The Impaired Professional: An Overview

Substance abuse in all its forms represents a major public health problem for our country. Economically, costs are well above those for other chronic diseases such as diabetes and cancer. Health-wise, substance abuse can be linked to heart disease, cancer, HIV/AIDS, and liver disease, among others. Socially, substance abuse is often a factor in drugged or drunk driving, spousal and child abuse, violence and stress (NIDA, 2005). Studies have found that 20 percent of substance use disorders have a co-occurring Axis I psychiatric disorder. Further, there is growing awareness of reward deficiency syndrome (RDS) and co-morbid process or behavioral addictions (Smith, 2010; Smith, Fortuna, Nosal, & Maxwell, 2012; Smith, Nosal, Gould, & Hines, 2013).

 

Substance abuse in the workplace varies widely by occupation and type of industry as reported in data from “Worker Substance Use and Workplace Policies and Programs: 2002–2004” (Larson Eyerman, Foster, & Gfroerer, 2007). Fewer studies exist on the incidence of substance abuse in specific professions, of which the most known are health professionals who appear to have no higher incidence than the national average by age and sex, with the exception of prescription drug abuse. 

 

However, when there is publicity such as the recent attack ads associated with California’s Proposition 46 showing possibly intoxicated physicians on call, legal and political pressure on a selective approach mounts for selective punishment. The movie Flight, in which Denzel Washington portrays an alcoholic, cokehead airliner pilot, exemplifies another demonization. The recent movie The Wolf on Wall Street depicts rampant illicit drug abuse and inappropriate sexual behavior in the financial sector. This latter issue offers a real life parallel in a recent court case in which an investment bank’s managing director is accused of using drugs with his coworkers and sleeping with a client’s wife. The firm’s other employees’ response was to volunteer for drug testing, which they passed. 

 

Mandatory drug testing for all is not an effective solution. Currently the drug testing world is divided between the Department of Transportation (DOT) model and the military, and everyone else. The development of a model of uniform standards for identification, intervention, and protocols, with a strong educational component, would aid significantly in the creation of evidence-based, cost-effective treatment. 

 

With the movement to recognize addiction medicine as a specialty in the 1980s, addiction treatment increasingly developed an integrated model of treatment based on abstinence from all drugs of abuse, including alcohol. Until then, drugs and alcohol had been differentiated, despite the fact that one of the cofounders of Alcoholics Anonymous (AA) was cross-addicted to barbiturates and alcohol (Seppala, Ries, R., & Galanter, 2014).

 

Scientific advances, particularly since the 1990s’ “Decade of the Brain,” have pressured the addiction treatment community to develop more integrated protocols incorporating evidence-based treatment that addresses not only the patient’s addiction, but also how biosocial, psychological, and spiritual needs effect and affect his or her addiction. Neurobiological advances allow a greater perception of how substance use affects the brain, and may, in time, allow for more precise examination of how various therapies influence addictive disease. Practitioners of addiction medicine are becoming increasingly aware that treatment cannot be conducted in silos, and that rigid modality-driven programs must give way to treatment plans and case formulations that look at all aspects of the individual under treatment. Such integrated treatment is particularly effective for substance-abusing adolescents with clinically significant comorbid psychiatric disorder (Smith, Wachter, & Golick, 2014). 

 

Addiction knows no age or socioeconomic boundaries. Doctors, lawyers, bankers, computer wizards, stockbrokers, auto mechanics, insurance agents, realtors, plumbers, secretaries, warehouse workers, florists, actors, authors, mothers, fathers, children, butchers, bakers, candlestick makers—all can struggle with addiction, in large part because of their genetic make-up, environment, and how early they started using their drug of choice. Professionals—physicians and other health care workers, attorneys, accountants, airline pilots, and others—seem to be at greater risk because of high stress induced by great responsibility, social situations that encourage the use of alcohol and other drugs, and the income to procure large quantities of one’s drug of choice. Health professionals are at particular risk because their workplace can be a source for certain abusable drugs, such as prescription opiates, and because they are familiar with dosages, administration, and side effects. As addiction has become recognized as a disease, federal legislation through the Wellstone-Domenici Act and the Affordable Care Act now mandates that mental health issues such as addiction be treated on a par with other chronic, relapsing diseases by the health care system (Smith, Lee, & Davidson, 2010). 

 

Physician Well-Being Programs  

 

At the recent annual meeting of the International Society of Addiction Medicine (ISAM) in Yokohama, the recently deceased Douglas Talbott received a lifetime achievement award for his pioneering work in establishing the Talbott Recovery Center for addicted health professionals. The ceremony provided an opportunity for me to reflect on the evolution of the field of addiction medicine and treatment for impaired health professionals, as Doug is important to the history of both movements. Physician well-being programs are the gold standard for treatment of substance use disorders (SUDs) in health professionals.

 

Addiction treatment was very stigmatized through the 1960s, with the public, law enforcement, and regulators feeling that any physician interested in treating addiction was likely himself—they were almost always “hims” at that time—an alcoholic or drug addict. Nonetheless, drug use had exploded in the late 1960s, and parents were beginning to clamor for information and help when their children experimented with drugs and alcohol. Veterans returning from the Vietnam War also put pressure on government to decriminalize addiction. 

 

In California, several physicians banded together and organized the Committee on Dangerous Drugs of the California Medical Society. Ultimately, this committee spawned the California Society of Addiction Medicine (CSAM) in the early 1970s as physicians began to realize that they could not appropriately treat certain medical conditions without also addressing the possibility of excessive alcohol and/or drug use. Under the talented directorship of Gail Jara, CSAM created programs for impaired physicians that were later adopted and adapted by various states, developed standards for drug and alcohol treatment as well as credentialing, and wrote legislation (Heilig, 1993; Smith, 2009). CSAM also laid the foundation for a landmark meeting, organized by the American Medical Association (AMA) and Dr. Manny Steindler in 1975, on the impaired health professional that had as its goal to review the status of addiction in physicians and programs designed to treat them. 

 

In turn, I represented CSAM and Doug Talbott represented his newly formed American College of Addictionology, based in Atlanta, to promote the formation of the American Society of Addiction Medicine (ASAM), which itself had appeared in several previous iterations (Heilig, 1993; Smith, 2009). ASAM was instrumental in the 1980s in developing standards for the Drug-Free Federal Workplace Program, setting in place protocols for standardized drug testing for safety-sensitive and other occupations (Smith & Davidson, in press). ASAM also lobbied the American Medical Association (AMA) for recognition that all drug dependencies, including alcoholism, are diseases and that medical practitioners need to base their practices on the disease model of addiction. After ASAM added cigarette and nicotine addiction, with its associated morbidity and mortality, the AMA granted specialty status for addiction medicine in 1990 (ASAM, 2014b). Addiction medicine became a board-certified specialty via the American Board of Addiction Medicine (ABAM) in 2009 (ASAM, 2014a).

 

Physician Health Programs (PHPs), also now known as Physician Well-Being Programs, provide a range of services, including educational programs that promote early referral to professional intervention services, formal evaluations, formal treatment, and long-term monitoring, an essential element of the treatment program. Early referral of physicians with substance use problems to appropriate medical groups such as hospitals and country medical societies before actual impairment and patient harm is the goal of such education. 

 

PHP policies usually specify that a formal evaluation be made at an authorized evaluation site experienced in dealing with substance-abusing health professionals. Although the incidence of alcoholism in health professionals is about the same as the national average by age and sex, the incidence of prescription opioid abuse is much higher, particularly in anesthesiologists. Therefore the PHP must be experienced with such a population and use an expanded drug testing panel in order to identify the drugs most likely to be abused by this group. The so-called “NIDA-5” tests (heroin, cocaine, methamphetamine, marijuana, PCP) are not geared to detect prescription opioids or benzodiazepines, which are widely abused in the medical workplace. 

 

After treatment and upon return to the workplace, the key to long-term recovery is relapse prevention, utilizing random drug testing coupled with recovery group attendance (Domino et al., 2005). The monitoring function involves random urine testing (Skipper & DuPont, 2011), coupled with recovery counseling for a set period, usually five years. PHP staff members respond immediately to any positive drug screen with an appropriate level of reevaluation and referral to further treatment if needed, with the potential for referral to the licensing board if clinically indicated or mandated. Studies indicate that up to 25 percent of physicians relapse (Skipper & DuPont, 2011). However, careful monitoring, aggressive intervention, and reentry into treatment reduce the severity of negative consequences of relapse. In addition, participating in organizations such as International Doctors in Alcoholics Anonymous (IDAA) and its annual meetings can promote long-term recovery. 

 

Addiction in medicine is nothing new, of course, and there are well-chronicled cases of prominent physicians—the psychiatrist Sigmund Freud and the surgeon William Halsted in the 1880s, and anesthetist Freeman Allen in the early 1900s—who developed substance abuse disorders due primarily to cocaine and morphine use (Schonwald, Skipper, Smith, & Earley, in press). At the time, cocaine could be bought without prescription in any pharmacy, most popularly as “patent medicine,” and was widely abused throughout medicine and society. The problem of drug addiction in both society and medicine was substantially higher per capita than it is at present (Musto, 1999). In 1888, a short article or editorial in the Journal of the American Medical Association describes the issue (“How the opium,” 2014). 

 

This period of cocaine and morphine addiction in medicine is currently being chronicled in the TV series The Knick about severe addiction in a fictional surgeon based on Dr Halsted. Nurse Jackie is another, more contemporary look at addiction in the health professions. 

 

Despite the long-standing, but mostly hidden problem of addiction in medicine, the organization of PHPs has evolved only during the past thirty or so years (Skipper & DuPont, 2011).These programs encourage early referral, sophisticated evaluation, and specialized treatment of care management of troubled physicians with substance use disorders.

 

There are many benefits to these unique programs. Early detection of potentially impaired physicians not only protects patients, but also saves physicians’ careers. Additionally, when addressing these problems clinically rather than during a crisis necessitating disciplinary action, complex and prolonged legal battles are avoided. PHPs safeguard both patients and physicians. In the process they have developed one of the most effective and successful models of recovery management that can be generalized to the treatment and monitoring of other professional groups.

 

The strongest incentive for early referral is the opportunity for confidential care and advocacy for physicians who cooperate with their PHPs. PHPs have proven successful with reports of five-year abstinence rates of 79 percent, return to work rates of 96 percent, and virtually no evidence of risk or harm to patients from participating physicians (Skipper and Dupont, 2011).

 

Anesthesiologists constitute the highest risk group with the most severe relapses, and their treatment requires additional features such as witnessed naltrexone administration, medication compliance with long-acting injectable naltrexone (Vivitrol), regular hair drug testing, and increased technological observation in the operating room for reentry into the medical workplace (Schonwald et al., in press). Schonwald et al. offer additional recommendations for treatment unique to anesthesiologists (in press). 

 

Physician Reporting Obligations  

Principle II of the AMA Code of Medical Ethics, Principles of Medical Ethics, states:

Physicians also have an ethical obligation to report impaired, incompetent, and/or unethical colleagues. Nonetheless, this obligation is often difficult when the individual under question may be a friend or colleague of many years, or one fears retribution, legal exposure or being seen as “upsetting the apple cart.” The Medical Insurance Exchange of California newsletter (Cleaver, 2013) discusses these issues, recommending as a first step that initially one simply initiate a conversation with the colleague in question, and offers a few sample scripts, including advising him or her that a lack of addressing the issues will result in a report to a well-being committee. Secondly, one would report concerns to the appropriate well-being body, often located within the hospital medical staff or a medical society committee. Reporting to the Medical Board is a last-ditch step, reserved for those cases in which patient safety is at immediate risk and/or the well-being committee is unable to resolve the matter (Cleaver, 2013). 

Some state laws ameliorate legal exposure. California, Alaska, Hawaii, and Idaho, for example, provide some assurance that the disclosing individual will be protected against personal liability provided the individual is acting in good faith and without malice (Cleaver, 2013).

 

Other Professional Well-Being Programs  

 

The California Board of Registered Nursing (BRN) created its diversion program in the mid-1980s. Like physicians, many nurses have the attitude that they’re immune to substance misuse, that use of alcohol and drugs is acceptable for coping with the stresses of their job, and they are reluctant to identify themselves as addicted. A nurse who goes through the BRN disciplinary process faces an investigation of the alleged abuse, hearings, and a supportive program of assessment, monitoring, and education. During the period of the investigation, the nurse is allowed to practice without restrictions and there is no intervention unless the case is extreme or the BRN takes disciplinary action. The intent of the program is to protect the public by identifying and rehabilitating registered nurses and to return them to safe nursing practice through a diversion program that provides a voluntary alternative to traditional discipline (Stanford, 2014).

 

The BRN program consists of a contractor who assesses and monitors participants; several Diversion Evaluation Committees comprising health professionals and a member of the public, all with backgrounds in substance use disorder and/or mental illness treatment; and about forty nurse support groups through the state. Participants self-refer or are referred by the BRN due to a complaint (Stanford, 2014).

 

The BRN contractor also has programs in place for pharmacists, dentists, physical therapists, physician assistants, and other health professionals (Stanford, 2014).

 

In California, The Other Bar is a network of recovering attorneys, judges, and law students who face substance abuse issues and provides support in the context of the stresses particular to the legal services field. The Other Bar supports a network of support meetings (not necessarily Twelve Step) and continuing education programs for lawyers relating to addiction, as well as some financial assistance for those entering treatment. The International Lawyers in Alcoholics Anonymous offers annual meetings and other support services. 

 

Accountants in some states (e.g. Minnesota, Ohio, Texas) have the support of similar programs. The services of these organizations may include education, assessments, intervention, peer support, and referrals for addiction and other practice-impacting stressors such as depression or other mental illness. 

 

Airline pilots have had an early intervention program in place since the late 1970s, when the Aeromedical Advisor to the Air Line Pilots’ Association (ALPA) recognized that alcoholism was an illness and persuaded the organization’s Board to establish a health program to address the illness. The Human Intervention Motivation Study (HIMS) is an occupational substance abuse treatment program specific to commercial pilots that coordinates the identification, treatment, and return to work process for affected aviators. Industry-wide, managers, pilots, health care professionals, and the FAA work together to preserve careers and enhance air safety. Since its inception, over 4,500 professional pilots have been successfully rehabilitated and returned to their careers (Martinez, 2004).

 

Elements of Treatment  

 

Skipper and DuPont (2011) have identified the most important elements of PHP case management. The PHP uses a clinical window of opportunity, usually an intervention in the medical workplace to move the addicted individual from the experience of the pain of the addict to the experience of hope, in order to avoid a crisis response that may trigger complex disciplinary and/or legal action (Skipper & DuPont, 2011). The PHP intervention focuses on the arena in which the physician’s identity is most enmeshed: the practice of medicine and the potential loss of identity, income, and social standing that would follow license revocation. 

 

Because of these factors, the health professional is often in a high degree of denial, with associated fear and depression, which manifests itself in a projective defense of his or her positive professional success rather than the negative consequences of their addiction on family, patients, health, and threat of legal action. The PHP model links recovery to meaningful positive rewards and relapse to consequences, establishing a behavioral contingency contract clearly identifying the crucial elements of aftercare activities monitored by regular drug testing to confirm compliance. Contingency management techniques developed in the PHP field are becoming more widely accepted and their effectiveness is well documented (Skipper & DuPont, 2011).

 

Another key component of treatment is the provision of comprehensive access and high quality treatment, coupled with monitored aftercare. Such treatment for health professionals is more focused on comprehensive care, including psychiatric evaluation, management of comorbid medical issues such as work-related pain and family programs, as the health professional’s family often suffers earlier than the professional. Posttreatment monitoring of worksite compliance entails long-term recovery outcomes. Monitoring for health professionals is often longer than standard treatment and may be required by the medical board or worksite.

Conclusion  

Despite the remarkable progress and evidence-based effectiveness of PHPs, many states are moving away from a public health approach. In California, the diversion program for physicians was disbanded in 2008 because of a legal attack that equated increased malpractice suits with physicians who had addiction problems, even though there is little evidence to support such a correlation. The physician diversion program established in the early 1980s helped many physicians seek early intervention and recovery. While California no longer has a formal PHP, some medical societies have peer review committees that work with impaired physicians. California Public Protection and Physician Health (CPPPH), led by Gail Jara (one of the original architects of the diversion program and CSAM), was formed in 2009 to promote physician wellness and coordinate the different services needed to address the full spectrum of physician health issues (CPPPH, 2014). It is worth noting that the nurses’ diversion program led by Carol Stanford, MPH, which started in the mid-1980s after the physician program, still exists and withstands legal attack.

When Millicent Buxton and Marty Jessup, RN, started the first nurses’ support group at the Haight Ashbury Free Clinics in the 1980s and then worked with the Betty Ford Center to develop the California Board of Registered Nursing diversion program, the environment was very different. Nurse addicts were criminals and physician addicts received treatment via diversion. Now the situation is reversed, based on political considerations rather than evidence-based policy evaluation.

The war on drugs has been extended to physicians. Despite advances in brain science and an improved understanding of recovery for health professionals, the remarkable progress of the last three decades that has contributed so much to the recovery movement is under attack at the same time that society is emphasizing diversion to treatment for other segments of society such as the criminal justice system. Society will need a consistent model based on scientifically proven best outcomes rather than politics to best promote public safety.

 

 

 

References  

 

American Medical Association (AMA). (2001). Principles of medical ethics. Retrieved from http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/principles-medical-ethics.page

 

American Society of Addiction Medicine (ASAM). (2014a). Education: Become certified/exam. Retrieved from http://www.asam.org/education/become-certified-exam

 

American Society of Addiction Medicine (ASAM). (2014b). ASAM historical timeline. Retrieved from http://www.asam.org/about-us/about-asam/asam-historical-timeline 

 

California Public Protection and Physician Health (CPPPH). (2014). About CPPPH. Retrieved from http://cppph.org/about-cppph/

 

Cleaver, G. (2013). Protecting patients and colleagues: When caring and your duty to report collide. The Exchange. Retrieved from http://www.miec.com/Portals/0/TheExchange/TheExchange_Issue4.pdf

 

Domino, K. B., Hombein, T. F., Polissar, N. L., Renner, G., Johnson, J., Alberti, S., Hankes, L. (2005). Risk factors for relapse in health care professionals with substance use disorders. JAMA, 293(12), 1453–60.

 

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How the opium habit is acquired. (2014). JAMA, 312(15), 1597. Reprinted from JAMA, 11(12), 419–20, published 1888.

 

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Schonwald, G., Skipper, G. E., Smith, D. E., & Earley, P. H. (in press). Anesthesiologists and substance use disorders. Anesthesia & Analgesia.

 

Seppala, M., Ries, R., & Galanter, M. (2014). Adapting twelve step approaches to specific clinical populations. Presentation, Annual Meeting, American Society of Addiction Medicine, Orlando, FL, April 10–13, 2014. 

 

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Smith, D. E. (2010). Editor’s introduction: Addiction and related disorders. Journal of Psychoactive Drugs, 42(2), 97–8.

 

Smith, D. E., & Davidson, L. D. (in press) Strategies of drug prevention in the workplace: An international perspective of drug testing and employee assistance programs. In N. El-Guebaly, M. Galanter, & G. Carrá (Eds.), Textbook of addiction treatment: International 

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Smith, D. E., Fortuna, J., Nosal, B., & Maxwell, K. (2012). Youth, drug abuse, and process addiction. Counselor, 13(5), 56–61.

 

Smith, D. E., Lee, D. R., & Davidson, L. D. (2010). Health care equality and parity for treatment of addictive disease. Journal of Psychoactive Drugs, 42(2), 121–6.

 

Smith, D. E., Nosal, B., Gould, L., & Hines, J. (2013). Adolescent process addictions and self-harm. Counselor, 14(5), 36–40.

 

Smith, D. E., Wachter, M., & Golick, J. (2014). The pauper at his palace: An integrated model for treatment of dual-diagnosis adolescents in the residential setting. Counselor, 15(5), 72–9.

 

Stanford, C. (2014). Treatment of the addicted nurse: Board of Registered Nursing diversion program. Presentation, 2nd Annual David E. Smith, MD, Symposium, San Francisco, June 28, 2014.