Healthcare professionals are not immune from alcohol use disorders. Any use of alcohol by health care providers is a danger to the patients they are treating. Because patients’ lives are dependent on the ability of medical professionals to think quickly and rationally, it is imperative that medical professionals not use alcohol excessively. However, this is not always the case. Students and residents are under the immense pressures of medical education and training. Practicing providers are under constant stress to perform at high levels, and alcohol can be a mechanism to cope with stress (Yancey & McKinnon, 2010).
Alcohol Use Problems in Health Professionals
Substance use among healthcare providers has long been identified as a significant issue (Bakhshi & While, 2014). Alcohol use rates among health professionals are high, with 10%-15% of all health professionals exceeding limits at some point during their careers. Certain medical professions report a higher rate of alcohol use. ER physicians, physicians in practice alone, and psychiatrists are three times more likely to have excessive alcohol use (Baldisseri, 2007).
Compare the rate of alcohol use disorder in the general population of age 18 and over of 7.6 percent of men and 4.1 percent of women (NIAAA, 2019).
Excessive use by a healthcare provider can impact their attitude in treating patients with alcohol use disorder. In 1973 the AMA requested state medical societies monitor and treat physician substance abuse (Galanter et al., 2007). It is important that providers be monitored for their potential abuse issues as they can have detrimental effects on patient treatment.
Medical Student Alcohol Use
Overall use of alcohol in medical students (91%) (Ayala, 2017) is substantially higher than that seen in the general population (56%) as measured by the 2017 National Survey on Drug Use and Health (NSDUH) data on young adults aged 18 to 25 with past month alcohol use (NSDUH, 2018). A study found that ⅓ of medical students fit criteria for binge drinking and over ¼ used cannabis in the past year (Ayalal, 2017).
Physician Alcohol Use
In a study of over 7000 physicians, alcohol use disorder was more common than the general public: 12.9% of male and 21.4% of female physicians met diagnostic criteria for the older versions of this diagnosis (Oreskovich, 2015). The problem of alcohol use as a coping strategy continues in practicing physicians. For practicing physicians, obtaining privileges of a license almost always requires disclosure of treatment; such requirements further hinder seeking treatment prior to or in practice.
Nurse Alcohol Use
Alcohol use disorder appears to be a little less common than in the general population (Kaliszewski, 2019). However, around 10% of nurses will misuse drugs or alcohol during their careers at some point (Kunyk, 2015). Nursing involves several stressors and other risks that contribute to substance use problems: access to controlled substances, psychological/emotional stress from the work, lack of education regarding substance use, and physical stress, fatigue and pain (Kaliszewski, 2019). The frequency of substance use problems varies with the nursing specialty (NCSBN, 2011). Emergency room nurses have high rates of substance use problems. Nurse anesthetists have high rates of controlled substance use. Oncology nurses have a higher rate of alcohol consumption than other specialties. Smoking is higher among psychiatric nurses and cocaine use is more common in critical care nurses. Pediatric nurses are fairly low for substance use on average.
Burnout and Alcohol Use Problems
Burnout correlates with alcohol and substance use problems (Jackson, 2016; Oreskovich, 2015).
- Medical students: In one study, ⅓ of medical students had symptoms of alcohol abuse/dependence and that use correlated with the burnout domains of emotional exhaustion and depersonalization (Jackson, 2016).
- Physicians: Of approximately 6600 physicians self-identified as having burnout in a survey of over 15,000 physicians, 23% said that they cope using alcohol (Kane, 2019).
- Nurses: A study of registered nurses found that typical 12-hour shifts are likely to lead to burnout and poor overall health.9 Some nurses may resort to substances to provide relaxation after a long and grueling day of work.
Stigma
The medical community at large has not always been forthcoming about individual provider substance use, despite the fact that physician addiction has been reported as early as 1869 (see review by Merlo & Gold, 2008). Fear of being professionally stigmatized because of alcohol use may prevent some health professionals from seeking needed treatment. This creates a dangerous situation for patients and leads to a higher likelihood of mistreatment.
Getting Help for Colleagues
Impairment among health professionals has the potential to impact the practice of other health professionals who are interacting with them in a multidisciplinary team. If you suspect your colleague has an alcohol use problem, you can seek to get them the help they need. Interestingly, addicted physicians that participate in a Physician’s Health Program experience higher success rates (measured by testing negative for alcohol or drugs) than physicians who attended other types of rehabilitation programs (DuPont et al., 2009). Health care providers may be sent to this type of treatment as a result of peer reports, as well as complaints from patients or family members, but they may only be in the pre-contemplative stage of change, which opens the possibility of relapse. Please see the Related Resources section for a review of the Stages of Change Model. Successfully monitoring your colleague and taking an interest in their recovery will lend support they may need to continue improving. However, some providers are reluctant to report their colleagues for fear that their own financial and occupation status may be in jeopardy (Yancey & McKinnon, 2010).
The legalities and ethics involved in reporting a colleague are beyond the scope of this content. They are well discussed in many other sources. See, for example, the article by BA Johnston, “Dealing with the Impaired Physician”, linked at the end of this content in Resources.
Treatment Options and Outcome
Treatment for excessive alcohol use is usually comprised of detoxification, along with psychiatric and medical evaluations, leading to ongoing rehabilitation (Yancey & McKinnon, 2010). Other components that can be included are immediate intervention, placement in an appropriate facility, uninterrupted therapy, rapid re-entry into practice, close monitoring, and a contingency plan. This type of situation may provide a stable support system with peers, which aids in recovery. Those who do not voluntarily enter into this type of rehabilitation program are often referred to an inpatient program as a preventative measure against putting their own patients in unnecessary harm. Within 5 years of admittance into a program, 78% of physicians were licensed and working in their specialty. In case reports, physicians say that returning to work can be awkward, but their partners are eager to see them return and people are generally supportive.
Impairment on the Job
Impairment among health professionals is defined as not only being unable to practice within “acceptable standards of practice”, but also the inability to provide medical services without flaws in professional judgment (Baldisseri, 2007). It is important to recognize alcohol impairment among health care providers as it can negatively impact patient health as well. The health professionals may downplay their own use, because they are well-aware what is/is not healthy use and feel they can control their levels (Baldisseri, 2007). However, being under the influence of alcohol while on duty can create dangerous circumstances for both the patient and the provider’s colleagues as well.
Personal Use Impacts Screening Techniques
Interviews of health professionals who admitted drinking shows that their own use may cloud their ability to effectively screen patients. Some of the General Practitioners interviewed would only screen for or identify a patient’s level of use as high if the patient was consuming more than the physician (Kaner et al., 2006, Frank et al., 2008). Using their own use as a measuring tool is not an appropriate approach to patient screening and can result in inaccurate patient assessments and inadequate treatment. Additionally, physicians who consume more alcohol are less likely to counsel patients on alcohol use. Also, health care providers may be hesitant to teach about alcohol reduction among patients when they themselves engage in the same sorts of behavior (Kaner et al., 2006). This puts patients in danger, because they cannot be properly identified as having an alcohol use problem if the provider has one as well.
Resources
Success Story: A Physician Coming to Terms with Alcoholism. Massechusetts Medical Society article, 2018.
Physician Impairment. Chapter 7 in Emergency Medical Residents Association Wellness Guide. Defines impairment, offers several brief cases, how to recognize it, what to do/when to report it.
Candilis PJ, Kim DT, Sulmasy LS. Physician Impairment and Rehabilitation: Reintegration Into Medical Practice While Ensuring Patient Safety: A Position Paper From the American College of Physicians. ACP Ethics, Professionalism and Human Rights Committee.Ann Intern Med. 2019 Jun 18;170(12):871-879. doi: 10.7326/M18-3605. Epub 2019 Jun 4.
PMID: 31158847. Free Journal Article: A position paper by from the American College of Physicians.
Johnson BA. Dealing with the Impaired Physician. [Curbside Consultation] Am Fam Physician. 2009 Nov 1;80(9):1007-1008.
International Doctors in Alcoholics Anonymous
Association for Medical Education and Research in Substance Abuse
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