Objectives Review substance use by physicians in the US Present the approach used to help impaired physicians in Virginia Review healthy approaches to physicians stress Physicians Health Status Overall mortality rates are half that of agematched general population Lower rates are due to decreased rates of cardiovascular disease, lung cancer and other diseases related to smoking Smoking Prevalence in the U.S.: 30 Year Trends 60 50 40 30 20 10 0 Men Women Physicians 1965 1975 1985 1995 Clinical Case A 41 yo male MD had a long history of self prescribing sedatives to treat anxiety and insomnia. His drug use gradually escalated to the point it was interfering with his work and home life. He tried repeatedly to control his use on his own, but without success. He began seeing a psychiatrist who felt he had a mood disorder, and did not directly address the substance abuse. Clinical Case- Continued He began to feel his life was intolerable and discussed suicide with his wife, although he did not disclose a plan. He subsequently died in a hunting accident of a selfinflicted gunshot wound to the head. Physician Suicide Male physicians appear to commit suicide at about the rate of the general population in the US, while the rate among female physicians may be two to four times higher The rate of suicide attempts among women physicians is lower than the general population- are physicians who attempt suicide more likely to be successful? (JAMA 1987;257:2949, Frank and Dingle. Am J Psych 1999;156:12) 1
Risk Factors for Physician Suicide Single marital status Chronic mental and physical disorders (especially depression) Poor health Substance abuse Career dissatisfaction Work harassment (women) Criteria for major depression (DSM-IV) At least five of the following for at least two weeks: Depressed mood Anhedonia Psychomotor agitation or retardation Change in weight Fatigue or loss of energy Feelings of worthlessness or guilt Decreased concentration Suicidal ideation Insomnia or hypersomnia Substance Abuse (DSM-IV) One or more of the following criteria during 12-month period: Failure to fulfill major role obligation Recurrent use in physically hazardous situation Recurrent legal problems due to substance use Continued use despite persistent or recurrent social or interpersonal problems Never met criteria for substance dependence Substance Dependence (DSM-IV) Three or more of the following seven criteria over a 12-month period Tolerance Withdrawal Substance taken in larger amounts or over a longer period than intended Persistent desire or unsuccessful efforts to cut down Substance Dependence (continued) A great deal of time is spent in activities to obtain the substance Important activities are given up or reduced because of substance use Substance use is continued despite having a persistent physical or psychological problem due to the substance Substance Use by Physicians in the US Physicians less likely to use cigarettes and illicit substances than the general public Physicians more likely to use alcohol Physicians much more likely to use minor opiates and benzodiazepines Overall, 8% of physicians reported ever having a substance abuse or dependence problem (Hughes, et al. JAMA 1992;267:2333) 2
Physician Use of Opiates and Sedatives Depending on age and gender, 6-23% of physicians had used non-prescribed opiates or sedatives in the past year These substances were used by 1-4% of the general population Most use of these substances by physicians was for self-treatment of symptoms The Rest of the Story Potential Factors Leading to Impairment Personality traits of physicians: If I only work harder, I will be loved Difficulty expressing emotions Difficulty seeking and accepting help Work stress / harassment Family history / family of origin issues Depression Self-medication Clues to Physician Impairment Self-prescribing of controlled drugs Use of large quantities of alcohol Driving under the influence Domestic difficulties Neglect of responsibilities Outbursts of anger Depressed mood Approach to Impaired Physicians Formal interventions may be required with referral to specialized treatment centers We may not act due to concerns about the potential impact on the impaired personfailure to intervene is likely to have greater consequences In Virginia, the Health Practitioner Intervention Program should be involved http://www.dhp.state.va.us/levelone/hpip.htm or 1-888 - 827-7559 Health Practitioner Intervention Program Established by Virginia General Assembly in 1997 (Code of Virginia 54.1-2515) Available to all licensed, certified, or registered health care practitioners Practitioners who are impaired by mental or physical illness or by substance abuse problems may participate 3
Virginia Health Practitioner Intervention Program Disciplinary action may be stayed if: There is no violation of law except diversion for personal use The practitioner entered with a written contract Disciplinary action has not previously been stayed The practitioner remains in compliance The Program has consulted with the appropriate regulatory board Treatment of Chemical Dependency among Physicians In Virginia Most are referred to specialized treatment programs Costs are often not covered by insurance Initial treatment- 28-96 days Evaluation and stabilization Intensive outpatient treatment Mirror image placement Extended Aftercare Treatment and Monitoring - VMI Assigned to staff person to coordinate care Establish contract - usually for 5 years Must have a primary care physician Placed in a monitoring group Required 12-step program and Caduceus attendance Worksite monitor Random drug screens Virginia Monitoring, Inc Current Enrollment (1998-2000) Field Nursing 433 Medicine 151 Pharmacy 47 Dentistry 22 Others 26 Total 697 Number Drugs of Choice Medicine Nursing Alcohol 42% 21% Opiates 36 56 Cocaine 10 6 Benzodiazepines 4 7 Other 3 3 Multiple 5 5 Outcomes of Substance Abuse Treatment among Physicians In general, treatment outcomes are better for physicians than others Treatment usually includes long-term monitoring On average, 70-80% of physicians completing initial treatment and signing long-term contracts maintain abstinence Most physicians are able to reenter practice 4
"You got to be careful if you don't know where you're going, because you might not get there. " - Yogi Berra Healthy Approaches to Physician Stress Increase self-awareness Spiritual pursuits- religion, meditation Psychotherapy Share feelings and responsibilities Protect time with family and friends Participate in group social activities outside of medicine Participate in formal experiential groups (Quill and Williamson. Arch Intern Med 1990;150:1857) Healthy Approaches - II Promote self-care Attention to work scheduling Express feelings Pursue interests outside of medicine Regular exercise Develop a personal philosophy Develop realistic short and long-term goals Prioritize goals Develop a time management system Physicians need to accept responsibility for much of the stress they perceive. Our own achievement orientation, our drive to excel, and our exaggerated sense of responsibility and self importance may lead us to think that we are helpless victims of awesome and uncontrollable stresses, the only solution for which is the comfort and refuge of alcohol or drugs. We as physicians need to cultivate a life that is not only dedicated but also balanced and healthy in mind, body, and spirit. Collins. Cleveland Clinic J Med 1998;65:106. 5