Impaired Physicians: Obliterating the Stigma

Freud's well-known use of cocaine is thought to have influenced his professional transition from a neurologist to the father of psychoanalysis. Similarly, it is believed that cocaine played a role in William Halsted's career success, including his development of paradigm-shifting surgical innovations. While many historians of medicine believe that quite a few of the successes of Freud and Halsted were influenced by their cocaine use, their addictions to cocaine and use of other substances (i.e., Freud's use of alcohol and Halsted's use of morphine) led to immense interpersonal conflict, physical harm, and personal anguish (1). Freud and Halsted are two examples of an underrecognized phenomenon: the impaired physician. This article provides an overview of physician impairment, a condition that is encompassed in the practice of forensic psychiatry, including prevalence, contributing factors, intervention, evaluation, and treatment.

Evidence suggests that addiction among physicians is similar to addiction in the general population. The prevalence of substance use disorders is reported to be 15% among physicians and 13% in the general public (2). In both the physician and general populations, experimentation of substance use at a young age and family history of addiction may contribute to the development of addiction (3). Both impaired physicians and their counterparts in the general population give similar reasons for initiating drug or alcohol use, including curiosity, peer pressure, and availability of a given substance (4). However, in contrast to the general population, physicians have very easy access to controlled substances. Consequently, common reasons for initiating use, facilitated by easy access, include attempting to treat psychiatric distress associated with burnout and attempting to self-treat physical pain (2, 5).

Use by Medical Specialty

Research suggests that differential patterns of substance use disorders are found in different medical specialties. However, specialties that are found to be overrepresented vary among different studies (2, 6). Nevertheless, anesthesiology has attracted significant attention because anesthesiologists with substance use disorders have particularly high rates of relapse, overdose, and suicide (3, 6, 7). Anesthesiologists disproportionately represent physicians who abuse and are addicted to fentanyl, which may be explained by the "secondhand exposure hypothesis." By using liquid-chromatography mass spectroscopy methods to measure fentanyl particles in the air of an operating room, Gold et al. (8) found the highest concentration of aerosolized particles to be located near the patient's expiratory circuit, which is close to where the anesthesiologist is positioned during an operation. Given that one of the contributing factors to the development of addiction is a family history of addiction, exposure to fentanyl particles may prime an anesthesiologist who is at greater risk due to family history by altering reward circuitry, thus resulting in cravings, drug-seeking behavior, and addiction (3, 8, 9).

Intervention and Treatment

Impaired physicians are difficult to identify for a variety of reasons. In addition to ease of access to substances, as mentioned previously, physicians may be more adept at hiding substance use from their colleagues compared with other professionals because they know the signs and symptoms of drug addiction and are better able to conceal them in the work environment (e.g., covering up track marks) (10). Additionally, physicians are less likely to self-report substance use because of professional implications, stigma, and lack of awareness about mechanisms for reporting and avenues for referral to treatment (10). Thus, most impaired physicians do not receive adequate treatment. Of those who do, nearly 75% are referred via external sources (e.g., colleagues, loved ones, a state board of medicine) (11).

For physicians who do enter treatment, the usual mechanism involves a state physician health program. Physician health programs are state-level entities that work with their respective boards of medicine to arrange treatment and subsequent monitoring of impaired physicians. Physician health programs formally emerged in the 1970s after a series of American Medical Association-sponsored reports and conferences on impaired physicians (12). After a physician suspected of impairment is referred to a physician health program, a qualified physician with expertise in either addiction psychiatry or addiction medicine performs a comprehensive evaluation, with a focus on addiction and psychiatric histories. Subsequently, recommendations for treatment and future monitoring are made to the state physician health program, which then drafts a contract detailing the requisite treatment and monitoring with which the physician must comply in order to retain the ability to practice medicine (10, 11).

Physician health programs typically have arrangements with a select group of treatment centers that deliver state-of-the-art treatment, usually with specific programs geared toward impaired physicians. Following acute medical detoxification, residential treatment for approximately 90 days is generally recommended, although some contracts allow for intensive outpatient treatment. Treatment is almost exclusively focused on abstinence, and participants receive individual, group, and family-oriented therapy. Attendance at Alcoholics Anonymous, Narcotics Anonymous, or Caduceus (i.e., a 12-step-based fellowship for physicians) meetings is usually required. Additionally, psychiatric comorbidities are closely evaluated and treated. The treatment centers may also provide resources for addressing outstanding addiction-related legal issues (10, 11).

Following successful completion of residential treatment, the impaired physician begins the monitoring phase of the contract. Participating physicians undergo frequent drug testing with a variety of modalities, including urine screening and hair and nail clippings. The specialized urine testing can detect "club" drugs, alcohol, hallucinogens, and other substances not detected in standard urine drug screens. During the monitoring period, which typically lasts 5 years, participating physicians are required to continue their attendance at monitored group meetings and mutual support meetings (e.g., Alcoholics Anonymous, Narcotics Anonymous). Additionally, individualized requirements for establishing care with a primary care physician, psychiatrist, or therapist may exist. The consequences for noncompliance with contract obligations (e.g., missed appointments and meetings, intentional false statements, relapse) depend on the severity of the offense. Consequences can include warnings, increased intensity or frequency of monitoring, mandated return to residential treatment, or referral to the state board of medicine for punitive measures (10, 11).

Pharmacotherapy for Physicians With Opioid Addiction

While pharmacotherapy for opioid use disorder in the general population is considered standard care, its role in the treatment of impaired physicians is not definitive (13). For physicians with opioid addiction who are enrolled in a physician health program, the prescription of opioid substitution therapy, specifically buprenorphine or methadone, is rarely utilized (11, 13). Many physician health programs have informal policies prohibiting opioid-substitution therapy use due to safety concerns. Buprenorphine and methadone have the potential to cause CNS side effects, and there is no robust literature demonstrating that physicians can practice medicine safely while undergoing treatment with opioid substitution therapy (13, 14).

Conversely, non-opioid maintenance therapy pharmacotherapy (e.g., naltrexone) may have considerable benefit. In 1984, Washton et al. (15) demonstrated that oral naltrexone could be successfully used in the treatment of physicians with opioid addiction. Merlo et al. (16) retrospectively studied the utility of either oral or injectable naltrexone treatment in a sample of anesthesiologists enrolled in a physician health program. In the cohort treated with naltrexone, more than 90% remained relapse-free throughout the duration of their monitoring contracts and successfully returned to work. However, more than 70% who were not treated with naltrexone relapsed at least once, with only 9% returning to work (16).

Outcomes and Implications

In a landmark study, more than 900 physicians from 16 physician health programs were followed longitudinally for the entire 5-year duration of their monitoring contracts. Seventy-eight percent maintained drug screen-confirmed abstinence from alcohol or drugs, and 72% returned to practicing medicine without restrictions (10, 17). Outcomes were consistent across physicians surveyed, irrespective of substance type or number of substances used. As mentioned previously, most physician health programs prohibit opioid substitution therapy, and therefore physicians with opioid addiction were monitored under abstinence-only contracts (e.g., without opioid substitution therapy). Interestingly, the physicians with opioid addiction had rates of 5-year abstinence, relapse, and return to work similar to the rates among physicians who had addiction problems with other substances (13). Of the physicians who completed 5-year monitoring contracts, more than 90% reported a satisfactory experience and would recommend the physician health program to others, and nearly 85% reported continued attendance at 12-step and other mutual support meetings (18).

The physician health program model has implications in addiction treatment that extend beyond the treatment of impaired physicians. Because of the success of physician health programs, professional licensing boards that govern commercial pilots, attorneys, and other health care workers have adopted this model of care. Despite issues and circumstances unique to impaired physicians (as well as other professionals with licenses), certain components of physician health programs may be extended to addiction treatment in the general public, with the potential to improve outcomes. Currently, most addiction treatment available to individuals in the general public focuses on standard sets of treatment services (e.g., medication and/or counseling) in time-limited settings (19). In contrast, the physician health program model focuses on 5-year outcomes with frequent monitoring and continued support, which could become the standard of care in mainstream addiction treatment (10, 19).

Conclusions

Physician impairment is an underrecognized problem that is inextricably linked with high rates of burnout and suicide. However, the advent of physician health programs has produced unparalleled success in addiction treatment and represents a paradigm shift, whereby addiction treatment is viewed as chronic disease management with ongoing treatment, monitoring, and support, similar to the treatment of hypertension or diabetes. The additional focus on long-term outcomes parallels that of cancer treatment (19). The dissemination and implementation of these core elements of the physician health program model is indispensable in addressing one of America's most significant public health crises: addiction.

Key Points/Clinical Pearls