Substance use disorders in physicians: Assessment and treatment
- Lisa J Merlo, PhD, MPE
Lisa J Merlo, PhD, MPE
- Assoicate Professor of Psychiatry
- University of Florida
- Scott A Teitelbaum, MD
Scott A Teitelbaum, MD
- Professor of Psychiatry
- University of Florida
- Kenneth Thompson, MD
Kenneth Thompson, MD
- Clinical Associate Professor of Medicine
- Pennsylvania State University
The term "impaired physician" has been used to refer to physicians with psychiatric, cognitive, behavioral, or general medical problems that have the potential to adversely affect the physician’s ability to perform specific duties. Because not all physicians with these conditions exhibit occupational impairment, it is becoming more common to describe these individuals as “physicians with potentially-impairing conditions.” The subgroups of greatest concern, and thus of study as well as clinical and regulatory attention, are physicians who exhibit excessive alcohol use, illicit drug use, and/or prescription drug misuse.
Most of the published data on this topic are limited to physicians in the United States, where treatment of physicians with substance use disorders is typically overseen by physician health programs (PHPs). Much of the information may be relevant to other types of clinicians [1,2] and other countries where these problems have received attention [3-12]. PHPs in the United States provide coordination, monitoring, and expertise in the care of physicians (and other healthcare professionals) with potentially-impairing conditions , which when combined with treatment of the person’s substance use disorder (SUD), have generally led to high rates of sustained remission and return to medical practice [14-19].
This topic addresses the assessment, treatment, and oversight of physicians impaired by SUDs. The epidemiology, clinical manifestations, identification, and engagement of physicians impaired by SUDs are discussed separately. Prescription drug misuse and continuing care for addiction are also discussed separately. The epidemiology, pathogenesis, clinical manifestations, assessment, diagnosis, and treatment of specific SUDs are also discussed separately.
See related topics:
- Dunn D. Substance abuse among nurses--defining the issue. AORN J 2005; 82:573.
- Monroe T, Kenaga H. Don't ask don't tell: substance abuse and addiction among nurses. J Clin Nurs 2011; 20:504.
- Magnavita N. Management of impaired physicians in Europe. Med Lav 2006; 97:762.
- Kumar P, Basu D. Substance abuse by medical students and doctors. J Indian Med Assoc 2000; 98:447.
- Rode H, de Rond M, Dam I. [Addicted colleagues: a blind spot amongst physicians?]. Ned Tijdschr Geneeskd 2013; 157:A5718.
- Jungerman FS, Palhares-Alves HN, Carmona MJ, et al. Anesthetic drug abuse by anesthesiologists. Rev Bras Anestesiol 2012; 62:375.
- Lev-Ran S, Adler L, Nitzan U, Fennig S. Attitudes towards nicotine, alcohol and drug dependence among physicians in Israel. J Subst Abuse Treat 2013; 44:84.
- Garcia-Guasch R, Roigé J, Padrós J. Substance abuse in anaesthetists. Curr Opin Anaesthesiol 2012; 25:204.
- Ismail S. Chemical dependency: an occupational hazard in the field of anaesthesia. J Pak Med Assoc 2010; 60:857.
- Maier C, Iwunna J, Soukup J, Scherbaum N. [Addicted anaesthetists]. Anasthesiol Intensivmed Notfallmed Schmerzther 2010; 45:648.
- Beelmann K. [Addicted physicians--intervention programme of the General Medical Council of Hamburg]. MMW Fortschr Med 2007; 149:32.
- Valtschanoff JG, Weinberg RJ, Rustioni A. Peripheral injury and anterograde transport of wheat germ agglutinin-horse radish peroxidase to the spinal cord. Neuroscience 1992; 50:685.
- DuPont RL, McLellan AT, Carr G, et al. How are addicted physicians treated? A national survey of Physician Health Programs. J Subst Abuse Treat 2009; 37:1.
- Collins GB, McAllister MS, Jensen M, Gooden TA. Chemical dependency treatment outcomes of residents in anesthesiology: results of a survey. Anesth Analg 2005; 101:1457.
- O'Connor PG, Spickard A Jr. Physician impairment by substance abuse. Med Clin North Am 1997; 81:1037.
- Gallegos KV, Lubin BH, Bowers C, et al. Relapse and recovery: five to ten year follow-up study of chemically dependent physicians--the Georgia experience. Md Med J 1992; 41:315.
- Hall, JD, Pomm, R, Frost-Pineda, K, Gold, MS. Treatment of alcohol dependent physicians: Impact of alcohol use during medical school. Biol Psychiatry 2002; 51:197S.
- Kleber HD. The impaired physician: changes from the traditional view. J Subst Abuse Treat 1984; 1:137.
- Morse RM, Martin MA, Swenson WM, Niven RG. Prognosis of physicians treated for alcoholism and drug dependence. JAMA 1984; 251:743.
- Dhai A, Szabo CP, McQuoid-Mason DJ. The impaired practitioner - scope of the problem and ethical challenges. S Afr Med J 2006; 96:1069.
- Graham C. Poland wrestles with problem of drunken doctors. Lancet 2006; 368:190.
- Warhaft NJ. The Victorian Doctors Health Program: the first 3 years. Med J Aust 2004; 181:376.
- Brewster JM, Kaufmann IM, Hutchison S, MacWilliam C. Characteristics and outcomes of doctors in a substance dependence monitoring programme in Canada: prospective descriptive study. BMJ 2008; 337:a2098.
- Wile C, Frei M, Jenkins K. Doctors and medical students case managed by an Australian Doctors Health Program: characteristics and outcomes. Australas Psychiatry 2011; 19:202.
- Wile C, Jenkins K. The value of a support group for medical professionals with substance use disorders. Australas Psychiatry 2013; 21:481.
- Pomm RM, Harmon L. Evaluation and posttreatment monitoring of the impaired physician. Psychiatr Ann 2004; 34:786.
- Platman S, Allen TE, Bailey S, et al. Physician health programs: the Maryland experience. J Addict Med 2013; 7:435.
- Crowley TJ. Doctors' drug abuse reduced during contingency-contracting treatment. Alcohol Drug Res 1985-1986; 6:299.
- Boyd JW. Deciding whether to refer a colleague to a physician health program. AMA J Ethics 2015; 17:888.
- Candilis PJ. Physician Health Programs and the Social Contract. AMA J Ethics 2016; 18:77.
- McLellan AT, Skipper GS, Campbell M, DuPont RL. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ 2008; 337:a2038.
- Merlo LJ, Greene WM. Physician views regarding substance use-related participation in a state physician health program. Am J Addict 2010; 19:529.
- Long MW, Cassidy BA, Sucher M, Stoehr JD. Prevention of relapse in the recovery of Arizona health care providers. J Addict Dis 2006; 25:65.
- Carlson HB, Dilts SL, Radcliff S. Physicians with substance abuse problems and their recovery environment: a survey. J Subst Abuse Treat 1994; 11:113.
- Mee-Lee D. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, American Society of Addiction Medicine, Chevy Chase, MD 2013.
- GMC. Doctors who commit suicide while under GMC fitness to practise investigation. 2014. www.gmc-uk.org/Internal_review_into_suicide_in_FTP_processes.pdf_59088696.pdf (Accessed on February 19, 2016).
- Roback HB, Moore RF, Waterhouse GJ, Martin PR. Confidentiality dilemmas in group psychotherapy with substance-dependent physicians. Am J Psychiatry 1996; 153:1250.
- Sanchez LT, Candilis PJ, Arnstein F, et al. Effectiveness of a Unique Support Group for Physicians in a Physician Health Program. J Psychiatr Pract 2016; 22:56.
- Federation of State Physician Health Programs. Physician Health Program Guidelines 2005. http://www.fsphp.org/2005FSPHP_Guidelines.pdf (Accessed on July 09, 2014).
- Bohigian GM, Bondurant R, Croughan J. The impaired and disruptive physician: the Missouri Physicians' Health Program--an update (1995-2002). J Addict Dis 2005; 24:13.
- Ganley OH, Pendergast WJ, Wilkerson MW, Mattingly DE. Outcome study of substance impaired physicians and physician assistants under contract with North Carolina Physicians Health Program for the period 1995-2000. J Addict Dis 2005; 24:1.
- Pelton C, Ikeda RM. The California Physicians Diversion Program's experience with recovering anesthesiologists. J Psychoactive Drugs 1991; 23:427.
- Winter RO, Birnberg B. Working with impaired residents: trials, tribulations, and successes. Fam Med 2002; 34:190.
- Herrington RE, Benzer DG, Jacobson GR, Hawkins MK. Treating substance-use disorders among physicians. JAMA 1982; 247:2253.
- Boisaubin EV, Levine RE. Identifying and assisting the impaired physician. Am J Med Sci 2001; 322:31.
- McAuliffe PF, Gold MS, Bajpai L, et al. Second-hand exposure to aerosolized intravenous anesthetics propofol and fentanyl may cause sensitization and subsequent opiate addiction among anesthesiologists and surgeons. Med Hypotheses 2006; 66:874.
- Skipper GE, Campbell MD, Dupont RL. Anesthesiologists with substance use disorders: a 5-year outcome study from 16 state physician health programs. Anesth Analg 2009; 109:891.
- Menk EJ, Baumgarten RK, Kingsley CP, et al. Success of reentry into anesthesiology training programs by residents with a history of substance abuse. JAMA 1990; 263:3060.
- Warner DO, Berge K, Sun H, et al. Substance use disorder among anesthesiology residents, 1975-2009. JAMA 2013; 310:2289.
- Fry RA, Fry LE, Castanelli DJ. A retrospective survey of substance abuse in anaesthetists in Australia and New Zealand from 2004 to 2013. Anaesth Intensive Care 2015; 43:111.
- Domino KB, Hornbein TF, Polissar NL, et al. Risk factors for relapse in health care professionals with substance use disorders. JAMA 2005; 293:1453.
- Lutsky I, Hopwood M, Abram SE, et al. Use of psychoactive substances in three medical specialties: anaesthesia, medicine and surgery. Can J Anaesth 1994; 41:561.
- Gossop M, Stephens S, Stewart D, et al. Health care professionals referred for treatment of alcohol and drug problems. Alcohol Alcohol 2001; 36:160.
- Lloyd G. One hundred alcoholic doctors: a 21-year follow-up. Alcohol Alcohol 2002; 37:370.
- Galanter M, Talbott D, Gallegos K, Rubenstone E. Combined Alcoholics Anonymous and professional care for addicted physicians. Am J Psychiatry 1990; 147:64.
- Galanter M, Dermatis H, Stanievich J, Santucci C. Physicians in long-term recovery who are members of alcoholics anonymous. Am J Addict 2013; 22:323.
- Merlo LJ, Campbell MD, Skipper GE, et al. Outcomes for Physicians With Opioid Dependence Treated Without Agonist Pharmacotherapy in Physician Health Programs. J Subst Abuse Treat 2016; 64:47.
- Merlo LJ, Greene WM, Pomm R. Mandatory naltrexone treatment prevents relapse among opiate-dependent anesthesiologists returning to practice. J Addict Med 2011; 5:279.
- Washton AM, Gold MS, Pottash AC. Naltrexone in addicted physicians and business executives. NIDA Res Monogr 1984; 55:185.
- Earley PH, Zummo J, Memisoglu A, et al. Open-label Study of Injectable Extended-release Naltrexone (XR-NTX) in Healthcare Professionals With Opioid Dependence. J Addict Med 2017; 11:224.
- Physician health programs
- Other health professionals
- COORDINATION AND MONITORING
- Contingency contracts
- Not specific to physicians
- Return to work
- Ongoing monitoring
- OUTCOMES OF PHYSICIAN HEALTH PROGRAMS
- - Anesthesiology residencies
- Risk factors for relapse
- MEDICATION FOR OPIOID USE DISORDER
- SUMMARY AND RECOMMENDATIONS