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Physician substance abuse
recognition, intervention, and recovery by Michael Kaufmann, MD OMA Physician Health Program The OMA Physician Health Program (PHP) was founded in 1995, with an initial mandate to provide assistance to physicians who experience problems with drug and alcohol abuse and addiction. Since its inception, the program has quired to differentiate between sub- than a collection of addictions. The assisted hundreds of physicians stance abuse and dependence.
majority of physicians treated for troubled by substance use disorders, addiction acknowledge abusing and much has been learned about many drugs and alcohol. Still, alco- the problem.
The prevalence of drug and alcohol hol is most often identified as the problems within the medical profes- sion has been the subject of specula- PHP data reveal that 47 per cent The salient features of a diagnosis of tion and misconception. Research of doctors monitored by the pro- substance dependence or addiction indicates that such problems are not gram list alcohol as their drug of usually include the inability to con- likely to be more common among phy- choice. Of these, half have a history trol one's use of these substances, sicians than the general population. of abusing a range of other drugs as preoccupation about using drugs or In a 1986 review of the issue, pub- well. Thirty-five per cent of the PHP drinking, continuing to do so despite lished in the Journal of the American participants were dependent upon adverse life consequences, and phy- Medical Association, Brewster said, opioids as their drug of choice, siological tolerance and withdrawal "Extreme statements regarding the seven per cent used cocaine, five per prevalence of problems with alcohol cent sedative and hypnotic drugs, It is important to view drug or and other drugs have often been and the remaining six per cent in- alcohol dependence as a primary dis- made without empirical support."1 clude a variety of other drugs, such order that is often progressive, and In 1992, Hughes et. al. reported as cannabis, solvents and anesthetic possibly fatal, if left untreated.
that in a survey of more than 9,000 Substance abuse is characterized physicians in all specialties, almost by the repeated, inappropriate use of eight per cent reported substance Risk factors
a mood-altering substance which, in abuse or dependence problems at Although data tend to suggest that some way, interferes with health some time in their lives.2 substance dependence affects doctors and/or quality of life. This diagnosis Regardless, if a physician is im- in ways similar to the general popula- can be made if substance dependence paired due to a substance use disor- tion, there are some considerations diagnostic criteria are not met. Sub- der, patient care can be affected, and pertinent to medical professionals stance abuse may progress to depen- the physician risks serious personal that merit discussion. dence if unaddressed.
morbidity, or even death.
In 1972, Vaillant reported on the Callers to the Physician Health psychological vulnerability of physi- Program who suffer from drug or alco- Commonly abused substances
cians. According to his prospective hol problems fall into both categories.
It is prudent to regard substance study, doctors were more likely to Expert assessment is sometimes re- dependence as a single entity, rather experience problems with drugs and Ontario Medical Review • October 2002 Ontario Medical Review • October 2002 There is rarely a single observation Signs of Addiction in Physicians
that will clearly identify an addictedcolleague. • Personality change As with other illnesses, an accurate • Loss of efficiency and reliability diagnosis is made by a physician • Increased sick time and other time away from work familiar with the signs and symp- • Patient and staff complaints about physician's changing toms of chemical dependence. Still, there are clues readily appar- ent in doctors affected by drug or alcohol abuse that can be appreciated • Increasing personal and professional isolation by any caring observer, especially if • Physical changes they are familiar with the doctor's • Unpredictable work habits and patterns baseline behaviour prior to the sub- • Moodiness, anxiety, depression, suicidal thoughts or gestures stance abuse becoming problematic.
Many of these observations have • Uncharacteristic deterioration of handwriting and charting been previously described in the • Unexpected presence in hospital when off-duty Ontario Medical Review.4 • Heavy "wastage" of drugs Generally, the affected physician • Inappropriate prescription of large narcotic doses will appear moody, withdrawn and • Insistence on personal administration of parenteral narcotics to more irritable than expected. Previ-ously decisive, reliable and predic- table, he or she may have difficulty • Long sleeves when inappropriate making decisions, fail to meet profes- • Frequent bathroom use sional commitments, and change • Alcohol on the breath routines, perhaps arriving at the hos- • Wide mood swings pital to do rounds at odd hours.
Excessive use of alcohol at social alcohol, require psychotherapy, and the most important. Self-treatment and CME events, and alcohol on the have marital problems, than were with prescription drugs is always ill- breath at work, are worrisome signs.
other matched non-health profes- advised. But self-administration of Any doctor who insists on adminis- sional controls.3 mood-altering drugs is a dangerous tering parenteral narcotics to patients Vaillant believed that physician and risky proposition. personally, and who has heavy vulnerability was related to unmet Anesthetists who self-administer "wastage" of drugs, must be viewed personal needs; some doctors choose potent opioids, such as fentanyl, are a medical career to help themselves a special case illustrating this point, Addicted doctors often become by helping others. as these drugs are particularly depen- depressed and, in advanced cases, While many dispute the existence dency prone.
may make suicidal gestures. Some of a "medical personality," PHP staff Many doctors experiencing prob- will be successful.
have observed personality traits com- lems with drugs and alcohol are re- These clues and others are listed in mon among physicians seeking assis- luctant to request help. They may Table 1 (above), originally prepared deny the magnitude of the problem by Dr. Graeme Cunningham, direc- These doctors are usually compas- in their lives, just as others around tor of alcohol and drug services at the sionate people, dedicated in the them might deny what they are Homewood Health Centre in Guelph.5 extreme to the well-being of their observing due to their own discom- It is important to recognize that patients — to their own detriment fort, lack of knowledge about how to the suffering doctor is very sensitive and often that of their families. They help, or other factors. to the shame and stigma that accom- tend to be perfectionistic, obsessive The suffering doctor may also be panies a drug or alcohol problem.
and rigidly self-controlled. Stressed fearful that to reach out might result Such physicians will go to great and lacking healthy coping strategies, in a report to regulatory authorities, lengths to conceal their disorder some find ease and comfort in drugs and represent the end of his or her from colleagues, even when they are or alcohol. Thus, the seeds of abuse career. This is seldom the case. no longer able to disguise their prob- and dependence are sown, especially But, together, these factors and when there is a family history of sub- others mean that doctors experienc- For this reason, observations made stance use disorders.
ing drug and alcohol problems sel- in the workplace might well represent Access to mood-altering drugs is dom receive assistance early in the illness that is fairly advanced, and de- another consideration, although not course of the disorder.
manding of immediate attention.
Ontario Medical Review • October 2002 Ontario Medical Review • October 2002 Intervention should be carried out themselves in their own way. Such It is not unusual for physicians in a as early as possible when impairment measures usually fail. community to be aware that one of due to substance abuse is suspected. The Physician Health Program their colleagues is struggling person- The intervention, which must be believes that it is essential for inter- ally in some way. In the earlier stages, properly planned and rehearsed, is venors to be prepared to notify regu- the nature of a problem might not be conducted by at least two individu- latory authorities in some way if the clear. Caring individuals will offer als in a position of importance in dependent physician refuses to com- the affected physician's life, such as ply with the intervention. One or two friendly colleagues can a partner, department head, or chief Outlining a clear consequence for approach the doctor and share their of staff. Sometimes, family members lack of compliance usually results in observations and concerns. are also involved. the desired outcome.
If especially concerned, a clinical The dependent physician is pre- Some suggest that such an interven- resource, such as a psychiatrist or sented with objective, documented tion, especially if there is a "threat" to therapist, might be made available in evidence of his or her behaviour of notify authorities, places the suffering advance of approaching the troubled concern in a caring but firm manner. doctor at risk of suicide. This risk is The minimum goal of the inter- minimized by arranging helping An offer to facilitate an appoint- vention is to motivate the physician resources in advance, and making sure ment with that resource is an affir- to follow through with an expert clin- that the time from intervention to mative, helpful action. And, it is ical assessment, arranged in advance. assessment or treatment is short.
necessary to follow-up with the doc- Sometimes, in more advanced Sometimes, this is achieved by escort- tor to verify that positive action has cases, the preferred outcome is to dis- ing the doctor to treatment directly been taken, and to affirm support.
continue clinical practice immedi- from the intervention. Unfortunately, in the case of the ately following the intervention, and At the least, intervenors and other addicted doctor, denial is often pre- enter treatment directly. caring individuals should remain in sent. This often results in deliberate, An expertly conducted and highly close contact with the doctor until it is conscious deception of others, as motivational intervention will likely assured that he or she is safe. To do well as less conscious self-deceit and yield the preferred result. Still, many less is not acceptable. minimization of the severity of the impaired physicians thus confronted Physicians have a moral and ethical will resist assessment and treatment, obligation to do their best to help Dependent physicians also likely preferring to handle the problem dependent colleagues, even if the feel guilt and shame about what theyhave done and how they see them-selves as a result of their illness. When these psychological forces are at play, the doctor confronted inan informal manner, no matter howwell-intentioned and thorough, maynot respond favourably.
Two myths must be confronted when considering addicted doctors.
The first is that they must "want help"before intervention is successful. Thesecond is that they must "hit bottom"before they will be receptive to assis-tance. These myths are represent serious misconceptions. Confronting animpaired colleague, while difficult,must be done swiftly and compe-tently. It can be a life-saving action.
The process of helpful confronta- tion is called intervention. It hasbeen well described by VernonJohnson and others,6 and an outlineof the intervention process has beenpublished in the Ontario MedicalReview.7 Ontario Medical Review • October 2002 Ontario Medical Review • October 2002 terviews to ascertain the health status of the recovering individual, as well Components of a Recovery Program
as to encourage full compliance withall prescribed recovery activities. Pro- • Outpatient aftercare: group and individual therapy gress reports are received from treat- • Caduceus peer support group ing clinicians, and random urine • Mutual help group: Alcoholics Anonymous (AA), Narcotics toxicology screens are performed. The Physician Health Program Anonymous International Doctors in AA (IDAA), Women for Sobriety conducts such a comprehensive • Pharmacotherapy (e.g., disulfiram, naltrexone) monitoring program, which also • Proper nutrition provides case management services • Regular exercise and advocacy for the doctor in re- • Healthy spiritual life covery. These programs usually con- • Healthy balance between work, rest and leisure activities tinue for five years or longer.
• Assessment, treatment of concurrent problems (e.g., psychiatric, • Family treatment and support The prevalence and expression of • Rigorous monitoring, including random body fluid analyses substance use disorders in physiciansis much like that in the general popu-lation. But outcomes, especially actions taken on a colleague's behalf population. These groups give recov- among those doctors enrolled in are personally difficult.
ering doctors an opportunity to monitoring programs, are better. The Physician Health Program is address special issues arising from The PHP experience to date reveals available to offer advice about inter- their professional lives.
that of the first 100 doctors moni- vention, or to participate directly Inpatient treatment is followed tored in recovery, more than 70 per when required.
by formal aftercare that lasts several cent have enjoyed sustained re- months to several years. mission of their substance depen- Treatment: substance abuse and addiction
Recovering doctors are usually dence, never experiencing a relapse.
Physicians who have been diagnosed encouraged to make use of commu- There are similar reports from many with substance abuse (but not depen- nity-based mutual help programs dence) benefit from education about such as Alcoholics Anonymous, or Substance dependence is, never- the benefits of abstinence, or low- other 12-step or similar programs. theless, a disease of relapse. Relapse, risk use of mood-altering substances.
Most also attend peer support when it occurs, should be treated An addiction medicine physician, groups (often called Caduceus seriously and promptly. Breaks in knowledgeable family physician, or groups), where they join other abstinence can be minor or life- other substance abuse professional health professionals in recovery. threatening. Once again, careful can provide this information.
These and other elements of a monitoring goes a long way toward Once a substance dependence/ comprehensive recovery program are prevention and early detection of addiction diagnosis is confirmed, listed in Table 2 (above).
treatment programs designed specifi- Special mention should be made The experience of relapse can be cally for the physician/patient are of the addicted physician's family.
helpful to the recovery process, point- Addiction affects the entire family, ing out untreated problems, or reveal- Inpatient treatment is not always and programs exist that provide edu- ing components of the recovery pro- required, but is the norm when a cation, counselling and support for gram that need strengthening. period of detoxification, or a respite spouses and other family members.
The majority of doctors who expe- from medical practice, personal cir- An untreated and unsupported rience relapse make the appropriate cumstances and stress, is required. family suffers needlessly, and can adjustments and continue to enjoy It is often difficult for physicians to predispose a relapse into addictive assume the role of patient, and inpa- behaviour by the physician.
In fact, it has been the experience tient programs designed specifically of the PHP that more than 90 per cent for physicians and other health pro- of the physicians monitored return to fessionals can facilitate this transition. In Ontario and many other North excellent health and productivity.
Most inpatient facilities do not American jurisdictions, there are for- segregate physicians in treatment, mal monitoring programs that re- but rather offer therapy groups for covering doctors may use to enhance Substance use disorders affect physi- health professionals in parallel to their recovery program. cians just as they affect members of those offered for the entire patient Monitoring includes regular in- the general population — medical Ontario Medical Review • October 2002 Ontario Medical Review • October 2002 training does not confer immunity, With respect to this problem, we 7. Kaufmann M. After the call: the nor does it result in excessive risk. really are our brothers' and sisters' Physician Health Program referral Denial (by physician, family and and intervention process. Ont Med colleagues) is a major symptom and Rev 1999;66(3):54-56. This article is a significant obstacle to timely diag- also posted online at: www.phpoma.
nosis and treatment. Thoughtful 1. Brewster JM. Prevalence of alcohol org/pdf/Mar99.pdf. intervention does work, and effective and other drug problems among phy- treatment is available. sicians. JAMA 1986; 255(14):1913-20.
Once the addictive disorder is in 2. Hughes PH, Brandenburg N, Bald- 1. Talbott GD, Gallegos KV, Angres remission, sustained abstinence, pro- win DC, et al. Prevalence of sub- DH. Impairment and Recovery in ductivity and healthy lifestyles are the stance use among U.S. physicians.
Physicians and Other Health Pro- expected norm. There are also treat- fessionals. In: Principles of Addiction ment and support programs for fami- 3. Vaillant G, et al. Some psychologic Medicine. American Society of Addic- lies of recovering doctors.
vulnerabilities of physicians. NEJM tion Medicine, Chevy Chase, Mary- Recovery from chemical depen- land, 1998, Chapter 3.
dence means improved physical, psy- 4. Kaufmann M. Recognizing the 2. All Physician Health and related chological and emotional health. signs and symptoms of distress. Ont columns published in the Ontario Social lives are improved, and fami- Med Rev 1999;66(5):46-47. This arti- Medical Review are posted on the lies are rebuilt. Even matters of the cle is also posted online at: www.
Physician Health Program Web site spirit flourish. This is the beauty of 5. Cunningham GM. Paying atten- So it falls to each of us as physi- tion to substance abuse in physi- Dr. Kaufmann, CCFP, FCFP, a former family
cians to care about the well-being of cians. Canadian Journal of Diagnosis practitioner, is medical director of the OMA
our colleagues, to be watchful for Physician Health Program. Dr. Kaufmann is
signs of drug or alcohol problems, 6. Johnson VE. I'll Quit Tomorrow.
certified in addiction medicine by the
and to be prepared to respond. Harper and Row, New York, NY, 1980.
American Society of Addiction Medicine.
Ontario Medical Review • October 2002 Ontario Medical Review • October 2002
East Asian Science, Technology and Society: An International Journal (2014) 8:57–79DOI 10.1215/18752160-2406053 The Reformulation Regime in Drug Discovery: RevisitingPolyherbals and Property Rights in the Ayurvedic Industry Laurent Pordie´ and Jean-Paul Gaudillie re Received: 21 March 2012 / Accepted: 29 May 2013q Ministry of Science and Technology, Taiwan 2014