“The most obvious, ubiquitous, important realities are often the ones that are the hardest to see and talk about.” –David Foster Wallace
Addiction can be a nightmare of isolation and shame, but it doesn’t have to be.
I will always remember my last night of withdraw; sitting in the busy waiting room of my training hospital. I kept thinking about what might happen if one of my EM attendings were to care for me. To see me sick, weak, and vulnerable. Nobody other than my family knew I struggled with alcohol abuse, and I was exhausted with the neverending cycle of trying to manage addiction on my own. This had to stop.
Physicians-in-training are at particular risk for developing addictions, but the topic is seldom discussed in an open and straightforward manner. This essay is designed to give the reader practical background knowledge on the topic of medical students and physicians struggling with addiction.
Background
Addiction affects medical professionals and laypersons indiscriminately. Medical professional substance abuse rates hover around 9-12%, equal or greater than non-medical populations. 1,2 Substances most frequently abused include alcohol and prescription medications with cocaine, amphetamines, marijuana and psychedelics appearing at lesser rates.3 Studies of resident physicians demonstrate that different specialties have tendencies toward different drugs of choice. For example, resident surgeons tend to abuse alcohol; emergency medicine alcohol, benzodiazepines, cocaine, and marijuana; psychiatry marijuana, benzodiazepines, psychedelics; anesthesia opioids and alcohol.4 Women and men physicians both suffer from substance abuse disorders, though usage patterns and risk factors seem to differ between sexes.5
Medical students and residents are at least as susceptible to addictive behaviors as their attendings.4 In 1991, the first serious survey of senior medical students illustrated that students are unlikely to self-report substance abuse or dependency, with only 1.6% responding that they wanted help with substance abuse, and only 25.7% aware of school policies.6 This reluctance to self-identify as substance dependent is noteworthy because at the time of the survey, medical student drinking patterns were demonstrated to be increased compared to their non-medical peers.7 Residencies also seem to under-estimate the number of residents suffering from substance abuse disorders. A lack of insight into the process, procedures, and realities of recovery has been identified as an issue with medical personnel throughout the entire spectrum of education and practice.7
Like any other disease, substance abuse is influenced by a mixture of environmental, genetic, and behavioral components. No longer minimized as simply the lack of discipline and moral failure, research is being conducted on the genetic and neurochemical predispositions underlying addition.8 Any addictive substance can result in a use disorder if abused long enough, but for some people the threshold for forming an addiction is lower. An addict often describes having a “magical connection” to their drug of choice which can be demonstrated via PET scan.9 Addicts often experience an exaggerated stimulating effect while using depressants.10 Relapse rates peak weeks or months after initiating abstinence because an addict’s cravings initially worsen before they improve.11 The neuroscience of addiction is increasingly utilized to design effective psychiatric treatment, and is providing some insight into how addiction overcomes the willpower and insight of highly functional people.12
Physicians are notoriously good at obscuring their illness and delaying treatment until the last moment, usually when they are finally faced with legal and/or professional consequences.13 Physicians make admirable “closet” addicts, finding their high professional standards at odds with their personal struggles. Obfuscation increases the severity of illness by increasing a sense of isolation and ultimately delaying treatment.14
Realities of Recovery
There is a difference between having a potentially impairing medical condition and endangering patients by practicing as an impaired physician. This distinction is recognized by many professional organizations, including the Federation of State Medical Boards. The Federation of State Medical Boards comments on this distinction in the following way:
Some regulatory agencies equate ―illness (i.e. addiction or depression) as synonymous with ―impairment. Physician illness and impairment exist on a continuum with illness typically predating impairment, often by many years. This is a critically important distinction. Illness is the existence of a disease. Impairment is a functional classification and implies the inability of the person affected by disease to perform specific activities.15
The potentially impaired student is in a unique situation where early intervention maximizes benefit to that student and future patients while minimizing professional risk. Student health services at medical schools are looking to intervene positively in these students’ lives before significant consequences occur.
Physician Health Programs
Physician health programs, sometimes called impaired physician organizations, are essential for obtaining professional advocacy with a strong legal backing. Similar to having a lawyer, physician health programs advocate to the medical board on behalf of the physician in recovery. After establishing a relationship with them, their job is to intervene for questions such as “have you ever received treatment for any addiction or psychological conditions?” Oftentimes their intervention is a key step in maintaining certification, and no medical professional should go in front of the board alone.
The Federation of State Medical Boards also encourages participation in physician health programs due to their ability to manage addiction cases effectively and confidentially:
As long as the physician is willing to abide by contracted agreements struck by the PHP (physician health program) and the physician does not pose a risk of harm to the public, the physician participant can maintain confidentiality. By maintaining confidentiality and avoiding physician discipline, hospitals and medical staffs are incentivized to refer physicians into a PHP early rather than wait for frank impairment and referral to the board for discipline.
The “physician health program” model of advocacy has been successful enough in the United States that the British Medical Journal has recently published articles suggesting Great Britain develop similar models for their medical system.16
Medical professionals are best treated at specialized centers designed for professionals. Centers specializing in care of medical professionals can be accessed through physician health programs, and treatment usually takes place over a 6-8 week partial, inpatient, or intensive-outpatient setting. Professionals have a different set of social and psychological dynamics than the general population, and they need to be treated by groups that specialize in these challenges. Physicians in recovery have a uniquely high recovery rate. For example, an emergency-medicine physician’s five year recovery rate is significantly above the national average, somewhere between 71-86%.3
Addiction centers for professionals also provide family support and education, advocacy for work-related issues, and psychological/medical support. They prescribe aftercare recommendations and help initiate monitoring protocols. Monitoring is typically achieved through random urine screens and/or home breathalyzer tests. As time passes, this monitoring becomes less stringent and is always confidential.
License Reinstatement
In cases where the physician’s licensure is revoked the revocation can be overturned after a period of time, and is often dependent on continued compliance with treatment and monitoring conditions. Medical license reinstatements are handled by the aforementioned Federation of State Medical Boards, but specialty certification must be reinstated as well.
Specialty certification boards typically have their own standards for reinstatement. For example, the American Board of Internal Medicine requires one year of monitored sobriety before re-evaluation.17 The American Board of Surgeons and American Board of Anesthesiologists both require completion of a rehabilitation program and compliance with treatment and monitoring.1819 The American College of Emergency Physicians recommends early recognition and non-punitive mechanisms of reporting that include mechanisms for physicians to return to practice.20
Hospital credentialing issues may appear in the future depending on the physician’s history and length of recovery time. Credentialing typically requires a physician to appear before a credentialing committee where the physician has an opportunity to discuss their recovery and present evidence of compliance held by their PHP.
Medical personnel with addictions sometimes have a history of abusing diverted medications and/or writing illegal scripts. In these cases, the Drug Enforcement Agency may open a case on the physician, requiring legal intervention on the physician’s behalf. Entering treatment and addressing illegal activities before DEA intervention is best if still possible, but recovering physicians may have their DEA license renewed after a probationary period. Physician health programs and hospital employee assistance programs have increased jurisdiction over cases where the physician voluntarily seeks assistance.
Read More
For those interested in researching more on this topic I would recommend starting by reading the two articles:713
- Aach RD. Alcohol and Other Substance Abuse and Impairment among Physicians in Residency Training. Annals of Intrnal Medicine Ann Intern Med. 1992;116(3):245.
- Mansky PA. Issues in the Recovery of Physicians from Addictive Illnesses. Psychiatric Quarterly. Doi:10.1023/a:1022197218945.
Conclusion
Substance abuse disorders among physicians and medical students occur at a rate similar to the general population. These disorders are no longer being minimized as a failure of personal integrity, and research is essential for designing effective treatment regimes. There seems to be a lack of general awareness about the way addiction manifests in medical populations. Physicians are less likely to receive treatment early on in the disease course, though their recovery outcomes are better than the general population. Physician health programs and physician treatment centers are essential advocates for recovering physicians, and medical licensing boards have policies for reintegrating a physician in recovery to the work force. Delay of treatment significantly complicates recovery and a physician ought to enter treatment before their disease progresses from potentially impairing to endangering to patients.
If a physician feels uncomfortable with their substance use, it is reasonable for them to get evaluated for a potential substance abuse disorder earlier rather than later.
A physician in recovery is as respectable as they are resilient. The recovery processes requires deliberate practice developing grit and conscientiousness, and these men and women learn a kind of patience only long-suffering can teach. They experience the kind of goodness available only to a person who has the strength to confess vulnerability.
I wish you more than luck.
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