Tuesday, November 25, 2014

Drug and Alcohol Abuse Among Physicians: How Concerned Should We Be?

By John Banja 

John Banja, PhD is a medical ethicist at Emory University’s Center for Ethics, a professor in the Department of Rehabilitation Medicine, and the editor of AJOB Neuroscience.

In next month’s (December, 2014) issue of the American Journal of Bioethics, I’ll have an article appear on drug and alcohol use among health professionals. My paper is a counter-argument to one that appeared in JAMA in 2013,1 which recommended that physicians who are involved in serious, harm-causing medical errors should be drug and alcohol tested on the spot. Now, I’ve studied the occurrence of medical errors for over a decade, and the more I thought about that proposal, the more I thought it was a bad idea. So I wrote the article, sent it to AJOB, and eventually it was accepted.2

The point of this blog post is to discuss something that stems from what I learned from the literature on drug and alcohol abusing physicians: most of them can go years, even decades, without the drug or alcohol abuse seriously affecting their work life or technical skills. Physicians who abuse alcohol—which is the most commonly abused substance—can go decades without anyone noticing performance deterioration.3 And when I asked an anesthesiologist recently about the second most popularly abused drugs, oxy- or hydrocodone based narcotics, and how long she thought a physician can be on them without anyone noticing, she pursed her lips and quietly said, “years” (although this doesn’t include intravenous injection of narcotics, where the impact on performance will probably become noticeable in months.)3-5

The hit Cinemax series “The Knick” loosely based its central character, Dr. John Thackery, on William Halsted, arguably America’s greatest surgeon at the beginning of the 20th century. Like Freud, Halsted became addicted to cocaine in the 1880s, but whereas Freud kicked his habit around the time of his writing The Interpretation of Dreams, Halsted never did. He suffered from a cocaine-morphine addiction for 30 years, consuming up to 195 milligrams of morphine a day at the height of his use. Yet, only his Hopkins colleague William Osler claimed to have ever seen him the worse for it (and only once) although we know Halsted’s health and general psychological equilibrium were not in good shape during those decades.6

William Halsted
(From the Medical Archives of the Johns Hopkins Medical Institutions)

So, while I continue to believe that drug testing physicians in the wake of their involvement in a medical error is a poor use of a health care organization’s resources—random drug testing among clinical personnel is a much better approach for a variety of reasons 2,4,5—I remain befuddled about the effect of a health professional’s drug or alcohol use on his or her performance levels. How many are using illicit drugs just to maintain their levels of competence? How widespread is such a phenomenon and for how long do professionals do it? Would some users experience a serious decline in their performance levels if they stopped using? Do many, like Halsted, titrate their drug use so that they don’t succumb (or they delay succumbing) to the substance’s negative effects while gaining the maximum performance effect from their habit? How many start and stop at will, or use for extended periods when the going gets rough and then abstain for extended periods when life gets better? Would some who’ve never used benefit from drug use?—which perhaps isn’t as preposterous as it sounds. In neuroethics, we joke about a surgeon in the not-too-far-off future saying to a family, “The operation I’m about to perform on your loved one will take many hours and be very complex. Even though I’ve performed it numerous times, I find that when I take the drug modafinil—which ramps up wakefulness and alertness—I feel more confident and experience no fatigue whatsoever. Nevertheless, I don’t want to abuse the stuff. So, if you’d like me to take a dose before I begin your loved one’s operation, I will, but I’ll have to charge you an additional $500. What would you like me to do?”

I’ve also come across data suggesting that 80 percent of persons who abuse narcotics, especially street folk, don’t develop a habit.7 They can quit if they want to but like most physicians who abuse drugs or alcohol, they use to self-medicate. I wonder, therefore, about whether we’re developed an exaggerated and unreasonable fear of these substances, at least for the majority of people. But just saying that sounds reckless and stupid, given the way serious addiction wrecks communities and people’s lives. Still, the rate of drug and alcohol abuse among physicians is around 10 to 12 percent, mirroring the general population’s, implying that about 80,000 doctors are abusing drugs or alcohol right now.3-5

While the last thing I’d want is for my physician or dentist’s performance to be affected by drugs or alcohol, the purely curious and inquisitive side of me wonders how often it’s already happened and what difference it made. And if we aspire to a rational policy about drug use and abuse, it seems to me these questions deserve a look, especially as we ramp up our physician health programs all around the country.


References

1.  Pham, J. G., P. J. Pronovost, and G. E. Skipper. 2013. Identification of physician impairment. JAMA 309: 2101-2102.
2.  Banja, J. 2014. Alcohol and Drug Testing of Health Professionals Following Preventable Adverse Events: A Bad Idea. The American Journal of Bioethics, 14(12): 25-36, 2014.
3.  Cicala, R.S. 2003. Substance abuse among physicians: What you need to know. Hospital Physician, July 2003: 39-45.
4.  Berge, K. H., M. D. Seppala, and A. Schipper. 2009. Chemical dependency and the physician. Mayo Clinic Proceedings 84: 625-631.
5.  Merlo, L.J. and M.S. Gold. 2009. Successful treatment of physicians with addictions. Psychiatric Times. Available at http://www.psychiatrictimes.com/addiction/successful-treatment-physicians-addictions.
6.  Markel H. 2011. An Anatomy of Addiction. New York, NY: Pantheon Books.
7.  Hart C. Sept. 16, 2013. The rational choices of crack addicts. New York Times. Available at http://www.nytimes.com/2013/09/17/science/the-rational-choices-of-crack-addicts.html?pagewanted=all&_r=0.


Want to cite this post?

Banja, J. (2014). Drug and Alcohol Abuse Among Physicians: How Concerned Should We Be? The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2014/11/drug-and-alcohol-abuse-among-physicians.html

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