Facing up to an occupational hazard: substance abuse
Substance abuse affects one in six residents. Here are some warning signs and ways you can help
From the February 2000 ACP–ASIM Observer, copyright © 2000 by the American College of Physicians–American Society of Internal Medicine.
By Christine Kuehn Kelly
Dr. Smith, a psychiatric resident at the University of Virginia, is HIV-positive. But there is something he fears more than seroconversion. "I'm also a substance abuser," he admitted. "And I'm more afraid of dying from drug abuse than from AIDS."
A heavy drinker and drug user since his teens, Dr. Smith would leave his residency for binge weekends that stretched into a week. "At one point, I had missed two nights on call and had spent $4,000. I gave my car away for $40 worth of crack." (The real names of physicians with substance-abuse problems in this article are being withheld at the request of their treatment programs.)
Perhaps the most frightening part of Dr. Smith's story is that he is far from alone. Substance abuse among physicians has long been an occupational hazard.
"Look around you at the next housestaff meeting," said G. Douglas Talbott, FACP, founder of the Talbott Recovery Campus in Atlanta, one of the nation's top chemical dependency treatment centers. "Out of every six physicians, one will be chemically addicted at some point in his or her career."
Despite such numbers, it's difficult for residents to recognize which colleagues have a problem. That's because there's a lack of adequate training about drug dependency, said Dr. Talbott, pointing out that addiction medicine is only a decade-old discipline. Although drug addiction is a bona fide disease, the majority of residents don't understand how it progresses, he said.
The good news is that drug addiction among physicians is highly treatable. Thanks to programs specifically designed for doctors, the overall recovery rate is 80% or more, higher than the success rate for the general population. When substance abuse is found early and treated, recovering residents are likely to be as successful as their colleagues.
But recognizing and treating the problem early on may mean more than saving a colleague's career or marriage. For residents who are deeply addicted, timely intervention can be lifesaving.
'It can't happen to me'
Experts say that it's no surprise that some residents look to drugs for support. Demanding clinical responsibilities, intense patient relationships, exhausting hours on the wards and easy access to drugs are a potent combination.
There's also what Dr. Talbott called the "M.D.-eity syndrome." "Physicians have an attitude of omnipotence, powerfulness and uniqueness," he said. "It's the attitudinal complex drilled into every resident, a sense that something like addiction can't happen to them."
Drug addiction and denial go hand-in-hand. "I started using alcohol when I was about 10, and I graduated to other drugs," said Dr. Jones, who now practices in Tulsa, Okla. He entered a 12-step recovery program, and he was drug-free by the time he started medical school.
Like many drug abusers, Dr. Jones was a high achiever who did well in his studies. "I was in the top 10% of my medical school class," he said, "so I figured I must have gotten over the problem." It wasn't long before he was once again drinking and smoking marijuana and taking 10 to 12 pills daily. His drugs of choice were the most commonly abused substances among residents: alcohol, marijuana and benzodiazepines, primarily hydrocodone/acetaminophen (Vicodin and Lortab). "I told myself I was taking the drugs because I had a headache," he recalled. "After all, I'm trained to administer these things."
Towards the end of his internship, he shared his drug history with his program director, who suggested he attend a recovery meeting. "Even then I was in denial," he said. "My work wasn't affected yet, so how could I have a problem?"
While it may seem unthinkable that a resident with such a serious drug problem would be able to continue caring for patients, experts say that patient care is usually the last area to be impacted by a dysfunctional physician. "Residents have a remarkable facility to function as physicians when impaired," said William Yarborough, ACP–ASIM Member, an associate professor of medicine at University of Oklahoma Health Services Center in Tulsa and medical director of a Tulsa alcohol and drug treatment center. The result is that the substance abuse continues, sometimes to the point where the resident is visibly impaired. In the most extreme cases, he said, the resident may die of an overdose.
Untreated, substance abuse quickly turns into a downward spiral. Marriages break up. Hospital support staff and nursing staff are antagonized. And finally, patient care is affected.
Because the stakes are so high, it's crucial not to waste time worrying about destroying a colleague's career by reporting drug problems. "If you see someone who is injured, you don't tell the person to get help and then walk away," said Dr. Smith, the psychatric resident from Virginia. "The same with addiction. It's absolutely not acceptable to let your colleagues with drug problems slide." You can and should share your concerns with the chief resident, he said.
And because denial is such a prevalent aspect of the disease, experts say that addicted residents often need to be confronted with specific evidence and be required to take a urine test. A specialist in the field of addiction medicine should evaluate the test.
Dr. Yarborough also pointed out that to encourage residents to get treatment early on, the process must be nonpunitive. "We have an ethical obligation to support recovering residents and to offer reasonable accommodation," he said. "Residents who feel turning themselves in means they won't be able to practice medicine will wait until they are sicker and are practicing bad medicine."
That's why residency programs need to have nonpunitive mechanisms in place to help residents deal with substance abuse, said Richard D. Aach, FACP, professor of medicine at Case Western Reserve University in Ohio. A formal process to address drug abuse should include orientation about the institution's substance abuse and impairment policies, a mechanism for seeking help for colleagues and a process for referral or self-referral.
Once a resident has been diagnosed, referral to a specialized program can increase the likelihood of successful treatment. Programs in the local community don't work because the residents are always recognized as doctors, said Michael Weisz, FACP, who also is an associate professor of medicine at the University of Oklahoma. (See "Physician recovery programs," this page, for a list of treatment programs.) Physicians in specialized programs, however, will be with other professionals who also have high public accountability: other health care professionals, lawyers, judges and pilots. "Here the MDs are just other professionals who happen to earn their living as doctors and who are here to work on their recovery issues," said a spokesperson for one of the specialized centers, the William J. Farley Center in Williamsburg, Va. "We rapidly dispel their 'terminal uniqueness.' " Residential programs that last up to six weeks are most successful, he added.
Monitoring is also a key to successful recovery. When the resident is finished with inpatient treatment, the recovery program will help coordinate efforts with the residency program and the state licensing board. Recovering residents need to undergo frequent, random drug tests. Experts say that this kind of close monitoring plays a major role in most doctors' successful recoveries. Some physicians even choose to continue monitoring long past the required time period, in part to prevent legal risk. "If recovering physicians are in an auto accident, for example, they would need to demonstrate they were not impaired," pointed out Dr. Talbott.
When residents return to their residency programs, they also have fences to mend. "Recovering residents need to openly meet with the other residents and staff and hear the pain they caused," said Dr. Weisz. "Residents are usually good at articulating this. They want to make sure the person is really in recovery." If an addicted resident stole drugs or missed shifts, suspicion and resentment may linger for a while.
Once they are in recovery, residents can move forward with their careers. Requirements vary, but most states allow physicians in approved recovery programs to be licenced. According to the American Board of Internal Medicine, residents can sit for the certifying exam when they are in a supervised recovery program and have externally documented sobriety for one year after a blemish on their license, revocation of hospital privileges or a negative proficiency evaluation resulting from substance abuse. The resident will also have to make up training time lost during treatment. Licensure applications will ask questions about substance abuse and functional impairment. If the resident was involved in criminal activity like writing bogus prescriptions, the state is likely to probate the license.
"Addiction is an equal opportunity disease," said recovering addict Dr. Smith. "It can happen anywhere, anytime. The main thing to realize is that it is a disease and can be successfully treated."
Christine Kuehn Kelly is a Philadelphia-based freelance writer who specializes in medical and health care topics.
For more information on identifying the possibility of substance abuse, see "The Telltale Signs of Possible Substance Abuse."
- Rush Behavioral Health, Downers Grove, Ill. 630-969-7300
- Springbrook Northwest, Newburg, Ore. 800-333-3712
- Talbott Recovery Campus, Atlanta, Georgia. 800-445-4232
- Williamsburg Place and the William J. Farley Center, Williamsburg, Va. 800-582-6066
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