The issue of alcohol and substance abuse and dependence in the United States has a significant impact on orthopaedic surgeons. Many of us have spent late nights in the emergency department (ED) treating traumatic injuries resulting from accidents involving alcohol or drugs.

What we are less likely to acknowledge, however, is that healthcare professionals may also abuse and be dependent on drugs and alcohol. During the past decade, front-page stories have drawn attention to the prevalence of substance abuse among U.S. physicians, and particularly among surgeons.

Not a new phenomenon
In 2004, the Boston Globe reported on an orthopaedic spine surgeon who left a patient on the operating table in midsurgery. The surgeon, who was addicted to methamphetamines, eventually went to federal prison for drug-related crimes.

More recently, the Austin American-Statesman reported on a local ED physician who was sentenced to 6 years in prison for prescribing thousands of doses of prescription narcotics without a medical purpose. Some went to the physician’s son and resulted in his death by drug overdose.

Just this year, the Dallas Morning News reported on a federal lawsuit accusing Baylor Health Care System of failing to properly monitor or investigate a neurosurgeon, despite repeated warnings about his “drug problem” and “lack of competence.” A spokeswoman for the Texas Medical Board characterized the case as one of the most “egregious’’ ever seen in the state.

The prevalence of substance use disorders in the United States has been well documented. Among those older than 12 years of age, 9.4 percent meet criteria for substance abuse or dependence (including alcohol and all other abusable substances). Males are twice as likely as females to meet the criteria, and these findings are generally consistent across demographic groups. Because alcohol is legal and commonplace, its abuse receives relatively more attention, although physician substance abuse runs the gamut from amphetamines to sedatives, including more “physician-specific” forms such as prescription narcotics and anesthetic agents (Table 1).

Incidence, impact among surgeons
The potential of alcohol abuse to afflict surgeons was highlighted by the results of a survey published in the Archives of Surgery in 2012. Among 7,197 surgeon respondents to an electronic survey, 15.4 percent had a score on the Alcohol Use Disorders Identification Test (AUDIT) consistent with alcohol abuse or dependence. Female surgeons had a higher point prevalence for alcohol abuse or dependence than male surgeons (25.6 percent vs. 13.9 percent), a surprising and substantial sex-linked difference, the etiology of which is unknown.

Surgeons who reported feeling burned out and those who reported psychological symptoms such as depression were more likely to have higher alcohol abuse or dependence scores. In particular, the “emotional exhaustion” and “depersonalization” domains of burnout were strongly associated with alcohol abuse or dependence.

Without intervention and treatment, physicians who are substance abusers may have a mortality rate of as much as 17 percent. In addition, more than one-third of surgeons indicated that they would be reluctant to seek help for treatment of depression, alcohol or substance use, or other mental health problems due to concerns that it could affect their license to practice medicine.

This survey was the first study of its kind to specifically look at the point prevalence of substance use disorders among physicians. Although the point prevalence may not be dramatically greater among physicians than among the general population, the repercussions of physician substance abuse could certainly have more consequences.

Of paramount concern is the fact that substance abuse may impair a surgeon’s ability to practice with skill and safety. Responding surgeons who admitted to a major medical error in the previous 3 months were more likely to have AUDIT scores consistent with alcohol abuse or dependence, generally confirming the association of impairment to medical malpractice and negligence lawsuits. No evidence, however, was found to indicate a correlation to patient injury or to impairment in the operating room.

What can be done?
Physician substance abuse and dependence has historically received little formal attention from those who should know better—physician educators and leaders. Most medical school, residency, and fellowship programs have little or no formal education or training about physician substance abuse. Many medical societies offer referral help, but do not proactively reach out to physicians at risk.

Among state medical societies, the Texas Medical Association offers 20 different web-based CME opportunities related to “physician health,” many of which deal with stress, burnout, and life balance; one is specifically related to substance abuse. Professional societies rarely discuss the issue at formal meetings (perhaps with the exception of anesthesiology organizations) or on their member websites.

At the time of this writing, the AAOS website has limited information on surgeon substance abuse. A search of the Journal of the AAOS for the words “substance abuse” yielded 175 articles, just a few of which discussed substance abuse in orthopaedic patients, and none of which had anything to do with substance abuse by surgeons. AAOS Now has published several articles about physician substance abuse; links can be found below.

Considering that about 15 percent of our colleagues develop a substance abuse problem during their careers, real-life recognition is important. Although substance abuse carries with it a social stigma of personal failure—like an uncontrollable habit or a moral weakness—modern medicine considers it a disease. According to Roger Cicala, MD, “The individual with a true substance abuse disorder is no more able to control their disease without treatment than a person with severe endogenous depression is able to stop feeling depressed through willpower. It is, therefore, of utmost importance that every physician become aware that ignoring the subtle symptoms in a friend and colleague will actually prevent that person from getting help and may ultimately have tragic consequences.”

What to watch for
The first signs of substance abuse are typically revealed in personal relationship strife and withdrawal from community activities. Work behavior problems eventually surface, but may be even more difficult to detect in physicians due to the abuser’s awareness of symptoms and the efforts taken to conceal them.

Because physicians are so adept at hiding the problem, it is the “profound consequences” of end-stage substance abuse that draw first attention. These include the following:

• accidental overdoses
• criminal charges from self-prescribing or diversion activities, driving while intoxicated, assault
• malpractice lawsuits related to impairment
• suicide

Unfortunately, long before the profound consequence, other behaviors (such as depression, mood swings, inappropriate anger, rage attacks, irritability, inability to concentrate, sleepiness, overspending, financial difficulties, gambling problems, etc.) have likely been present, yet left unaddressed by colleagues (see “What to Watch For.”).

Physician substance abuse and dependence is a treatable and reversible condition with an excellent prognosis when identified early. Appropriate intervention, treatment, and monitoring can result in a very positive outlook, with a relapse rate for surgeons equal to that of nonsurgeons. Furthermore, with adequate monitoring, surgeons can safely return to the operating room after successful treatment. These findings should also decrease the shame and stigma associated with alcohol or substance abuse or dependence and encourage surgeons to pursue treatment and rehabilitation, which is paramount to promoting patient safety and well being.

Michael M. Albrecht, MPAff, MD, is a member of the AAOS Medical Liability Committee.

Editor’s note: Articles labeled Orthopaedic Risk Manager (ORM) are presented by the Medical Liability Committee under the direction of Robert R. Slater Jr, MD, ORM editor. Articles are provided for general information and are not legal advice; for legal advice, consult a qualified professional. Email your comments to feedback-orm@aaos.org or contact this issue’s contributors directly.

References:

1. Swidey N: What Went Wrong? Boston Globe, March 21, 2004.
2. Kreytak S: Austin doctor gets about 6 years in prescription drug case. Austin American-Statesman, June 25, 2012.
3. Swanson DJ: Plano’s Baylor hospital faces hard questions after claims against former neurosurgeon. Dallas Morning News, March 1, 2014.
4. Oreskovich MR, Kaups KL, Balch CM, et al: Prevalence of alcohol use disorders among American surgeons. Arch Surg 2012;147(2):168-174. doi:10.1001/archsurg.2011.1481.
5. Shanafelt TD, Balch CM, Dyrbye L, et al: Special report: Suicidal ideation among American surgeons. Arch Surg 2011;146(1):54-62. doi:10.1001/archsurg.2010.292.
6. Gold K, Teitelbaum S. Physicians impaired by substance abuse disorders. Journal of Global Drug Policy and Practice. 2006.
7. Cicala RS: Substance abuse among physicians: What you need to know. Hosp Phys 2003;39(7).

Addicted Physicians Additional Resources:
Helping Addicted Physicians Recover
When a Colleague Is in Trouble…
Taking Care of Ourselves to Better Care for Our Patients…
How to Deal with the ‘Problem Physician’…