Carroll B is a 37-year-old general surgeon referred to Talbott Recovery Campus (TRC) for assessment of substance abuse and drug addiction. His history revealed that he began drinking when he was 12. Initially, he demonstrated a high tolerance to alcohol, and drank more than his teenage peers, but showed little or no intoxication throughout high school and college. In medical school, he binge drank for several days once or twice a year, becoming intoxicated until he lost consciousness.

"Hidden drinking" (away from the city and hospital where he worked) characterized his five years of residency. When his physical appearance began to suggest a substance abuse problem, a supervisor cautioned him about drinking. Dr. B then obtained from a fellow resident a prescription for 50 Xanax tablets to help with the restlessness, anxiety and nervous symptoms accompanying his acute alcohol withdrawal. Occasionally, he would travel out of town and continue his regime of vodka and Xanax, which, although pleasurable, had begun to cause drug amnesia (blackouts).

After residency and having joined a five-person surgical group, Dr. B continued his substance abuse with office samples of Xanax and prescriptions from fellow physicians. His tolerance to Xanax increased, and he consumed eight to ten pills daily. His four-year relationship with the woman he had planned to marry disintegrated as he had become impotent. His friends, leisure time and athletic activities diminished and disappeared as his daily Xanax dosage increased.

Dr. B's Xanax was never prescribed from a formal physician/patient relationship, and his senior partner became concerned. The surgical group asked him to undergo a comprehensive 96-hour evaluation. On the second day of hospitalization and evaluation, he went into severe sedative/hypnotic withdrawal. Neuropsychological testing showed impairment from sedative/hypnotic drugs, and family history revealed the disease of alcoholism in his father and both grandfathers.

He completed a 90-day treatment program. Five years later, he is sober, happy and in excellent physical condition. He maintains a five-year marriage and has two children. He continues to be followed by the Physicians Wellness Committee and the State Medical Society program, which he volunteered to participate in after his five-year monitoring program through the treatment center.

Alcohol and drug abuse/dependence affects a significant number of health professionals. However, limited data on the rates of incidence exist because substance-abusing professionals rarely report for fear of disciplinary action employers rarely document and significant data from professionals who found recovery in self-help groups have not been gathered.

One of the largest surveys measuring psychiatric and substance abuse epidemiology is the National Institute of Mental Health Epidemiologic Catchment Area program (ECA). Data from the ECA study indicate that the overall rates for alcohol disorders, as defined by the Diagnostic and Statistical Manual of Mental Disorders, third edition, are 13.5 percent for lifetime prevalence. The ECA survey also reported an overall lifetime prevalence of drug abuse and drug dependence of 6.2 percent. Physicians and other health professionals are believed to have the same incidence and prevalence rates for alcohol/other drug abuse and dependence disorders as the general population. Some studies (McAuliffe et al. 1987) report that physicians and other healthcare professionals have unique risk factors for substance abuse, including: access to pharmaceuticals; family history of substance abuse; denial, emotional problems; stress at work or at home; thrill seeking; self-treatment of pain and emotional problems in a permissive professional and social environment.

Hughes et al. randomly surveyed 9,600 physicians of the AMA master database, grouped by specialty and career stage. Those in the health professions may be a higher risk for primary introduction of substance use due to the unique set of factors related to their work. Our own experience over 20 years, sensitive to the above data, has dictated a working hypothesis of 13-15 percent incidence of the disease of chemical dependency in health professionals.

Health professionals are experts at pharmacology, and the access to medications presents a unique and looming danger. In addition to easy access, the attitude about meditations in the health professions is inherent optimism that medications work and health professionals are capable and self-controlled enough to self medicate (Coombs, 1997, Hughes, et al.,1992). Medications are strategic interventions for treatment of patients, and the health professional becomes an expert at drug classifications, dosages and effects. Our experience tells us that many physicians, nurses, dentists, pharmacists, and other health professionals, including counselors, have on occasion self-medicated with mood altering drugs while at work.

Health professionals care for patients with medical and psychological disorders who are dependent on their expertise. Dealing daily with these patients can be challenging for even a seasoned practitioner. Disastrous consequences can result for practitioners from the emotional engagement between patients and "successful practitioners" that feel their patients' pain. The care-giving role presents challenges to establishing and maintaining boundaries between the care-giver and the client. Professionals, who unwittingly become enmeshed emotionally with their clients, are at risk for experiencing a host of emotions related to their clients' condition or progress.

Culturally, alcohol is a common antidote for a stressful day, even for health professionals (Talbott, 1994, ECA, 1991). When stress becomes increasingly uncomfortable or interferes with the primary role of the professional (their work) attempts to relieve the stress, even temporarily, may lead to alcohol and drug use. Inevitably, the professional lives of counselors and other health professionals will intrude upon their social lives and leisure time. The use of alcohol as stress relief rather than social enjoyment often accompanies what limited social life exists for them. These stress-relieving habits may be a gateway to the use of sedative/hypnotic or stimulant drugs (Coombs, 1997, Talbott & Gallegos, 1997).

Some common factors we have identified for self-medication in more than 4,500 health professionals treated at our center are:

• Situational life crises — death, divorce, job change, terminal illness of family member
• Emotional disruption — depression, sleep disturbance, manic depression, anxiety disorder
• Psychological disturbances — crisis, mood alterations, distorted perceptions
• Physical illness — acute disease processes such as accident, injury, back pain, migraines
• Pain-presents unique features and often leads to disastrous self-medication

That the diagnostic signs and symptoms of substance abuse in professionals occur last in the job arena is a crucial point as it is common for health professionals to be first identified in the workplace, meaning there have already been significant consequences in the family, physical, social, financial and perhaps legal areas (Angres, et al.,2000, Coombs, 1997, Crosby& Bissell, 1989).

As Table 1 indicates, there is a progression of signs and symptoms. Obviously, there is some overlap in symptomotology and the process usually does not always occur in sequence.

Peer identification

For many years, there was a professional conspiracy of silence in the health professions that prevented awareness, early identification and intervention. Many health professionals continued to progress in their disease toward terminal or fatal consequences without appropriate intervention. Inherent in this "conspiracy of silence" was patient liability as practitioners who were actively chemically dependent continued in their roles. Conversely, those who were identified through blatant or catastrophic events suffered pain, humiliation or public shaming, disciplinary action and perhaps criminal prosecution. Late identification of health professionals with alcohol/other drug problems generates legal risks, as many lawsuits filed include not just the health professional, but his/her peers, associates, superiors, professionals and administrative individuals.

Today, with education and realization of the legal culpability of peers, there are professional health committees formed for most disciplines in each state. Peer advocacy committees offer help to colleagues with alcohol/drug problems, gambling, eating disorders sexual disorders, psychiatric disorders and behavioral problems.

There is an identifiable enabling process that surrounds an impaired health professional. Peers rationalize changes in behavior and performance as they look for other causes of the problem and often attempt to "help" or counsel the chemically dependent colleagues to protect them. Supervisors, staff and co-workers may defend and attempt to rescue the chemically dependent professional from omissions and errors, as they perceive personal endangerment for their peer/colleague (loss of job or license).

The family is often the first to observe the effects of the disease process associated with chemical dependency and psychiatric disorders. In many areas of the country, family education through print, lectures and workshops have increased early identification of impaired health professionals. Two areas stressed in family education are the disease precept of addiction and the consequences and characterization of the disease causing the illness of spouses, parents, children and siblings. When family members understand addiction as a primary, psychosocial and biogenetic relapsing disease that has affected them, they play a significant role in the patients' treatment and their own recovery process. Every hospital, clinic and treatment facility should have a well-developed Health Care Professionals Committee. This committee is advised to have written, legally sound, well-developed and treatment-empathic protocols. These protocols are directed toward early identification of an impaired practitioner, with patient safety as a primary issue. If impairment is present, successful intervention and treatment should then follow.

Health professionals are usually well trained to assume leadership roles in clinical practice and generally have great difficulty in acknowledging personal needs. It is common to hear, "I could not reach out for help." Addiction counselors are also deemed "experts" on alcohol/other drug abuse and dependence. Unfortunately, knowledge does not render any professional immune to a primary disease. The philosophy of the treatment center/hospital/practice/clinic in handling impaired practice or alcohol/other drug abuse or relapse is crucial to promoting an advocacy environment for early identification by peers/colleagues and supervisors. If the environment is perceived as punitive in cases of alcohol/other drug dependence, there is less likelihood of early identification and appropriate assessment/treatment. For professionals, as with our CD patients, the same truths hold true — the earlier the treatment, the better the outcome.

There are three common methods of dealing with chemically dependent professionals:

1.  Tolerate
   

   A common administrative choice in dealing with suspected chemically dependent professionals is non-action compounded by the "conspiracy of silence." If no action is taken, there is no liability for false accusation, and there is no time-consuming documentation, confrontation and potential legal retaliation from the employee. Unfortunately, the employer often feels as though they are doing the health professional a "favor." It is common for agencies to transfer the chemically dependent professional to a different unit, different shift or change of responsibility. Through enabling, employees can remain in a system for years without appropriate treatment. Clearly inherent in this inaction is the liability generated for the employer through errors of omission, negligence and malpractice by the chemically dependent health professional and patient safety is compromised. These patients represent a danger of not being able to practice with skill and safety and therefore are liable for licensure board censure.

2.  Terminate
   

   Another common choice for dealing with chemically dependent professionals is to terminate their employment. As soon as a problem is suspected, data is solicited to provide adequate documentation of violations of agency policy, usually absenteeism, improper charting of medications, patient complaints or other peripheral behavioral signs of the chemical dependency. The employer may view termination as rapid problem solving, but the sick professional perceives this as a punitive action and suffers personal humiliation and disgrace. If the professional is not reported to the board of licensing or credentialing, they will immediately seek employment in another facility or hospital, in or out of the state. The chemically dependent professional is "now someone else's problem." This results in increasing liability for the new employer, the professional's patients and the chemically dependent health professional as the disease progresses. Under present medical licensure laws, physicians who are terminated must be reported to the national data bank.

3.  Intervene
   

   Following identification, intervention is usually necessary, as most professionals do not self-refer. Two factors play a significant part in this inability to reach out for help: 1) rationalization of consequences of the alcohol/other drug use, and 2) the professional's identity with the role of "caregiver" is enmeshed with the professional's ego as he or she minimizes their use and effects. The professional is usually advanced in the disease by the time they are identified and have enablers in all life spheres (family, friends, work) who may attempt to rescue the professional from intervention. During the intervention rehearsal sessions, these enabling individuals should be eliminated from the intervention team.

The helping professions foster often unrealistic and altruistic images for their members, which only further complicates identification of the practitioner who needs help. Physicians, nurses, dentists, pharmacists, counselors and other health professionals are often burdened by these unrealistic expectations to the exclusion of their families, social activities and self-care. It is quite common for a health professional to continue working with their painful physical conditions or emotional distress.

Intervention with health professionals requires attention to detail and contingency planning.

1. Data from many sources must be carefully documented.
2. An intervention team must be assembled under the leadership of a trained interventionist.
3. The team should include family, peers, superiors, friends and significant others.
4. Rehearsal of the team speaking to "an empty chair" is beneficial.
5. Site selection, time of day and anticipation of denial and refusals by the patient must be a part of team planning.
6. Specific treatment plans and arrangements should be made before intervention.
7. Plans must be structured for the intervention team if the impaired health professional rejects overtures, becomes hostile or threatens the team.
8. Plans completed for repeat intervention or careful monitoring if psychiatrically indicated.
9. Intervention goals should be structured to send the patient for assessment before treatment is initiated.

Intervention with health professionals is a highly successful strategy for addressing impaired practice, offering the patient the opportunity for an evaluation/assessment while caring and supportive intervention participants help the patient maintain ego integrity. This intervention differs from family interventions: 1) It is professionally based and focused on practice; 2) The intervention team must recognize that the ego identity of the professional is fused with the role they perform, and attempt to focus on objective data; 3) There are potentially significant financial implications if the professional is unable to practice, so leverage in the intervention is focused on practice and employment.

A five-person experienced multidisciplinary team accomplishes assessment and includes:

• an internist certified or eligible by ASAM,
• an addiction medicine specialist,
• a psychiatrist certified in addiction medicine by either ASAM or AAPA,
• a neuropsychologist trained in addiction medicine,
• a family therapist who is experienced in addiction medicine.

Ideally, this assessment should be accomplished in a carefully monitored environment of a hospital setting, because many health professionals have access to drugs, which may mask withdrawal or result in faulty urine drug screens.

Most of the assessment can be accomplished in a 96-hour period. It is essential, whenever possible, that the health professional be accompanied by his or her main significant other (MSO). Several members of the five-person assessment team then can interview this individual. Our experience shows that it is beneficial to have additional members of the family attend the assessment and be present at the summary session, and a panel of experienced well-trained consultants who can deal with problems and complications outside of the primary addiction medicine problems. The assessment leader may extend the 96-hour time frame so that every diagnostic possibility can be explored, if necessary. All of the team's efforts are focused in the summary final session. A diagnosis and recommendation for treatment comprise the final session attended by the patient and his/her MSO and other appropriate family members.

Experience has shown that a 20-hour limit should be imposed for impaired health professionals to respond to the assessment team's recommendations.

Four initially effective options that may be recommended by the assessment team:

1. Hospitalization for detoxification —usually 4 to 7 days and often accomplished during the assessment.
2. Outpatient counseling combined with frequent attendance (5 out of 7 days) at a 12-step program.
3. Three- to four-week inpatient treatment program.
4. Intensive residential outpatient program.

The key to treatment programs for health professionals is that each option for treatment programs must be based on intensive long-term monitoring.

Treatment programs are based on a 12-step program or a therapeutic equivalent. Education about the primary, psychosocial, biogenetic diseases of addiction, application of non-chemical coping techniques and intensive family therapy are the crucial components to an effective program. In a successful health professional program model, patients after a brief hospital stay are transferred to the intensive residential program.

Professionals should be enrolled in a program that provides targeted treatment for chemically dependent professionals, with staff who are experts in treatment of professionals, and where there are other health professionals of their discipline in treatment. Experienced clinicians in specialized centers assist the patient's recovery while anticipating the common defensive posturing of the professional, manipulations, disruptive behaviors and Axis II diagnoses.

The health professional is a challenging patient due to many of the factors identified regarding their ego identity, knowledge and leadership capabilities. In treatment it is not uncommon for professionals to attempt to:

• Minimize their disease and its consequences
• Withhold and block feelings and emotions
• Attempt to manipulate the treatment team
• Care-take and diagnose other patients and staff
• Undermine staff physicians diagnoses and treatment recommendations
• Manipulate their assignments and treatment schedule
• Take charge in peer groups
• Mobilize other patients in developing a "we vs. them" conflict with staff
• Use anger and threats to neutralize authority of the staff

Following four to six weeks in the initial program, the patient may be enrolled in the "Mirror Image Program" if they are assessed to need extended treatment. Elements comprising the decision for extended treatment include:

• Significant relapse
• Unsatisfactory treatment experiences, to date
• Dysfunction in the home/family
• Malignant disease history, severe morbid disease, etc.

The Mirror Image sites, in both private and public sectors, offer the impaired health professionals placement as a "counselor" in training. For six to eight weeks, they treat alcohol and drug addicts with their own disease and, in doing so, see themselves.

The family component is critical to re-establishing healthy relationships, and at our Campus, patient residences are structured as a surrogate family. There is a deliberate mix in the recovery residence of both professional and "real people" (non-health professionals are called "real people" by the health professionals in treatment). This mix also addresses itself to combining in the individual residence the patients just entering into treatment and those who have been in the program an extended period of time. Intensive family week workshops are prescribed for the patient's nuclear family, and there is an option of an additional week of family therapy for families that need additional help.

The discharge date is carefully evaluated against a set of established criteria and presented to the patient after four to six weeks during an individual discharge conference with the health professional in a group setting with three or four other health professionals who are being discharged. Each health professional is asked to elaborate on their experience of the various phases of their program, their characterization of individual staff members, and suggestions they have for improvement of their care. This conference is co-facilitated with the CEO, Medical Director and Program Director. Anonymity of these sessions is stressed so that criticism and evaluation of the staff and program can be open and honest. Substantial programmatic, staff and facility changes have resulted from these conferences.

The recovering health professional and the facility contract to enter into a long-term continuing care program. Experience of more than twenty-five years has demonstrated that five years of continued monitoring is valuable. Over 93 percent of relapses occurred during the first five-year period, the majority occurring in the first twenty-four months (Talbott, 1995). Monitoring is accomplished within a group setting, and a significant other usually accompanies the patient. The recovering health professional's meeting with seven or eight others and their main significant others on a weekly basis is gradually decreased, based on individual need over a five-year period.

It is apparent that just depending and reporting on the 12-step meetings and results of the urine drug screens by themselves are not adequate. Monitoring must be holistic and frequently immediate members of the family, like spouses and children, need to play a supportive role in the monitoring sessions. These immediate family members often pick up relapse behaviors or true relapse long before other members do, including the patient.

1. Meetings
2. Sponsor
3. Monitoring
4. Emotional traps (anger, guilt, depression, anxiety, insomnia, etc.)
5. Additions/subtractions to addiction history (secrets)
6. Compulsive behavior (sex, food, nicotine, gambling, theft, spending)
7. Current therapy/treatment/medications (prescribed, OTC)
8. Relationships (family, spouse, MSO, parents, children, friends)
9. Physical health-exercise program
10. Leisure time-fun
11. Work (professional status, duties, attitudes)
12. Financial status
13. Legal-licensure status
14. Additional training and/or continuing medical education
15. Spiritual program
16. "Soft" part of your recovery program

    Planning for the patient's re-entry to practice involves the primary treatment team, the professional's employer or partners, the professionals program or other referral sources. Contingent upon the treatment teams' recommendation role modifications may be necessary for the professional's early recovery. Some examples of modifications for health professionals include:

    Professional role change	→	Temporary reassignment of professional duties
    Restrictions on access to drugs	→	Limited prescribing and dispensing
    Work hours	→	Modified schedule
    Monitoring by peer	→	Clinical review and support
    Workplace adaptations	→	Stock drugs, samples, nitrous oxide

    
    
    

    G. Douglas Talbott, MD, is the founder/medical director of the Talbott Recovery Campus in Atlanta, Georgia. This campus serves as a national Impaired Health Professionals Treatment Program having treated over 5,000 health professionals. Dr. Talbott is past president of the American Society of Addiction Medicine (ASAM), vice-president of the International Society of Addiction Medicine, Clinical Professor of Family Practice, Morehouse School of Medicine, Adjunct Professor of Pharmacology, Mercer University School of Pharmacy. Talbott is co-author of Healing the Healer: The Addicted Physician.

    Linda R. Crosby, MSN, RN, is an expert in the field of chemically dependent professionals and programs for recovery monitoring. Crosby served as senior author of To Care Enough: Intervention with Chemically Dependent Colleagues. She has served as chairperson for many professional assistance programs, including NAADAC's Peer Assistance Committee. She is director of Business Development at the Talbott Recovery Campus in Atlanta, Georgia.

    References
    American Psychological Association (1987). Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised (DSM III-R). Washington, D.C.: American Psychological Association.
    Coombs, R.H. (1997). Drug-impaired professionals. Cambridge, MA: Harvard University Press.
    Crosby, L. (1992). Peer assistance for alcoholism and drug abuse counselors. Arlington, VA: NAADAC.
    Crosby, L. & Bissell, L. (1989). To care enough: intervention with chemically dependent colleagues. Center City, MN: Hazelden.
    Hughes, P., Brandenburg, N., Baldwin, D. et al. (1992). Prevalence of substance abuse among US physicians. JAMA, 267, 2333-2339.
    McAuliffe, W.E., Santangelo, S., Magnuson, E., Sobol, A., Rohman, M., & Weissman, J. (1987). Risk factors of drug impairment in random samples of physicians and medical students. International Journal of Addiction, 22(9):825-841.
    Talbott, G.D. (1994). Physician social drinking in changing times. Atlanta Medicine, November.Talbott, G.D. (1995). Reducing relapse in health providers and professionals. Psychiatric Annals, 25:11.
    Talbott, G.D., & Gallegos, K.V. (1997) Physicians and other health professionals, in Lowenstein, J. (Ed.) Substance abuse: a comprehensive textbook, third edition. Baltimore, MD: Williams and Williams. (Chapter 74).
    Talbott, G.D., Gallegos, K.V., & Angres, D.H. (1998). Impairment and recovery in physicians and other health professionals. in Graham, A.W. & Shultz, T.K. (Eds.) Principles of addiction medicine, second edition. Chevy Chase, MD: American Society of Addiction Medicine. (Chapter 3).

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Paul Esquilin   |170.134.7.xxx |2007-12-04 10:49:03 unless something has changed in the human brain a drug is a drug.And Alcohol being the most widely used legal drug since the dawn of time and kills more people then all the drugs put together there is no question in my mind that an addict can easily fall into the trap of relapse of he/she believes that they never had a problem with alcohol.The Brain cannot distinguish,a drug is a drug. Reply 0   0

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