The Addicted Healthcare Professional

Dr Jane MarshallSouth London & Maudsley NHS Foundation Trust

MSc seminar: March 2014

Substance Use Disorders in Doctors: Extent of the Problem

• Edwards (1975) - Lancet: “The Alcoholic Doctor” - a case of neglect.

• Murray (1976) - BMJ: “Characteristics and prognosis of alcoholic doctors”– 36 doctors followed up for mean of 63 months

• 5 dead• 29 alive - 8 practising satisfactorily

– recovery (7); continuous drinking (9)– occasional relapse (10)

Substance Use Disorders in Doctors: Extent of the Problem

• Hughes et al (1992)– National sample of 9600 US physicians– Anonymous self-report postal survey– 7-page questionnaire on use of 13 substances– 59% response rate after 3 mailings– Sample size of responsees: n=5426

Substance Use Disorders in Doctors: Extent of the Problem

• Hughes et al (1992) cont’d– Alcohol use

• daily use - 10%• heavy drinkers - 6%

– Unsupervised drug use in previous year• benzodiazepines - 11.4%• minor opiates - 17.6%

Substance Use Disorders in Doctors: Extent of the Problem

• UK estimates:– “..some 1 in 15 doctors in UK may suffer some form of

dependence”• Perception that those affected are:

– mainly male– beyond midpoint in career– more likely to be in general practice

BMA Working Party Report (1998)

Alcohol Use Disorders in Doctors: UK

• 1998:“..some 1 in 15 doctors in UK may suffer some form of dependence” (BMA Working Party)

• 1998: 7% of GPs admitted to using alcohol frequently to cope (Firth-Cozens)

• 1998: 60% junior doctors exceeding safe limits and 10% drinking at hazardous levels (Birch et al)

• 2007: Postal survey of hospital consultants– 17 % drinking at hazardous levels (Taylor et al)

Newcastle House Officers: Alcohol Use

Lancet (1998)

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

Men Women Total

Low risk

Med-high risk

Hazardous

Binge drinking

Newcastle House Officers: Cannabis Use

Lancet (1998)

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

Men Women Total

Cannabis-current

Weekly use

Monthly use

Prescription medication

• Doctors are at increased risk of using prescribed medication especially:– Opiates and benzodiazepines.

• Ease of access• Knowledge• Ability to prescribe/inject

Prescription medication

• Doctors are advised not to treat themselves but… • Forsythe et al (1999) found that:

– Over 70% self-prescribed– 10-15% admitted prescribing anti-depressants,

anxiolytics, opiates and hypnotics.

Drug use by speciality

• Psychiatry / Emergency Medicine– Mood altering substances

• Anaesthesia– Over-represented in treatment programmes– Easy access to powerful narcotics

• General practice

Hughes et al 1992

Risk Factors for Alcohol or Drug Use

• Genetic predisposition• Psychological vulnerability• Stressful work environment/overwork• Maladaptive response to anxiety and stress• Knowledge and accessibility of drugs in the workplace• Self-medication• Need to maintain image of competence (in turn a risk

factor for isolation)• Need to maintain image of “healer” compulsion to

spend long hours at work

Occupational Stressors • Excessive workload• Working patterns (shift and night work)• Poorly functioning teams• Poor communication• Bullying and harassment• Poor levels of support (lone working)• Poor management

Psychological profile of the addicted doctor (1)

• Dysfunctional family background lacking strong support structures

• Low self-esteem• Feelings of self-doubt and inadequacy• Emotionally immature• Unduly sensitive

Psychological profile of the addicted doctor (2)

• Difficulty organising and expressing feelings• Low tolerance for frustration combined with

an unrealistic need for perfection• Goal-directed• Academically at the top of the class

Psychological profile of the addicted doctor (3)

• Intellectualisation• Denial• Guilt• Shame• Secrecy

Women Doctors

• Younger and more likely to be single• Lower risk for substance use and dependence (<5%)• More likely to use sedative-hypnotics than male

doctors• More likely to develop problems in personal lives• Higher rates of psychiatric co-morbidity and co-

dependence on other drugs

“Recognising the signs”

• Evidence of inadequate work performance– Poor time-keeping– Extended breaks– Repeated brief periods of

absence for trivial or inadequate reasons

– Poor performance of duties– Impaired concentration and

memory

South London and Maudsley NHS Foundation Trust, 2007

• Observation of behaviour and appearance– Smell of drink– Under the influence of drink

during working hours– Mood changes, irritability,

lethargy– Deterioration of relationships

with fellow workers– Borrowing money– Hand tremor, slurred

speech...– Deteriorated standards of

personal appearance

Why are colleagues reluctant to help?

• Misplaced loyalty• Insufficient evidence• Too complex and messy• Uncertain as to what to do, who to contact

Principles of Clinical Care for Doctors (1)

• Doctors who are ill should be treated as patients, not colleagues

• Rules on confidentiality should be strictly observed• Additional safeguards to ensure privacy should be

in place• Doctors should be registered with a local GP

Department of Health, 2008

Principles for Clinical Care of Doctors (2)

• Doctors treating doctors should have appropriate expertise and seniority

• Out-of-area care should be arranged unless local care is specifically requested

• Doctors should receive the same care and risk management as other patients

Department of Health, 2008

What is needed?

• Accessible and appropriate services– Access to information– Designated care

pathways and services– Occupational health

services– Confidentiality

Department of Health, 2008

Role of Occupational Health• Health promotion• Coordination of care of the healthcare professional• Management of rehabilitation and return to work

– Organisation of risk assessments, and arrangement of tests and further referrals where appropriate

– Recommendations re: work patterns or work area in agreement with the relevant manager

Outcomes (1)

• USA: 1980s and 1990s• Medical Associations/Boards of Medical

Examiners: – Florida, New Jersey, Oregon and Missouri– 80-90% good outcomes over 3 years– treatment and monitoring

Outcomes (2)

• Morse (1984) JAMA• Prognosis of physicians treated for alcoholism

and drug dependence:– 83% favourable outcomes over 1-5 years– better outcomes than patients of equivalent

standing from the general population– 30% engaged in AA (-> 100% favourable outcome)

Physician (Impairment) Health Programmes

• All US States and Canadian Provinces have PHPs

• Variety of models for management, funding, services provided

• Core component: Mandate for managing the pathway of care for impaired

individuals, with continuous monitoring for 2-5 years dependent on condition utlilising formal contracts for care

• Increasingly providing “voluntary” arrangements

5-Year Follow-up of 904 doctors McLellan et al, 2008

• Consecutively enrolled in 16 physician health programs (USA)• 87% male; average age 44 years; 63% married• Primary substance used:

– Alcohol 50.3%; Opioids 35.9%; Stimulants 7.9; – Other substances 5.9%

• Multiple substances 50%• Intravenous use 13.9%• Specialties: mainly Family Medicine; Anaesthesiology;

Emergency Medicine; Psychiatry• 78.7% licensed and working at 5-year follow-up

Substances Used (n=904)

Physicians Enrolled in 16 State Physician Health Programs: 5-year Follow-up McLellan et al 2008

VariableCompleted contract

(n=515)Contract extended

(n=132)Failed to complete contract (n=155)

Followed sample (n=802)

Licensed or practising medicine

477 (92) 97 (73) 15 (10) 589 (73)

Licensed or working (not clinical)

13 (3) 12 (9) 17 (11) 42 (5)

Retired or left practice voluntarily

7 (1) 3 (2) 18 (12) 28 (4)

Licence revoked 9 (2) 14 (11) 64 (41) 87 (11)

Died 3 (1) 0 (0) 27 (17) 30 (4)

Unknown 6 (1) 6 (5) 14 (9) 26 (3)

 Occupational Status at 5-year Follow-Up McLellan et al 2008

Drug testing during monitoring period for 647 physicians who completed their contracts

VariableCompleted contract

(n=515) Contract extended (n=132) Both groups (n=647)

Average duration of contract (months)

54 64 56

Mean No of drug tests per physician

82 121 94

No (%) with at least one positive drug test result

57 (11) 69 (52) 126 (19)

No (%) with a repeat positive result*

8 (16) 25 (38) 33 (26)

As the British Medical Association calls for action over alcohol and drug abuse among medics, a former doctor tells how alcoholism ruined his career - and of the difficulties of admitting to a drink problem in the healthcare world.

'I was an alcoholic doctor'

It was mostly when I was off duty, but I'm talking possibly a bottle of vodka a day. I might have a top up in the day if I could leave the environment of Casualty to go somewhere where I might have a bottle stashed.

Special Investigation: Why ARE so many doctors addicted to drink or drugs?

By Andrew Malone

The patients were waiting dutifully. But their young female doctor seemed reluctant to attend to their ailments at morning surgery. As the minutes ticked by, her door remained firmly shut.

The reason for her absence soon became apparent. When staff finally went to investigate, Emily Heinzman was found slumped unconscious over her desk at Oulton Medical Centre, near Leeds. The room reeked of alcohol; the dishevelled doctor was snoring loudly and oblivious to the world.

Read more: http://www.dailymail.co.uk/news/article-1277955/Special-Investigation-Why-ARE-doctors-addicted-drink-drugs.html#ixzz1rlphP47e

At her upmarket docklands apartment in Leeds, she kept thousands of tablets in dozens of bottles. There was codeine, temazepam, diazepam and co-codamol - all highly addictive substances that are often used as a temporary treatment for drug addicts

But prescription drugs weren't her only addictions. She was also a heavy cocaine user. And she was handing out stolen drugs to her friends and holding late-night parties at her flat in Leeds, where drink and narcotics flowed.

Indeed, when the law finally caught up with her, cocaine - along with countless other substances - was found to be coursing through her veins.

Finally arrested and brought to court last year, it transpired that she'd been living this secret lifestyle for several years, treating patients at the same time as she was bingeing on drugs and alcohol.

Maudsley Healthcare Professionals Series

(Gossop et al 2001)

• 62 referrals - 46 attended a first appointment – Mean age 44 years; 24 admitted to inpatient unit

• Doctors (46%); nurses (39%); others (15%)• Senior grade (44%); middle grade (37%);

junior grade ( 20%)• Alcohol problems (59%) • Drug problems (n=19, 41%) – mainly opiates

(n=11) or anaesthetic agents (n=6)

Maudsley Healthcare Professionals Series

(Gossop et al 2001)• Alcohol:

– more likely to be older and more senior;– Average daily quantity consumed: 26 units

• Drugs:– 9/19 primarily injected - opiates (n=5) and

anaesthetic agents (n=4)

• Polysubstance use (72%)– ⅓ of alcohol and ½ of drug patients using benzos

• Drug users more likely to be using cannabis

Reasons for Referral

Occupational Stressors

Maudsley Case Note Audit: 1998-2006

• Clinical case note audit • Healthcare professionals referred to a

specialist addictions service at the South London and Maudsley NHS Foundation Trust

• N= 130: – Doctors (n=77); Nurses (n=34); Others (n=19)– ⅔ male

Maudsley Case Note Audit: 1998-2006

• 77 doctors, 80% male; average age 45 years• Primary substance:

– Alcohol (67%)– Prescription drugs (11%)– Alcohol + prescription drugs (13%) – Alcohol + illicit drugs( 4%) – Alcohol + prescription + illicit drugs (3%) – Illicit + prescription drugs (1%)

• Multiple substances• Years of problematic use prior to referral (9.5 years)

Substance Used

Psychiatric Co-Morbidity

Work Related Incidents (%)

Sources of Referral for DoctorsMaudsley Case Note Audit: 1998-2006

Practitioner Health Programme (PHP), Vauxhall, London

PHP: 3-Year Results

PHP : 3-Year Diagnoses (n=574)

3-Year Mental Health Diagnoses

3-Year Alcohol and Drug Diagnoses

79% abstinent and attending PHP regularly9% on maintenance treatment

Networks• GPs• Consultant Psychiatrists• Occupational Health Physicians• CCGs/Acute Trusts• LETBs/Postgraduate Deaneries• Royal Colleges• NCAS• GMC/GDC• Defence Organisations• Sick Doctors Trust• British Doctors and Dentists Group• NHS Pensions• Medical Schools• DVLA• BMA• Royal Medical Benevolent Fund....

As the British Medical Association calls for action over alcohol and drug abuse among medics, a former doctor tells how alcoholism ruined his career - and of the difficulties of admitting to a drink problem in the healthcare world.

'I was an alcoholic doctor'

It was mostly when I was off duty, but I'm talking possibly a bottle of vodka a day. I might have a top up in the day if I could leave the environment of Casualty to go somewhere where I might have a bottle stashed.

Special Investigation: Why ARE so many doctors addicted to drink or drugs?

By Andrew Malone

The patients were waiting dutifully. But their young female doctor seemed reluctant to attend to their ailments at morning surgery. As the minutes ticked by, her door remained firmly shut.

The reason for her absence soon became apparent. When staff finally went to investigate, Emily Heinzman was found slumped unconscious over her desk at Oulton Medical Centre, near Leeds. The room reeked of alcohol; the dishevelled doctor was snoring loudly and oblivious to the world.

Read more: http://www.dailymail.co.uk/news/article-1277955/Special-Investigation-Why-ARE-doctors-addicted-drink-drugs.html#ixzz1rlphP47e

At her upmarket docklands apartment in Leeds, she kept thousands of tablets in dozens of bottles. There was codeine, temazepam, diazepam and co-codamol - all highly addictive substances that are often used as a temporary treatment for drug addicts

But prescription drugs weren't her only addictions. She was also a heavy cocaine user. And she was handing out stolen drugs to her friends and holding late-night parties at her flat in Leeds, where drink and narcotics flowed.

Indeed, when the law finally caught up with her, cocaine - along with countless other substances - was found to be coursing through her veins.

Finally arrested and brought to court last year, it transpired that she'd been living this secret lifestyle for several years, treating patients at the same time as she was bingeing on drugs and alcohol.

Barriers to Seeking Help

• Heavy workload and difficulty taking time off• Fear of stigma of mental illness• Fear of lack of confidentiality and privacy• Feelings of shame• Concerns about professional future• Experience of how other colleagues have been

treated• Insufficient knowledge of services

Thank You

jane.marshall@slam.nhs.uk