Substance abuse in physicians: the elephant

in the room S. BENJAMIN D. VISTA, MD

• "Elephant in the room" is an English metaphorical idiom for an obvious truth that is either being ignored or going unaddressed. The idiomatic expression also applies to an obvious problem or risk no one wants to discuss.

• It is based on the idea that an elephant in a room would be impossible to overlook; thus, people in the room who pretend the elephant is not there have chosen to avoid dealing with the looming big issue.

The majority of health consumers are concerned about the effect alcohol and drug use by their physician could have on the quality of care they receive.

Harris, L. Consumer’s Perception of substance abuse by health care providers. Reearch abstracts presented at AMA Eighth National Conference on Impaied Health Professionals.Chicago 1987.

Questions to be discussed

• What is an “impaired physician?

• How does one identify an impaired physician?

• How does one intervene, treat and rehabilitate?

prevalence

• UNKNOWN

• DEARTH OF DATA

• MDs follow the same trends as the general population

• 1991. National Institute’s of Mental Health’s Epidemiologic Catchment Area (ECA):

• ALCOHOL USE DISORDERS • 13.5 % LIFETIME PREVALENCE (9,045 FILIPINO MDs) • MEN: 23% (15,410 FILIPINO MDs) • WOMEN: 4.7% (3,149 FILIPINO MDs)

• ILLICIT DRUG DISORDERS • 6.2% LIFETIME PREVALENCE (4,154 FILIPINO MDs) • MEN 7.7% (5,159 FILIPINO MDs) • WOMEN: 4.8% (3,216 FILIPINO MDs)

Robbins and Regier, Psychiatric disorders in America: the epidemiologic catchment area study, NY Free Press, 1991

NO STUDIES ON HOW MUCH DAMAGE IS DONE BY MD SUBSTANCE ABUSE AND DEPENDENCE

Chemical dependency seems to be the single

most frequent disabling illness for

the medical professional

Talbott GD, Wright, C. Chemical dependence and health care professionals. N Eng J Medicine, 1972

ETIOLOGY

Risk factors

• No “professional” personality type

• Psychological vulnerabilities Vaillant GE, et al, Some psychologic vulnerabilities of physicians. N Eng Jof Med 1972

• Passivity • Self-doubt • Pessimism • Dependency •

• Narcissistic personality type

• Self-prescribing

RISK FACTORS

• ACCESS TO PHARMACEUTICALS

• FAMILY HISTORY OF SUBSTANCE ABUSE

• EMOTIONAL PROBLEMS

• STRESS AT WORK/HOME

McAuliffe, WE, et al.Int Journ Addiction 1987

RISK FACTORS

• THRILL-SEEKING

• SELF-TREATMENT OF PAIN/EMOTIONAL PROBLEMS

• CHRONIC FATIGUE

IDENTIFYING THE PROBLEM

FAMILY

EMOTIONAL/SPIRITUAL

PHYSICAL

COMMUNITY

JOB

Bissel, L. Alcoholism in the professional. NY, 1984

CLUES FROM THE FAMILY

• Withdrawal from family activities, unexplained absences

• Spouse becomes a solicitous caretaker

• Fights, dysfunctional anger, spouse tries to control MD’s substance abuse

• “SPOUSAHOLICS”

• Child abuse

CLUES FROM THE FAMILY

• Children attempt taking charge of family affairs

• Children develop abnormal antisocial behavior

• Sexual problems: impotence, extra-marital affairs

• Partner relations problems

Lowinson, et al. Comprehensive Textbook of Substance Abuse

community

• Isolation and withdrawal from community activities, church, friends, leisure, hobbies, peers

• Embarrassing behavior at clubs or parties

• DUI, legal problems, role-discordant behavior

• Unreliability

• Unpredictable behavior: risk-taking, excessive spending

CLUES FROM CURRICULUM VITAE

• Numerous job changes in past five years

• Frequent relocations for unexplained reasons

• Complicated and elaborate medical history

• Unexplained time-lapse between jobs

CLUES FROM CURRICULUM VITAE

• Indefinite and inappropriate medical references and vague letter of reference

• Working in inappropriate job for qualifications

• Decline of professional productivity

Physical status

• Deteriorating personal hygiene

• Deteriorating dressing habits

• Multiple physical signs and complaints

• Numerous prescription and drugs

Physical status

• Frequent hospitalizations

• Frequent visits to physician and dentist

• Accidents and trauma

• Serious emotional crisis

office

• Appointments and schedule become disorganized, progressively late

• Behavior to staff and patient hostile, withdrawn, unreasonable

• “Locked door” syndrome

• Ordering excessive supply of drugs from local druggist or by mail order

• Patient’s begin to complain to staff about doctor’s behavior

• Absence from office: unexplained or frequently sick

AT THE hospital

• Making late rounds or inappropriate abnormal behavior

• Decreasing quality of performance in staff presentations, chart entries and the like

• Inappropriate orders or overprescribing medications

• “hospital gossip” about odd behavior

• Involved in malpractice suits and legal sanctions

AT THE hospital

• ER staff reports constant unavailability or inappropriate responses to calls

• Failure or prolonged response to calls

• Reluctance to undergo immediate physical examination or drug test

• Heavy drinking at staff functions

BARRIERS TO Early identification/ diagnosis

• MALIGNANT DENIAL: denial that is deeply inculcated in professional training

• CONSPIRACY OF SILENCE

• IT IS MORE DIFFICULT TO DIAGNOSE FEMALE MDs: gender attitude, cultural factors

ADDICTION CYCLE

Denial (CS or UCS)

Guilt/shame/remorse

Inabilty to seek help Addiction gains more control

Confrontation

TREATMENT TEAMS

INTERVENTION TEAM MEDICAL TEAM

FAMILY THERAPY TEAM

ADDICTION MEDICINE/PSYCHIATRY

TEAM

CLIENT

INTERVENTION TEAM

MEDICAL TEAM

ADDICTION MEDICINE/PSYCHIATRIC

TEAM

FAMILY THERAPY TEAM

TREATMENT GOALS

• Abstinence

• BIO-PSYCHO-SOCIAL ASSESSMENT

• Classify as to Levels of Care (ASAM) • OUTPATIENT

• INTENSIVE OUT-PATIENT/PARTIAL HOSPITALIZATION

• MEDICALLY MONITORED IN-PATIENT

• MEDICALLY MANAGED IN-PATIENT

ELEMENTS IN SUCCESSFUL

TREATMENT OF THE IMPAIRED MD

UNDERSTAND AND ACCEPT THAT THEY HAVE A PRIMARY

BIOPSYCHOSOCIAL DISEASE

• NEUROBIOCHEMISTRY OF THE ADDICTION

• SOCIOCULTURAL CONSEQUENCS

• Acceptance of the disease concept can quickly begin the absolution of the guilt, shame and fear that inevitably accompany the impaired physician

KEY PARADIGMS

• “ They are not responsible for their disease, but they are responsible for their recovery”

• “ They should not THINK their way into sobriety, rather they must LIVE their way to sobriety”

IDENTIFY THE TRIGGERS

EMOTIONAL PERSONAL

PHYSICAL

SITUATIONAL

Non-chemical coping

• “extended unlearning”

• Abstinence from trying to sleep then having two hour “planned insomnia time”

• Abstinence from coffee and tobacco, low salt high protein intake

• Hot baths

Non-chemical coping

• Massage

• Counseling

• Charting the insomnic episodes and jotting down associated thoughts

• Learning more about the addiction

Balance in changing priorities

• Workaholics and perfectionists: work is priority!

• RECOVERY depends on a balance of MEDICAL, EMOTIONAL AND SPIRITUAL GROWTH (AA)

• Change in priorities: •Recovery and growth is first

•Family is second

•Profession is third

Family involvement

• Role is CRITICAL at all stages of treatment

• “parentolics, childolics, siblingolics”

• Group therapy: 12 step self-help groups

Stages of recovery

• Total abstinence from mood-altering substances

• A conscious decision to take those specific actions that increase the likelihood of success like changing values, perception and behaviors

• Knowledge about the natural history of the illness and its recovery

• Knowledge of the skills to begin and continue

• The ability to to identify strengths and weakness in their recovery program

• The willingness to accept feedback from others

• The ability not to deny or evade problems, stresses and behaviors

Stages of recovery

• TRANSITION: starts when they believe they have a problem. it ends when they are willing to seek help

• STABILIZATION: they complete detoxification and withdrawal, physical and emotional healing begins, craving subsides, feeling of hopefulness an motivation for recovery

• EARLY RECOVERY: period of internal change, letting go of guilt, shame, fear and resentment, compulsion to use substances diminishes, non-chemical coping strengthens

Stages of recovery

• MIDDLE RECOVERY: balance begins to be restored, wreckage of the past is cleaned up, relationships are healthy

• LATE RECOVERY: relationships strengthened

• MAINTENANCE: recovery principles are applied daily

Gorski, T, Passages through recovery: an action plan for preventing relapse. Hazelden, 1989

Maraming salamat po!