the impaired professional
TRANSCRIPT
![Page 1: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/1.jpg)
The Impaired Professional
Peter Cohen, D.O.
![Page 2: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/2.jpg)
Definition
The American Medical Association (AMA) defines impairment as the inability to practice medicine with reasonable skill and safety to patients by reason of physical or mental illness, including alcoholism and drug abuse.
![Page 3: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/3.jpg)
Stages of Addiction
Use
Abuse
Physical dependence
Psychological dependence
Tolerance
Addiction
![Page 4: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/4.jpg)
Use
Sporadic consumption of a substance with no consequences of that consumption.
![Page 5: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/5.jpg)
Abuse
A maladaptive pattern of substance abuse that causes clinically significant impairment that does not meet criteria of addiction.
Includes impairment in social, occupational, and family functioning.
![Page 6: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/6.jpg)
Physical Dependence
A state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation or rapid dose reduction of a drug.
![Page 7: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/7.jpg)
Psychological Dependence
A subjective sense of need for a specific psychoactive substance either for its positive effects or to avoid negative psychological effects associated with abstinence.
![Page 8: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/8.jpg)
Tolerance
Affect of drug decreases over time
Greater doses of the drug is needed to achieve the same effect.
![Page 9: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/9.jpg)
Addiction
A psychological phenomenon that consists of the compulsive seeking and use of a substance despite adverse social, psychological and physical consequences.
![Page 10: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/10.jpg)
Addiction is a Disease
A primary chronic disease with genetic psychosocial and environmental factors influencing its development and manifestation.
The disease is progressive and can be fatal.
![Page 11: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/11.jpg)
Addiction is a Disease
![Page 12: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/12.jpg)
Addiction is a Disease
Imaging studies have shown evidence of
tissue malfunction in the brains of those
with addiction, and in the hearts of people
with heart disease.
![Page 13: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/13.jpg)
Signs and Symptoms
Characterized by impaired control over drinking and drug use.
Preoccupation with drugs or alcohol.
Use of substance despite adverse consequences.
Distortion in thinking (denial).
![Page 14: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/14.jpg)
Prevalence
The prevalence of addiction in population of United States physicians is generally reflective of the general population.
Current estimates are that approximately 15% of physicians will be impaired at some point in their careers.
![Page 15: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/15.jpg)
Substances Abused
Alcohol- 39.5%
Opiates- 33.9%
Cocaine- 11.9%
Sedatives- 3.7%
Marijuana- 2.8%
Inhalants- 1.8%
Amphetamines- 1.8%
Others- 4.6%
![Page 16: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/16.jpg)
Substance Abuse (cont.)
Physicians are as likely to have experimented with elicit substances as their age peers.
Less likely to be current users of elicit substances.
High incidence of prescription drug abused as compared to the general population (self prescribed, self medication, injury).
![Page 17: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/17.jpg)
Which doctors are most affected?
Anesthesia- 21%
Emergency medicine- 18%
Family medicine- 15%
![Page 18: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/18.jpg)
Risk Factors
High stress
Strong desire for achievement
Conscientious
Ability to deny personal problems
Highly educated
Healer
Difficulty asking for help
![Page 19: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/19.jpg)
Identification of the Impaired Physician
CAGE
C: Have you tried to cut down
A: Do you get annoyed when people comment about your drinking?
G: Do you feel guilty?
E: Do you need an eye opener?
![Page 20: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/20.jpg)
Identification of the Impaired Physician Continued
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment.
Brief intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.
Referral to treatment provides those identified as needing more extensive treatment with access to specialty care.
![Page 21: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/21.jpg)
Signs of Addiction
Addiction is progressive.
Depression
Irritability
Mood swings
Inappropriate level of response
Isolation
Avoidance
![Page 22: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/22.jpg)
Signs of Addiction (cont.)
Impact of social life
Health issues
Financial issues
Legal issues
Moral standards change
Clinical performance
![Page 23: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/23.jpg)
Barriers to getting help
Doctors are the healers, “We don’t get sick.”
Taught to tough it out
Denial, shame, difficulty asking for help
Reporting a colleague is difficult
Enabled by family and friends
![Page 24: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/24.jpg)
Addiction is a family disease
Family affected
Work environment affected
Coworkers affected
Patients affected
Friends affected
![Page 25: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/25.jpg)
Intervention
The goal of intervention is to convince the physician to voluntarily enter treatment.
May need to threaten physician with fine or license suspension.
May need to report to board of medicine.
![Page 26: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/26.jpg)
Intervention (cont.)
Intervention is the process of presenting facts to the addict about their behavior in a way that lessens denial and encourages entering a program for diagnosis and treatment.
![Page 27: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/27.jpg)
Guide for Intervention
Avoid confronting physicians alone.
Express positive regard for their abilities.
Describe specific observable problem behaviors.
Avoid accusation or blame.
Avoid arguing or negotiating. Be kind and empathetic.
![Page 28: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/28.jpg)
Guide for Intervention (cont.)
Have a specific plan of action.
Clearly indicate consequences for not following plan.
Insist upon immediate action.
Provide for safe transition and transportation to the next step in the plan.
Refer to professional assessment program (PRN).
![Page 29: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/29.jpg)
Florida Statutes
Statute 459.015 Section E states, “You may be held for disciplinary action if failing to report to the department or the department impaired professional consultant (PRN) any person who the licensee knows is in violation of the rules of the board.”
![Page 30: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/30.jpg)
Florida Statutes (cont.)
Statute 459.015 Section W states, “You may be held for disciplinary action if you are unable to practice medicine with reasonable skill and safety to patients by reason of illness or substance abuse.”
![Page 31: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/31.jpg)
Florida Statutes (cont.)
Statute 456.076 Treatment Programs for the Impaired Practitioner Section A states, “When the department receives a written or legally sufficient complaint alleging that a licensee is impaired as a result of abuse of alcohol, drugs, mental or physical condition which could affect their ability to practice with skill or safety and no other complaint other than impairment exist the reporting of such information shall not be grounds for discipline as long as the licensee does the following:
![Page 32: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/32.jpg)
Florida Statutes (cont.)
1. The licensee has acknowledged the impairment problem.
2. The licensee has voluntarily enrolled in treatment program.
3. The licensee has voluntarily withdrawn from practice, entered treatment, and agrees to return to practice only after completing treatment.
Release of medical records to the consultant.
![Page 33: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/33.jpg)
Florida Statutes (cont.)
Statute 456.076 Section B states, “If the board does not receive a complaint and licensee agrees to withdraw from practice and complete treatment, the board will not be involved.”
![Page 34: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/34.jpg)
Treatment
1. Initial assessment to determine level of care.
Residential
Partial hospitalization
Intensive outpatient
2. Treatment may last from 3-6 months and is done using a team approach.
![Page 35: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/35.jpg)
Long Term Monitoring
Usually 5 year contract
Avoidance of all mood altering drugs
Random drug testing
Weekly monitor group meeting
Alcoholics Anonymous (AA) Narcotics Anonymous (NA) 12-Step Meeting
![Page 36: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/36.jpg)
Physician Resource Recovery Network (PRN)
Established in the late 1970s
Aid in identification, intervention, and appropriate referral for treatment
Protect the safety and welfare of the public
PRN has the ability to monitor individuals for 5 years or more under individualized contracts.
![Page 37: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/37.jpg)
Treatment Outcomes
Prognosis for physicians is better than the general population.
Physicians are more likely than the general population to return to a productive life.
900 physicians, 16 states
72% return to work
50% complete 5-year program
Of those 50%, 91.4% return to work
![Page 38: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/38.jpg)
Treatment Outcomes
Florida PRN Physician addicts were evaluated at 5 years .
91.4% returned to work
The majority of these physicians had as their primary drug either
alcohol 34.3 %
opiates 34.3%
Both 17.1%
![Page 39: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/39.jpg)
Prevention
![Page 40: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/40.jpg)
Medical Student Wellness Initiative
Collaboration between state physician health program(PRN) the Florida medical association, and council of all Florida Medical School Deans
Prevention
![Page 41: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/41.jpg)
Medical Student Wellness Intiative
Participation all 9 medical schools in the state of Florida
Anonymous online survey
Asses various health behaviors, risk behaviors, psychiatric symptom, substance use, coping mechanisms, awareness of PHP
![Page 42: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/42.jpg)
General Well- Being
82% reported being satisfied with their medical training
63% reported their physical health had worsen since starting medical school
60.6% reported psychological health had worsened
79.8% reported their stress level as “significant” or “severe”
71.3% reported not getting enough sleep
![Page 43: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/43.jpg)
Psychological stress
Over 10% reported thoughts of suicide
70.1% indicated feeling they would benefit form psychological resourses
42.27% questioned their decision to become a physician
![Page 44: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/44.jpg)
Tobacco use
Only 6.4% reported smoking cigaretes
![Page 45: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/45.jpg)
Alcohol use
96% of students have used alcohol
70.4% acknowledged binge drinking
31% reported drinking more alcohol than when they stared med school
6.7% admitted being concerned they might have a drinking problem
![Page 46: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/46.jpg)
Marijuana use
46% of students reported lifetime use
22.7% reported using marijuana during medical school
12.2% of users reported increased usage during medical school
17.9% report using marijuana weekly.
![Page 47: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/47.jpg)
Prescription Stimulants.
Lifetime use 28.7%
46% of users increased during Medical school
Primary reasons 90%to help study
65%before exams
60% ADHD
55% to stay awake
37% competitive nature of med school
![Page 48: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/48.jpg)
Opiods
Lifetime use 32% ( during med school
9.1%)
Primary reasons 79% pain
45% doctor or parent told them to
24% to sleep
16% to relax or calm down
![Page 49: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/49.jpg)
Drug misuse/Abuse
64% stimulants users admit to taking meds not prescribed
20% opoid users admit meds not prescribed
1.79% of medical students acknowledged they might have a drug problem.
![Page 50: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/50.jpg)
Self Help Programs
![Page 51: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/51.jpg)
Alternative to 12 step. Self Help Groups for People in Recovery
SMART Recovery
Moderation Management
Women for Sobriety
LifeRing
SOS
Rational recovery
![Page 52: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/52.jpg)
12-Step Treatment
Honesty
Openness
Willingness
Acceptance
Go to meetings
Get a sponsor
Work the 12 steps
![Page 53: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/53.jpg)
12-Steps
1. We admitted we were powerless over alcohol- that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over the care of God as we understood Him.
![Page 54: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/54.jpg)
Step 1
Step 1
Addresses denial, promotes honesty and self-examination, resistance can be great, accepts identity as an alcoholic or addict.
Principle: Honesty
![Page 55: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/55.jpg)
Step 2
Step 2 The person recognizes that they need
help. “I alone can do it, but I can’t do it alone.”
Sanity is recognition that continued use of alcohol or other drugs will have continued negative effects
Helps open the person to new internal experience
Principle: Hope
![Page 56: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/56.jpg)
Step 3
Step 3
Difficult for atheist, helped by thinking of an accepting and loving life force within
Practicing “letting go” weakens the grip of obsessions, craving, worries, resentments
Principle: Faith
![Page 57: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/57.jpg)
Retrospective Findings in Physician Addicts
50% of physician addicts have substance use and problems in medical school related to substance use.
50% have a positive family history for addiction.
30% smoke cigarettes.
Only 50% of opiate addicts inject drugs.
![Page 58: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/58.jpg)
Retrospective Findings in Physician Addicts (cont.)
Major Depressive Disorder has a high prevalence in opiate addicts.
Average length of addiction before treatment of opiate addicts is 6 years.
Average length of addiction before treatment for alcoholics is 14.5 years.
![Page 59: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/59.jpg)
Guidelines for Training Programs
Most physicians and house staff are not aware of any policy on substance abuse in their own medical institution.
All teaching hospitals need to educate and organize a process to address substance abuse among its healthcare professionals.
Clearly defined policy and procedure for referrals.
Pre-employment drug testing.
![Page 60: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/60.jpg)
Conclusions
Addiction is a disease that knows no boundaries of profession, ethnicity, sex or age.
It is even prevalent in our precious medical community.
We, as healthcare professionals, have a moral obligation to our patients and our fellow colleagues to help identify those who are tormented by the disease of addiction and take the appropriate action to help them.
![Page 61: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/61.jpg)
Questions
![Page 62: The Impaired Professional](https://reader031.vdocuments.us/reader031/viewer/2022021800/620c81f9ddaccd30244276c7/html5/thumbnails/62.jpg)
References Merlo, L. J. & Gold, S. (2008). Prescription opioid abuse and
dependence among physicians: Hypothesis and treatment. Harvard Review Psychiatry, 191-190.
Pomm, R., Dwyer, D., Kalem, K., & Kennedy, Y. (2007) Florida’s impaired practitioner program.
Thompson, K. & Teitelbaum, S.A. (2008). Impaired healthcare provider. Uptodate. Retrieved July 21, 2008 from http://www.uptodateonline.com.novacat.edy/online/content/topic.do?topicKey=subabuse/5798
Unknown author. (year unknown). Impaired professionals. Retrieved July 25, 2008 from http://www.psychiatry.ufl.edu/aec/courses/501/impairedprofessionals.pdf
Florida Statutes 456.076 and 459.015.