In addition, drug abuse has been directly associated with physician suicide,19 and accidental death may occur during periods of intoxication. The physician may also encounter legal difficulties secondary to substance use (eg, for driving under the influence or for domestic violence)20 or risk the loss of his job or medical license.
Hospitals and clinics are put at risk because intoxication is likely to compromise the physician’s ability to provide competent care. Further, colleagues may provide substandard care as the result of incomplete or inaccurate charting by the impaired physician. Because patient safety must always be considered paramount, co-workers must take responsibility for the identification of physicians with addiction.21 Identification of the problem represents the first step toward recovery.
Barriers to treatment
Despite the many reasons to seek or encourage treatment, however, many barriers can prevent physicians who have a substance use disorder from obtaining the help they need.22 First, a hallmark symptom of addiction is denial, which may be magnified in physicians, because they typically use sophisticated methods of rationalization and may develop elaborate justifications for their behavior. Many physicians have received little education regarding the nature of addiction and may falsely believe that they can manage the disease on their own. Personality traits, such as self-reliance, independence, and perseverance—which contribute to physicians’ occupational success—may lead either to dismissal of the problem or to attempts at self-treatment.3
Many physicians with an addiction disorder are adept at hiding their addiction, and the problem can be difficult to identify. Unfortunately, even physicians who recognize their impairment may be reluctant to seek treatment because of concerns about the negative consequences of being identified. The perceived risks of seeking treatment may outweigh the perceived benefits for some, particularly when the physician feels as though he is still able to practice competently.
Physician colleagues have moral, ethical, and legal obligations to report any coworker whose impairment threatens patient safety,23,24 but the disease is progressive and typically does not impair work performance until the more advanced stages.25,26 Thus, impairment observed in the workplace suggests a serious problem. Workplace warning signs listed in Table 1 should be considered sufficient evidence to warrant an immediate intervention.
Colleagues and family members may be hesitant to report a physician in whom they suspect drug or alcohol(Drug information on alcohol) addiction because of concerns about the ramifications of making such a report.27 Physician colleagues should note that it is not necessary to be certain of the exact DSM-IV diagnosis before making a referral; attempts at diagnostic certainty may delay treatment and can put the physician’s colleague in the uncomfortable role of detective.
The avoidance of “punishment” and the promotion of “treatment” is critical to the success of programs for physicians who have an addiction disorder. Most states now have a Physician Health Program (PHP) to assist with the treatment of drug and/or alcohol abuse in physicians, and cooperation with the PHP generally prevents the physician from experiencing punitive measures. In addition, many states protect the confidentiality of physicians who willingly participate in the PHP and do not require that a report be made to the Board of Medicine.
Typically, the first step in the successful treatment of a physician with a substance use disorder is diagnosis and referral to a PHP. Guidelines for making such a referral are outlined in Table 2. The physician with a substance use disorder is most likely to be successful in a treatment program in which the staff members are familiar with treating health care professionals. These environments foster acceptance of the diagnosis and are helpful in reducing shame because of the presence of peers. However, it is not advisable to attempt treatment for a physician with an addiction within his own medical community. Transference issues, concerns about limits of confidentiality, and personal bias can interfere with disclosure and limit-setting or can create professional conflicts.28,29
Dr X is a 45-year-old anesthesiologist with no family history of addiction. He denied smoking, but endorsed occasional drinking (typically fine wines) as well as experimentation with marijuana during college. An honors student throughout high school and college, Dr X went on to medical school and was selected for a very competitive anesthesiology residency program. During residency, he was routinely evaluated as one of the top trainees and went on to join a major anesthesiology group. Ten years into practice, he first self-administered sufentanil(Drug information on sufentanil) intranasally. Within 3 days, Dr X had progressed to self-injecting up to 30 mL of sufentanil per day. As a result, he would awaken with symptoms of withdrawal at 3 am every day. After injecting, he would go to work. After more than 6 months of daily use, he overdosed in the hospital. He was stabilized and admitted to a center specializing in the treatment of chemically dependent professionals. After 3 months of inpatient treatment, Dr X was discharged; he continued to be monitored by a state PHP under a 5-year contract. The contract included agreement to frequent random urine testing (results of all tests were negative) and participation in outpatient support groups. Dr X has been in recovery for more than 5 years and is currently practicing addiction medicine.