Understanding and Addressing Physician Substance Use and Misuse

Grinspoon,Peter;

Doctors and health care professionls are having a difficult time right now. Even before the COVID-19 pandemic, our rates of burnout were steadily rising to the point that half of physicians have at least 1 symptom of burnout. We have one of the highest suicide rates of any profession, with female physicians being particularly vulnerable. A quarter to one-third of our students and trainees are reported to be suffering from clinical depression. The pandemic has exacerbated all the stressors that are fueling these tragic statistics.

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A related issue that is not discussed nearly as thoroughly or as openly as it should be is that of physicians and addiction. Physicians become addicted to drugs or alcohol at least as commonly as the general population does. It is thought that 10% to 14% of physicians suffer from addiction to drugs or alcohol during their careers.¹

I suspect that the rates are higher, as our current system of addressing this problem is punitive and dehumanizing. It incentivizes physicians hiding their addiction and avoiding unwanted attention that comes from seeking help. Most individuals will not ask for help if they receive punishment and judgment as a result. After 2 years of a pandemic during which physicians and nurses absorbed the brunt of the stress, with rates of all types of addiction in other populations skyrocketing across the country, it is difficult to imagine that this problem of physicians and addiction has not become even more prevalent.

Personally, I am 14 years into recovery from a severe and, toward the end, all-consuming addiction to prescription opioids. During my addiction, and my halting steps toward recovery, I learned about the challenges and obstacles that face physicians who struggle with substance use disorders. As is my modus operandi, I learned about these things the hard way: I had the state police and the US Drug Enforcement Administration (DEA) in my office; received 3 felony drug charges leading to several years probation; stayed in an out-of-state rehabilitation facility for 3 months; lost my medical license for 3 years; and had to donate about 20 gallons worth of urine for drug testing over a period of 5 years.

Once it was deemed I was in stable recovery, I was invited to become an associate director of our state’s physician health program (PHP). In this role, I sat at the exact same table I did 10 years previously, now on the other side of where I had been sitting during my early addiction when I began getting in trouble and realized I needed help. Now I was being offered the privilege of helping other physicians. Having participated in this issue from both sides, I have insight into how physicians become addicted, how they are treated, what they go through, and how they try to heal.

I also understand how stressful it is when someone realizes that a colleague is impaired and the agonizing decisions that can come with this realization. Finally, I feel as if I have some insight into the problems that predispose us toward these dangerous addictions.

Are all types of physicians afflicted to the same extent? According to a 2014 article from the Journal of Dual Diagnosis²:

Other research suggests that anesthesiology residents have a high risk of developing substance use disorders—often to injectable fentanyl—as well as a higher risk of subsequent relapse during their professional career.³ When I was an associate director at the PHP, debates often took place on whether it was safe to let anesthesiologists who were addicted to injectable opioids return to work, as both relapse and death were not uncommon outcomes.

Findings from some older studies may be enlightening. For example, according to research from 1992 and 2011 based on data from an anonymous survey of 5426 doctors, some medical specialties were associated with higher use of certain substances than others. Anesthesiologists used more opiates, emergency medicine physicians used more illicit drugs, and psychiatrists used more benzodiazepines; surgeons and pediatricians had comparatively low rates of drug use, with the exception of tobacco.^4,5 And, according to data from a 1991 study, psychiatrists seem to be at higher risk of self-prescribing sleeping pills and/or tranquilizers than their peers.⁶

However, it is important to note that addiction can affect any physician regardless of specialty, gender, race, or life circumstances.

In addition to the usual conditions that predispose individuals to addiction—family history, trauma history, undertreated anxiety and depression, poor distress tolerance—physicians have extra stressors that greatly enhance our risk. No one would argue that we have little anxiety in our professional lives. When you think about it, we have the same stressors as everyone (eg, depression, divorces, caring for older family members, illnesses, financial problems, troubles with our children), plus we have the added stress of trying to be good doctors in a profoundly broken system. Many of us face moral injury daily as we try to do what is right for our patients in the face of hospital and insurance policies that undermine us. We click on the electronic medical records (EMRs) late into the evening, trying to catch up, after our children fall asleep. This is not healthy or sustainable.

We also have knowledge about and access to easily abusable prescription opioids and sedatives. The mixture of additive stress and open access to medications is a perfect storm for addiction (which is why I called my memoir Free Refills). It starts slowly, and before you know it, you are withdrawing, afraid to get help, and feeling trapped. To ask for help is to risk bringing the medical board crashing down on your head. Who would do this voluntarily? The culture of medicine dictates we are supposed to be strong and independent and are viewed as (and feel) weak or substandard if we ask for help further worsens this situation.

Unfortunately, sometimes you cannot and may not recognize it. Do not blame yourself. Doctors are great at hiding their addictions, especially from themselves. Usually there is no “smoking gun,” ie, someone smelling of alcohol, slurring words, nodding off, or getting caught injecting in a bathroom, or swigging on a flask between patients. However, there are signs that something is wrong, be it addiction, depression, psychosis, or some other problem.

One might notice a relatively rapid decrease in a colleague’s competence at work, newfound tardiness, irritability, and/or deteriorating personal hygiene. A once-affable colleague might be isolating themselves, pushing others away, being quarrelsome, and keeping odd hours in the hospital. When I was addicted, I would return to my office to snort oxycodone by myself. In retrospect, it was lonely and miserable, but I could not stop. Anyone who saw me in the office would have assumed I was just working late—but why would a primary care physician with small children be in his office at 11 at night?

According to the letter of the law, we are mandated reporters—we must report a colleague who is impaired to the medical board of our state, or to the PHP, which is the legal equivalent in terms of discharging our mandated reporter duties. Many PHPs have “diversionary” programs in which, if there are no criminal charges or allegations of patient harm, physicians can get treatment without the board necessarily finding out about it. (In reality, however, the board often does find out because, if anything goes wrong—if there is even a paperwork problem—physicians can be reported to the board. This obviously defeats the purpose of the “diversionary” program.)

There are other pathways. I truly believe it is in the spirit of the law to confront a colleague, with empathy, and to tell them, “I suspect you are impaired, and if you do not get help, I will have to report you. Let’s work on getting you help.” This can be done with your supervisor, to give it more weight, if your colleague denies there is a problem. If your colleague truly will not get help, you may be forced to take the nuclear option, which is then to actually report them. However, this is often not my first step unless they pose an imminent danger to patients or to themselves.

Addictions tend to get worse, especially in high-stress professions. As they say in recovery lore, addictions usually end in “jails, institutions, or death.” I can tell you from vast experience that this is largely true for physicians who do not acknowledge that they have a problem and accept help.

Addicted physicians can also harm patients—something that is exceedingly difficult to come to terms with for the rest of your life (and which can result in a devastating lawsuit). They can get into criminal difficulty, usually via illegal diversion of medications. We have all heard horror stories about this happening, such as when doctors or nurses steal fentanyl.

What I tell medical students and doctors is this: You will get help for your addiction. It is merely a question of whether you get help on your own terms (ie, put yourself in a program that you choose, consult with an addiction psychiatrist, or report yourself to a PHP; you get a lot of “points” for self-reporting, although you are in their clutches once you do so)—or on someone else’s terms, as I did. These terms tend to be much more destructive, harsh, and painful, such as my experience of having the state police and the DEA visit my office and having the medical board shoot first and ask questions later.

If you are struggling, the best thing you can do is find a trusted colleague or manager, confide in them, ask for help, and arrange to get the help you need.

PHPs generally monitor and oversee treatment, and the treatment preferences are evolving. It used to be that everyone was sent to rehab for 90 days, in addition to a longitudinal program of support group meetings, drug testing, therapy, and work with an addiction psychiatrist. Doctors are “monitored” for 3 to 5 years and are eventually let back to work if the medical board feels they are in stable recovery and pose no threat to patient care.

These days, there is less emphasis on rehab and more focus on intensive outpatient programs, in which one can receive plenty of group therapy, counseling, and care from specialists. Good riddance to rehab is what I say: I spend about 50 pages in Free Refills discussing how unscientific, expensive, religiously oriented, and generally useless I found rehab. We mostly repeated slogans from the “Big Book” of Alcoholics Anonymous, written in 1937, all day long. I do not know of any independently verified evidence that rehab, per se, actually helps individuals with their addictions. We can do much better for our addicted physicians.

Physicians who work with their PHPs and successfully compete their contracts generally have a good outcome, with 70% to 80% of doctors achieving stable recovery and being able to go back to work.⁵ Part of this is due to the leverage that is used against doctors like a blunt instrument. I was essentially told, “If you keep flunking drug tests, you will not go back to practicing medicine.”

It worked. The success also has to do with the resources doctors have to throw at their problems and the long-term, coherent follow-up. According to 1 study, “Over the course of 5 years of care, 78% never had a single positive drug or alcohol test result and 72% were able to return to practice.”⁷

Not all doctors make it. Two of my colleagues overdosed and died lonely deaths, locked in bathrooms—both were anesthesiologists, as it happens. I know several other physicians who are homeless and many who have never made it back to clinical work.

For the sake of fairness and completeness, it is important to mention that PHPs have recently been criticized for having too much power over physicians and for having little to no independent oversight. Physicians cannot appeal the PHP’s decisions. If and when the PHPs make mistakes, such as sending a thriving medical cannabis patient to rehab for “cannabis use disorder,” there is no recourse. You simply do what they say even if you think you are not addicted to cannabis or alcohol or are not suffering from whatever it is they have labeled you with—or you do not get your medical license back. This clearly needs to improve with openness and transparency.

In a 2019 article called “Practicing What We Preach—Ending Physician Health Program Bans on Opioid-Agonist Therapy,”⁸ several colleagues of mine called out the cruelty and hypocrisy of PHPs denying doctors access to buprenorphine (Suboxone). When used for opioid use disorder, buprenorphine leads to a 50% reduction in overdosages and deaths. The rationale for denying doctors buprenorphine was that they would be “impaired” if they took it—but there is no good evidence for this claim. One might reasonably point out that, as doctors are allowed to use alcohol, Ambien or benzodiazepines, sedating antihistamines, gabapentinoids, and muscle relaxants, why not buprenorphine?

This merely represented an internalization of society’s stigma against addiction, and it has been jeopardizing the lives of physicians. “Sunlight is the best disinfectant,” and, as such, this policy has since purportedly been modified (it is difficult to monitor because of confidentiality).

Physicians who become addicted represent a profession-wide call for help. What can we do to lessen or prevent this problem? How can we best care for our caregivers?

To start, doctors have to be recognized as individuals who struggle with the same challenges and problems as everyone else does. We need all the institutions that we deal with to take this into account. For example, the medical boards snoop for mental illness and often include in their renewal forms questions such as, “Have you taken a leave of absence in the last several years?” If a doctor can practice safely, this is none of the board’s business.

Next, the entire ecosystem of physician health has to become more supportive and nurturing and less punitive. Doctors need to be empowered to ask for help and have reasonable assurances that, by doing so, they (1) will get good help and (2) will not damage their careers beyond repair. A physician who is getting help and is being carefully monitored by their PHP is perfectly safe for patient care. What is not safe is when people are afraid to get help for common, yet deadly, problems.

Finally, we need to address the mental health challenges of our entire profession. If medical students and residents need time for therapy appointments, of course we need to grant this. If individuals need time off to deal with crises, this must be granted. We need to encourage individuals to ask for help—no more “Physician, heal thyself.”

We need to acknowledge the pressure that we are all under and find ways to alleviate it, such as unchaining us from the EMRs. We need to push back against the crumbling social contract in which we give more and more of ourselves, and society gives us less and less in return every year. Increasingly, doctors are commodified and flat-out exploited; many are leaving the profession and it is taking a devastating toll on those of us who decide to stay.

We need to support our brothers and sisters in medicine, especially when they are faltering. There is no reason for us to buy into the stigma or judgment—we know better. We need to lift each other up, treat each other with compassion, and work together so that, once again, our profession will be a healthy, safe, and sane place in which doctors can flourish.

Dr Grinspoon is a primary care physician, educator, and cannabis specialist at Massachusetts General Hospital in Boston; an instructor at Harvard Medical School in Boston, Massachusetts; and a certified health and wellness coach. He is the author of the forthcoming book, Seeing Through the Smoke: Cannabis: Finding Truth Among Tangled Beliefs, as well as the groundbreaking memoir Free Refills: A Doctor Confronts His Addiction. He is a board member of the advocacy group Doctors for Cannabis Regulation. He is also a TedX speaker and commonly lectures on the topics of cannabis, psychedelics, addiction, opioids, and physician health.