Profile of an Impaired Physician

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Profile of an Impaired Physician

• Melissa Lee Warner MD
• Wm J Farley Center at Williamsburg Place
• 800-582-6066

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AAFP This Week (vol. 4, 36, 9/9/03)

• Patients with drug or alcohol dependence or
  abuse problems will be hard to detect unless the
  physicians ask them about their use
• 94 of the 22 Million people with these problems
  fail to recognize them themselves
• Of the 362,000 people who sought treatment 354,00
  could not get help

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Prevalence Rates

• 10-15 General Population
• Highest Rates in Hospital Trauma/Ortho Population
  (80)
• AMA Discharge
• Drug abuse, particularly alcohol and narcotic
  abuse, is the one common risk factor pervading
  all hospital settings
• In 2002, the top 2 diagnoses related to AMA
  discharge were drug abuse disorders and alcohol
  abuse disorders
• clinicians should maintain a high level of
  suspicion for potential drug and/or alcohol
  dependence when patients, particularly elderly
  patients, wish to leave AMA.
• physician must address the patients concerns
  and, when necessary, convey a clear desire and
  ability to treat withdrawal symptoms.
• Dostal, et al., 2006 Dept Emergency Med,
  Northwestern Univ.

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Incidence of Addictive Disorders in Healthcare
ProfessionalsZiegler MD

• Alcoholism- 11-12 lifetime prevalence (same as
  general population)
• Other drug dependencies- 4-6 lifetime prevalence
• Illicit drug addiction among healthcare
  professionals lower than general population
• Prescription drug addiction higher

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Profile

• Can you tell by looking at them?

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Find The Physician (Addict)
Rush Limbaugh Radio Host Prescription Narcotics
Congressman Patrick Kennedy Prescription
Narcotics
Brett Farve 3 time MVP Prescription Narcotics
Jim Flemming Comedian
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• How Do Physicians (with addiction) Present?
• Univ of Chicago study in 1991 of 740 occupations
• Highest social status
• Most respected profession
• Malpractice, Managed Care, Decrease in public
  opinion
• M-Deity syndrome MDs looked on as Gods begin
  to assume that role
• Problems with family life, medical marriage
• Physicians are comforted by peers, patients
  effusive praise
• Problems such as chemical dependency are ignored
  or enabled
• Denial and shame increase, making it more
  difficult to disclose a problem
• Conspiracy of silence
• Chemical dependency is the same disease among
  physicians and non-physicians, but because of
  specific barriers, specific modifications to
  intervention, treatment and aftercare are needed
  in this population.

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Risk Factors for Development of Addictive
Disorders

• Genetics
• Intoxicant Use
• Stressors
• Greatest Variable

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At-Risk Diagnostic Categories(Treated with
intoxicating Medications)

• Non-Malignant Chronic or Recurrent Pain
• Musculoskeletal, HA, GI
• Anxiety Syndromes
• Sleep Disturbances
• Weight Management
• Attention/Concentration Problems
• No Adult Onset ADHD

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Intoxicating Medications

• Opiates
• Ultram
• Benzodiazepines
• Ambien, Sonata, Lunesta,Klonopin
• Stimulants
• Concerta, Adderall
• Barbiturates
• Fiorinal/cet, Esgic
• Soma

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Significant Historical Correlates

• Family History of Addiction
• Personal Use of Intoxicants
• Nicotine Use
• Early High Tolerance/ Tolerance of any kind
• Co-Morbidity
• Bi-Polar Disorder
• Abuse History
• Serious Mental Illness

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5 FactorsPain Management

• Family Hx of Addictive Disorder
• Personal Hx of Addictive Disorder or Abuse
• Psychiatric Disorder
• Sexual Abuse History
• Nicotine Dependence
• 1st Cigarette w/in 1 Hour of Awakening

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The Addicted Physician Manejwala MD

• Typically, the hospital/ practice is the last
  place addiction manifests symptoms
• Physicians hold the workplace sacred
• Disruptions in family, personal health,
  community, social, spiritual and leisure life can
  all occur while the workplace remains relatively
  unaffected
• Even very small intrusions of addiction into the
  workplace should be taken extremely seriously in
  physicians

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Workplace Symptoms

• Initially
• Chaotic or labile personal and professional
  lifestyle
• Poorly explained accidents and injuries
• Family and marital discord
• Long sleeves and tinted glasses
• Deterioration in appearance/ hygiene
• Significant weight change
• Irritability or hostility when confronted
• Increased use of cologne, perfume, breath
  fresheners
• Resumption of tobacco use
• Spending sprees, gambling, risky investments
• Increasing medical problems and symptoms
  requiring medication

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Subtlety

• Any change from known practice/ personal style
• Will be attributed to anything else (but
  addiction)
• It could well be both (e.g.. Divorce and
  addiction)
• Even very small intrusions of addiction into the
  workplace should be taken extremely seriously in
  physicians
• Tip of the Iceberg

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Workplace Symptoms (later)

• Deterioration in handwriting and quality of
  record-keeping
• Diction delinquencies
• Nonresponsive on call
• Failure to adhere to schedule
• Late mornings, midnight rounds
• Failure to follow patients appropriately and
  consistently
• Failure to make appropriate referrals or to
  request consultation when appropriate
• Altercations with patients, peers or hospital
  staff
• Poorly explained complications and misdiagnosis
• Change in prescribing habits Inappropriate and
  inconsistent telephone interactions
• Change in type of controlled substances kept in
  the office, ordered from vendors, or requested
  from pharmaceutical reps

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Common Presentation

• Others saw symptoms but raised no concern
• Mythology couldnt be addiction
• am EtOH (first order kinetics)
• withdrawal/intoxication
• Stigma misdirected attempt to protect
• Normalization of approach to screening/detection
• Treatable illness that effects all

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Even very small intrusions of addiction into the
workplace should be taken extremely seriously in
physicians Tip of the Iceberg
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Common Handicap

• No drug testing done at the time of concern
• UDS
• NIDA 5 vs. 12
• Hair testing
• EtG- ethyl glucaronide

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Summary

• 1/10 Physicians
• Wont self-diagnose
• Detectable/ Treatable
• De-Stigmatize
• Provide Protocols
• Include testing
• Even very small intrusions of addiction into the
  workplace should be taken extremely seriously in
  physicians

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JCAHAO Directive

• Physician Wellness Committees/ Protocols
• Role of the Medical Board

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Williamsburg Place The Wm. J Farley Center

• Melissa Lee Warner M. D.
• Family Practice/ Addiction Medicine
• Omar Manejwala M. D.
• Psychiatry/Addiction Medicine
• 800.582.6066
• www.farleycenter.com