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  • Physician Substance Use and Addiction

    by Michael Kaufmann, MD

    doctor-240x180The OMA Physician Health Program (PHP) was founded in 1995, with an initial mandate to provide assistance to physicians who experience problems with drug and alcohol abuse and addiction. Since its inception, the program has assisted hundreds of physicians troubled by substance use disorders, and much has been learned about the problem.

    Risk factors
    PHP staff have observed personality traits common among physicians seeking assistance.

    These doctors are usually compassionate people, dedicated in the extreme to the well-being of their patients — to their own detriment and often that of their families. They tend to be perfectionistic, obsessive and rigidly self-controlled. Stressed and lacking healthy coping strategies, some find ease and comfort in drugs or alcohol. Thus, the seeds of abuse and dependence are sown, especially when there is a family history of substance use disorders.

    Access to mood-altering drugs is another consideration, although not the most important. Self-treatment with prescription drugs is always ill advised. But self-administration of mood-altering drugs is a dangerous and risky proposition.

    Many doctors experiencing problems with drugs and alcohol are reluctant to request help. They may deny the magnitude of the problem in their lives, just as others around them might deny what they are observing due to their own discomfort, lack of knowledge about how to help, or other factors. The suffering doctor may also be fearful that to reach out might result in a report to regulatory authorities, and represent the end of his or her career. This is seldom the case.

    But, together, these factors and others mean that doctors experiencing drug and alcohol problems seldom receive assistance early in the course of the disorder.

    Recognition
    There is rarely a single observation that will clearly identify an addicted colleague. As with other illnesses, an accurate diagnosis is made by a physician familiar with the signs and symptoms of chemical dependence.

    Still, there are clues readily apparent in doctors affected by drug or alcohol abuse that can be appreciated by any caring observer, especially if they are familiar with the doctor’s baseline behaviour prior to the substance abuse becoming problematic.

    Generally, the affected physician will appear moody, withdrawn and more irritable than expected. Previously decisive, reliable and predictable, he or she may have difficulty making decisions, fail to meet professional commitments, and change routines, perhaps arriving at the hospital to do rounds at odd hours.

    Excessive use of alcohol at social and CME events, and alcohol on the breath at work, are worrisome signs. Any doctor who insists on administering parenteral narcotics to patients personally, and who has heavy “wastage” of drugs, must be viewed with concern.

    It is important to recognize that the suffering doctor is very sensitive to the shame and stigma that accompanies a drug or alcohol problem. Such physicians will go to great lengths to conceal their disorder from colleagues, even when they are no longer able to disguise their problems at home.

    For this reason, observations made in the workplace might well represent illness that is fairly advanced, and demanding of immediate attention.

    Help
    It is not unusual for physicians in a community to be aware that one of their colleagues is struggling personally in some way. One or two friendly colleagues can approach the doctor and share their observations and concerns. If especially concerned, a clinical resource, such as a psychiatrist or therapist, might be made available in advance of approaching the troubled doctor.

    An offer to facilitate an appointment with that resource is an affirmative, helpful action. And, it is necessary to follow-up with the doctor to verify that positive action has been taken, and to affirm support.

    However, a doctor confronted in an informal manner, no matter how well-intentioned and thorough, may not respond favourably.

    Two myths must be confronted when considering addicted doctors. The first is that they must “want help” before intervention is successful. The second is that they must “hit bottom” before they will be receptive to assistance.

    These myths represent serious misconceptions. Confronting an impaired colleague, while difficult, must be done swiftly and competently. It can be a life-saving action.

    The process of helpful confrontation is called intervention. Intervention should be carried out as early as possible when impairment due to substance abuse is suspected.

    The intervention, which must be properly planned and rehearsed, is conducted by at least two individuals in a position of importance in the affected physician’s life, such as a partner, department head, or chief of staff. Sometimes, family members are also involved.

    The dependent physician is presented with objective, documented evidence of his or her behaviour of concern in a caring but firm manner. The minimum goal of the intervention is to motivate the physician to follow through with an expert clinical assessment, arranged in advance. Sometimes, in more advanced cases, the preferred outcome is to discontinue clinical practice immediately following the intervention, and enter treatment directly.

    Physicians have a moral and ethical obligation to do their best to help dependent colleagues, even if the actions taken on a colleague’s behalf are personally difficult. The Physician Health Program is available to offer advice about intervention, or to participate directly when required.

    Treatment:
    Once a substance dependence/addiction diagnosis is confirmed, treatment programs designed specifically for the physician/patient are available. Inpatient treatment is not always required, but is the norm when a period of detoxification, or a respite from medical practice, personal circumstances and stress, is required. Inpatient treatment is followed by formal aftercare that lasts several months to several years.

    Recovering doctors are usually encouraged to make use of community-based mutual help programs such as Alcoholics Anonymous, or other 12-step or similar programs. Most also attend peer support groups (often called Caduceus groups), where they join other health professionals in recovery.

    Special mention should be made of the addicted physician’s family. Addiction affects the entire family, and programs exist that provide education, counselling and support for spouses and other family members. An untreated and unsupported family suffers needlessly, and can predispose a relapse into addictive behaviour by the physician.

    Outcomes
    The prevalence and expression of substance use disorders in physicians is much like that in the general population. But outcomes, especially among those doctors enrolled in monitoring programs, are better.

    Substance dependence is, nevertheless, a disease of relapse. Relapse, when it occurs, should be treated seriously and promptly. Breaks in abstinence can be minor or life-threatening. Once again, careful monitoring goes a long way toward prevention and early detection of relapse events.

    The experience of relapse can be helpful to the recovery process, pointing out untreated problems, or revealing components of the recovery program that need strengthening. The majority of doctors who experience relapse make the appropriate adjustments and continue to enjoy good health. In fact, it has been the experience of the PHP that more than 90 per cent of the physicians monitored return to excellent health and productivity.

    Conclusion
    Recovery from chemical dependence means improved physical, psychological and emotional health. Social lives are improved, and families are rebuilt. Even matters of the spirit flourish. This is the beauty of recovery.

    So it falls to each of us as physicians to care about the well-being of our colleagues, to be watchful for signs of drug or alcohol problems, and to be prepared to respond.

    With respect to this problem, we really are our brothers’ and sisters’ keepers.

    Copyright © Ontario Medical Association and reprinted by permission. Excerpted from “Physician Substance Use and Addiction: Recognition, Intervention and Recovery.” The complete article can be found here.
    Dr. Kaufmann, CCFP, FCFP, a former family practitioner, is medical director of the OMA Physician Health Program. Dr. Kaufmann is certified in addiction medicine by the American Society of Addiction Medicine.

    About the Authors

    Renascent Alumni
    Members of Renascent's alumni community carry the message by sharing their experiences and perspectives on addiction and recovery. To contribute your alumni perspective, please email alumni@renascent.ca.