Evaluation and Treatment of Impaired Professionals

Overcoming drug and alcohol dependency is challenging for anyone, and an extra layer of complexity is added when the person is a trusted professional such as a physician, nurse, lawyer or airline pilot. These professionals face the same challenges as anyone seeking sobriety, but they also must contend with the possibility of losing their professional licenses and their entire livelihood.

This makes the treatment of impaired professionals a special area of expertise in the recovery community, and professionals who find themselves dependent on alcohol or drugs must seek out and receive care specially tailored to their needs. There are specific factors that can lead physicians and other professionals down the road to addiction. People who work in high-stress positions requiring life-and-death decisions may turn to alcohol or drugs for relief, and that reaction may be exacerbated by work schedules that disrupt a normal lifestyle and make it difficult to cope in more healthy ways, such as interacting with family and friends. Research indicates that some traits common among physicians can make them more susceptible to drug and alcohol dependency. They tend to be compulsive perfectionists, for instance, and that can encourage anxiety and depression, which in turn can lead to addiction. Researchers also have found that physicians may have more difficulty than most people with letting go of their work to enjoy leisure activities and vacations, difficulty setting limits and a need to assume control of uncontrollable events. All of these factors can predispose a physician to addiction, though there are no guarantees that any particular physician will take that path.

Statistically, physicians are not necessarily at any greater risk than the general population for substance use disorders, with about 10 to 12 percent developing chemical addictions during their careers. But they tend to use prescription drugs more often than the general public because of their proximity to drugs in the workplace and the ability to write their own prescriptions. A survey by researchers at the Institute for Behavior and Health in Philadelphia found that the most common drugs of abuse among physicians were alcohol (50 percent) and opioids (35 percent), with the other 15 percent addicted to stimulants and sedatives. For more on that survey, see www.ncbi.nlm.nih.gov/pubmed/19482236.

The medical community first began to recognize the number of impaired professionals in the 1970s, and since then treatment professionals have developed special programs, known as Physician Health Programs (PHPs), to help them recover while accommodating their professional needs. The American Medical Association (AMA) defines physician impairment as “any physical, mental or behavioral disorder that interferes with ability to engage safely in professional activities.” Some PHPs are sponsored by state medical societies and others are available at the hospital level, all of them relying on cooperation from licensing boards and hospital medical disciplinary entities to allow physicians to ask for the help they need without suffering immediate loss of their licenses or privileges. But far from letting impaired physicians off the hook, these programs employ a tough-love approach requiring them to acknowledge their dependency and how it can affect their patients.

The AMA says physicians have an ethical duty to report impaired colleagues, but surveys indicate that many physicians doubt anything will come of such reports and some are reluctant to make a report for fear of retaliation. Impaired professionals also want to avoid such a report being entered into the National Practitioner Data Bank (NPDB), a database of information about disciplinary actions and other professional factors for physicians. However, the NPDB guidelines state that the entrance of an impaired practitioner into a rehabilitation program is not reportable to the NPDB if no professional review action was taken and the practitioner did not relinquish clinical privileges. That changes if a physician is required to enter a program involuntarily. If ordered into a program for more than 30 days because of competence or professional conduct, the physician must be reported to the NPDB.

Some states also require a report to the state licensing agency or medical board if a physician enters a rehabilitation program, depending on certain circumstances. For more on state policies regarding reporting, see www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/grpol_policy-on-physician-impairment.pdf.

When family, friends or colleagues suspect that a physician or other professional is chemically dependent, an intervention is usually the right response. In an intervention, the impaired professional is confronted by those who care about him or her, along with authority figures to whom that person answers. When carried out in the workplace, it is best to have a specific policy in place on how and when interventions are conducted, which can help prevent the event from being derailed by emotions and manipulations. Hospitals often will conduct interventions under the auspices of an employee assistance program (EAP), the human resources department or a hospital physician wellness committee.

While it can be helpful to include coworkers who are friends with the impaired professional, it is important to note that impaired professionals respond better to a workplace-initiated intervention than they do to family interventions. These professionals typically are motivated most strongly by the prospects of losing their jobs, their licenses, their privileges at the hospital and their professional reputations.

Once an impaired professional acknowledges the need for help, the next step is to obtain a comprehensive evaluation from a team of trained professionals with differing areas of expertise. The Positive Sobriety Institute offers the Multidisciplinary Comprehensive Assessment Program (M-CAP), which is appropriate for healthcare providers, pilots, attorneys and business executives. The program acts as a diagnostic tool to ensure that an individual can practice with reasonable skill and safety. An expert team of board-certified physicians, psychologists and addiction medicine clinicians with decades of successful outcomes administers the M-CAP over the course of one, two or three days, based on the individual needs of the patient and the referring entity.

M-CAP includes psychological, psychiatric and neuropsychological evaluations by a board-certified addiction psychiatrist and board-certified general psychiatrist, personality and neurocognitive testing by a board-certified neuropsychologist, drug use, abuse and dependence screening, toxicology testing of urine and other body materials, special assessments for process addictions and recommendations to referral sources on fitness for duty and return to work. The end result of M-CAP is a detailed report that could be used in a deposition or court of law, if necessary.

An effective treatment program for impaired professionals requires staff who are properly trained for this type of patient, a history of treating impaired professionals and a peer group. The impaired professional must be in a treatment environment allowing interaction with similar professionals who can relate to each other’s challenges. They don’t necessarily have to all be in the same profession, but doctors and lawyers will relate better to one another than a physician and a young, unemployed addict.

There is considerable debate among recovery professionals about how long an impaired professional should be treated on an inpatient basis, with some programs requiring a minimum 90 days, non-negotiable. The Positive Sobriety Institute has had success with shorter programs for impaired professionals, with an average stay of about 45 days – half the time required at many facilities. The institute has published data supporting the efficacy of the programs for impaired professionals, and the more flexible, individualized length of stay is important for professionals whose jobs are at risk. Physicians are now employed by hospitals and other entities more than in the past, so it is critical to minimize the time away from work while maintaining the essential elements of treatment.

An emerging trend is the young physician or attorney who is dependent on not just alcohol or other commonly used drugs, but also on heroin. This is a new phenomenon only recognized recently, and the trend may be fueled by the fact that heroin is more easily available than in recent years. Young professionals first become dependent on prescription opiates but then find that heroin is easier to obtain.

The treatment for these young professionals dependent on heroin is largely the same as with other impaired professionals.