BACKGROUND AND OBJECTIVES:Physician health programs (PHPs) have demonstrated efficacy, but their mechanism of influence is unclear. This study sought to identify essential components of PHP care management for substance use disorder (SUD), and to assess whether positive outcomes are sustained over time.METHODS:Physicians with DSM-IV diagnoses of Substance Dependence and/or Substance Abuse who had successfully completed a PHP monitoring agreement at least 5 years before the study (N = 343) were identified as eligible. Of the 143 (42%) that could be reached by phone, 93% (n = 133; 86% male) completed the anonymous online survey.RESULTS:Virtually all PHP program components were rated as being at least "somewhat helpful" in promoting recovery, with the plurality of respondents rating almost all components as "extremely helpful." The top-rated components were: signing a PHP monitoring agreement, participation in the PHP, formal SUD treatment, and attending 12-step meetings, with each receiving a mean rating of at least 6.2 out of 7. Notably, 88% of respondents endorsed continued participation in 12-step fellowships. Despite the significant financial burden of PHP participation, 85% of respondents reported they believed the total financial cost of PHP participation was "money well spent."DISCUSSION AND CONCLUSIONS:Components of PHP monitoring were viewed as acceptable and helpful to physicians who completed the program, and outcomes were generally sustained over 5 years. More studies are needed to confirm these preliminary findings.SCIENTIFIC SIGNIFICANCE:This study documents the perceived cost-benefit of participation in a PHP among a small sample of program completers.

ABSTRACT The prevalence rate of addiction among physicians is similar to the general population, with approximately 10% to 12% of U.S.-based physicians developing substance use disorders (SUDs) during their lifetimes. To address this public health concern, physician health programs (PHPs) have been created to facilitate the early identification, evaluation, treatment, and monitoring of physicians. Although a number of published studies provide outcome information from PHPs, there has been no comprehensive review of the related literature. The objective of this narrative review is to summarize the treatment outcomes, including treatment types, rates of relapse, rates of contract completion or extension, as well as licensure and work status rates of a nationally representative physician cohort and related subpopulations from a single dataset. Based on the studies included in this review, our findings reveal that physicians who completed their PHP contracts have more favorable treatment outcomes than members of the general population who receive mainstream treatment. In addition, our review describes unique features of physician rehabilitation facilitated by PHPs. However, further prospective research is needed to ensure a standardized and comparable dataset and facilitate performance improvement.

The prevalence rate of addiction among physicians is similar to the general population, with approximately 10% to 12% of U.S.-based physicians developing substance use disorders (SUDs) during their lifetimes. To address this public health concern, physician health programs (PHPs) have been created to facilitate the early identification, evaluation, treatment, and monitoring of physicians. Although a number of published studies provide outcome information from PHPs, there has been no comprehensive review of the related literature. The objective of this narrative review is to summarize the treatment outcomes, including treatment types, rates of relapse, rates of contract completion or extension, as well as licensure and work status rates of a nationally representative physician cohort and related subpopulations from a single dataset. Based on the studies included in this review, our findings reveal that physicians who completed their PHP contracts have more favorable treatment outcomes than members of the general population who receive mainstream treatment. In addition, our review describes unique features of physician rehabilitation facilitated by PHPs. However, further prospective research is needed to ensure a standardized and comparable dataset and facilitate performance improvement.

Objectives: There is little published evidence on how well family medicine physicians (FMPs) with substance use disorder (SUD) perform in Physician Health Programs (PHPs). We examined outcomes for FMP compared with non-FMP physicians. Methods: This study utilized data from a 5-year, longitudinal, cohort study involving 904 physicians with diagnoses of SUD consecutively admitted to one of 16 state PHPs between 1995 and 2001. We compared 175 FMPs to 687 other physicians. Outcome measures were relapse, successful completion of monitoring contract at 5 years, and licensed and employed at 5 years. Results: Of the 3 outcome variables measured: relapse, successful completion of monitoring contract at 5 years, and licensed and employed at 5 years, FMPs had similar rates of success on all variables except monitoring contract completion at 5 years when compared with the other physician cohort. Conclusions: In this study, FMPs with SUD do as well as other physicians in PHPs at 5 years. However, FMPs were less likely to complete the monitoring contract at 5 years as compared to the other physician cohort.

Scientific evidence combined with new health insurance coverage now enable a chronic illness management approach to the treatment of alcohol use disorders (AUDs), including regular monitoring of blood alcohol content (BAC), as a useful indicator of disease control. Recent technical advances now permit many different types of remote, real-time monitoring of BAC. However, there is no body of research to empirically guide clinicians in how to maximize the clinical potential of remote BAC monitoring. As an initial step in guiding and supporting such research, the manufacturer of one remote BAC monitoring system sponsored a group of experienced clinicians and clinical researchers to discuss 8 issues that generally affect remote, clinical BAC monitoring of “adults in outpatient AUD treatment.” The expert panel unanimously agreed that remote BAC monitoring for at least 12 months during and after the outpatient treatment of AUD was a clinically viable deterrent to relapse. There was also consensus that positive test results (ie, recent alcohol use) should lead to intensified care and monitoring. However, there was no agreement on specific types of clinical intensification after a positive test. The panel agreed that sharing positive and negative test results with members of the patient support group was helpful in reinforcing abstinence, yet they noted many practical issues regarding information sharing that remain concerning. Significant differences within the panel on several important clinical issues underline the need for more clinical and implementation research to produce empirically-supported guidelines for the use of remote BAC monitoring in AUD treatment.

Aims: To compare treatment outcome among substance dependent physicians enrolled in a physician health program (PHP) who have a history of alcohol use only, any opioid use, or non-opioid drug use, in order to determine whether the distinctive PHP system of care management is as effective for individuals with opioid use disorders as for those with alcohol or other drug use disorders.Methods: A 5-year, retrospective chart review, intent-to-treat analysis was conducted for all physicians admitted to 16 physician health programs (N = 702; 85.5% male; age range = 24-75). Analyses compared treatment outcomes for participants based upon their substance(s) of abuse [i.e., 1) "Alcohol Only" (n = 204), 2) "Any Opioid" with or without alcohol use (n = 339), and 3) "Non-Opioid" drug use with or without alcohol use (n = 159)].Results: In this sample, 75-80% of physicians across the three groups never tested positive for alcohol or drugs during their extended care management period with random drug testing. This included physicians with opioid dependence who did not receive opioid substitution therapy (OST). Of the 22.1% of physicians who had a positive test, two thirds (i.e., 14.5% of the total sample) had just one positive test, and only one third (i.e., 7.6% of the total sample) had more than one positive test. These results were similar in all three groups.Conclusions: These results indicate that individuals with opioid use disorders who are managed by PHPs can achieve long-term abstinence from opioids, alcohol, and other drugs without OST through participation in abstinence-based psychosocial treatment with extended, intensive care management following discharge. (C) 2016 Elsevier Inc. All rights reserved.

Letters21 April 2015Physician Drug Testing Is Unscientific and Is Unlikely to Achieve Stated AimsGregory E. Skipper, MD, Julius Cuong Pham, MD, PhD, and Peter J. Pronovost, MD, PhDGregory E. Skipper, MDFrom Promises Treatment Centers, Santa Monica, California, and Armstrong Institute for Patient Safety & Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland.Search for more papers by this author, Julius Cuong Pham, MD, PhDFrom Promises Treatment Centers, Santa Monica, California, and Armstrong Institute for Patient Safety & Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland.Search for more papers by this author, and Peter J. Pronovost, MD, PhDFrom Promises Treatment Centers, Santa Monica, California, and Armstrong Institute for Patient Safety & Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/L15-0078-2 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:We thank Dr. Donohoe for sharing his views on physician drug testing. He suggests that impaired physicians cannot be identified through drug testing for various reasons, including misconceptions surrounding substance abuse, business interests, legal costs, and vague hospital procedures. Many of these points do not relate to the effectiveness of drug testing but rather a larger social context around it.Although it is true that drug testing will not detect all cases of abuse (for example, alcoholics in withdrawal and testing too long after sentinel events), these 2 examples hardly represent all of the situations in which drug ...References1. Stout PR, Bynum ND, Mitchell JM, Baylor MR, Ropero-Miller JD. A comparison of the validity of gas chromatography–mass spectrometry and liquid chromatography–tandem mass spectrometry analysis of urine samples for morphine, codeine, 6-acetylmorphine, and benzoylecgonine. J Anal Toxicol. 2009;33:398-408. [PMID: 19874645] CrossrefMedlineGoogle Scholar2. Skipper GE, Specht T. State PHPS protect the public—and save careers. Physician Health News. 2013;18 February 4-5. Google Scholar Author, Article, and Disclosure InformationAuthors: Gregory E. Skipper, MD; Julius Cuong Pham, MD, PhD; Peter J. Pronovost, MD, PhDAffiliations: From Promises Treatment Centers, Santa Monica, California, and Armstrong Institute for Patient Safety & Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=L15-0079. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoCalifornia's Proposition 46: A Wolf in Sheep's Wool Julius Cuong Pham and Peter J. Pronovost Physician Drug Testing Is Unscientific and Is Unlikely to Achieve Stated Aims Martin Donohoe Metrics Cited byDepression and Substance Use Disorders in Physicians 21 April 2015Volume 162, Issue 8Page: 598KeywordsBlood sugarDisclosureDrug abuseDrugsHealth careLaboratory testsLife expectancyResearch laboratoriesSpecificitySubstance abuse ePublished: 21 April 2015 Issue Published: 21 April 2015 Copyright & PermissionsCopyright © 2015 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

In this issue of the Journal of Graduate Medical Education, Bell and colleagues1 address the question of prevalence of drug testing for residents and medical students. The authors found that, within a sample of family medicine residencies, most programs performed pre-employment testing of residents but not medical students. In response to positive drug tests, programs were equally likely to deny a residency position or provide a position after rehabilitation. This paper adds to reports on this important topic. Data surrounding physician drug testing are sparse, and scientific inquiries like these are sorely needed. Up to one-third of physicians will be impaired at some point in their lives, either through drugs, alcohol, or mental health issues.2 The best evidence we have suggests that physicians have a lifetime prevalence for substance use disorders of 10% to 15%, a rate similar to that of the general population.3 Thus, physicians are not immune to the problem of drug abuse, either in their home life or in their care for patients. We have previously described a framework for protecting patients from impaired physicians that involves early identification through routine drug testing and rehabilitation of the potentially impaired individual.4 In other high-risk industries that involve public safety, this type of testing is routine and well accepted.5,6 Drug testing of physicians is a topic that has drawn recent attention and political controversy. On November 4, 2014, Californians voted down a ballot measure, Proposition 46, the Medical Malpractice Lawsuits Cap and Drug Testing of Doctors Initiative.7 In addition to other components, this measure would have required drug testing of physicians after an adverse event. Although we support the framework and there is empirical evidence for physician drug testing, the California measure was ill-conceived, and the physician drug testing component was likely a cover to increase the medical malpractice limits within the state. Still, the measure makes it apparent that a public desire for patient protection and physician drug testing exists. Bell and colleagues1 established the prevalence of drug testing among training programs, with family medicine as the model. Although it is reassuring that nearly 70% of programs perform pre-employment testing, one-third of programs do not. Moreover, only about 10% of programs perform some amount of random drug testing. Although pre-employment testing is important, periodic random testing adds important information, improves the performance of pre-employment testing, and is routinely performed in other safety-sensitive industries (eg, aviation, nuclear regulatory, railway systems, criminal justice, and others).8 In this study, the health system rather than the residency program initiated the majority of the drug testing. Indeed, it is unclear whether many program directors were aware of the drug testing policies of the health systems in which their programs function. Perhaps health care systems have the infrastructure and policies in place to deal with testing results. Health care systems are responsible for the delivery of health care, so they are ultimately responsible for their employees, among them, medical students and residents. Although most residency programs stated they used pre-employment drug testing, they did not describe how they defined this testing. Except for marijuana, it is unclear what type of drug test panel was used. The conventional National Institute on Drug Abuse 5 drug test panel is limited and inadequate to detect today's substances of abuse.9 Health care provider organizations should standardize the selection of the drug test panels to match the population being screened. Opponents of drug testing express concern over the accuracy of testing. Although the potential for false positives exists, confirmatory testing using gas chromatography-mass spectrometry yields a nearly 100% accurate result (defined as a correlation between measured and known concentration).10 The risk for false positive results is further reduced by independent testing using split test samples, review by a medical review officer, and an in-depth evaluation of the individual when appropriate. Other industries have used these processes for years.11 Opponents of drug testing also cite the costs of testing programs. The individual cost of urine drug screens, with test panels that include most drugs used by unlicensed professionals, are low ($15 to $50 per urine sample).12 In addition to the cost for the test panel, additional costs include sample collection (∼$30 to $40 per sample), medical review officer ($50 to $84 per hour), quality control samples (∼$30 per sample), confirmatory independent gas chromatography-mass spectrometry testing (∼$25),13 and program administration (varies). There are economies of scale for these costs. An anesthesiology program that included both pre-employment and random drug testing, using more advanced and expensive testing panels, estimated their costs to be about $50,000 per year. These costs are balanced against the costs of impaired physicians and the benefits of drug testing, including reduced absenteeism, increased productivity, and decreased accidents.13 This last benefit in health care is probably most important as it involves not only a financial cost but also the health and lives of our patients. Finally, opponents of drug testing question the efficacy of drug testing for detecting and preventing drug abuse. The argument is that “physicians would not put their patients at risk by coming to work impaired, so why bother testing for drugs/alcohol.” This argument has 2 shortcomings. First, the best evidence suggests physician substance use occurs at a rate similar to that of the general population. Second, although physician professionalism does uphold their fiduciary relationship to their patients (a physician's practice is the last place impacted by their impairment), chemical dependency, as a mental illness, will, if not detected early, ultimately undermine a physician's practice and patient safety.14 From an effectiveness perspective, published results in health care suggest that programs are able to detect and deter drug use. For pre-employment testing at large urban medical centers, between 4% and 10% of samples are positive.15,16 Among anesthesiology residents at 1 program, approximately 1% were positive.17 In addition to detection of impaired physicians, an important benefit of drug testing is the potential deterrent effect. Some colleagues might seek assistance or employment elsewhere, knowing that they will be drug tested. Among health care workers at a large urban medical center, positive drug tests fell from 10.8% to 5.8% after a formal pre-employment testing program was put in place.15 In the anesthesiology program previously cited, pre-employment and random drug testing led to a decrease in positive samples from 1% to 0%.17 More data in this area are needed. Although possession of marijuana remains illegal under federal law, recent legalization of marijuana in some states adds a layer of complexity to the issue of drug testing. In many ways, marijuana, in those states where it is legal, might be viewed similarly to alcohol use. Whether or not marijuana is legal, providing patient care while impaired puts patients at risk; therefore, signs of impairment should trigger the need for drug testing. States that have laws regulating the use of marijuana often administer blood tests for tetrahydrocannabinol (THC) to determine a driver's level of impairment. In both Colorado and Washington state, drivers who are found to have THC in their bloodstream at a level of ≥5 ng/mL are considered “under the influence,” and may be subject to penalty.18,19 This practice might be acceptable in the medical practice setting as well. In summary, Bell and colleagues1 have added to the understanding of drug use and testing among physicians in the United States. Studies like this are needed in order to inform our policies around management of physician impairment and to identify areas that require further attention. These efforts help to improve the safety of our patients and the health of our colleagues.

In this issue’s historical article, “Freeman Allen: Boston’s Pioneering Physician Anesthetist,” we learn of Dr. Allen’s many contributions to the field of anesthesiology as well as his qualities as a sensitive, moral, and highly intelligent human being.1 We also learn that he is the first documented and prominent physician anesthesiologist to become addicted to morphine. The article describes his tragic death from suicide during one of several hospitalizations for morphine addiction at Butler Hospital in Providence, RI. What do we know about substance use disorders today that we did not know in the early 1900s? In 1935, pioneers of drug abuse research began to study and treat heroin addicts at the Addiction Research Center at the Public Health Service Hospital in Lexington, KY. When Congress created the National Institute on Drug Abuse (NIDA) in 1974, the Addition Research Center was folded into NIDA’s Intramural Research Program. NIDA was created in response to the rising problem of drug abuse and addiction in the late 1960s and the resultant societal consequences. Research largely funded by NIDA has produced an explosion of knowledge in the neurobiology of addiction, as well as epidemiology, prevention, diagnosis, treatment, and monitoring of individuals with substance use disorders. We now know that addiction is not a moral deficiency but a primary chronic disease, much like diabetes.a,b In diabetes, the defective organ is the pancreas. The result is altered glucose homeostasis. Some the consequence are foot ulcers and blindness. In addiction, the defective organ is the brain. The result is altered neurotransmitter homeostasis. The consequences include lying, cheating, stealing, and general badness. The socially unacceptable behaviors associated with addiction naturally elicit a response to blame the addict for his or her behavior. However, addiction is not a disease of choice.a Addiction is a disease that impairs areas of the brain’s ability to make healthy choices. Like other chronic diseases, addiction is relapsing in nature, is rarely cured, and requires sustained treatment, including addressing the biopsychosocial and spiritual factors that influence the development and manifestation of addiction. As defined by McCauley,2 “Addiction is a stress-induced defect acting on a genetic vulnerability in the reward learning areas of the mid brain and the emotion choice areas of the frontal cortex.” The defining behaviors of addiction are loss of control, craving, compulsion, and continued use despite harm.c Addiction is considered a substance use disorder, along with illicit drug use, problematic drug use, drug misuse, and drug abuse. The DSM-5 divides substance abuse disorders into mild, moderate, and severe categories depending on how many diagnostic criteria out of 11 a given patient meets. Craving has been added as a diagnostic criteria in DSM-5, while legal issues have been eliminated.d The definition of addiction adopted by the American Society of Addiction Medicine in 2011 is an important contribution and reflects our current understanding of substance use disorders.c Genetic load accounts for about 50% of the risk of addiction.3 Additional major risk factors include Axis I/II disorders, adverse childhood experiences,4 and early initiation of substances of abuse including alcohol and tobacco.5 Contributing risk factors include poor coping skills to deal with stress, dysphoria, and anxiety as well as a lack of resilience. Traits such as impulsivity, compulsivity, control issues, risk taking, and the desire for immediate gratification can be seen in people with substance use disorders. It seems intuitive that all human beings including physicians can have risk factors for addiction. It follows that if appropriate environmental triggers are present, physicians may develop substance use disorders. It is therefore no surprise that such prominent physicians as the neurologist Sigmund Freud and the surgeon William Halsted developed substance use disorders. Both of these giants of medicine were practicing in the 1880s, Freud in Vienna and Halsted at New York’s Bellevue Hospital. Freud used cocaine as a treatment for morphine addiction, which was overprescribed then as it is now, and as a treatment for depression. Freud began to experiment on himself with cocaine. The resulting article, Uber Coca, published in 1884, described cocaine’s physiological and potential therapeutic effects but essentially ignored cocaine’s local anesthetic properties. This fascination with cocaine’s perceived positive effect on his own depression may have contributed to Freud’s abandoning basic neurobiology research and instead focusing on the human mind.6 Meanwhile Freud’s colleague at the Vienna Allgemeines Krankenhaus, Carl Koller, focused on the local anesthetic properties of cocaine for cataract surgery while working as an intern in Ophthalmology. At Bellevue Hospital, William Halsted was aware of Carl Koller’s work and began to inject cocaine into his arm. He ultimately became addicted to cocaine. Halsted was hospitalized on several occasions for cocaine addiction at Butler Hospital in Rhode Island, the same hospital where Freeman Allen was treated for morphine addiction and committed suicide. Much of what we know about William Halsted’s substance use disorder is based on a Journal of the American Medical Association article in 1969 by Penfield,7 the famous Canadian neurosurgeon, titled “Halsted of Johns Hopkins: The Man and His Problem as Described in the Secret Records of William Osler.” Sir William Osler, another renowned Canadian physician, revealed that Halsted was addicted to morphine as well as cocaine by the age of 34 when he was invited to join Osler, Welch, and Billings in what would later be called the “Big Four” founders of Johns Hopkins Medical School. At first, Halsted was given a minor appointment as Welch knew of his addiction. Eventually, this was overlooked because of Halsted’s brilliant surgical skills. Osler and Welch assumed Halsted was “cured” because of his excellent performance and promoted him to full surgeon. Osler describes that several months after Halsted’s promotion he observed Halsted in morphine withdrawal. Subsequently, Halsted admitted to not being able to wean himself below 180 mg morphine daily. The contributions to medicine and mankind of Freud, Halsted, and Allen and many other addicted physicians should motivate us to provide treatment to our colleagues with substance use disorders. We are motivated because addicted colleagues are often both personal friends and suffering patients. However, we too easily forget the substantial contributions to society by many addicted individuals, including physicians. One of the lessons of Freeman Allen’s story is that addicted colleagues, properly treated, may make lasting contributions. In light of what we know today about substance use disorders, what can we say about Freeman Allen’s struggle with his addiction to morphine? Dr. Allen had a genetic load for addiction. We know his mother was addicted to morphine. Less well known is that his uncle, Fredrick William Stowe, was an alcoholic.e Fredrick attended Harvard Medical School but left to enlist in the Union Army for the Civil War. He was wounded in the Battle of Gettysburg. Fredrick had a lifelong struggle with alcohol addiction. It appears that Fredrick was the inspiration for the character Tom Bolton in My Wife and I and We and Our Neighbors, written by his mother, Harriet Beecher Stowe. As noted on the Harriet Beecher Stowe Center Web site, “Stowe insightfully described alcoholism as an illness, at a time when most people believed it was a moral failure.”f As is common among addicts, Freeman Allen was a risk taker, exposing himself to yellow fever. Perhaps risk-taking behavior was necessary for anesthetists of his time, given the risks imposed by the limited knowledge and primitive technology applied to the profound physiologic trespass of the new discipline. We can conjecture that he was desensitized to using morphine, which he championed as a premedication for his patients. He certainly had ready access to morphine. We also know that he was despondent, depressed, and ultimately committed suicide. Little was known about substance use disorders or their treatment during his life. That is, in part, why he succumbed to his disease. So what do we know today about physicians in general, and anesthesiologists in particular, with substance use disorders? The lifetime prevalence of substance abuse disorder in the general population is approximately 10% to 14%.8–10 The lifetime prevalence in physicians is thought to be similar. This means that among the approximately 850,000 physicians and 50,000 anesthesiologists in the United States, there may be as many as 120,000 physicians and 7000 anesthesiologists who will be affected by a substance use disorder during their lifetime. If these figures are even remotely accurate, this represents an important public health issue, given the risks of being cared for by an impaired physician. The problem of substance use disorders among physicians has been addressed, in part, by the creation of physician health programs (PHPs)11 to treat affected physicians. Unfortunately, data suggest that only 1% of physicians with a lifetime prevalence of substance use disorders are referred to a PHP.12 As part of our dedication to patient safety, physicians in general, and anesthesiologists in particular, must do a better job of identifying colleagues with substance abuse disorders to facilitate intervention, diagnosis, and earlier referral to treatment. This can be accomplished, in part, by educating colleagues and their families about substance abuse disorders. There are also policies that can be put into place, such as random urine and/or hair drug testing, and mandatory drug testing when substance abuse is suspected. Knowledge and understanding of signs and behaviors that may signal a substance use disorder and active surveillance in anesthesia training programs and practice sites increase early referral and patient safety. Data suggest that anesthesiologists, emergency department physicians, and psychiatrists are overrepresented among physicians referred to PHPs.13 However, because very few physicians with substance abuse disorders are referred to PHPs, we do not know whether anesthesiologists, emergency department physicians, and psychiatrists are at a higher risk of substance use disorders, or are simply more likely to be detected (or to self-identify) and be referred for treatment. There are several unique features of substance abuse disorders in anesthesiologists. First, no other specialty has easier access to the equipment (needles, syringes) than anesthesiologists. Second, no other specialty has greater proficiency at venous cannulation. Third, no other specialty has easier access to commonly abused IV drugs, including potent IV opioids. Last, no other specialty is as skilled at precisely controlling the effects of IV opioids and other abusable drugs. This combination of access to equipment and drugs, and proficiency with both, creates a unique risk for abuse among anesthesiologists confronted with biological, psychological, social, or spiritual stressors. Occasional self-administration of IV short-acting opioids can lead to tolerance, escalating doses, and full-blown addiction in a matter of weeks to months. Death may follow quickly if the addiction is not discovered and treated. Opioid addicts often paradoxically describe opioids as energizing, which may explain why addicted physicians can appear to function well, at least initially, while actively injecting into a hidden IV port. Anesthesiologists are especially stigmatized for opioid addiction. This may be due to the fact that an anesthesiologist trusted to provide care for the patient is instead diverting the opioid from the patient, who needs opioids for analgesia, to his or her own use. The addicted anesthesiologist steals from the patient, which is a crime. This stigma causes further shame and guilt in the addicted anesthesiologist, which he or she already has no shortage of, furthering the need for relief with more opioids. Thus, the rapid downward cycle may reflect not only the pharmacology of short-acting IV opioids, but also the overwhelming psychosocial and spiritual turmoil of the addicted anesthesiologist. The unique risk factors for substance abuse disorders among anesthesiologists may explain why anesthesiologists have a much higher rate of IV drug abuse than other physicians (odds ratio, 6.3)12 when enrolled in a PHP. Fortunately, anesthesiologists in rigorous PHPs have excellent outcomes, similar to other specialties in terms of survival, abstinence, completion of monitoring, and return to work in their specialty. They are also less likely to fail a drug test during monitoring. These favorable outcomes for anesthesiologists may be due to additional features in treatment and monitoring not used for other physicians, including witnessed naltrexone administration (or more recently the advent of sustained release parenteral naltrexone), regular hair drug testing, and increased technological surveillance in the operating room suite.14 It is our view that anesthesiologists who have a substance use disorder should sign a contract with a PHP and generally undergo residential care for a minimum of 90 days in a physician-oriented program. After completing adequate treatment, the PHP provides subsequent outpatient monitoring, including appropriate drug testing, counseling, group therapy, and attendance in a 12-step–based support group such as Narcotics Anonymous for at least 5 years. It is controversial whether anesthesiologists with substance use disorders should return to work in their specialty. We recommend that each anesthesiologist be evaluated on a case-by-case basis by a qualified addictionologist with experience in treating anesthesiologists. Relapses among anesthesia providers have produced strong, even visceral reactions in the medical community. Some question whether any anesthesiologist should return to the operating room environment. We believe systematic assessment tools and clinical research should guide who should and who should not safely return to a high drug access environment. If return to work is deemed appropriate, it should be done slowly and in combination with the above steps to detect relapse and protect our patients. It is important and possible for all those suffering from a substance abuse disorder to achieve biological, psychological, social, and most importantly spiritual recovery. Quoting Dr. Thomas Hora, “all problems are psychological, but all solutions are spiritual.”15 Freeman Allen was never was given an opportunity for recovery. He died of his disease. The lesson of his tragic trajectory is that we must all be vigilant to substance use disorders in our friends, family, and professional colleagues. We owe it to ourselves. We owe it to our colleagues. Most critically, as physicians, we also owe it to our patients. DISCLOSURES Name: Gabriel Schonwald, MD. Contribution: This author helped in manuscript preparation. Attestation: Gabriel Schonwald approved the final manuscript. Name: Gregory E. Skipper, MD, FASAM. Contribution: This author helped in manuscript preparation. Attestation: Gregory E. Skipper approved the final manuscript. Name: David E. Smith, MD, FASAM, FAACT. Contribution: This author helped in manuscript preparation. Attestation: David E. Smith approved the final manuscript. Name: Paul H. Earley, MD, FASAM. Contribution: This author helped in manuscript preparation. Attestation: Paul H. Earley approved the final manuscript. This manuscript was handled by: Steven L. Shafer, MD.

Objective: The objective of this study was to compare outcomes of psychiatrists and nonpsychiatrist physicians enrolled in state physician health programs for substance use disorders. Methods: The study used the data set from a five-year, longitudinal cohort study of 904 physicians, including 55 psychiatrists, with diagnoses of substance abuse or dependence consecutively admitted to one of 16 state physician health programs between 1995 and 2001. Results: There was a higher proportion of women among psychiatrists than among other physicians, but there were no other significant differences between the cohorts. Five-year outcomes were similar between psychiatrists and the other physicians, with at least 75% of psychiatrists continuing their medical practice after five years of monitoring and treatment. Conclusions: Psychiatrists were not overrepresented compared with other physician groups and had similar clinical outcomes at the five-year follow-up. Physician health programs appeared to be effective treatment programs for psychiatrists with substance use disorders.

BACKGROUND:The aim of this study was to estimate the prevalence of cannabis use among Swiss students and to assess their attitudes regarding health and safety issues associated with drug use.SUBJECTS AND METHODS:After a workshop, 173 students (23.1% male, 75.7% female; 44.4% age 16, 43.8% age 17 and 11.8% age 18) from a Swiss school were surveyed by questionnaire.RESULTS:59.3% (n=103) of all participants had tried cannabis, and 30.1% of those who reported cannabis use had consumed more than 100 joints. Of those 103 students with cannabis experience, 6.8% rated the risk of cannabis-related psychic effects as low, and 9.8% were not concerned about driving under the influence of cannabis. In cases of heavy cannabis use, the chance of increased tobacco, alcohol or other drug use is higher than for those with less or no cannabis use at all (odds ratios of 4.33-10.86).CONCLUSIONS:This paper deals primarily with cannabis prevalence data in adolescents from previous studies and sources, and shows that our findings deviate significantly - and surprisingly - from past research. Our data from a school survey indicates higher cannabis use than data from official drug policy studies. Additionally, our data shows that the students' self-reported attitudes towards health and safety issues were mostly realistic. The examination of methodological issues that might impact prevalence estimates should be added to the cannabis literature.

INTRODUCTION:Emergency physicians (EPs) are reported to have a higher rate of substance use disorder (SUD) than most specialties, although little is known about their prognosis. We examined the outcomes of emergency physician compared to other physicians in the treatment of substance use disorders in Physician Health Programs (PHP).METHODS:This study used the dataset from a 5-year, longitudinal, cohort study involving 904 physicians with diagnoses of SUD consecutively admitted to one of 16 state PHPs between 1995 and 2001. We compared 56 EPs to 724 other physicians. Main outcome variables were rates of relapse, successful completion of monitoring, and return to clinical practice.RESULTS:EPs had a higher than expected rate of SUD (odds ratio [OR] 2.7 confidence interval [CI]: 2.1-3.5, p<0.001). Half of each group (49% of EPs and 50% of the others) enrolled in a PHP due to alcohol-related problems. Over a third of each group (38% of EPs and 34% of the others) enrolled due to opioid use. During monitoring by the PHPs, 13% of EPs had at least one positive drug test compared to 22% of the other physicians; however, this difference was not significant (p=0.13). At the end of the 5-year follow-up period, 71% of EPs and 64% of other physicians had completed their contracts and were no longer required to be monitored (OR 1.4 [CI: 0.8-2.6], p = 0.31). The study found that the proportion of EPs (84%) continuing their medical practice was generally as high as that of other physicians (72%) (OR 2.0 [CI: 1.0-4.1], p = 0.06).CONCLUSION:In the study EPs did very well in the PHPs with an 84% success rate in completion and return to clinical practice at 5 years. Of the 3 outcome variables measured, rates of relapse, successful completion of monitoring, and return to clinical practice, EPs had a high rate of success on all variables compared to the other physician cohort. These data support the conclusion that EM physicians do well following treatment of SUD with monitoring in PHPs and generally return to the practice of emergency medicine.

Objectives: To test the robustness of the findings of previous studies in a large aggregated sample regarding (a) the impact of a patient's suicide on therapist's distress; (b) identify a potential subgroup of therapists needing special postvention; (c) and assess potential differences in overall distress between professional groups and at different levels of care.Methods: A questionnaire, characterizing the therapists, their reactions and the patients, had been sent out to 201 psychiatric hospitals in Germany providing different levels of care. Aggregated data from previous studies have been used.Results: In 39.6% of all cases, therapists suffer from severe distress after a patients' suicide. The global item "overall distress" can be used as an indicator to identify a subgroup of therapists that might need individualized postvention. No significant difference in overall distress experienced was observed between professional groups and at different levels of care.Conclusion: Our data suggest that identifying the severely distressed subgroup could be done using a visual analogue scale for overall distress. As a consequence, more specific, individualized and intensified help could be provided to these professionals, helping them to overcome distress and thereby ensuring delivery of high quality care to the patient. (C) 2013 Elsevier Inc. All rights reserved.

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Objective: Surveys assessing alcohol use among physicians have most commonly employed the Alcohol Use Disorders Identification Test (AUDIT) or the AUDIT-C, the most common short version of the AUDIT. As with other screeners, prevalence estimation is dependent on the accuracy of the test as well as choice of the cutoff value. The aim of the current study is to derive more precise prevalence estimates of alcohol problems in physicians by correcting for false-positive and false-negative results.Method: In the context of a survey, the AUDIT was sent out via email or standard postal service to all 2484 physicians in Salzburg, Austria. A total of 456 physicians participated. A published correction formula was used to estimate the real prevalence of alcohol use problems.Results: Applying a cutoff of 5 points for the AUDIT-C, 15.7% of female and 37.7% of male physicians screened positive. Use of a correction based on general population data and the sensitivity and specificity of the AUDIT-C resulted in much lower prevalence rates: 4.0% for female and 9.5% for male physicians. Using the full AUDIT, 19.6% of the female physicians and 48% of the male physicians were screened positive. Using the correction, the estimated prevalence rates for females and males were 6.3% and 15.5%, respectively.Conclusions: Our findings demonstrate that uncorrected screening results may markedly overestimate the prevalence of physicians drinking problems. (C) 2013 Elsevier Inc. All rights reserved.

BACKGROUND:Monitoring alcohol use is important in numerous situations. Direct ethanol metabolites, such as ethyl glucuronide (EtG), have been shown to be useful tools in detecting alcohol use and documenting abstinence. For very frequent or continuous control of abstinence, they lack practicability. Therefore, devices measuring ethanol itself might be of interest. This pilot study aims at elucidating the usability and accuracy of the cellular photo digital breathalyzer (CPDB) compared to self-reports in a naturalistic setting.METHOD:12 social drinkers were included. Subjects used a CPDB 4 times daily, kept diaries of alcohol use and submitted urine for EtG testing over a period of 5 weeks.RESULTS:In total, the 12 subjects reported 84 drinking episodes. 1,609 breath tests were performed and 55 urine EtG tests were collected. Of 84 drinking episodes, CPDB detected 98.8%. The compliance rate for breath testing was 96%. Of the 55 EtG tests submitted, 1 (1.8%) was positive.CONCLUSIONS:The data suggest that the CPDB device holds promise in detecting high, moderate, and low alcohol intake. It seems to have advantages compared to biomarkers and other monitoring devices. The preference for CPDB by the participants might explain the high compliance. Further studies including comparison with biomarkers and transdermal devices are needed.

Background Whereas urinary ethyl glucuronide (EtG) levels above 1,000ng/ml reflect with a high probability ethanol (EtOH) consumption, levels below this cutoff are difficult to interpret as both extraneous (nonbeverage) EtOH exposure, recent drinking, and more distant high EtOH intake (several days ago) might yield similar results. This might be of particular relevance in medico-legal cases. To overcome this dilemma, phosphatidylethanol (PEth) might be a promising marker, because blood PEth is only positive following significant alcohol use. The aim of our study was therefore to employ PEth as a marker to differentiate between the different conditions.Methods Subjects included were 252 participants in monitoring with the Alabama Physician Health Program. All subjects testing positive for EtG and/or ethyl sulfate (EtS) who denied drinking after routine supportive confrontation were subject to information about PEth testing. If they still denied drinking, PEth testing was performed and the result communicated. EtG, EtS, and PEth testing was performed in a commercial laboratory using liquid chromatography tandem mass spectrometry methods.Results Of a total of 18 subjects who tested positive for EtG and/or EtS, 10 denied drinking. Of the 7 who denied drinking after PEth explanation, in 5 cases, their claim was supported by a negative PEth result. In 2 cases, a positive PEth result was in contrast to their claim.Conclusions PEth results in combination with previous low positive EtG/EtS results allow differentiating between innocent/extraneous exposure and drinking. Negative PEth testing following low positive EtG/EtS results helps to further elucidate the findings and support the claim of the patient of recent alcohol abstinence. Positive PEth testing following positive EtG/EtS results confirms recent drinking.

A high suicide risk has been reported among veterinarians in comparison to the general population. Postulated causes have included depression, substance abuse, work-related stress, reluctance to admit psychiatric problems, and access to lethal drugs and/or familiarity with euthanasia. Members of the Student Chapter of the American Veterinary Medical Association (AVMA), all veterinarians licensed in Alabama, and all US veterinary-association executive directors were surveyed regarding their attitudes concerning mental health issues, including veterinarian suicide. Only 10% of veterinary student respondents (N = 58) believed that suicide risk is higher among veterinarians than in the general population. Of the 22 state associations executive directors who participated in the survey, 37% believed that suicide is a significant concern for veterinarians and only 44% indicated that a veterinary wellness program was available in their respective states. Of the 1,455 licensed veterinarians in Alabama, 701 responded to the survey; 11% of respondents believed that suicide among veterinarians was a problem. In addition, 66% of respondents indicated that they had been "clinically depressed," but 32% of those with depression had not sought treatment. More females (27%) than males (20%) admitted that they had "seriously considered suicide" (p < .01). Female veterinarians were more likely than male veterinarians (15% versus 7%) to indicate that they were "not sure they'd made the right career choice" (p < .001), and 4% of all respondents indicated "definitely not being happy with their career." It is of concern that veterinarians not only have a higher risk of suicide but that they also have fewer support structures. The wide discrepancies between the published risk of suicide for veterinarians and their own views of their risk suggests an inadequate awareness of their own mental health vulnerability which could put them at higher risk.