It's time to take a sober look at physician addiction

Substance abuse among doctors underreported, undertreated.
How you can help

By Giancarlo La Giorgia

Hugh Laurie of House

He was in even more pain after the accident, so he asked a colleague for a Vicodin script. Soon he was hooked again, but at least he was functioning. That is until he helped himself to another colleague's prescription pad. Soon the cops were involved and staff physicians found themselves closing ranks. After all, he's the best diagnostician they've got.

The above tale is fictional, part of the latest season of popular medical drama House, in which Dr Gregory House (Hugh Laurie) nearly gets thrown in the slammer for double-doctoring, until his boss lies for him — and slips him a new Vicodin script. But it could just as easily be torn from the pages of the local College's disciplinary committee report. Physician drug addiction is a big problem and it's not getting any better.

WHAT CAN YOU DO?
Suspecting substance abuse in a colleague is never easy, but with an incidence of 8% (around the same as the general population), you're probably going to run into it at some point. Still, old stigmas die hard. "Unfortunately, addiction is still viewed as a moral issue," said Dr Penelope Ziegler during a presentation at the recent AMA/CMA International Conference on Physician Health in November.

Dr Ziegler specializes in treating addicted healthcare professionals at the William J Farley Center, an inpatient treatment facility in Williamsburg, VA. Ingrained attitudes, she said, are a big reason substance abuse among physicians remains so poorly understood and treated. "Physicians are often inadequately educated about chemical dependency in medical professionals and can be very intolerant of addiction in their peers," she said, adding that this same mentality affects addicted physicians themselves as well. "Physicians rely heavily on their intellect to solve problems, so there's a strong denial component among addicts. Admitting they have a disease they alone cannot cure is a very difficult barrier to break through."

According to Dr Ziegler, another major barrier to proper assessment and treatment is what she called a 'conspiracy of silence.' "There's this notion that [an addicted doctor's] confidentiality is inviolable or that they shouldn't be reported, unless a very serious event occurs. This is all fear-based, of course, since the outcome is unknown and it's worried that exposing a chemical dependency might end the implicated doctor's career," she said.

Despite improvements over the years, Dr Ziegler notes that many doctors lack the skills to identify substance abuse, in many cases mistaking inappropriate conduct for behavioural problems.

"There's rarely a single observation that will clearly identify an addicted colleague," wrote Dr Michael Kaufmann in the Ontario Medical Review. "As with other illnesses, an accurate diagnosis is made by a physician familiar with the signs and symptoms of chemical dependence." (See Tell-tale signs your colleague's hooked)

BACK INTO THE ABYSS
Dr Ziegler laments underfunding of treatment programs for doctors, warning that we all pay the price when they relapse.

The topic of relapse was dealt with in another workshop at the conference given by Dr Mick Oreskovich, medical director of the Washington Physician Health Program (WPHP). Dr Oreskovich presented findings from a 2005 JAMA study that looked at relapse risk factors in 292 physicians enrolled in the WPHP over an 11-year period. It confirmed that chemically dependent healthcare professionals are at higher risk of relapse if their drug of choice is a major opioid, such as fentanyl, sufentanil, morphine or meperidine. (Doctors are believed to be more likely than the general population to get hooked on opioids and other prescription meds.)

"A quarter of the study's participants had a relapse, the likelihood of which was almost doubled if their drug of choice was a major opioid," said Dr Oreskovich.

Moreover, Dr Oreskovich noted that the risk of relapse among major opioid users was even higher if the physician had a family history of substance abuse or coexisting psychiatric illness. The combination of all three factors drastically increased the risk of relapse. He recommended that these factors be considered when monitoring physicians returning to the workplace after major opioid addiction treatment, especially in the case of anesthetists who decide to continue practising anesthesia, for whom there was also a markedly increased risk of relapse.

However, Dr Oreskovich stressed that as compelling as the study's data may be, it shouldn't be used to predict the outcome of a physician's recovery. He pointed out that the best predictors of successful recovery and reduced risk of relapse were length of treatment and active monitoring. Also, that among the physicians who did not relapse after followup of five years or more, 100% returned to practising medicine, as opposed to only 61% who did relapse. "This underscores the importance of allocating the resources to monitor a physician recovering from substance abuse," he said.

To get help for yourself or a colleague, contact your local physician health program (for a full listing of Health Resources click here).