Impairments in physicians present risks to the public, the physician, the family, the hospital, and to professional colleagues of the physician. Impairment may result from psychiatric illnesses such as depression, from advancing age, from physical disabilities and from dependence upon drugs. While all of these may have serious consequences, this booklet will be limited to drug addiction because the majority of those afflicted develop the disease during the most productive portions of their professional careers.
Chemical dependence is a chronic, relapsing disease that affects individuals in all social strata and in all walks of life. It occurs no more frequently among physicians that it does in the general public, although it is particularly noticeable when it occurs in professionals. For an addiction to develop, there must be a drug that is readily available and an urge to use that drug. The urge is genetic and behavioral in origin; availability is situational. To become an addict, the physician must have an inherent susceptibility to the disease and must be able to obtain drugs. Drug type and availability are usually dictated by the physician’s medical specialty
Although there are no precise data regarding the prevalence of dependence on alcohol and other drugs in anesthesiologists, recent survey data indicate that in anesthesia training programs in the United Sates, the disease appears at a rate of about 0.5 percent per year of all personnel in those programs. As yet, there are no similar data for anesthesiologists in private practice. Both the survey data and reports from treatment centers have clearly shown that the potent opioids, fentanyl and sufentanil, are the drugs abused most frequently by anesthesiologists, comprising about 70 percent of cases. In the survey, alcohol and cocaine each accounted for about 10 percent of the cases, while the remainder were divided nearly evenly among several other drugs, including benzodiazepines, potent inhalation agents, nitrous oxide, sodium thiopental, lidocaine and propofol.
The disease is progressive, with a rapidity of onset that depends upon the “drug of choice.” While addiction to alcohol may take decades to become apparent, addiction to the potent opioids frequently becomes apparent within weeks. Unless the disease is recognized and treated appropriately, it will result in social, psychological and physical harm to the abuser, and may end in death.
Early detection is usually difficult, since the signs and symptoms of dependency are frequently quite subtle until the later stages of addiction have developed. Identification is also hampered by the overwhelming denial of the disease, not only by the addict but also by colleagues and family members. Self-reporting is unusual, in large part because of the denial and also because of the fear of losing one’s job, one’s license to practice medicine and the respect of others.
It is therefore imperative that physicians, their families and other health professionals be well-educated about chemical dependence. Education of hospital administrators is equally important. Hospital and departmental policy manuals should contain procedures for managing addicted physicians. Only then will we as physicians be in a position to aid chemically dependent colleagues.
The goal of these educational efforts and substance abuse policies is to assure 1) timely identification of these individuals, 2) intervention to facilitate rapid entry into treatment programs, 3) adequate time for appropriate treatment, and 4) subsequent follow-up care, which is imperative for successful return to the workplace. This sequence can lead to an excellent prognosis for long-term recovery
Definition Addiction is the overwhelming compulsion to use drugs in spite of adverse consequences. It is a chronic, progressive disease that results in loss of control of one’s life. Unless it is recognized and treated skillfully, addiction will result in disability and will often end with death. Physician dependence frequently develops but is not present in all drug addictions.
Abuse involves the inappropriate use of drugs (including alcohol) but is not accompanied by the uncontrollable compulsion seen with addictions. The person who is arrested for driving under the influence of alcohol, who realizes transgression and is able to avoid further incidents, has abused the drug. In contrast, the person who irrationally blames the arrest on outside influences such as the officer’s career goals and who continues drinking uncontrollably, is addicted.
Disease The American Medical Association recognized addiction as a disease in the early 1970s. There is conclusive documentation of the inheritance of alcoholism, and there is strong support for biochemical etiologies of addiction to both alcohol and to other drugs. Addiction presents as a characteristic constellation of pathological signs and symptoms that occur through the interaction of a susceptible host, a causative agent (drug) and an environment in which the drug is available. When exposed to a critical combination of drugs and external conditions, vulnerable individuals will become addicts, and some will die from their disease. The ASA survey documented the deaths of several anesthesiologists during each year that is was conducted. The disease appears to be far more common in men than in women. While about 25 percent of individuals in anesthesia training programs in the United States are women, the ASA survey showed that only 10 percent of addictions in that cohort involved women. Data from treatment programs support this observation. This variation, however, may be due to case selection and reporting, rather than demonstrating a true difference in incidence by gender.
Signs and Symptoms The signs and symptoms of the disease usually develop in a characteristic progressive fashion, beginning with changes in 1) community activities, 2) family life, 3) employment, and 4) day to day work habits. Most of them are subtle and difficult to recognize.
The rapidity of onset of the disease appears to be directly related to the potency of the drug of choice. Thus, addiction to alcohol may take decades before becoming apparent. In contrast, addiction to fentanyl characteristically takes less than a year and sufentanil less than a month, respectively, before the disease is perceptible to others.
Many of the manifestations of addiction that appear in Table 1 [page 6] are seen outside of the hospital. This is especially true with addictions to alcohol and most orally administered drugs, both of which develop slowly. Thus, the physician’s spouse, partner or friends may be the first to recognize the early warning signs of the disease.
Since addictions to the potent opioids, fentanyl and sufentanil, develop rather rapidly, most of the signs and symptoms of addiction to these drugs, which are included in Table 2 will be apparent in the hospital setting.
Unfortunately, the most common response of persons when faced with the possibility of addiction in a colleague or friend is to categorically deny that it is present. Denial involves the development of rationalizations for irrational behavior patterns. For example, the addict with a closet full of stolen syringes may be able to convince himself and those around him that he is keeping them in the event that his diabetic father runs out of his own supply. * Denial is a pathologic alternative to facing the prospect that the signs and symptoms point to addiction. Unfortunately, with the exception of witnessed selfadministration, none of the signs and symptoms seen at home or at work is diagnostic. Thus, in order to recognize the disease, the myriad of indicators must be viewed as a whole. For example, a collection of syringes, long hours at work even when not on call, loss of interest in sports, forgetting a child’s birthday party, mood swings and other signs each taken in isolation do not bring to mind the possibility that they result in addiction. When examined collectively, however, they may.
Tolerance During the relatively short course of addiction normally seen with fentanyl or sufentanil, the addict develops an incredible tolerance to the drugs, resulting in the use of progressively larger doses. Over a six- to 12-month period, a fentanyl addict may attain a habit of 80 to 100 ml of fentanyl per day. Within weeks of the onset of addiction to sufentanil, daily use may be as much as 10 to 20 ml. A tenth of these doses would kill a person who is drug-naive.
Many recovering anesthesiologists have said that the first time they “used,” the feeling was indescribably good. They have also reported that they were never able to attain the same sensation again, in spite of using progressively escalating doses of drug. In fact, as their addictions progressed, they had to “use” almost continuously to avoid the symptoms of withdrawal that accompany abstinence in those who have developed a physical dependence.
Physicians who choose potent opioids are usually identified more rapidly than those who become addicted to other drugs. The latter group may successfully conceal the effects of chemical abuse on their professional activities for years. The rapid deterioration that results from the abuse of potent opioids leads to the perception among both medical and non-medical communities that anesthesiologists are more prone to addiction than practitioners of any other specialty. They are not. However, when they become addicted, the disease tends to become apparent more quickly than in others because fentanyl and sufentanil are the drugs most commonly used by anesthesiologists.
Gathering Information and Reporting the Findings
The presence of behavioral changes suggestive of chemical dependence raises a suspicion but should never be construed as conclusive proof of drug abuse. However, when the disease is suspected, it is important that the possibility be investigated in an expeditious but caring and confidential manner.
Suspicion of a drug problem should be reported to the proper person or committee. Depending on the particular institution, this may be the physician well-being committee of the state medical society, a peer assistance committee, the department’s chair, a direct supervisor or other relevant individual. It should be the responsibility of this person to investigate confidentially the available information and to seek corroborating documentation. The investigation may involve interviews with associates, colleagues, family members, friends and others acquainted with the person in question, as well as reviews of anesthetic and pharmacy records.
For the protection of the suspected addict, it is important not to go directly to police or other authority whose prime charge is to prosecute. Anyone who has diverted controlled drugs for personal use has, by law, committed a felony and is subject to prosecution. This individual is, at the same time, however, acutely ill and urgently in need of treatment. Prosecution may be in the individual’s future, but treatment should be the primary intent of the initial investigation.
Potential Legal Issues Laws regarding chemical dependence in physicians vary from state to state. Some require that all cases of chemical dependence in physicians be reported; some mandate reporting abuse of all drugs except alcohol; and others have no statutory requirement to report impaired physicians at all. Laws that demand reporting directly to regulatory boards, rather than to committees whose goal is to assist the ill physician, may tend to cripple the activities of these advocacy committees. As a result, unless the aim of the board is advocacy, few physicians in these states will receive the needed medical care. Impairment is not primarily a legal issue, but it is imperative for those concerned to contact the medical society in the state of record should questions arise regarding specific methods of management.
Hospitals, medical staffs and individual physicians have occasionally been found negligent for failure to monitor or restrict the privileges of an impaired physician. Therefore, to be aware of and yet to ignore chemical dependence may result in legal liability. That is the basis of the “snitch law” which is enforced in some states. If reasonable care is taken to see that an impaired physician is identified and treated in accordance with accepted medical practice, liability --other than possible imputed liability for any malpractice engaged in by the impaired physician --is generally reduced or eliminated.
In most state, legislation provides immunity from liability to members of a professional society or medical staff committee whose purpose is to review the quality of medical services. Persons who give information to such committees are also usually granted immunity, providing they believe the information is true, they are not reporting it with malice, and they discuss it only with the committee.
I recently heard from a Quality Risk Manager who appreciated the information regarding risk reduction in our previous issue and offered to forward the newsletter to all physicians on staff. If there is a Risk Manager with your hospital that would benefit from receiving our newsletter, please either forward an issue to them or let Nancy Morton, The Physician Lifeline editor, know their names and email addresses.
* We have used the masculine pronoun because addiction is much more common in men.