Substance Abuse Among

Health Professionals
August 15, 2014

Lecturer : dr Anila Paul MBBS, MSCAS

Learning Objectives

Understand physician impairment

particularly emotional health and substance
abuse/ dependence
How to identify, assess, diagnose, provide
treatment and return to practice.
Support for Health Professionals

Introduction
Health professionals- Medical students, Doctors,
mainly Family medicine , Internal Medicine
Anesthetists, Emergency physicians, Psychiatrists
and Dentists, Nurses, Pharmacists , veterinarians
Rarely reported. 1 in 15 Doctors AOD. Why?
Stigma, Fear of disciplinary action, loss of license,
Colleagues and workplace are not aware of the
signs and symptoms and the impact of problem on
Quality of life and Quality of service to patients.
( Miller, M.N & Mogowen ,R.K 2000) (Seppala,et
al2010)

Understanding Physician
Impairment
Definition- A situation where health
practitioner is unable to perform their
professional responsibilities because of
1. Medical Diseases
2. Mental Illness or Emotional ill-health
3. Substance Abuse and Dependence
( McCance-Katz, E.F. 2010)

Understanding Physician
Impairment Contd
Mental Illness in Physicians
Clinical Depression- 28 and 40/ 100,000 population
vs 12.3/100, 0000 in general population
Life time prevalence is 12.8% in Men and 19.5% in
Women ( Center et al.2003)
Suicide- Strong link between depression, Suicide and
Substance abuse with 40% suicides in physician due
to alcohol ( Miller,M.N & Mogowen, R.K.2000)
Emotional Ill-Health: Burn out, dissatisfaction with
work, marital problems, divorce, stress at workplace

Substance Abuse & DependenceAeitology

General Factors: Bio psychosocial Factors ( Family
History AOD and FH of psychiatric illness)
Physician Specific Factors
Cigarette use > 1 pack per day
High stress and long working hours
Occupational access to controlled substances
Self medication, self-prescribing and selfinvestigation
Multiple jobs in multiple communties
Multiple affairs/ multiple marriages ( Cicala,R.S
2003)

Physician Specific Factors

Personal Characteristics
Workaholics, High levels of empathy, desire for social
status, achievement orientated, Increased stress, life
style disrupted due to inconsistent work schedules,
self-controlled , comfortable providing health than
receiving health. ( Shaw, et al 2003)
Medical Training- Stressful process, long medical
training academic demands, sleep deprivation,
burnout especially during internship, lack of emphasis
on interpersonal and communication skills, poor
interpersonal support ( Clode, D. 2004) &( Gossop et
al 2001)

Prevalence

10-15% health professionals ( DHHS, 2011)

Males more than Females
Family medicine (20%)
Internal medicine (13.1%)
Anesthetists (10.9%)
Emergency Medicine ( 7.1%)
Psychiatrists ( 6.9%)
( Seppala, M.D. & Berge, K.H. 2010)

Drugs of Choice

Fentanyl, Narcotics
Propofol, Ketamine
Alcohol,
Amphetamines
Tranquilizer,
Benzodiazepines
Cocaine

How do you identify Physicians with

SA/Dep
Professional Indicators
Unpredictable behaviours with staff and patients
Drug errors, failure to discard wastage,
False recording of drug administration
Frequently late or absent, or gives others a break
frequently
Closes doors and locks office frequently
Visits hospital at unusual times and not when on call
Increase patient complaints
Quality of charting or notes deteriorates

Physical Status

Facial bruising
Drowsy or sleepy at work or missing work
Slurred speech, Alcohol breath, needle marks
Poor physical appearance, poor hygiene, weight
loss
Frequent illness
Emotional distress or depression
Intoxicated
( NCETA Consortium & Cicala, R.S. 2003)

Social Indicators & Professional

History

DUI
Children develop problem behaviours
Multiple affairs
Marital discord
Isolation
Professional History
Frequent job changes, Unexplained time
lapses between jobs, vague reference
letters.

What do you do if you suspect a

problem?
Dont confront your colleague or talk to him/
her in private
( they will deny, quit practice, counter
accusations, potential to self-harm)
Consider 3 things:
Patient safety,
Colleague Safety,
Appropriate intervention- Report with
evidence to clinical director/ Medical director

Dealing with Health professionalsTIPS

Recognize that a great deal of courage to present to
treatment
Assess and Treat them as a PATIENT not a
colleague.
Dont assume they know everything. Give
information that you would to a patient.
Never allow them to prescribe or procure
medications.
Be directive about follow up
Consider the impact on their work and advice
Seek advice from Medical board or Nursing board.

Assessment- Physician Wellness

program

Medical evaluation
Psychiatric Evaluation
SA evaluation
Neuropsychological evaluation
Collateral information
Family therapy evaluation
Assessment team determine diagnosis and
treatment recommendations.

Treatment
Facilities that specialize in treatment of
health professionals
Long term residential care ( 30-90 days):
Detox, group therapy, family therapy etc
Outpatient Therapy: Counseling, Urine drug
screens, Pharmacotherapy etc
Pharmacotherapy: Naltrexone/ GABA,
Methadone, Buprenorphine

Return to Practice- Re-Entry

Initial rehab is complete
Participation in continuing treatment
Abstinence initiated and maintained for a
period of time
Voluntary entry into the Physician health
program- monitors the ongoing treatment
and abstinence

Return to Practice- Re-entry

Re-entry into practice under contract ( 2-5 years)
and continued monitoring, attending self help
groups, RDS
Contract: treatment, urine toxicology screen,
worksite monitoring, self- help group
participation.
Is it effective?- Relapse do occur, many
successfully completed treatment and returned to
practice, Success rates 70-90%
(McCance-Katz, E.F 2010)

Ongoing Support

Intense long term support

Family and Friend support
Self help groups ( AA, NA, GA)
Mentoring
Monitoring- Biochemical , mandatory Urine,
blood and hair samples- First 2 years, Random
tests
Clinical Monitoring- By a specialist
Doctor Support networks, Doctor support
helpline, Practitioner health program ( PHP), etc

On going support

NZ campaign improve health of GP

Doctors health advisory scheme
Stress reduction strategies
Role boundaries
NZ rural GP network for spouse and Nurses
Peer review groups
Supervision and mentoring

Why is it important to identify and

treat?
ADDICTION IS A PRIMARY DISORDER
ADDICTION IS A CHRONIC RELAPSING
DISORDER
ADDICTION IS FATAL
ADDICTION IS PROGRESSIVE
TREATMENT WORKS!!!

References
1.Cicala, R.S (2003). Substance Abuse Among
Physicians: What you need to know, Hospital
Physcian, pp 39-36
2. Miller, M.N & Mogowen, R.K. ( 2000).The
Painful Truth: The Physicians are not
invincible, Southern Medical Journal, 93(10)
3. Clode, D. (2004) The Conspiracy of Silence:
Emotional health among medical
practitioners, Royal Australian College of
General Practitioners, South Melbourne.

References
4. The Association of Anaesthetists of Great
Britian and Ireland. London.( 2011). Drug and
Alcohol abuse Amongst Anaesthetists: Guidance
on Identification and Management.
www.aagbi.org
5. Gossop,M., Stephens, S., Stewart, D.,
Marshall, J., Bearn, J. & Strang, J. ( 2001). Health
care professionals referred to treatment for
Alcohol and Drug problems. Alcohol &
Alcoholism, 36(2), pp.160-164. Doi:
10.1093/alcalc/36.2.160

References
6. DHHS ( Department of Health and Human
services, Nebraska, 2011)
7. Shaw, M.F & McGovern, A. (2003). Physicians
and Nurses with substance Abuse Disorder.
Journal of Nursing, 47(5), pp. 561-571.
8. NCETA Consortium ( 2004). National Center for
Education and Training on Addiction. Alcohol and
Other Drugs: A Handbook for health
professionals. Australian Government department
for Health & Ageing. www.nceta.flinders.edu.au

References

9. Mc Cance-Katz, E.F.( 2000). Doctors and

Addiction: Helping Good people with a Bad
Disease. A power-point presentation,
University of California, California Department
of Alcohol and Drug Programs.
10. Seppala, D.M & Berge, K.H. ( 2010). The
Addicted Physician: A rational response to an
irrational disease. Minneosta Medicine, 93(2),
pp. 46-49.