Helping and Learning from Addicted Physicians

I scared some people awhile back when I pointed to addiction’s prevalence among physicians as example of how there is no contradiction between being professionally successful and having a substance use disorder. I suspect this recent study showing extensive drinking problems among surgeons generated similar anxiety. The study is not without flaws (particularly a low response rate), but its central finding resonates with what other research using a range of methods has found: The rate of substance use disorders among physicians (nurses too) is as high or even slightly higher than among the general population.

What is addiction among physicians like, what happens to such doctors, and what does it teach us about addiction and drug policy?

Some Examples of Addiction among Physicians (altered a bit for privacy)

1. Benny was a friendly, well-liked, surgical resident whose heavy pot use was the subject of humour rather than concern among the medical staff, who considered it a harmless hobby in which he engaged off duty. Unfortunately Benny was called into surgery at a time he didn’t expect and went into the procedure still under the influence of cannabis. Everything seemed to go well until afterwards, when Benny couldn’t find his hospital locker key. Still a bit foggy-headed, he assumed he’d dropped it somewhere in the halls and it would eventually turn up. He went home in his scrubs to get some sleep. The next day he got an urgent telephone call from the attending surgeon. The patient had developed a high fever and begun vomiting uncontrollably. The medical team felt a hard protrusion at the surgical site and feared that a clamp had been left inside the patient. Emergency surgery revealed that the object was in fact Benny’s locker key.

2. Richard was an experienced anesthesiologist who was dependent both on alcohol and opiate pain medication. At the outset of a surgical procedure, while badly hung over, he administered the wrong dose of anesthesia, causing the patient’s heartbeat and breathing to stop. When the nursing staff tried to sound the alarm Richard became belligerent, saying nothing was wrong and ordering everyone not to sound a code blue. After precious time had gone by, Richard was eventually overruled and a frantic effort was made to resuscitate the patient. The patient did not die but was in a comatose state, which to the best of my knowledge she is still in today.

3. Chi-Ah was a high achieving medical student with an abiding interest in geriatrics. She worked incredibly long hours throughout medical school and residency, graduated with honours and became a skilled and beloved doctor. In the process, she also became dependent on the stimulants and sleeping pills she used to manage her existence. While examining one of her elderly patients, Chi-Ah suddenly became very confused and wandered out into the waiting room. Her grey-haired patients looked up at her reverently — the wonderful young doctor who had dedicated her career to helping them — and then were shocked as she said loudly “God I’m tired!”. Chi-Ah then blacked out, pitched forward across the waiting room table, and landed on a woman in a wheelchair, badly bruising the patient’s face and breaking her own ankle.

What Happens to Addicted Physicians?

For decades, what generally happened to addicted doctors is easy to summarize: Nothing. There are many reasons for this, including self-protective tendencies within the guild and the widely shared belief among doctors that they are above the frailties of lesser mortals. Medicine was dragged into facing up to addiction within the ranks by external pressure in response to numerous scandals. In the UK, the most famous was the case of the serial killer Dr. Harold Shipman. Many felt that if his drug problems had been investigated more thoroughly when they first came to light, he would never have remained in a position to murder several hundred patients.

Addiction is taken much more seriously today, and the modal intervention is the Physicians’ Health Programme. These programmes have the dual function of helping addicted physicians and protecting the public from the damage they may cause. Although some physicians come to PHPs voluntarily, many are referred under threat of losing their licence.

Importantly, PHPs do not fall into the well-meaning trap of assuming that if an addicted physician enters treatment, everything will no doubt work out all right in the end. Instead, PHPs couple treatment with long-term and rigorous drug and alcohol testing. Physicians on the monitoring programme sign a contract agreeing to swift and certain consequences for substance use. The PHP have a huge motivational lever in place: The power to temporarily or permanently remove the physician’s licence to practice medicine.

The results of PHPs are spectacular: Over 80% biologically-confirmed and total abstinence at 5 year follow-up. The results are so remarkable that Dr. Tom McLellan’s advice is that if you go into the emergency room on the morning after New Year’s Eve, the best way to ensure that your doctor will not be hung over is to insist on an addicted doctor.

What Can We Learn From Addicted Physicians?

1. Even people with severe substance use disorders respond to management programs that include swift and certain consequences for use and non-use. Reality-Based Community readers are well-familiar with programmes such as HOPE Probation and 24/7 Sobriety. The principals of those programmes have long been shown effective in physicians. The problem is that crime policymakers, who like most people buy into the idea that doctors are somehow fundamentally different than the rest of humanity, react to data on physicians’ health programmes by saying “Surely, that stuff works on doctors, but they are nothing like people on parole and probation!”. This has since been shown to be profoundly wrong-headed: Human beings (doctors or otherwise) are simply more likely to change when the consequences of their behaviour come quickly and consistently than when they are slow and probabilistic.

2. The idea that if we just educated people about all the various drugs they would make safe, wise choices about which to use is complete rubbish. Physicians have years of training in biochemistry and pharmacology, far more than could ever been attained in the general population, and yet they are as much or more prone to addiction.

3. Relatedly, greater access to substances in a population produces more cases of addiction. Why do doctors, who have so much more to lose than people who are unemployed or in poverty, have rates of addiction as high or higher than the rest of the population? Because they have much higher access to drugs (both because of their prescribing privileges and their high incomes). It is amazing that some people argue that “addicts will always get their fix” no matter what, or, that neighborhoods with high addiction rates simply have less collective willpower to resist than do neighborhoods with low addiction rates. In truth, the more substances are available, the more people will use them and the higher the rate of addiction will be. That’s why controlling the supply of addictive drugs is good public health policy.

[Cross-posted at The Reality-Based Community]

Keith Humphreys

Keith Humphreys is a professor of psychiatry at Stanford University. He served as a senior policy advisor at the White House Office of National Drug Control Policy from 2009 to 2010.