Substance Use Disorders in Physicians

April 10, 2014 | Healthcare Risk, Quality, & Safety Guidance

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SUD, a disorder recently recognized in the 2013 Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), comprises what had once been two separate disorders: substance abuse and substance dependence, also known as addiction. In the previous version of the manual, substance abuse of a drug, including alcohol, was defined in terms of the harmful social consequences of repeated substance use, such as failure to meet family or professional obligations, while addiction, or substance dependence, was defined by the presence of various physiological and behavioral symptoms relating to tolerance, withdrawal, and patterns of compulsive use. Today, SUD is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 or more of the former substance abuse and substance dependence criteria—a total of 11 criteria—occurring within a 12-month period* (APA). See DSM-5: Substance Use Disorder for a complete list of diagnostic criteria.

_______________ * Because most of the clinical literature on substance use employs the terms "abuse" or "dependence" rather than the new, overarching term "substance use disorder," most of the references cited in this Risk Analysis use the older terms, as they were used in cited articles. _______________

Physicians and other healthcare professionals are thought to have the same rate of alcohol or drug use disorders as the general population—researchers estimate that approximately 10% to 15% of all healthcare professionals will misuse drugs or alcohol at some time during their career. This means that most clinicians will work with someone with SUD during their professional lives and should know what to do about it. Alcohol is most commonly misused, followed by opiates and stimulants. Men are at higher risk of developing drug abuse, and female physicians are more likely to abuse alcohol rather than prescription drugs. (Baldisseri)

While the overall rate of substance abuse may be similar to that of the general public, the choice of substance differs. Physicians in general are more likely to misuse prescription drugs than the general public (Merlo and Gold), especially benzodiazepines and opiates, probably because those drugs are easily available and clinicians are familiar with them (Baldisseri). See Table. Selected Prescription Drugs with Potential for Abuse for a description of the kinds of prescription drugs physicians are most likely to abuse. Certain medical specialties also seem to have higher rates of substance abuse, with anesthesiologists having the highest rate (three times higher frequency compared with other physicians) (Garcia-Guasch et al.). In addition to anesthesiologists, most studies consistently find that emergency department (ED) physicians, psychiatrists, and physicians in solo practice have higher rates of substance use, while pediatricians, pathologists, radiologists, obstetricians, and gynecologists have the lowest rates (Baldisseri).

Different specialties also tend to abuse different classes of drugs. In one large national study, 15.4% of surgeons met the diagnostic criteria for alcohol abuse or dependence (Oreskovich et al.). Psychiatrists have been reported to have a high rate of benzodiazepine use, while ED physicians are more likely to abuse marijuana and cocaine than other substances (Baldisseri). The vast majority of anesthesiologists who enter treatment for addiction use opiates such as fentanyl and sufentanil, while only 10% are addicted to alcohol (Berge et al. "Chemical"). As with everyone with an SUD, physicians may abuse multiple substances. However, unlike the general public, physicians can use their pharmacological knowledge to select substances that help them manage the effects of their primary substance of abuse. For example, one doctor describes using Xanax to mask withdrawal from alcohol (Merlo et al.). Moreover, this knowledge of pharmacology may lead physicians to think they can control...

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