Case Synopses
Alcohol
Dr. P is a 60-year-old white male anesthesiologist with a 40-year history of alcohol abuse. Five years ago, he was questioned about alcohol on his breath before starting an 8:00 am case. He immediately took a blood alcohol concentration (BAC) test, which was below detectable limits, and proceeded with the case. Two years later, the operating room staff thought they detected the smell of alcohol on his breath; that time, his BAC was 0.12. Dr. P denied having had anything to drink since midnight but admitted to drinking vodka tonics the night before. He was referred to the state physician’s health program (PHP), where he was evaluated by an addictionologist certified by the American Board of Addiction Medicine. Dr. P successfully completed an intensive outpatient program and then entered into a monitoring agreement with the PHP. He actively participated in the facilitated group meetings and attended 12-step meetings but did not get a sponsor or work the steps. Random urine testing was negative until 1 month ago. Dr. P had had three drinks after his wife retired for the night and was selected for a random urine drug screen the following morning. He notified the PHP facilitator of his relapse before the positive result was reported.
Tobacco
Dr. K is a 62-year-old white male anesthesiologist with a 100 pack-year history of cigarette smoking. He has smoked two packs a day since age 12 and has suffered from chronic bronchitis and chronic obstructive pulmonary disease for at least the past 12 years. He has made numerous attempts to stop smoking—including cold turkey, hypnosis, and nicotine patch—without success. He now believes that he is “too old” to quit. He slipped on a wet floor in the operating room last week and fell against the anesthesia machine. Since then, he has had left-sided chest pain at the site of the impact and had a lateral chest film taken today. He read the film himself and saw a cavitating lesion in the right upper lobe.
Cannabis
Dr. B is a 28-year-old black male anesthesiologist who joined a prestigious private practice after finishing his chief residency at a major university anesthesiology program. He immediately became a favorite of many surgeons and operating room staff. He was seen smoking cigars on his way home on a number of occasions. After 6 months in private practice, he purchased a new car that was valued at over $100,000. The following Friday, after finishing his cases and leaving the hospital, he was arrested for misdemeanor possession of marijuana and drug paraphernalia after a police officer saw his car pulled to the side of the road. Dr. B was caught with six rolled “joints.” The incident was discovered by his partners within 24 hours, and he was given the option to self-report to the state PHP or have his partners report him to the state Board of Medicine. He was evaluated and found to have a long history of polysubstance dependence that had evolved into cannabis dependence and alcohol abuse. He was treated in a long-term residential treatment program and entered into a 5-year monitoring agreement with the PHP. His license was placed on probation for 2 years after treatment and then restored to unencumbered active status. He returned to private practice after completing residential treatment.
Cocaine
Dr. W is a 44-year-old white male anesthetist who was reported to his state PHP after being seen snorting a white powder, presumed to be cocaine, in the men’s room during the hospital Christmas party. He was contacted 2 days after the party and denied any drug abuse. A urine drug screen was requested immediately, and Dr. W reluctantly complied. It was positive for benzyleconine, a cocaine metabolite. Dr. W was not allowed to continue working and, after reporting to his state PHP, had an evaluation by an addiction psychiatrist and was admitted to a residential substance abuse treatment program. After successfully completing the formal program, he entered into a 5-year monitoring and advocacy agreement with the state PHP.
Problem Analysis
Definition
Nonopiate abuse and dependence are common among health care professionals. Alcohol and tobacco are the most commonly abused chemical substances, but marijuana is the most commonly abused illicit chemical substance in the general population.
It is widely believed that tobacco, alcohol, and marijuana are the most commonly abused substances among physicians. Alcohol dependence appears to be as common among physicians as among their age-, sex-, and socioeconomic-matched controls. Cannabis abuse is common among medical students and younger physicians; however, with the aging baby boomers and the recent changes in state laws related to cannabis, the incidence in older physicians is rising. Alcohol dependency is more common among older physicians. Although the abuse of other illicit or licit substances, such as cocaine, is not as prevalent, it may cause significant impairment and have detrimental effects on the lives of health care providers, their patients, and their families. Although the diversion and abuse of prescription drugs by physicians and other health care personnel are also a concern, this problem is not discussed here.
Substance use disorders can have a number of negative effects, including severe medical and legal implications. Chemical dependence can impair function in relation to acute intoxication, drug-seeking behavior, chronic dependence, and substance withdrawal. In this chapter, we focus on the recognition of nonopiate dependence—specifically alcohol, tobacco, marijuana, and cocaine. Also, we consider behaviors associated with such substance use, the diagnosis of dependence, its implications, and the management and prevention of substance dependency.
Recognition and Risk Assessment
Diagnosis
Several screening tests are available for the diagnosis of substance abuse, such as the CAGE and AUDIT programs for alcohol; these have now been modified for marijuana abuse. Clinical diagnosis of substance abuse is often difficult because denial and lying are part of the disease of addiction. Denial is the hallmark of many initial clinical interviews. Physicians may admit to use, but only on occasion. They may quote the New York Times or High Times to defend their use, as opposed to a respected medical, addiction, or psychiatric text or journal. They may actually say that marijuana smoke is not dangerous to one’s health and deny any similarities to tobacco smoking or secondhand smoke. Among health care professionals, direct observation of drug use, possession, inappropriate procurement of drugs, or signs and symptoms of intoxication or withdrawal can help make the diagnosis. The diagnosis of a substance use disorder is based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. The medical history and physical examination, along with confirmatory laboratory testing, are useful for diagnosis. Although there could be other reasons for changes in personality, family problems, infertility (males), withdrawal from social activities, and impaired ability to perform professional duties, a positive drug test moves a substance use disorder to the top of the differential diagnosis.
Physicians rarely refer themselves to addiction specialists for drug abuse or dependence problems. Laboratory testing is the gold standard for confirming substance use and is also helpful during treatment. Drug testing cannot detect all marijuana, cocaine, or other illicit drug users, however. Random testing does not detect all substances of abuse and may not detect infrequent use. For example, even daily users have only a 50% probability of testing positive in any given month when urine testing is done eight times per year. Urine testing is standard for the evaluation and treatment of substance abuse; detection times for some common drugs of abuse are given in Table 3.1 . There have also been advances in the testing of other biologic substrates, including hair, nails, sweat, and oral fluid. Thin-layer chromatography and enzyme-linked antibody testing are the most comprehensive, inexpensive, and widely used drug screening tests, but combined gas chromatography with mass spectroscopy for confirmation is the gold standard for drug testing. Marijuana impairment must be diagnosed with blood tetrahydrocannabinol (THC) concentrations because the usual test for cannabis use screens for THC metabolite, which may remain positive for weeks after regular use. The window of detection for alcohol use may be extended from hours to several days by testing for alcohol metabolites ethylglucuronide and ethyl sulfite in urine. True random drug testing should be a mandatory part of all health care provider health programs.
| Substance | Detection Times |
|---|---|
| Amphetamines | Up to 24 hours |
| Barbiturates | 5–10 days |
| Benzodiazepines | 5–7 days |
| Cannabinoids | 1–3 days; greater with chronic use |
| Cocaine | 1–3 days |
| Opiates | 1–3 days |
| Phencyclidine | Up to 3 days |
Laboratory tests may also help in the diagnosis of a chronic substance abuse problem, but they are usually performed late in the course of the disease. Heavy consumption of alcohol (e.g., one bottle of wine a day) for a few months almost always results in macrocytosis (mean corpuscular volume between 100 and 110 fL), even before anemia occurs. Alcohol-related liver disease may be reflected in abnormal serum γ-glutamyltransferase, aspartate transaminase, and alanine transaminase levels. In fact, unlike in other liver diseases, aspartate transaminase may be more than two times greater than alanine transaminase when alcoholic hepatitis is present. The Food and Drug Administration has also approved a test that measures serum carbohydrate-deficient transferrin to identify long-term excessive alcohol use.
Alcohol and Tobacco
Symptoms of alcohol or tobacco dependence include the following:
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Impaired control over use
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Preoccupation with obtaining the substance
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Continued use, despite adverse consequences
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Distorted thinking, especially denial of substance dependency
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Development of tolerance to the effects
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Withdrawal symptoms when use is discontinued
Although no specific constellation of symptoms is specific for the diagnosis of alcohol use disorder, physical examination findings consistent with alcohol abuse are elevated blood pressure, evidence of physical harm from falls or accidents, tremors, obstructive lung disease (due to concurrent tobacco use), and unexplained tachycardia, hepatosplenomegaly, or peripheral neuropathy. In contrast to alcohol, the health consequences of tobacco dependence generally take years to develop and are related primarily to lung cancer or chronic pulmonary disease. Quitting smoking has immediate positive health effects, reduces the risk for adverse consequences over time, and increases the smoker’s life expectancy (see http://www.cancer.org for more details).
Cocaine
A number of clinical and behavioral signs and symptoms of cocaine use are usually evident. Some are related to acute intoxication, and others appear after chronic use or during withdrawal ( Table 3.2 ). Although cocaine is more commonly abused as a “street drug” (snorted as powder or smoked as crack), it is also used medicinally as a topical anesthetic and vasoconstrictor (e.g., in awake oral or nasal intubation as well as ear/nose/throat surgery and rarely as a topical local anesthetic in combination with tetracaine and adrenaline). If so, health care professionals may have access to unadulterated cocaine, similar to fentanyl and other highly potent narcotics. Street cocaine is often adulterated or “cut” with other substances that have the potential to cause additional harm.
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