SUBSTANCE USE DISORDERS IN PHYSICIANS Christopher Welsh M.D. University of Maryland School of...

SUBSTANCE USE SUBSTANCE USE DISORDERS IN DISORDERS IN

PHYSICIANSPHYSICIANSChristopher Welsh M.D.University of Maryland

School of Medicine

Copyright Alcohol Medical Scholars Program

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““WHY SHOULD I WHY SHOULD I STAY AWAKE?”STAY AWAKE?”

It might be my colleague It might be my patient It might be me

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KEY POINTSKEY POINTS

SUDs similar to the general population

Benzodiazepines and opioids higher

Identification is often difficult and delayed

Treatment outcomes are often better

Impaired Physician Programs are helpful

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DEFINITIONSDEFINITIONSSubstance Use DisordersSubstance Use Disorders(SUDs) (SUDs) DEPENDENCE

Tolerance Withdrawal Inability to cut down/control use Considerable time spent using/obtaining/recovering Important activities given up/reduced Use despite negative consequences

ABUSE (less severe) Failure to fulfill role obligations Use in hazardous situations Recurrent, related legal problems

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EPIDEMIOLOGYEPIDEMIOLOGY VERY VARIABLE!!!!

Population studied

Methods used

Terminology

Diagnostic criteria

Changes over time?

Concern about anonymity

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EPIDEMIOLOGYEPIDEMIOLOGYGeneralGeneral

Similar rates of SUDs to general population 8-14%

Less SUDs compared to other occupations Roofers, painters

Increased rates of use & SUDs with: Benzodiazepines Prescription opioids

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EPIDEMIOLOGYEPIDEMIOLOGYMedical StudentsMedical Students

Use begins prior to medical school

Types of drugs same as general pop.

Alcohol use & dependence variable

Drug use and dependence less

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EPIDEMIOLOGYEPIDEMIOLOGYResidentsResidents

Rates of dependence:10-14%

Alcohol & illicit drug use begins prior

Benzo & opioid use begins during Self-treatment Self-prescribed

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EPIDEMIOLOGYEPIDEMIOLOGYPracticing PhysiciansPracticing Physicians

Prevalence of dependence: 8-14% Still means 60-75,000 affected M.D.s in U.S.!!!!

Use & misuse of prescription opioids

& benzodiazepines up to 5Xs

higher

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EPIDEMIOLOGYEPIDEMIOLOGYBy SpecialtyBy Specialty

HIGHEST

Emergency Medicine

Psychiatry

Anesthesiology

LOWEST

OB-GYN

Pathology

Radiology

Pediatrics

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REASONS FOR USEREASONS FOR USE Recreational

Seen more in medical students

Performance Enhancement Seen more in Emergency Medicine

Self-medication (pain, anxiety, “stress”) Seen more in residents & attendings

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PROGRESSIONPROGRESSION Family

Community

Finances

Spiritual/emotional

Physical health

Job performance Often one of the last things affected

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CONTRIBUTING CONTRIBUTING FACTORSFACTORS

Family History

Personality characteristics

Health/lifestyle

Stress???

Availability???

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IDENTIFICATIONIDENTIFICATION Urine drug screening

Employment/school application

Physician screening

Impaired Physicians Programs

Reporting

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““WARNING SIGNS”WARNING SIGNS” Isolation Friction with colleagues Disorganization Inaccessibility Frequent absencesRounding on patients at odd hours Inappropriate or forgotten orders Slurred speech during off-hours calls Prescriptions for family members OD or suicide attempt

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WHY THE DELAYWHY THE DELAYIN DETECTION?IN DETECTION?

Independence

“Malignant denial”

“I can take care of myself”

“Knowledge is protective”

Fear of consequences

“Conspiracy of silence”

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““CONSPIRACY OF CONSPIRACY OF SILENCE”SILENCE”

Reputation

Financial

Fear & intimidation

Professional pride

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REPORTINGREPORTING Ethical obligation

Disabled Doctors Act

Federal law

Requirements vary by state

Protection from law suit varies

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TREATMENTTREATMENTTHE GOOD NEWS!!! Variable data

Most show better outcomes

70-90% “success rate”• little correlation with substance

• little correlation with specialty

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TREATMENTTREATMENTGoalsGoals

Abstinence

Acceptance of chronic disease concept

Identification of triggers

Development of non-chemical coping

skills

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TREATMENTTREATMENTKey Factors For SuccessKey Factors For Success

Duration of aftercare

Physician’s Health Program involvement

Family involvement

12-Step involvement

Witnessed urinalysis

Contingency contract

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TREATMENTTREATMENTStumbling BlocksStumbling Blocks

Uniqueness

Role-reversal

Over-identification w/ performance

Identification (by treatment provider)

Medical knowledge

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TREATMENTTREATMENTPhysician-specificPhysician-specific

In-Patient Talbott, Farley

12-Step “Caduceus meetings”

Pros & Cons

Combined approaches

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““RE-ENTRY”RE-ENTRY” Most return to practicing medicine

Change to a less high-risk specialty

Imposed prescribing restrictions

Altered work schedule

Specialization in addictions

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““PREVENTION”PREVENTION” Medical school policies

Medical school education

State Impaired Physicians Programs

• Protect the public

• Provide “rehabilitation” (vs punishment)

JCAHO-mandated hospital programs

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KEY POINTSKEY POINTSA ReviewA Review

SUDs similar to the general population

Benzodiazepines and opioids higher

Identification is often difficult and delayed

Treatment outcomes are often better

Physician Rehab Programs are our friends

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WHERE TO GET HELPWHERE TO GET HELP

State Agency#

School Resources#

Your email address

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NURSESNURSES Rates similar to general population

Higher use of benzodiazepines & opioids more parenteral use

Higher in emergency room & critical care

Especially difficult to monitor

Watch for diversion

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DENTISTSDENTISTS Less good data

More use of inhaled anesthetics

Possibly higher opioid use and SUDs

Related to higher suicide rate?

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PHARMACISTSPHARMACISTS Estimates of dependence: 10-18%

Less parenteral use

@ 50% have used CS w/o script @ 20% on regular basis primarily self-medication

@ 60% of students have used CS w/o script @ 40% on regular basis primarily recreational

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VETERINARIANSVETERINARIANS Little good data

More Ketamine use

Other higher-potency opioids

Inhaled anesthetics

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