his full confidence. He had never been able to reduce the amount to less than three grains daily; on this, he could do his work comfortably and maintain his excellent physical vigor (for he was a very muscular fellow). I do not think anyone suspected him, not even Welch."   Nolan S and Halstad W: Idiosyncrasies of a surgical legend. Harvard Med Alumni Bulletin. 65: 17-23, 1991.

Stimson G, Oppenheimer B, and Stimson C. Drug Abuse in the medical profession. Brit J Addiction. 79: 395-402, 1984: In 1920, the English Parliament passed the Dangerous Drug Control Act in an attempt to control addiction through the registration of addicts. Nearly 25% of the addicts who registered were doctors, dentists, nurses, or veterinary surgeons.

Brewster J. Prevalence of alcohol and other drug problems among physicians. JAMA. 255:1913-1920, 1986:  When alcohol and other drugs are considered together, the prevalence among MD’s may be no higher than that of the general population.

Robins L, Reiger D. Psychiatric Disorders in America: The Epidemiologic Catchment Area Study. New York: The Free Press, 1991: 

• Lifetime risk for alcohol disorders in the general population is 13.5% overall:
• 23.8% for men
• 4.7% for women
• Lifetime prevalence of drug abuse and dependence is 6.2% overall:
• 7.7% for men
• 4.8% for women
• Nearly 1 in 5 Americans will develop problems with alcohol and-or drugs during their lifetime.

• Currently, there are > 684,400 MD’s in the US
• 80.5% men, 19.5% women
• Based on the ECA data, it can be estimated that:
• 137,397 MD’s (131,124 men, 6,273 women) will experience an alcohol disorder during their lifetime
• 48,829 MD’s (42,423 men, 6, 406 women) will have a drug disorder during their lifetime
• Chemical dependence is the single most frequent disabling illness among MD’s (Talbott G, Wright C. Occupational Medicine. 2: 581-591, 1987.)

• "It is a physician’s ethical responsibility to take cognizance of a colleague’s inability to practice medicine adequately by reason of physical or mental illness including alcoholism and drug dependence"

• A national effort is necessary:

1. To safeguard the health of patients from the care rendered by impaired physicians, and
2. To help impaired physicians return to optimal professional functioning.

• All 50 states have now developed procedures.

McAuliffe W. Int J Addiction. 22:825, 1987:

• Access to pharmaceuticals (availability)
• Family history of substance abuse (genetics)
• Personality factors (e.g., grandiosity, guilt)
• Stress at home and/or at work
• Thrill-seeking
• Self-treatment of pain, sleep patterns, emotional disorders
• Chronic fatigue
• Social/economic status

Hughes P, et al. Prevalence of substance use among US physicians. JAMA. 267:2333-2339, 1993: MD’s are 5X more likely than controls to take sedatives and minor tranquilizers without medical supervision.

Vaillant G. Physician cherish thyself. The hazards of self prescribing. JAMA. 267:2373-2374, 1992: Identified self-prescribing (and self-treatment with prescription drugs) as a risk factor for chemical dependence.

Jex S, et al. Relations among stressors, strains and substance use among resident physicians. Int J Addiction. 27:479-494, 1992:  Certain specialty groups and MD’s in academic medicine have excess risk for addiction.

• There is no specialty that "protects" a physician from a substance use disorder
• Although incidence varies in various series, certain specialties are generally over-represented:
• Anesthesiology
• Obstetrics/Gynecology
• Family Medicine/General Practice
• Emergency Medicine
• Physicians (all types) in Academic Medicine
• Early identification and diagnosis are critical.
• Barriers to early diagnosis:
• "conspiracy of silence"
• denial on the part of family, friends, colleagues, even patients
• These barriers are the products of a lack of education concerning the true nature of addiction as a primary biogenetic and psychosocial disease.
• Tenacious denial is the common feature of alcoholic/addict physicians
• Knowledge of the effects of drugs and alcohol create the delusion that special insight provides immunity
• Alcoholic/addict physicians cannot see themselves as sick; do not accept dependency as a disease
• Family members and colleagues contribute to the denial by covering up/making excuses for the physician, don’t demand he/she seek help

• Sequential, progressive deterioration in every facet of life:

Family Life

Community

Finances/legal matters

Spiritual and emotional health

Physical health

Professional performance

• Job performance is protected at the expense of every other life dimension

• The physician withdraws from family activities; there are unexplained absences

• The spouse becomes a caretaker

• Fights increase in frequency; there is dysfunctional anger; the spouse tries to control the physician’s substance abuse

• Substance abuse disorders become a family illness.

• There is child abuse (emotional and/or physical)

• The children assume responsibility for maintaining normal family functioning

• The children develop abnormal, antisocial behavior (depression, promiscuity, running away from home, substance abuse)

• Sexual problems emerge (impotence, extramarital affairs)

• The spouse disengages, seeks separation or divorce, abuses drugs and/or alcohol, or enters recovery (Al-Anon)

• Becomes isolated and withdraws from community activities, church, friends, leisure, hobbies, and peers
• Exhibits embarrassing behavior at clubs or parties
• Receives DUI citations, experiences legal problems, and exhibits role-discordant behaviors
• Behavior is unreliable and unpredictable in community and social activities
• The physician is unpredictable in personal behavior, engaging in excessive spending, risk taking behaviors

• The physician’s personal hygiene deteriorates
• His/her clothing and dress habits deteriorate
• The physician has multiple physical signs and complaints
• The physician writes numerous prescriptions for personal use
• The physician experiences frequent hospitalizations, and/or has numerous visits to physicians and dentists
• The physician is involved in multiple episodes of accidents and trauma
• There is evidence of a serious emotional crisis

• Schedule and patient appointments become disorganized; starts progressively later in the day
• The physician’s behavior toward staff and patients is hostile, withdrawn, or unreasonable
• The physician spends time behind "locked doors"
• The physician orders excessive office supplies of drugs
• Patients complain to staff about the physician’s behavior
• The physician is frequently absent from the office or has unexplained or frequent illnesses

• Makes rounds late or exhibits inappropriate or abnormal behavior
• Decrease in quality of performance in staff presentations, writing in charts, record keeping, etc
• Enters inappropriate orders for or over-prescribes medications
• Nurses, other staff report a change in behavior
• Becomes involved in malpractice suits and/or legal sanctions against him/herself or the hospital
• Unavailable for or responds inappropriately to pages and/or telephone calls
• Engages in heavy drinking at staff functions
• Is reluctant to undergo physical exams or drug screening

• Has changed jobs often during past five years
• Frequent geographic relocations without clear reasons
• Frequent hospitalizations
• Complicated and elaborate medical history
• Unexplained time lapses between jobs
• Indefinite or inappropriate professional references and vague letters of references
• Employment in one or more positions not appropriate to his/her qualifications
• Decline in professional productivity

• Use a trained, experienced leader for the team
• Leader selects, trains, and coaches team members from the most significant persons in the physician’s life (knowledge, objectivity)
• Selection of site (quiet, non-threatening, neutral)
• Determination of goals (all members of team must agree on the choices to be given to MD)
• Documentation of information
• Rehearsal (each team member practices role)
• Outcomes (options, transportation, action plans, and consequences for non-compliance are agreed upon in advance and executed immediately)

• The PHC was formed to intervene, assist and advocate for Arkansas physicians with substance use disorders
• Activities for 2000 (J Ark Med Assoc 97:386, 2001):
• Participants include MD’s, respiratory therapists, dentists, dental hygienists, and optometrists
• 83 participants are being monitored
• 7 MD’s and 3 DDS relapsed in the past 4 years; 2 MD’s no longer practice; the other 5 + 2 DDS have completed relapse therapy and are being monitored
• Advocacy continues with HMO’s, hospitals, etc.
• Assisting hospitals to comply with JCAHO MS.2.6

• Understanding and acceptance of the disease concept of addiction
• Identification of trigger mechanisms
• Development of non-chemical coping mechanisms
• Achieving balance by changing priorities
• Family involvement
• Involvement in mutual help groups (AA, NA)
• Peer-oriented therapy

• The prognosis of the adequately treated physician alcoholic/addicts is excellent, if the physician engages in the recovery process
• Recovery is a long term (lifelong) process
• Continuing engagement in a mutual help program and in peer-group support has proved to be an essential component
• Random alcohol/drug screens assist in maintaining successful recovery

• Treatment works
• Long-term abstinence and personal well-being correlate with strict aftercare monitoring and improved recovery surveillance techniques
• Death is more prevalent among those who leave treatment prematurely and among those who relapse
• The majority of physicians who successfully complete treatment and participate in aftercare monitoring can successfully return to the practice of medicine

• Member of Medical Profession
• Professional Performance Adversely Affected By:
• Mental Illness
• Alcoholism
• Drug Dependence

• Primary
• Chronic
• Genetic Factors
• Psychological
• Environmental
• Progressive
• Fatal
• Impaired Control
• Preoccupation
• Continued Use Despite Consequences
• Distortions in Thinking – Denial

• 12% to 15% All Physicians
• 23% all White Males Abuse or Impairment
• 15 – 18% Psychoactive Substance Abuse Disorders in the General Population

• Family
• Finances
• Legal
• Hospital
• Spiritual
• Emotional
• Office
• Health
• Church
• Community
• Friends
• Colleagues
• Children

• Denial
• Embarrassment
• Shame
• Fear – License
• Fear – Legal
• Cultural
• Lack of Information
• Peer Denial
• Family Denial
• Conspiracy of Silence – Involves Everyone

• Short Term Treatment – 28 days
• Long Term Treatment – 4 to 6 months
• Alcoholics Anonymous
• Narcotics Anonymous
• Caduceus Groups
• Alanon
• Familt Therapy
• Individual Therapy

• Multiple Participants (colleagues)
• Timing – doctor is sober, and very soon after a participant crisis
• Location – quiet, non-threatening
• Documentation of specific impaired behaviors
• Non-judgmental attitude – the patient has a disease
• Anticipation of possible reactions
• Intervention goals established in advance
• Have all plans made in advance with treatment options and reservations made

• Contracts
• Meetings
• Drug Screens
• Advocacy
• Sponsorship
• IDAA
• ADAA

• 95% Success
• Currently 34 under active contract
• Currently 2 in treatment
• Currently >100 monitored