Helping and Learning from Addicted Physicians

I scared some people awhile back when I pointed to addiction’s prevalence among physicians as example of how there is no contradiction between being professionally successful and having a substance use disorder. I suspect this recent study showing extensive drinking problems among surgeons generated similar anxiety. The study is not without flaws (particularly a low response rate), but its central finding resonates with what other research using a range of methods has found: The rate of substance use disorders among physicians (nurses too) is as high or even slightly higher than among the general population.

What is addiction among physicians like, what happens to such doctors, and what does it teach us about addiction and drug policy?

Some Examples of Addiction among Physicians (altered a bit for privacy)

1. Benny was a friendly, well-liked, surgical resident whose heavy pot use was the subject of humour rather than concern among the medical staff, who considered it a harmless hobby in which he engaged off duty. Unfortunately Benny was called into surgery at a time he didn’t expect and went into the procedure still under the influence of cannabis. Everything seemed to go well until afterwards, when Benny couldn’t find his hospital locker key. Still a bit foggy-headed, he assumed he’d dropped it somewhere in the halls and it would eventually turn up. He went home in his scrubs to get some sleep. The next day he got an urgent telephone call from the attending surgeon. The patient had developed a high fever and begun vomiting uncontrollably. The medical team felt a hard protrusion at the surgical site and feared that a clamp had been left inside the patient. Emergency surgery revealed that the object was in fact Benny’s locker key.

2. Richard was an experienced anesthesiologist who was dependent both on alcohol and opiate pain medication. At the outset of a surgical procedure, while badly hung over, he administered the wrong dose of anesthesia, causing the patient’s heartbeat and breathing to stop. When the nursing staff tried to sound the alarm Richard became belligerent, saying nothing was wrong and ordering everyone not to sound a code blue. After precious time had gone by, Richard was eventually overruled and a frantic effort was made to resuscitate the patient. The patient did not die but was in a comatose state, which to the best of my knowledge she is still in today.

3. Chi-Ah was a high achieving medical student with an abiding interest in geriatrics. She worked incredibly long hours throughout medical school and residency, graduated with honours and became a skilled and beloved doctor. In the process, she also became dependent on the stimulants and sleeping pills she used to manage her existence. While examining one of her elderly patients, Chi-Ah suddenly became very confused and wandered out into the waiting room. Her grey-haired patients looked up at her reverently — the wonderful young doctor who had dedicated her career to helping them — and then were shocked as she said loudly “God I’m tired!”. Chi-Ah then blacked out, pitched forward across the waiting room table, and landed on a woman in a wheelchair, badly bruising the patient’s face and breaking her own ankle.

What Happens to Addicted Physicians?

For decades, what generally happened to addicted doctors is easy to summarize: Nothing. There are many reasons for this, including self-protective tendencies within the guild and the widely shared belief among doctors that they are above the frailties of lesser mortals. Medicine was dragged into facing up to addiction within the ranks by external pressure in response to numerous scandals. In the UK, the most famous was the case of the serial killer Dr. Harold Shipman. Many felt that if his drug problems had been investigated more thoroughly when they first came to light, he would never have remained in a position to murder several hundred patients.

Addiction is taken much more seriously today, and the modal intervention is the Physicians’ Health Programme. These programmes have the dual function of helping addicted physicians and protecting the public from the damage they may cause. Although some physicians come to PHPs voluntarily, many are referred under threat of losing their licence.

Importantly, PHPs do not fall into the well-meaning trap of assuming that if an addicted physician enters treatment, everything will no doubt work out all right in the end. Instead, PHPs couple treatment with long-term and rigorous drug and alcohol testing. Physicians on the monitoring programme sign a contract agreeing to swift and certain consequences for substance use. The PHP have a huge motivational lever in place: The power to temporarily or permanently remove the physician’s licence to practice medicine.

The results of PHPs are spectacular: Over 80% biologically-confirmed and total abstinence at 5 year follow-up. The results are so remarkable that Dr. Tom McLellan’s advice is that if you go into the emergency room on the morning after New Year’s Eve, the best way to ensure that your doctor will not be hung over is to insist on an addicted doctor.

What Can We Learn From Addicted Physicians?

1. Even people with severe substance use disorders respond to management programs that include swift and certain consequences for use and non-use. Reality-Based Community readers are well-familiar with programmes such as HOPE Probation and 24/7 Sobriety. The principals of those programmes have long been shown effective in physicians. The problem is that crime policymakers, who like most people buy into the idea that doctors are somehow fundamentally different than the rest of humanity, react to data on physicians’ health programmes by saying “Surely, that stuff works on doctors, but they are nothing like people on parole and probation!”. This has since been shown to be profoundly wrong-headed: Human beings (doctors or otherwise) are simply more likely to change when the consequences of their behaviour come quickly and consistently than when they are slow and probabilistic.

2. The idea that if we just educated people about all the various drugs they would make safe, wise choices about which to use is complete rubbish. Physicians have years of training in biochemistry and pharmacology, far more than could ever been attained in the general population, and yet they are as much or more prone to addiction.

3. Relatedly, greater access to substances in a population produces more cases of addiction. Why do doctors, who have so much more to lose than people who are unemployed or in poverty, have rates of addiction as high or higher than the rest of the population? Because they have much higher access to drugs (both because of their prescribing privileges and their high incomes). It is amazing that some people argue that “addicts will always get their fix” no matter what, or, that neighborhoods with high addiction rates simply have less collective willpower to resist than do neighborhoods with low addiction rates. In truth, the more substances are available, the more people will use them and the higher the rate of addiction will be. That’s why controlling the supply of addictive drugs is good public health policy.

Author: Keith Humphreys

Keith Humphreys is the Esther Ting Memorial Professor of Psychiatry at Stanford University and an Honorary Professor of Psychiatry at Kings College Lonon. His research, teaching and writing have focused on addictive disorders, self-help organizations (e.g., breast cancer support groups, Alcoholics Anonymous), evaluation research methods, and public policy related to health care, mental illness, veterans, drugs, crime and correctional systems. Professor Humphreys' over 300 scholarly articles, monographs and books have been cited over ten thousand times by scientific colleagues. He is a regular contributor to Washington Post and has also written for the New York Times, Wall Street Journal, Washington Monthly, San Francisco Chronicle, The Guardian (UK), The Telegraph (UK), Times Higher Education (UK), Crossbow (UK) and other media outlets.

21 thoughts on “Helping and Learning from Addicted Physicians”

  1. I’m not really following the line from your first anecdote to “addiction”.

    If you (a) have a job where emergencies come up and (b) you use intoxicants at all, then there is always some chance that an emergency will come up while you are under the influence. And since you’re under the influence you’re not going to be in a position to make good decisions about whether you are competent to work in those settings. Obviously this is bad, but it’s not clear to me what this has to do with addiction, unless your claim is that people who ever use intoxicants to the point where their judgement is impaired are addicted.

    1. Elliptical writing on my part; I am trying to not be too specific so as to keep the people obscured. It wasn’t an emergency surgery, it was at a time the doctor concerned didn’t expect because he had some memory deficits from his heavy pot use..he got his schedule mixed up and then didn’t have the judgement to say that he couldn’t come in and then he didn’t do the pocket emptying procedure when he scrubbed and then it didn’t occur to him that his missing key might not be in the hall way. This wasn’t a malicious person, he cared about his patients. He was addicted to a drug and as a result did things that violated his own values and his professional responsibilities as well.

  2. Can I complain about strawmen arguments?
    “It is amazing that some people argue that ‘addicts will always get their fix’ no matter what”

    Most pro-legalization folks will acknowledge that more access equals more use. But argue that the harm from criminalizing outweighs the harm from increased use.

    1. Mobius: This isn’t a straw man, it has been invoked in op-eds against alcohol minimum pricing in the UK in recent months, and comes up in virtually every discussion of alcohol and tobacco taxation. Look in Hansard’s and you will see the same argument made on the floor of Parliament. I heard the same argument in many state legislatures this year during debates on methamphetamine. As for legalization of currently illegal drugs, if you trawl through comments here, you will find many many people questioning what you and I know to be true: More access equals more use.

      So, if a straw man is a bad argument, yes, it’s a bad argument. But if you mean by straw man an argument that it isn’t used, that’s just not true, it’s one of the more common arguments around.

      1. Is there a name for ‘addressing the most extreme version of opponents arguments’? Yes, some use that argument. I don’t believe they are a big faction, just more vocal. (like Ron Paul supporters)

        If easy of access is a major factor, I would expect Doctors would have a higher usage rate for drugs they have ready access to, as compared to non-medical drugs. Does the data show that? Higher use of opiates in pill form, less comparatively of pot.

        1. Mobius: You didn’t respond to the alcohol example — “addicts will always get their fix” is a completely mainstream argument not a fringe one, google on minimum price and UK and you will find it in op-eds all across the political spectrum. State and National elected officials make it as well, it’s not just a few oddballs.

          Doctors have more access to all drugs than the general population, they can prescribe a large range of them AND they have more income as well, allowing them for example, to drink more, buy more pot etc. Those that get addicted also get sometimes into trading relationships, i.e., they supply opiates in exchange for street drugs.

    2. I agree with Keith here. Pro-legalization folks cover the spectrum, but include many people who are incapable of understanding that almost any policy decision entails a downside, and therefore requires a balancing act. This is particularly true for kids, who constitute many of the pro-legalizers. (IMO, the drug warriors are far worse, but there is a lot of ditziness among the ranks of the legalizers.)

    3. The problem is that crime policymakers, who like most people buy into the idea that doctors are somehow fundamentally different than the rest of humanity, react to data on physicians’ health programmes by saying “Surely, that stuff works on doctors, but they are nothing like people on parole and probation!”

      This is the one that sounds like a straw-man to me. I thought that pretty much all of the policy wonks had jumped on the HOPE bandwagon.

      Now I have seen policy wonks inferring that HOPE can significantly impact the violence of the global black market. What’s left out of that discussion is that you can’t impose HOPE on a free society — it has a very limited scope of applicability and is not effective (or constitutional) beyond that scope. As a re-legalization advocate, I’m all for using it where it works effectively and is indicated by criminal behavior beyond the simple production, sale, and/or use of banned drugs, and I don’t know why anyone wouldn’t be. But wouldn’t this be a much more effective way of dealing with the negatives resulting from drug abuse, as opposed to the blanket criminalization of the 80% (Pereto’s law generalization) of drug users who aren’t otherwise criminals and all of the negative effects that go along with complete prohibition? That is another point that most crime policymakers ignore when discussing the merits of programs like HOPE and 24/7.

      Keith’s point 2 assumes that those advocating education claim 100% effectiveness, but we don’t. We claim that education, treatment, and regulation are preferable and more effective than prohibition and draconian enforcement, which also is obviously not 100% effective either. It also seems like an awkward indictment of the DARE program coming from someone in favor of prohibition — does this mean that Keith considers DARE “complete rubbish”? His statement seems to assume that drug education is 0% effective, and I don’t believe that either. It’s not a binary effect.

      Keith’s point 3 misses an important detail: accessible to whom? As a result of drug prohibition, illegal drugs are more accessible to minors than legal drugs. Study after study have confirmed this fact. Personal anecdote: I first smoked a joint (in my teens) fully two years before consuming my first beer. One was readily available to me, the other was much harder for me to obtain. You guess which was which. If one were to random-sample two groups of marijuana smokers, minors around 15 years of age and middle-aged adults, and ask them about their sources of obtaining this illegal drug, I think we’d find that marijuana is more accessible to minors much more likely to abuse it than it is to older adults much more likely to use it responsibly. We’d probably also find a significant portion of middle-aged adults citing minors under 21 as sources for their illegal drug. Is this what we’re aiming for with our drug policies?

      1. Freeman:
        This is the one that sounds like a straw-man to me. I thought that pretty much all of the policy wonks had jumped on the HOPE bandwagon.

        With respect, as someone who knows many elected officials, opinion makers and the like in a number of countries — your assumption is not correct; there is resistance to HOPE in many quarters.

        does this mean that Keith considers DARE “complete rubbish”?
        That doesn’t follow from my argument here, but since you asked, I have said that DARE does not work in the Lancet, in the media, and in many other fora.

        1. With respect, as someone who knows many elected officials, opinion makers and the like in a number of countries — your assumption is not correct; there is resistance to HOPE in many quarters.

          Thank you for the check on my faulty assumption. I knew the hardcore Libertarians don’t like it, but I had no idea it was getting so much resistance from governments. I wonder what the objections are?

          We’re in agreement on the effectiveness of DARE, but I think it’s more a problem with the structure and content of the program than drug education itself. Honest and respectful presentation of facts works better than scare tactics and banging the abstinence-only drum.

          On the larger issue of addicted doctors, I’m not surprised to learn that their addiction rate is “as high or higher” than the general case, though I wouldn’t say that makes much of a case for the assertion that greater access means greater addiction rates. As you say, “they have much higher access to drugs (both because of their prescribing privileges and their high incomes)” and yet their addiction rate appears not to be significantly above average. Drug use cuts across all socio-economic boundaries and there is always a small percentage of users who will abuse and end up addicted. When it comes to addiction, having more to lose is meaningless. Doctors, lawyers, talk-radio hosts, congressmen, mayors, are not super-human and are just as susceptible as the poorer guy who ends up being the junkie on the street corner whose image as an addict we’re more familiar with (because he’s more visible).

          Econ 101: Demand drives supply. I propose that addiction rates aren’t higher because drugs are more available in a given neighborhood, drugs are more available because addiction rates are higher there. Supply goes where the market is and the latest wisdom is that addicts are 80% of the market. My observation is that almost all addiction is the result of people self-medicating for some kind of pain and losing control. If it isn’t one drug, it will be another. That’s how it happened to Rush Limbaugh and that’s how it happens in miserable conditions and why you see it concentrated in those places (like prisons, where the strictest measures imaginable are taken to prevent access). That’s why I insist that addiction is a medical issue and legality shouldn’t enter into it. The 80% or so who don’t lose control don’t need to be policed or forced into treatment and doing so is a huge waste of peace and prosperity, to put it nicely and mildly.

      2. 1. HOPE drastically reduces drug use (80% of more) among heavy drug users who are also criminally active.

        2. Heavy drug users consume 80% or more of the volume of drugs consumed.

        3. For the hard drugs, about 75% of the heavy users are criminally active enough to get arrested for something (other than drug possession) in the course of a year.

        .8 x .8 x .75 = .48

        Ergo, applying HOPE to all heavy drug users under criminal justice supervision would be expected to reduce imports of cocaine, heroin, and meth by about half. There’s nothing inconsistent with a free society in telling people who break other laws that, as part of their punishment, they can’t use their favorite drugs.

        So the claim that, in a free society, HOPE can’t much reduce drug imports would seem to be unjustified. That hasn’t kept it from being asserted.

        On the broader point, HOPE is inconsistent with too many ideologies and interests to find easy acceptance. The policy wonks love it, but it is spreading very slowly, and against strong resistance.

        1. So the claim that, in a free society, HOPE can’t much reduce drug imports would seem to be unjustified. That hasn’t kept it from being asserted.

          You’re right, it hasn’t — and it looks like I’m about to assert it again, though to be precise I have only expressed doubts about it’s ability to significantly impact the violence of the black market drug trade.

          .8 x .8 x .75 = .48 Ergo, applying HOPE to all heavy drug users under criminal justice supervision would be expected to reduce imports of cocaine, heroin, and meth by about half.

          Drug offenders under criminal justice supervision are generally already subject to strict drug-testing, so a good portion of that 75% is off the market anyway and can’t properly be factored into expected reduction of demand. HOPE proponents claim their method is more effective because repeat offenders quickly learn that drug-test failures are not always enforced, but if 75% of heavy users of hard drugs are getting arrested every year, it can’t possibly be the same 75% all the time or our prisons wouldn’t be so full of them, so there has to be a fair amount of turnover and first-time offenders in that mix, for whom I can assure you drug-testing under threat of (re)incarceration is very effective (right up until probation/parole is completed — after that, fuggedaboutit — and I’ll bet the same is true under the HOPE program, as I recall the term of the HOPE study everyone is citing was just one year — are there longer term studies available?). 75% of heavy users getting arrested every year is not the same thing as 75% of heavy users being convicted but not sentenced to prison (where HOPE can’t possibly work) and being on parole or probation at any given time, so there go a bunch more. I won’t guess as to what’s left other than to say that I would be happily surprised if we could measure a 20% reduction in demand for drugs if we put every parolee and probationer on the HOPE program every time. Now where have I seen it asserted that marijuana legalization wouldn’t make a significant enough dent in cartel profits and black market violence to make it worthwhile? I’m just making the same assertion here with regards to HOPE, aren’t I?

      3. Keith considers DARE to be complete rubbish because it is complete rubbish. Aside from that, it’s a perfectly fine waste of money and personnel resources.

        Google “DARE” and effectiveness: you will find that the only “research” finding DARE effective is written by people with a vested interest in continuing the program. This phenomenon bit me in the heinie about ten years ago when I was helping a friend in CJ with an analysis. I was concerned when the models showed DARE was slightly worse than doing nothing. My colleague was relieved, and explained the facts of (this aspect of) life to me.

  3. Keith,

    Is PHP the modal or model intervention? Either makes sense in the context…

      1. Exactly. The fact that it sounded like it ought to be the model was what had me confused. Well, that and the fact that I’ve been reading a lot of student writing in the last ten days…

  4. This begs the question, “If we are able to treat addiction so effectively, why do we treat most other addicts differently?”

    1. Bingo! But many people have trouble getting that, because they think doctors are not like other people.

      1. Don’t doctors also think they are not like other people? (Not that I don’t like them!)

        It seems to me that if you run a guild in which residents are worked crazy, inhumane and unrealistic hours, aren’t you kind of asking for this? It is funny that people can go through medical school and still know so little about health.

        1. M.D.’s (Medical Diety, also Me Doctor [You NOT!]) know lots about the health of other people and (far too often) very little about their own. There is something funny (in the tragic sense) about a doctor who is about 80 pounds overweight and a smoker telling a patient he needs to lose about 20 pounds and stop smoking.

          The post-graduate medical education system is reforming itself into the 20th Century (slowly, but it’s going to take a while — they are starting from the 18th). It’s an open question whether they will achieve humane working conditions for resident physicians and safe conditions for the patients before HOPE programs are widely adopted.

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