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Am Fam Physician. 2021;103(5):302-304

Author disclosure: No relevant financial affiliations.

Case Scenario

A 34-year-old physician, H.M., is an established patient in my practice. H.M. presents for a follow-up visit after finishing inpatient treatment for opioid use disorder. Your patient shares that six weeks ago they were approached by their medical director to discuss concerns from the clinic staff about H.M.'s behavior, which included late arrivals to work, unexpected absences, mood swings, and weight loss. After the meeting, H.M. agreed to an evaluation by a physician health program, and an opioid use disorder was diagnosed. Inpatient treatment was recommended, and H.M. is still on a medical leave of absence. H.M. is currently prescribed sertraline (Zoloft), 50 mg by mouth daily, and buprenorphine/naloxone (Suboxone), 8 mg/2 mg sublingually daily. H.M.'s aftercare plan includes attending community recovery meetings, focusing on self-care, and spending time with their spouse and children. H.M. reports “feeling better than I have in years” and states that they have had no cravings for opioids. The patient is attending cognitive behavior therapy sessions for treatment of depression and opioid use disorder and is enrolled in the state's physician health program.

As a family physician, what role do I play in supporting H.M.'s recovery from substance use disorder (SUD)?

Commentary

Physicians are not impervious to SUDs. Studies have suggested that the prevalence of SUDs among physicians is 10% to 15%, similar to the general population.1 Alcohol use disorder is the most common type of SUD in physicians, and a national survey of U.S. physicians for all specialties found that female physicians reported alcohol use disorder at a higher rate than male physicians.2 In addition, some medical specialists, such as anesthesiologists, may experience higher rates of nonalcohol SUD because of occupational exposure and access to medications in the workplace.3 There are limited published data on this topic, and reporting bias is likely because of the sensitivity around an SUD diagnosis for practicing physicians; therefore, the true prevalence of SUD among physicians is unknown. Physicians experience several risk factors for the development of SUDs, including high levels of work-related stress; exposure to illness, trauma, and death; and untreated depression or other mental illness.4 With evidence-based treatment and peer and professional support, physicians who have an SUD can recover their health and continue meaningful careers in medicine.

Impairment vs. Illness

Physicians are considered safety-sensitive workers. Health systems, medical licensure boards, and physician health programs may work in tandem to ensure public safety while assisting ill and impaired physicians. The primary purpose of categorizing physicians as safety-sensitive workers is to protect patients from any undue harm that might be caused by the health care professional who has not yet received help for a potentially impairing medical condition. Impairment is a functional classification; an impaired physician is one who is unable to care for patients safely and effectively. A physician with an SUD is an individual with an illness, but this alone does not qualify as impairment. Physicians who are impaired by an SUD should be identified and offered assistance; this process often requires the expertise of a physician health program. An SUD does not always indicate impairment, but without treatment it typically leads to loss of clinical competency and several personal and professional problems.5 With intervention and treatment, such problems may be prevented or resolved. The American Society of Addiction Medicine issued a public policy statement in February 2020 about physicians affected by SUDs. The statement addresses key points such as the need to individualize treatment, appropriate management of relapse, and patients' right to privacy. It also provides helpful guidance for those in leadership positions within their health care systems.6

Recognizing Impairment

Impaired physicians may present late to care, often under duress. It can be difficult for colleagues to identify impaired physicians.7 Signs and symptoms may include an accumulation of personal difficulties, including home life disruption, isolation, erratic moods, and increasing interpersonal conflicts at work. Changes in physical appearance, work hours, and unexplained absences may also indicate an impairment from an SUD. In addition, classic signs of opioid withdrawal (agitation, anxiety, sweats, complaints of abdominal pain, noticeable mood changes) or alcohol withdrawal (tremor, sweats, agitation) may be noticed at work.

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Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to afpjournal@aafp.org. Materials are edited to retain confidentiality.

This series is coordinated by Caroline Wellbery, MD, associate deputy editor.

A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside.

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