The prevalence of chemical dependency (excluding nicotine) among physicians has been estimated to be 10 percent to 15 percent, similar to that in the general population, according to background information in the article. Following completion of primary treatment, recovery is best achieved through continuing group therapy and regular attendance at mutual help groups. Data on the incidence of relapse and risk factors contributing to the likelihood of relapse after initial treatment for substance use are lacking.
Karen B. Domino, M.D., M.P.H., of the University of Washington, Seattle, and colleagues conducted a study to identify factors that might predispose individuals to relapse. The study included 292 health care professionals enrolled in the Washington Physicians Health Program, an independent post-treatment monitoring program. The participants were followed up between January 1, 1991, and December 31, 2001.
Twenty-five percent (74 of 292 individuals) had at least 1 relapse. The researchers found that a family history of a substance use disorder increased the risk of relapse (2.3 times greater risk). The use of a major opioid (e.g., fentanyl, sufentanil, morphine, meperidine) increased the risk of relapse significantly in the presence of a coexisting psychiatric disorder (5.8 times increased risk) but not in the absence of a coexisting psychiatric disorder. The presence of all 3 factors--major opioid use, dual diagnosis (presence of a coexisting psychiatric disorder), and family history--markedly increased the risk of relapse (13.3 times). The risk of subsequent relapses increased after the first relapse (1.7 times increased risk).
"In health care professionals with a substance use disorder, the presence of a coexisting psychiatric illness or a family history of substance use disorder significantly increased the likelihood of relapse, as did the presence of prior relapse," the authors write. "Use of major opioids also increased risk of relapse in the presence of family history and even more dramatically in those with a dual diagnosis, and the combination of all 3 risk factors further magnified the likelihood of relapse. State physician health programs might wish to consider managing substance-using professionals who have one or more of these 3 risk factors and those with prior relapse with more intensive and more prolonged monitoring."
(JAMA. 2005;293:1453-1460. Available post-embargo at JAMA.com)
Editorial: Physician Substance Abuse and Recovery - What Does It Mean for Physicians--and Everyone Else?
In an accompanying editorial, David R. Gastfriend, M.D., formerly of Massachusetts General Hospital and Harvard Medical School, Boston, discusses the findings by Domino et al.
"It remains to be seen how improved detection and better-matched recovery planning will address those with the doubled relapse risk of dual diagnosis and the multifold risk of the triple-threat: dual diagnosis, opioid dependence, and family history. These data suggest that analyzing the trajectories of recovering physicians may improve the knowledge base for anticipating and matching the needs of physicians entering recovery. But retrospective cohort analyses from single states using clinically derived data, while better than no data at all, are inadequate in this millennium. Better data are needed, such as multi-state data from prospective studies with research quality instrumentation. It is time for physician health programs to become formal research programs, or better yet, to form a national research program."
"Individualized monitoring plans and treatment contracts that take into account various risk loadings should improve outcomes for patients with substance use disorders. Success from substance use disorder treatment should be sought and expected not just for physicians but for every patient--but only if the conditions available for physician recovery can be provided to all. These 'ifs' are pivotal: if intervention occurs early, if structure is provided as well as support, if treatment resources are provided as if a life and career matter, and if close monitoring and treatment matching are provided with active treatment intervention and escalation to meet the clinical need. Surely this type of care is costly. Why should such high-quality care be provided? Because a brain disease that subverts self-preservation is a disease nonetheless, and helping patients recover from this disease can save lives, families, and productive careers," Dr. Gastfriend concludes.
(JAMA. 2005;293:1513-1515. Available post-embargo at JAMA.com)
Editor's Note: Dr. Gastfriend is now vice president of medical affairs, Alkermes Inc., Cambridge, Mass. He receives support through a grant from the National Institute on Drug Abuse.
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