The consequences of addiction among healthcare professionals (HCPs) are not limited to the usual problems we are well aware of in others with this disease. In the healthcare workplace patient harm is a real, preventable possibility. Addiction in this setting can undermine professional peer morale, and healthcare systems, clinics and hospitals can be at risk for legal retribution (Berge, K.H., Seppala, M.D. & Schipper, A.M., 2009). The nature of the healthcare workplace is unfamiliar to most counselors and treatment programs. Addiction among HCPs can result in great harm to the practitioner and to others, requiring programs and counselors that specialize in this area of addiction treatment. Counselors working with HCPs face unique challenges, but they also play a tremendous role in the remarkable outcomes of physicians with addiction.

The Seattle Post Intelligencer reported the case of an anesthesiologist who was “diverting drugs from my patients” and described him as intoxicated with Demerol during surgery (Smith, C., 2003). A female patient was left in a “persistent vegetative state” (essentially a lasting coma) after the routine surgical procedure. The anesthesiologist stopped her oxygen while she was still paralyzed and could not breathe on her own. Both he and the hospital were sued and he entered addiction treatment. A surgical technician in Colorado was indicted last year after it was found that she had likely infected up to 5,700 people with Hepatitis C (Denver Post, 2009). At least 35 people have tested positive for Hepatitis C as a result of her actions. The surgical technician, who was addicted to heroin, stole and injected herself with syringes of fentanyl, refilled them with saline and replaced the contaminated syringes to be used on patients, resulting in patients being subjected to inadequate anesthesia, excess pain and exposure to Hepatitis C.

While some claim these are sensational examples of rare events, the actual number of such events is undetermined. These horrific situations usually only get discussed when exposed by the patient, the family or the legal system, after the healthcare professional gets caught. Counselors cannot expect HCPs to admit to these indiscretions, and certainly not in a typical group setting.

Addiction is a significant problem among HCPs. Accurate numbers are difficult to come by, but data from physician populations reveals that the rate of addiction during a physician’s career is estimated to be the same or somewhat higher than in the general population—10 to 12 percent (Hughes, P.H., Brandenburg, N., Baldwin, D.C. Jr., et al., 1992; McLellan, A.T., Skipper, G.S., Campbell, M. & DuPont, R.L., 2008). It is unknown whether the rate of addiction among nurses is any different than the general population (Maher-Brison, 2007).

Compared to the general public, physicians are more likely to use prescribed medications, but the primary problem remains alcohol (50.3 percent) (McLellan, A.T., Skipper, G.S., Campbell, M. & DuPont, R.L., 2008). Anesthesiologists are the exception to this, in that the most common drug of abuse among this group is highly potent injected opioids, such as fentanyl/sufentanil, which are at least 100 times more powerful than heroin (Kintz, P., Villain, M., Dumestre, V. & Cirimele, V., 2005). In a study of 16 state physician health programs that examined 904 consecutive physicians placed under monitoring, five medical specialties comprised greater than half of the physicians: family medicine (20 percent), internal medicine (13.1 percent), anesthesiology (10.9 percent), emergency medicine (7.1 percent) and psychiatry (6.9 percent) (McLellan, A.T., Skipper, G.S., Campbell, M. & DuPont, R.L., 2008). Anesthesiologists comprise 5.2 percent of physicians nationwide; therefore, they are remarkably over-represented in physician health programs (American Medical Association, 2007). All HCPs need specialty treatment, but anesthesiologists, nurse anesthetists and other operating room personnel require special attention due to the dangers associated with diversion and use of the most powerful substances known.

A university hospital referred one of its physicians to the state HCP program for evaluation after she was caught stealing opioids. Although the physician did not admit to having a problem, she agreed to enter a residential treatment program for evaluation. She drove from the office of the HCP program to her home in disgrace. There she gathered a large syringe of morphine with plans to kill herself rather than enter treatment. She sat in her car in the treatment program parking lot for an hour trying to decide whether or not to take her life. Fortunately, she chose to undergo the evaluation and save the morphine for later. Once involved in the program she divulged her plan, provided the morphine to staff and fully engaged in the recovery process.

Most states have HCP programs for addicted physicians that are affiliated with the state medical board or the state medical association. However, many states do not provide the same level of intervention and monitoring for other HCPs, including nurses. Nurse anesthetists—with the same access to opioids as anesthesiologists—have no monitoring programs in many states. As a result, they are often undertreated, and many die as a result of their addictions. State physician programs emerged in the 1970s after the American Medical Association (AMA) recognized the extent of the addiction problem (AMA, 1973).

Rapid confirmation that a substance-use problem may exist, with immediate intervention, prevent the potential for harm to patients, workplace complications and harm to the addicted healthcare worker. The hospital does not need evidence “beyond a reasonable doubt” to intervene, as personnel are not being accused of a crime (Berge, K.H., Seppala, M.D. & Schipper, A.M., 2009). Instead, they are undergoing a work-fitness evaluation seeking evidence of an illness, one the individual may be the last to fully recognize. Once confronted about the possibility of addiction the HCP may act desperately; thus, great care must be taken to prevent suicide or other adverse outcomes (Myers, M.F. & Gabbard, G.O., 2008).
Many states, like Minnesota, have laws that require reporting of impaired physicians and allows for discipline of physicians who do not report such situations. Reporting to state HCP programs is an alternative to licensing board discipline, which usually provides evaluation and treatment with a rehabilitative model. These state HCP programs provide supportive, non-disciplinary assistance to physicians, and sometimes other HCPs with an illness that may impair the ­ability to practice with reasonable skill and safety. State HCP programs may subsequently report physicians to the medical board should they fail to comply with the required monitoring and aftercare plan. Minnesota law includes reporting immunity, which protects those reporting and those cooperating with an investigation about a physician from civil liability or criminal prosecution (MN Statute 1996, 214.34). State laws and the reporting processes in some states minimize the resistance associated with reporting a colleague and protect those who do so. It is crucial that treatment programs know the laws of each state they deal with.

Addiction is a disease of the brain’s reward circuitry where the dysfunction is primarily in the limbic system and the pre-frontal cortex. Advances in the neurobiology of addiction have revealed supraphysiologic release of dopamine, establishing an excessive signal of reward by addictive substances (Kalivas, P.W. & Volkow, N.D., 2005). Pre-frontal inhibition of drug use secondary to conscious recognition of mounting consequences would be a normal response, but is undermined as limbic drives prevail. Survival itself is reprioritized and becomes secondary to the ongoing use of the drug (Hyman, S.E., 2005).

This reprioritization explains how the addicted HCP can continue to use drugs while the potential adverse consequences mount. The use of the drug becomes paramount, and the damaged brain does not recognize consequences; it only strives for more of the drug. The addicted typically do not fully recognize their plight or the risks they are taking to continue drug use. The prominence of the new limbic drive for the drug recruits higher cortical centers, using the healthcare professional’s intelligence against themselves to preserve continued drug access and use. It should not be surprising that the addicted will deny use; bargain for situations that facilitate continued use; and even give up careers, family and sometimes life itself in the pursuit of the addictive substance. Treatment for addiction is rarely sought spontaneously.

HCPs often resistant to treatment
Addiction counselors who work with HCPs must be seasoned veterans with the confidence, skills and tact to deal with very intelligent, often intimidating and sometimes manipulative individuals. HCPs rarely admit to having addiction upon initial intervention and evaluation (Berge, K.H., Seppala, M.D. & Schipper, A.M., 2009) even with remarkable evidence to the contrary. They resist treatment and use their intelligence to deny and hide the problem, often using their credentials to intimidate addiction counselors, who must be ready and able to mitigate such situations. They pose challenges to the standard means of history taking and diagnosis. This author worked with a physician that emptied his bladder, catheterized himself and filled his bladder with clean urine prior to urine drug screening to avoid detection of drug use. Another physician had been doing a medical procedure and was noted by several nurses to have alcohol on his breath. He denied this, and tried to intimidate the nurses and his colleagues as they sought help from the state health professional program, who were well aware of him due to a history of alcohol dependence. Later, upon threat of loss of license, he admitted to regular alcohol use occurring over a several month period. Qualified, experienced counselors have little difficulty with such situations, and they need a treatment team with similar experience with this population in order to provide appropriate, effective treatment services.

Unfortunately for the physician and other HCPs with addiction who are unable to recognize the problem, there are many reasons that peers and family do not identify or intervene early in the course of addiction. Medical schools provide few, if any, days of training in addiction, and the vast majority of primary care physicians have been shown to be unable to recognize and appropriately treat alcoholism (CASA, 2000; McGlynn, E.A., Asch, S.M., Adams, J., et al., 2003). Colleagues are hesitant to engage in another’s private affairs and will resist acting on a disease they have very little knowledge about Farber, N.J., Gilbert, S.G., Aboff, B.M., et al., 2005).

Addiction can be misunderstood as a choice, not an illness, inhibiting action by others. There may be a “conspiracy of silence” in the workplace and the home, limiting any involvement on the part of friends, family and colleagues. If the practice is small, or the physician is in a position of power in a hospital or large clinic, other employees may fear for their jobs and careers if they mention the possibility of addiction. Family members may know of the addiction earlier than those in the workplace, but they could be hesitant to act for fear of financial consequences, loss of job, loss of prestige and loss of licensure. Fear of litigation can limit appropriate attention to this disease. Stigma and bias also interfere, as people often cannot believe a physician could have addiction or only believe addiction occurs in the lower socioeconomic classes (Talbott, G.D., 1982).

Limited discussion of patient morbidity and mortality by HCPs in treatment programs is commonplace and may be legitimate, due to legally protected information that cannot be shared; but the culture of medicine also contributes to the lack of attention to clinical ­mistakes and adverse events in the healthcare workplace. Among physicians (especially surgeons) and other healthcare personnel there may be a credo that prevents emotional expression related to negative clinical outcomes. Such a culture also prevents discussion of personal problems and recognition and attention to addiction among colleagues. As a result, self doubt, guilt and shame are addressed only in isolation. These factors must be recognized by counseling staff, and addressed within the course of addiction treatment, which requires a safe, healing environment that fosters appropriate disclosure.
The healthcare professional peer group process is ideal for such therapeutic activities, when facilitated by experienced counselors. Such groups model a healthy, new and different way of expressing thoughts and emotions related to workplace problems that would not be appropriate for groups with non-HCPs. HCPs also find it hard to fool each other. When an orthopedic surgeon denied he had workplace access to Propofol—a hypnotic anesthetic that was named in the Michael Jackson case—his peers immediately responded in disbelief and listed multiple ways he could readily find and use this drug. Addiction counselors must be well aware of issues specific to healthcare professionals and properly ­distinguish when and how to therapeutically address events related to the healthcare workplace.

HCP treatment programs must provide extensive, professional evaluations to establish an accurate diagnosis, determine potential co-occurring psychiatric problems, provide information for treatment planning, satisfy state HCP program requirements and establish a record for return to work decision making. Proper evaluation includes a physical examination, psychological and psychometric testing, an assessment of ­family functioning and a psychiatric evaluation. Physi­cians seldom enter treatment without coercion and will initially only rarely describe the history in an accurate manner secondary to both denial and conscious decision making. They recognize little incentive to admit to a drug problem and are afraid and anxious secondary to potential job loss and licensure issues (Talbott, G.D., 1982). They also are driven by the continued pursuit of powerfully reinforcing drugs that limit objective self-examination. Collateral information is essential to the diagnostic evaluation and may be the only way to obtain a history adequate to making an accurate initial diagnosis (Berge, K.H., Seppala, M.D. & Schipper, A.M., 2009). Most treatment programs specializing in HCPs require signed release of information forms or they will not complete these specialized evaluations or initiate treatment. Evaluation and treatment requires a multidisciplinary team with experience working with HCPs (Graham, A.W., Schultz, T.K., Mayo-Smith, M.F. Ries, R.K., Wilford, B.B., 2007).
Addiction professionals working with this population need to understand the language of medicine, the medical workplace, access to prescribed medi­cations, some of the unique stressors associated with medical practice, the potential for co-morbid psychiatric illness and the personality traits and disorders common to physicians and other healthcare personnel. They also need knowledge of numerous, prescribed, addicting medications, workplace access to these medications, the unique stressors of the healthcare workplace and the risks associated with return to work, especially related to relapse. Psychiatric illness and cognitive impairment can complicate treatment, recovery and successful return to work. As a result these issues are specifically screened and evaluated. The diagnosis of addiction is ade by history and relies on behavioral descriptions. It often requires gathering a history of substance use related behavioral changes from multiple sources to make a diagnosis in a healthcare professional. Addiction counselors must clearly and correctly document information supporting the addiction diagnosis and treatment planning decisions, knowing that the medical record will often be used in legal proceedings.

HCP treatment programs include group and individual psychotherapy, education about addiction, and skills training to prevent a return to drug and alcohol use (Berge, K.H., Seppala, M.D. & Schipper, A.M., 2009). They also emphasize fellowship and encourage physicians to learn from one another and re-establish positive relationships with a level of intimacy that helps with acceptance and healing. These programs require complete abstinence from alcohol and drugs, and the vast majority use a 12 Step model based on the principles of Alcoholics Anonymous. A recent study revealed that 95 percent of physicians were treated using a 12 Step model and 78 percent entered residential treatment for a mean of 72 days (range 30 to 90 days) (Kintz, P., Villain, M., Dumestre, V. & Cirimele, V., 2005). It is necessary to provide a milieu that establishes a safe place for physicians and other HCPs to become patients and to express themselves in a manner that allows for acceptance of addiction and pursuit of recovery. Group therapy with other HCPs breaks through some of the defenses that can limit self-examination and supports recognition of cues and triggers unique to the health-care ­setting. They have the opportunity to discuss the stressors associated with medical practice and their predicaments, including medical board involvement, legal issues and potential problems with the Drug Enforcement Adminis­tration. Most HCPs are tremendously ashamed of taking drugs from the workplace and injecting themselves and have great difficulty admitting to this. They often think of themselves as the only person who has ever diverted drugs for self-use. Group therapy with other addicted HCPs often results in admission of addictive behaviors and enhances acceptance. Addiction treatment is arranged to help people break the cycle of addictive behaviors and address associated problems that have usually gone unnoticed secondary to the numbing power of addictive drug use. Participants examine their relationships, their use of money, their families, their decision-making and other major life areas. Addiction can alter perspective so significantly that physicians often enter treatment convinced that their work or other stressors have caused drug use, only to realize, once sober and in recovery, they are very happy and proud to be doctors.

Prior to completing treatment physicians and other HCPs should undergo a practice assessment to examine their ability to return to work. This assessment provides the opportunity to establish the risks of returning to practice, to determine a treatment plan supportive of abstinence in the workplace, to address relapse prevention and to initiate the decision-making about timing of return to practice (Berge, K.H., Seppala, M.D. & Schipper, A.M., 2009). Some physicians and other HCPs can go right back to the workplace, whereas others require further treatment or a period of abstinence prior to returning to work. Some will have to consider a different type of practice or another specialty. A very small group will not return to the practice of medicine. Return to work decisions are difficult and require the expertise of a treatment team well-versed in healthcare professional treatment and decision-making, the staff of the state HCP program, and the help of others in the medical workplace. Several factors predict relapse in HCPs, including: a positive family history for addiction/alcoholism; a psychiatric illness in addition to addiction; use of a major opioid and a psychiatric illness; and use of a major opioid, a psychiatric illness and a positive family history (Domino, K.B., Hornbein, T.F., Polissar, N.L., et al., 2005). This information is being used in treatment, monitoring and return-to-work decisions for addicted physicians.

Anesthesiologists, nurse anesthetists and other operating room personnel who return to their prior workplace will be handling the very drugs they were addicted to, which is unlike almost all other addicted patients, and specifically includes the risks of cues and triggers associated with prior drug use. As a result, recommendations have been made to prevent their return to the operating room (Berge, K.H., Seppala, M.D. & Lanier, W.L., 2008). Currently a group, including the author, is working on a return-to-work decision making tool for ­anesthesiologists and nurse anesthetists that will help define expectations of the individual and the state monitoring program to standardize the decision-making and reduce relapse risk.
A primary role of state HCP programs is monitoring recovery activities after successful treatment completion, and requires communication and collaboration with the treatment program. Most physicians can return to practice with a solid recovery program and monitoring in place. Recovery rates of physicians rank alongside those of commercial airline pilots, which are the highest measured at 74 to 90 percent. As a result, a rehabilitation model and support for return to practice is appropriate. How­ever, without appropriate monitoring, the risk would be formidable and return to the medical workplace should not be considered. State HCP programs contract with recovering individuals and require compliance with activities known to support ongoing abstinence and recovery from addiction. These activities include: group therapy with other healthcare professionals, individual therapy, mutual help meetings (AA, NA, etc.), oversight meetings, drug screening—both random and for cause—and workplace monitoring. Require­ments can also include psychiatric care, family therapy and limitations on work place, work hours and prescribing (Berge, K.H., Seppala, M.D. & Schipper, A.M., 2009). Ex­tensive high-quality specialized treatment; motivation to maintain licensure; and return to practice and long-term monitoring all are driving factors that result in positive outcomes for physicians. This is not well established or studied among other HCPs, but similar programs exist for non-physician healthcare professionals in some states, with outcomes supporting this approach.  

Addiction is a relatively common illness and affects physicians at the same or slightly higher levels than the general population. Unfortunately, other HCPs do not receive the same treatment and monitoring in many states. Treatment in specialty programs designed for HCPs is necessary to address the issues unique to physicians and other healthcare personnel. Physicians have remarkable recovery rates when involved in appropriate treatment and monitoring programs. All medical personnel with exposure to powerfully addictive medications in the workplace should have access to HCP programs and monitoring systems to ensure appropriate treatment and the highest likelihood of successful abstinence and recovery. We can learn from the remarkable positive outcomes of physicians to improve the recovery rates of other HCPs as well as anyone with addiction.

Marvin D. Seppala, MD, Chief Medical Officer, Hazelden Foundation and Hazelden Springbrook, in Newberg, Oregon, has specialized in treating healthcare professionals since its inception in 1988. Hazelden’s main campus in Center City, Minnesota will be re-establishing a healthcare professionals program in early 2010.

References
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Kam   |Registered |2011-04-08 10:45:30 I do with Kevin about this article. He has said every thing I could think off. I worked in a health care setting where the challenges he was speaking about very very apparent. I do find Physicians or nurses the biggest have a lot more denial because they feel insecure they are supposed to know all this and yet they are here with many of their own patients that they sent to our centers. Reply 0   0

Kevin  - Excellent article   |67.59.9.xxx |2010-04-14 11:20:49 This article is a thorough and excellent exploration of the challenges in this area of addiction treatment. As a monitoring professional in a state HCP program, I found myself surprised at just how accurately this article describes what I deal with every day in my work. The additional challenges for treating addicted anesthesiologists and nurse anesthetists is also captured very well. Big thumbs up! Reply 0   0

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