Health Professionals and Opioid Addiction

By: Anne Geske

Just like airline pilots, the ability of health professionals to place public safety first, doing their job well and unimpaired, is essential. Health professionals are keenly aware of their ethical and moral responsibilities. But through the lens of addicted thinking, an individual may rationalize that their use of opioids won’t lead to impaired judgment. That their diversion—appropriating patients’ prescription medication—won’t affect patient safety or lead to malpractice claims.

Unique factors and risks

Generally speaking, health professionals experience chemical dependency at the same rate as the rest of the population. But when the substance is opioids, unique factors and risks come into play for people in the health professions.

First, there can be extreme stress on the job. Physicians have a much higher risk of depression and burnout (emotional exhaustion, depersonalization, and a low sense of personal accomplishment) compared to the general population.1

 Marc Myer, MD, works at Hazelden Betty Ford as medical director for Adult Services Minnesota, as well as the Health Care Professionals Program. According to Dr. Myer, for the health professional population subset, addiction to opioids frequently does not begin after long-term use of opioids prescribed for pain, but as a coping mechanism—a way to self-medicate stress.

Second, there’s access. When stress leads health professionals to reach for a substance as a coping mechanism, access to opioids is there, especially for those who administer anesthesia and medications.  

Third, physicians’ and nurses’ very knowledge about disease and medication can lead them to intellectualize their substance use behavior, thinking I know how they work, so I’ll be able to control their use.2

And then there’s shame and isolation. Dr. Myer believes that addiction is a disease driven by shame. “I find that healthcare professionals are riddled with shame at a much greater degree even than the general population because,” he says. “Due to their substance use, they oftentimes violate their own ethical and moral standards. And then they end up becoming isolated because of fear of retribution or loss of licensure, loss of income, loss of career. So it puts them in a very difficult position to reach out and seek help.”

Stressful work environments, burnout, access, intellectualization, and isolation may create a unique set of risks for health professionals, but the results of opioid use disorder (OUD) are every bit as deadly.

“The scary thing for me,” says Dr. Myer, “is that those folks out there who are deep in the throes of addiction feel alone, like they can’t reach out. And many will die of their addiction before they get to treatment. So I hope that as a society we focus our approach more on a therapeutic intervention to a chronic disease rather than a punitive one. That doesn’t mean that physicians and other healthcare professionals shouldn’t take responsibility for their actions, but it should be considered within the context of their state of mind while addicted.”

Compassion, not punishment

 Employers of health care professionals know they have a responsibility to the public. How much do they also have a stake in the success, well-being and careers of their employees? Laurie Drill-Mellum, MD, chief medical officer of Constellation, says, “We have to make sure that people are treated fairly, with dignity and respect. We see the effects of addiction and how it can land on patient care and safety, which we all care about—including the people who struggle with this issue.”

A compassionate, not punitive, model of chemical dependency treatment is known to be most effective. To that end, most states have a confidential program for medical professionals that operates outside of the state licensing board. Participants can seek help without risk of losing their license if they follow the program. Once enrolled, their adherence is monitored. If they’re noncompliant, they could lose their license.

One such successful program is South Dakota’s Health Professionals Assistance Program (SDHPAP), which monitors health professionals identified as having a substance abuse disorder. Craig Uthe, MD, a family medicine physician and medical adviser to SDHPAP, states that the two cornerstones of the program are accountability and consequences.

“We have a personal plan of action that’s individualized for every participant, using guidelines and policies that are generally followed by the Federation of State Physician Health Programs,” says Uthe. “Addiction is a disease. It was recognized that physicians wouldn’t acknowledge [admit or seek treatment for] their disease if the result was going to be punishment. So many states, including South Dakota, have created trusted, confidential and protected programs away from board disclosure if the individual is willing to get treatment for their disease and not be a risk to the public's health.”

Dr. Myer believes such programs make a positive difference. He says, “It’s very clear that when health professionals are able to reach out to a non-punitive program, they will self-report and get help earlier at much greater rates than if they have to go straight through a licensing board. We know from this model that the earlier they get help—and the more support they get—the better the outcomes.”

The good news is that after completing treatment and obtaining ongoing support, the five-year success rate for physicians is greater than 80 percent—much higher than the general population.3

Awareness and communication

Administrators of medical facilities and owners of private practices will want to evaluate awareness and planning around their employees and OUD. What can a medical facility do to update efforts around awareness and communication? First, understand that there’s no need to reinvent the wheel. Ruth Martinez, executive director at the Minnesota Board of Medical Practice, says she has seen groups “examining this issue in silos, redundantly going through processes without bringing their information together and aggregating information in a way that more broadly communicates a message.” Each state’s medical board has its own list of resources.

Policyholders of MMIC, UMIA, and Arkansas Mutual have access to online resources and phone consultations. When necessary, phone consultants refer Walt Flynn, a human resources consultant at W.J. Flynn and Associates, to policyholders. Flynn frequently talks to small- and medium-sized practices about employees suspected of using substances. “Broadly speaking,” he says, “the best practice is to actually confront the behavior. You’d be amazed at how many times things go unevaluated because people are afraid to confront or call out the behavior.”

Nurses and other staff see physicians as holding a position of power within the organization, and they might be afraid to report. “I’m always impressed with how courageous people are in being willing to deal with this,” says Flynn. “If you’re an administrator for a physician group, and one of the physicians is a partner or owner of the practice, it’s a lot to step up and confront. Basically, you’re going to the owner of your group and calling them out. I’ve seen many situations where that’s exactly what’s occurred, and thank goodness.” Flynn also makes referrals as necessary for impairment assessment, drug testing, and fitness for duty exams. Physicians require confidentiality, so often referrals will be made to out-of-town resources.

Dr. Drill-Mellum acknowledges that OUD in health professionals poses significant risks, and reiterates that competent, legal, and compassionate intervention is what works. “We are a company that was formed by and for physicians,” she says. “We recognize this is a problem, and we offer services to help mitigate these issues, whether it’s potential patient litigation or stress-related dependency. We try our best to be of service to our colleagues and peers.”

References

1.      Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-13.

2.      Myer M. Trends, treatment and transformation: changing the course of addiction in the health care professional Webinar. Published June 3, 2015. Available at https://tinyurl.com/ld96fc3.

3.      DuPont RL, McLellan AT, Carr G, Gendel M, & Skipper GE. How are addicted physicians treated? A national survey of physician health programs. 2009. J Subst Abuse, 37(1).

Resources

Federation of State Physician Health Programs lists programs by state for physicians and other health professionals: http://www.fsphp.org/state-programs

Physicians Serving Physicians, co-sponsored by MMIC, is a confidential Minnesota organization that helps physicians with addiction issues http://psp-mn.com/:

Addiction Self-Assessment

*    I continue my addictive behavior after experiencing serious consequences.

*     I regret my behavior.

*     I can’t stop my addictive behavior whenever I want.

*     Others express concern about me.

*     I’m worried about my behaviors.

*     I don’t limit my behaviors to certain times of the day or to certain places.

*     I get into arguments with family members or friends about my behavior.

*     My behavior causes me shame and embarrassment.

*     I use my behavior to make me feel better.

*     My work is in jeopardy because of my addictive behaviors.

*     I have had financial difficulties because of my behaviors.

*     I engage in addictive behaviors to boost my self-confidence or self-esteem.

*     I would be concerned if my clients knew about my behaviors.

*     I have put my family in embarrassing or potentially dangerous situations.

*     I have lied about or minimized my addictive behaviors.

*     I have changed my circle of friends/acquaintances in order to more easily engage in my behavior.

*     I have not been aware of the needs and well-being of my family.

*     I celebrate good news by engaging in my addictive behaviors.

*     I have considered suicide because of my behavior.

*     I am preoccupied with my past, present or future behaviors.

See Resources in this article for where to find help in your state.

Adapted with permission. Physicians Serving Physicians, Edina, MN. http://psp-mn.com/