1. SUBSTANCE USE DISORDERS IN PHYSICIANS Christopher Welsh M.D. University of Maryland School of Medicine Copyright Alcohol Medical Scholars Program

2. 2 Copyright Alcohol Medical Scholars Program “WHY SHOULD I STAY AWAKE?” § It might be my colleague § It might be my patient § It might be me

3. 3 Copyright Alcohol Medical Scholars Program KEY POINTS § SUDs similar to the general population § Benzodiazepines and opioids higher § Identification is often difficult and delayed § Treatment outcomes are often better § Impaired Physician Programs are helpful

4. 4 Copyright Alcohol Medical Scholars Program DEFINITIONS Substance Use Disorders (SUDs) § DEPENDENCE l Tolerance l Withdrawal l Inability to cut down/control use l Considerable time spent using/obtaining/recovering l Important activities given up/reduced l Use despite negative consequences § ABUSE (less severe) l Failure to fulfill role obligations l Use in hazardous situations l Recurrent, related legal problems

6. 6 Copyright Alcohol Medical Scholars Program EPIDEMIOLOGY § VERY VARIABLE!!!! l Population studied l Methods used l Terminology l Diagnostic criteria l Changes over time? l Concern about anonymity

7. 7 Copyright Alcohol Medical Scholars Program EPIDEMIOLOGY General §Similar rates of SUDs to general population l 8-14% §Less SUDs compared to other occupations l Roofers, painters §Increased rates of use & SUDs with: l Benzodiazepines l Prescription opioids

8. 8 Copyright Alcohol Medical Scholars Program EPIDEMIOLOGY Medical Students § Use begins prior to medical school § Types of drugs same as general pop. § Alcohol use & dependence variable § Drug use and dependence less

9. 9 Copyright Alcohol Medical Scholars Program EPIDEMIOLOGY Residents § Rates of dependence:10-14% § Alcohol & illicit drug use begins prior § Benzo & opioid use begins during l Self-treatment l Self-prescribed

10. 10 Copyright Alcohol Medical Scholars Program EPIDEMIOLOGY Practicing Physicians § Prevalence of dependence: 8-14% l Still means 60-75,000 affected M.D.s in U.S.!!!! § Use & misuse of prescription opioids & benzodiazepines up to 5Xs higher

11. 11 Copyright Alcohol Medical Scholars Program EPIDEMIOLOGY By Specialty § HIGHEST l Emergency Medicine l Psychiatry l Anesthesiology §LOWEST l OB-GYN l Pathology l Radiology l Pediatrics

12. 12 Copyright Alcohol Medical Scholars Program REASONS FOR USE § Recreational l Seen more in medical students § Performance Enhancement l Seen more in Emergency Medicine § Self-medication (pain, anxiety, “stress”) l Seen more in residents & attendings

13. 13 Copyright Alcohol Medical Scholars Program PROGRESSION § Family § Community § Finances § Spiritual/emotional § Physical health § Job performance l Often one of the last things affected

14. 14 Copyright Alcohol Medical Scholars Program CONTRIBUTING FACTORS § Family History § Personality characteristics § Health/lifestyle § Stress??? § Availability???

15. 15 Copyright Alcohol Medical Scholars Program IDENTIFICATION § Urine drug screening § Employment/school application § Physician screening § Impaired Physicians Programs § Reporting

16. 16 Copyright Alcohol Medical Scholars Program “WARNING SIGNS” § Isolation § Friction with colleagues § Disorganization § Inaccessibility § Frequent absences §Rounding on patients at odd hours § Inappropriate or forgotten orders § Slurred speech during off-hours calls § Prescriptions for family members § OD or suicide attempt

17. 17 Copyright Alcohol Medical Scholars Program WHY THE DELAY IN DETECTION? § Independence § “Malignant denial” § “I can take care of myself” § “Knowledge is protective” § Fear of consequences § “Conspiracy of silence”

18. 18 Copyright Alcohol Medical Scholars Program “CONSPIRACY OF SILENCE” § Reputation § Financial § Fear & intimidation § Professional pride

19. 19 Copyright Alcohol Medical Scholars Program REPORTING § Ethical obligation § Disabled Doctors Act § Federal law § Requirements vary by state § Protection from law suit varies

20. 20 Copyright Alcohol Medical Scholars ProgramTREATMENT THE GOOD NEWS!!! § Variable data § Most show better outcomes § 70-90% “success rate” little correlation with substance little correlation with specialty

21. 21 Copyright Alcohol Medical Scholars Program TREATMENT Goals § Abstinence § Acceptance of chronic disease concept § Identification of triggers § Development of non-chemical coping skills

22. 22 Copyright Alcohol Medical Scholars Program TREATMENT Key Factors For Success § Duration of aftercare § Physician’s Health Program involvement § Family involvement § 12-Step involvement § Witnessed urinalysis  Contingency contract

23. 23 Copyright Alcohol Medical Scholars Program TREATMENT Stumbling Blocks § Uniqueness § Role-reversal § Over-identification w/ performance § Identification (by treatment provider) § Medical knowledge

24. 24 Copyright Alcohol Medical Scholars Program TREATMENT Physician-specific § In-Patient l Talbott, Farley § 12-Step l “Caduceus meetings” § Pros & Cons § Combined approaches

25. 25 Copyright Alcohol Medical Scholars Program“RE-ENTRY” § Most return to practicing medicine § Change to a less high-risk specialty § Imposed prescribing restrictions § Altered work schedule § Specialization in addictions

26. 26 Copyright Alcohol Medical Scholars Program “PREVENTION” § Medical school policies § Medical school education § State Impaired Physicians Programs Protect the public Provide “rehabilitation” (vs punishment) §JCAHO-mandated hospital programs

27. 27 Copyright Alcohol Medical Scholars Program KEY POINTS A Review § SUDs similar to the general population § Benzodiazepines and opioids higher § Identification is often difficult and delayed § Treatment outcomes are often better §Physician Rehab Programs are our friends

28. 28 Copyright Alcohol Medical Scholars Program WHERE TO GET HELP State Agency # School Resources # Your email address

29. 29 Copyright Alcohol Medical Scholars Program NURSES § Rates similar to general population § Higher use of benzodiazepines & opioids l more parenteral use § Higher in emergency room & critical care § Especially difficult to monitor § Watch for diversion

30. 30 Copyright Alcohol Medical Scholars Program DENTISTS § Less good data § More use of inhaled anesthetics § Possibly higher opioid use and SUDs § Related to higher suicide rate?

31. 31 Copyright Alcohol Medical Scholars Program PHARMACISTS § Estimates of dependence: 10-18% § Less parenteral use § @ 50% have used CS w/o script l @ 20% on regular basis l primarily self-medication § @ 60% of students have used CS w/o script l @ 40% on regular basis l primarily recreational

32. 32 Copyright Alcohol Medical Scholars Program VETERINARIANS § Little good data § More Ketamine use § Other higher-potency opioids § Inhaled anesthetics