Medicine & Self-Medication: What Every Resident & Fellow Should Know About Impairment

1. Medicine & Self-Medication:What Every Resident & Fellow Should Know About Impairment Andrew L. Parker, Ph.D. UCSF Faculty & Staff Assistance Program

2. Introduction & Overview • FSAP and its services to physicians, residents, and fellows • Objectives of this Presentation: • Review the UCSF Policy on Substance Abuse • Discuss the magnitude of the problem • Learn to recognize its signs and symptoms • Learn some of the characteristics of Substance Abuse • Identify issues and resources in treating Substance Abuse

3. UCSF Policy on DRUG-FREE WORKPLACE • The University Policy on Substance Abuse in the Workplace prohibits illegal use, possession, or distribution of controlled substances by University employees in the workplace, as well as use of legal or illegal substances in a manner which impairs performance. • Employees found to be in violation of this policy may be subject to corrective action, up to and including dismissal

4. Impairment Definition: • Refers to a physical or mental condition that causes a physician, resident, or fellow to be unable to practice medicine with reasonable care and safety commensurate with his/her level of training.

5. What does this mean for physicians? • Currently, there are > 684,400 MD’s in the US • 80.5% men, 19.5% women • Based on the NIMH epidemiological catchment area data, it can be estimated that: • 137,397 MD’s (131,124 men, 6,273 women) will experience an alcohol disorder during their lifetime • 48,829 MD’s (42,423 men, 6, 406 women) will have a drug disorder during their lifetime • Chemical dependence is the single most frequent disabling illness among MD’s (Talbott G, Wright C. Occupational Medicine. 2: 581-591, 1987.)

6. What is Lifetime Prevalence among Practicing Physicians? • Best Estimate — Impairment from Substance Abuse: ≥ 10-15% • Controlled studies using DSM diagnostic criteria indicate that healthcare professionals have similar rates (8-14%) of overall substance abuse and dependence to the general population (Brewster, 1986) and slightly lower rates compared to other occupations (Anthony, 1992; Stinson, 1992). • Overall, the prevalence of substance use disorders in healthcare professionals appears to be about equal to that in the general population. (Welsh, 2002)

7. Medical Specialty and Addiction • There is no specialty that "protects" a physician from a substance use disorder • Although incidence varies among specialties, certain specialties are generally over-represented: • Anesthesiology • Obstetrics/Gynecology • Family Medicine/General Practice • Emergency Medicine • Physicians (all types) in Academic Medicine

8. How Common is Substance Use among Residents? Stratified Randomized National Sample of 1785 PGY III’s • Use within past 30 days • 87% use alcohol, 5% daily • 7% use marijuana, 5% daily • 1.4% use cocaine, not daily • 3.7% use benzodiazepines, not daily

9. History & Pattern of Substance Abuse in Medical Students and Residents • Use of all drugs except benzodiazepines tends to begin prior to medical school • Types ofsubstances used tend to parallel current popular drugs of abuse (alcohol and marijuana highest) • The heaviest users in medical school were the heaviest users prior to school • Rates of illicit drug use for medical students are similar to age matched controls • Beginning with residency, use of controlled substances (benzodiazepines and opioids) increases in physicians relative to the general population

10. Factors contributing to substance abuse by medical students and physicians • Access to pharmaceuticals (availability) • Family history of substance abuse (genetics) • Personality factors (e.g., compulsivity, grandiosity, guilt) • Stress at home and/or at work • Thrill-seeking • Self-treatment of pain, sleep patterns, emotional disorders • Chronic fatigue • Social/economic status

11. What is (and is not) Addiction? • The American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine recognize the following definitions and recommend their use: • Physical dependence: is a state of adaptation that is manifested by a drug class specific withdrawal syndrome, which can be produced by: • abrupt cessation • rapid dose reduction • decreasing blood level of the drug, and/or administration of an antagonist • Tolerance: is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time

12. What is (and is not) Addiction? • Addiction: is a primary, chronic, biopsychosocial disease, with genetic, psychological, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include • impaired control over drug use • compulsive use • continued use despite harmful consequences • craving • chronic and progressive condition • Pseudo-addiction: describes the behavior of patients whose pain is undertreated, and therefore engage in behaviors that are seen as being aberrant and drug-seeking, but really are just due to uncontrolled pain

13. Signs and Symptoms of Substance Abuse and Addictive Disorders in Physicians Sequential, progressive deterioration and impairment in every facet of life: • Physical health • Family Life • Social Life • Professional performance

14. Signs and Symptoms: Physical Health • Personal hygiene deteriorates • Clothing and dress habits deteriorate • Has multiple physical signs and complaints • Writes numerous prescriptions for personal use • Experiences frequent hospitalizations, and/or has numerous visits to physicians and dentists • Is involved in multiple episodes of accidents and trauma

15. Signs and Symptoms: Family Life • Withdraws from family activities; there are unexplained absences • The spouse/partner becomes a caretaker/enabler • Fights increase in frequency; there is dysfunctional anger; the spouse tries to control the physician’s substance abuse • Substance abuse disorders become a family illness. • Older children assume responsibility for maintaining normal family functioning • Children develop abnormal, antisocial behavior (depression, promiscuity, running away from home, substance abuse) • Sexual problems emerge (impotence, extramarital affairs) • The spouse disengages, seeks separation or divorce, abuses drugs and/or alcohol, or enters recovery (Al-Anon)

16. Signs and Symptoms: Social Life • Becomes isolated and withdraws from community activities, church, friends, leisure, hobbies, and peers • Exhibits embarrassing behavior in public • Receives DUI citations, experiences legal problems, and exhibits role-discordant behaviors • Behavior is unreliable and unpredictable in community and social activities • Is unpredictable in personal behavior, engaging in excessive spending, risk-taking behaviors

17. Signs and Symptoms: Professional Performance • Schedule and patient appointments become disorganized; starts progressively later in the day • Makes rounds late or exhibits inappropriate or abnormal behavior • Behavior toward colleagues, staff and patients is hostile, withdrawn, and/or unreasonable • Patients complain to staff about the physician’s behavior • Spends time behind "locked doors" • Frequently absent from the office or has unexplained or frequent illnesses

18. Signs and Symptoms: Professional Performance • Decrease in quality of performance in staff presentations, writing in charts, record keeping, etc • Enters inappropriate orders for or over-prescribes medications • Nurses, other staff report a change in behavior and/or judgment • Becomes involved in malpractice suits and/or legal sanctions against him/herself or the hospital • Unavailable for or responds inappropriately to pages and/or telephone calls • Is reluctant to undergo physical exams or drug screening

19. Barriers to Diagnosis & Treatment • Barriers to early diagnosis: • "conspiracy of silence" • denial on the part of family, friends, colleagues, even patients • Fear of facing underlying problem without self-medication option • These barriers are the products of a lack of education concerning the true nature of addiction as a primary biopsychosocial disease • Tenacious denial is the common feature of alcoholic/addict physicians • Knowledge of the effects of drugs and alcohol create the delusion that special insight provides immunity • Alcoholic/addict physicians cannot see themselves as sick; do not accept chemical dependency as a disease • Family members and colleagues contribute to the denial by covering up/making excuses for the physician, don’t demand he/she seek help

20. Elements of Successful Treatment • Understanding and acceptance of addiction as a biopsychosocial disease • Identification of trigger mechanisms • Development of non-chemical coping mechanisms and recreational activities • Achieving balance by changing priorities • Involvement of family, significant other, peers • Involvement in mutual support groups (AA, NA, Lifering) • Peer-oriented therapy

21. Clinical Diagnostic Evaluation Model(Preferred Approach for Physicians Well-Being Committees)* • A Clinical Diagnostic Evaluation (CDE) is a designed to determine whether or not an individual meets diagnostic criteria for addictive disease and/or mental illness • CDE’s are: • conducted on outpatient basis • multidisciplinary • led by addiction specialist • collegial and non-confrontational • require participation of spouse, partner, or significant friend * Garrett O’Connor, MD Chief Psychiatrist, Betty Ford Center and Medical Director Licensed Professionals Treatment Program

22. A Clinical Diagnostic Evaluation (CDE) • Identifies possible medical causes for impaired behavior by individuals at work, at home, or elsewhere (causes may include addictive disease, mental illness, neurological disorders or metabolic conditions) • Assesses the physician’s level of occupational, mental, social or physical impairment, if any • Evaluates physician’s fitness for duty to perform safety sensitive operations • Determines what, if any, treatment is indicated • Documents CDE findings that can reduce liability to physician and his/her organization in event of litigation • Confers with referents prior to, during and following evaluation

23. Resources & Treatment Options • Physician’s Well-Being Committee • Medical Board Diversion Program * • FSAP • Employee Health — if work-related injury or disability involved • Treatment modalities and alternatives • Detox • Inpatient • Day-treatment • Outpatient • Self-help (12-Step and other support groups) • Individual/Family Therapy

24. Outcomes • The prognosis of the adequately treated physician alcoholic/addict is excellent, if they actively and voluntarily engage in the recovery process • Recovery is a long-term (lifelong) process involving both sobriety and lifestyle change • Continuing engagement in a mutual help program and in peer-group support has proved to be an essential component • Random alcohol/drug screens assist in maintaining successful recovery

25. Conclusions • Untreated substance abuse and addiction poses serious consequences for patient safety and career success • Treatment works • Long-term abstinence and personal well-being correlate with strict aftercare monitoring and improved recovery surveillance techniques • Death is significantly more prevalent among those who leave treatment prematurely and those who relapse often • The majority of physicians who successfully complete treatment and participate in aftercare monitoring can successfully return to the practice of medicine

26. Physician specific treatment programs • Talbott Recovery Campus 5448 Yorktowne Drive Atlanta, Georgia 30349 800-445-4232 www.talbottcampus.com • Williamsburg Place 5477 Mooretown Road Williamsburg, Virginia 23188 1-800-582-6066 www.williamsburgplace.com • Betty Ford Professional Recovery Program (PRP) 39000 Bob Hope Drive Rancho Mirage, California 92270 800-854-9211 www.bettyfordcenter.org

27. Closure • Questions/comments.