Substance abuse and the medical profession

While stress and distress among doctors can creates risks for patients, it can also increase psychiatric morbidity, relationship difficulties and substance abuse. Estimates vary about how many doctors have or currently practice while compromised by alcohol and or other drugs. A question also exists about whether rates of substance abuse are higher among doctors than other professionals. A snap shot of two studies shows the following:

A recent literature review indicates that alcohol abuse is no more common among medical students than medical practitioners, but the use of prescription drugs, usually by self-prescription, is more common among doctors than the general population, presumably due to relative ease of access^[3].
A 1994 study in New South Wales found just 0.4% of the medical profession had ceased to prescribe schedule eight drugs as the result of confirmed self-administration of opioids, most commonly pethidine^[4].

For many years doctors have had an ethical responsibility to report a colleague whose practice they believed to be incompetent. Some observers have noted that unfortunately the medical profession as a whole tends to view ill health in colleagues with indifference until a crisis occurs.^[5].

Substance abuse is a difficult issue for the medical profession. A number of factors make identification of colleagues at risk challenging. These can include:

Strenuous efforts by the affected doctors to hide the problem.
Reluctance of doctors to recognise the signs and symptoms of substance abuse.
The fact that some substance-abusing doctors function reasonably well until the situation is far advanced^[5]

Mandatory obligation to report

Doctors and other health professionals have a legal obligation to make a mandatory notification once they have formed a reasonable belief that a colleague has behaved in a way that constitutes notifiable conduct in relation to the practice of their profession and this includes practicing while impaired through substance abuse.

Getting help and support

Most States and Territories have Doctor’s Health Advisory Services to enable doctors to obtain telephone or face-to-face advice and some support on an anonymous basis if necessary (See Key support services)

A shared responsibility

The profession as a whole has a responsibility to care for, guide and educate colleagues towards sustaining a healthy work-life balance. It is critical that hospitals, medical colleges, medical boards and the governments continue to promote good health for doctors and provide access to early expert assistance when it is needed.

Always contact the Avant Medico-legal advisory Service for advice about making decisions that could impact you and your colleague.

Tips

Dealing with substance abuse

1. If you think you have a substance use problem

Many individuals (including doctors) use alcohol to unwind at the end of the day. When a day has been particularly stressful the amount consumed is likely to be higher than usual. Recurrent episodes of extremely stressful events can lead to repeated episodes of high risk drinking and associated consequences.

Doctors, in addition, have easy access to a variety of psychoactive medications that can be used to help coping.

Substances may also be used to manage symptoms of anxiety and depression.

Warning signs may include:

Dissatisfaction with work
Increasing workload – unable to complete tasks
Difficulty sleeping – and/or the use of sedatives in order to sleep
Mood changes
Problems with relationships - socially, at home or at work

Responding to concerns

Seek help – your first “port of call” should be your own GP. Your GP can refer you to local support services if necessary
Seek peer support from respected colleagues
Doctors’ health programs and services are confidential sources of assistance where you can get help

2. If you are concerned about a colleague’s alcohol or drug use

Warning signs may include:

Behaviour change - evasive, secretive, tends to isolate
Poor work performance
Episodic lateness for work
Depressed mood
Intoxication (a late sign)

Responding to concerns

The “cup of coffee chat”
Away from the work place
One on one or with another trusted colleague
Express concern and provide a listening ear
Referral to a source of assistance – eg. Doctors’ health program or doctors’ health advisory service

Under the influence at work

The tale

A pathologist received a letter from the Medical Board advising that, based on concerns about his alcohol intake, the Board required him to attend a drug and alcohol specialist. The Medical Board attached a letter of notiﬁcation, which had come from the practice manager at the pathology practice where the member worked.

Issues raised

The practice manager said that the pathologist would often turn up at work looking like he was just recovering from a hangover and his breath smelt of alcohol. He was late in providing reports and mislaid important slides. He displayed a pattern of being sluggish and irritable in the morning, but after several hours’ absence during lunchtime he would return quite cheerful and extroverted.

A wake-up call

The pathologist was shocked, as he had no indication that there were any concerns about his behaviour. Nobody had approached him either informally or formally. He felt angry and let down that the ﬁrst notiﬁcation was from the Medical Board. He refused to attend work that day. Eventually he attended the drug and alcohol specialist who, based on the history provided, determined that his alcohol intake was excessive.

Personal complexities

The pathologist had come from a family of heavy drinkers and it would be not out of the ordinary for him to drink twenty-ﬁve standard drinks over the course of a Saturday night. The specialist explored with the pathologist what stressors he had in his life and the pathologist revealed that he was going through a painful divorce where his wife could not accept that the marriage was over. The specialist indicated to the member that this was a wake-up call. Alcohol was impacting on his work and there were concerns over his alcohol-affected behaviour.

A new direction

The member was referred to a Board health program so that protective measures could be put in place, not only to support the member but also to protect the public. The protective measures included zero alcohol, urine testing and counselling. Over a period of time, with ongoing supportive counselling, the pathologist began to realise that he did have an alcohol problem that needed to be managed. He became more open at work about his difﬁculties and instead of his colleagues turning away from him, they became much more supportive in dealing with his alcohol problem.

Jenkins K. Keeping the doctor healthy: ongoing challenges. MJA 2009 191:435
Willcock S, Daly M, Tennant C et al. Burnout and psychiatric morbidity in new medical graduates. MJA 2004:181:357–360
Elliot L, Tan J, Norris S. The Mental Health of Doctors - A systematic literature review. August 2010. beyondblue. http://www.beyondblue.org.au/index. aspx?link_id=4.1262
Cadman M, Bell J. Doctors detected self-administering opioids in New South Wales, 1985-1994: characteristics and outcomes. MJA 1998;169:419–421
Cicala, R. Substance abuse among physicians: What you need to know. Hospital Physician 2003; 39:39–46
Ibid.
Health Practitioner Regulation National Law Act 2009, ss. 140