Health Profession as a Risk Factor for Psychoactive Substance Use

Abstract

The concepts of addiction and substance abuse are not new, but historically, the medical community has been reluctant to accept and publicly acknowledge addiction, particularly of its own members. As a result, there have been relatively few reports in the medical literature. Most of the literature on substance abuse consisted of anecdotal reports. Historically, addicted physicians either went unnoticed or were treated punitively. As early as 1869, Paget reported on a group of medical students and mentions physicians impaired by “habits of intemperance.”

Much progress in neurobiology has provided a useful neurocircuitry framework with which to identify the neurobiological and neuroadaptive mechanisms involved in the development of drug addiction. The brain reward system implicated in the development of addiction is composed of key elements of the basal forebrain with a focus on the nucleus accumbens and central nucleus of the amygdala.

Illegal addictive drugs can lead to functional or structural impairment of the central nervous system. Pathomechanisms include excitotoxicity, which may lead to an acute or subacute leukoencephalopathy, and vascular complications, including vasoconstriction, vasculitis, or hypertension, which may lead to intracranial hemorrhage or ischemia.

Both genetic and environmental variables contribute to the initiation of use of addictive agents and to the transition from use to addiction. Addictions are moderately to highly heritable. Family, adoption, and twin studies reveal that an individual’s risk tends to be proportional to the degree of genetic relationship to an addicted relative.

The development of substance misuse problems in doctors cannot be reduced to a single factor. A number of studies have reported high rates of psychological and psychiatric problems including anxiety and depression. Personality problems, stress at work, family stress, bereavement, an injury or accident at work, pain and a non-specific drift into drinking have also been cited.

The causes of physician addiction are not fully understood, although it appears that many factors can contribute to the development of this disorder. For example, the ready access that physicians have to drugs and their ability to self-prescribe have been suggested as potential pathways to addiction. Indeed, despite the fact that physicians are less likely than the general population to smoke cigarettes or use alcohol or illicit drugs, rates of prescription drug abuse are higher among physicians. Currently, more attention is being paid to this important issue, particularly within the field of anesthesiology. Yet, not all physicians who have an addiction disorder abuse prescription drugs.

Another sex difference found from a study was that more male physicians were likely to have behavioral, professional boundary, substance abuse, or substance abuse with psychiatric problems. The higher prevalence of male physicians with behavioral and professional boundary problems may be due to differences in personal traits of men and women. Stereotypical masculine traits of higher aggression, independence, and more controlling behavior were found to be more prevalent in men. Women may act aggressive as well; however, their actions may be masked by indirect aggression or in a retaliatory manner and thus less observable.

Several specialties were found to have preferences for specific substances: emergency physicians were twice as likely to use marijuana as all physicians ; a strong association was found between psychiatrists and benzodiazepine use ; for minor opiates family practitioners (24%) and obstetricians/gynecologists (20.5%) had a significantly higher prevalence than all physicians (17.6%). Small numbers reported major opiate use and cocaine (1.1% each for all physicians); this precluded detailed statistical analysis. However, the trend was for higher major opiate use among emergency medicine physicians, anesthesiology(11%) and chronic pain specialists.