Patients in white coats

“Sometimes I’d be in the operating room and it would look like I had the flu. So I’d excuse myself and run to the bathroom, take 10 (Tylenols with codeine), and in maybe five or 10 minutes I was back to normal,” described Richard Ready, former chief of neurosurgery at a prominent Chicago hospital.

 

It is not a rare event: about 32,000 physicians are addicted to alcohol or drugs, making up eight percent of all physicians, according to estimates in Germany. There are no figures for Austria. In the USA, the American Medical Association even assumes that one in eight physicians could be addicted. The number of unreported cases is probably much higher, because addiction among physicians is highly stigmatized.

This is one of the reasons why anonymous reports of addicted physicians rarely circulate in public. When they do, they speak of using alcohol, cocaine, fentanyl, tilidine, or morphine to get high while on duty or to come down afterward.

Alcohol or medication is meant to dampen frustration, pressure and anxiety. After all, the daily work of many physicians is stressful. Added to this are high self-demands and, not least, many addictive substances — drugs, painkillers and narcotics — within easy reach. This toxic cocktail means that medical professionals are twice as likely to become addicted as the general population. In the worst case, this can even end in suicide.

One of the few who has taken on this problem and has long advocated an inpatient facility for addicted physicians is the Viennese psychiatrist and psychotherapist Michael Musalek, former medical director of the Anton Proksch Institute, a therapy center for the treatment of addictions.

medinlive: What treatment options are currently used by addicted medical professionals?

Musalek: When medical professionals are treated in addiction clinics, it is usually at a very late stage. Then, when it is already known in the environment. The big problem with addiction is not the addiction itself, but the significance of the addiction. In the beginning, the addiction is not visible to the environment, and the addict naturally tries to hide it, precisely because of stigmatization. And especially at this time it would be good to start treatment early, the earlier you treat, the better the prognosis. Medics come into treatment late, at a time when everyone has already noticed that they are addicted, and then it is usually already a very advanced problem, and therefore the prognosis for treatment is usually worse than for patients who are treated early…

 

medinlive: Initially, addicted medics can be treated on an outpatient basis?

Musalek: In the long term, addiction treatment is always outpatient treatment. With some addictions, inpatient treatment is also needed if the withdrawal syndrome is very strong or in order to be able to take someone out of their pathogenic milieu or because there are comorbidities, both physical and psychological, that simply require intensive treatment. In terms of withdrawal treatment, there are many differences in the different forms of addiction. With alcohol, 80 percent of withdrawals can be done on an outpatient basis. Only 20 percent need inpatient treatment. It’s completely different with drug or tranquilizer addiction. Here we have a ratio of 90:10; inpatient treatment is practically always needed, and only in very few exceptional cases is it possible to carry out purely outpatient withdrawal treatment. This is due to the fact that withdrawal is much more protracted here, and it is also more difficult because withdrawal symptoms occur during withdrawal that are similar to those that actually led to the use of the addictive substance. As a rule, drug addiction is an attempt at self-treatment, which makes it correspondingly difficult to get rid of it.

medinlive: Now, drug addiction is generally higher among physicians — also because of the easy availability.

Musalek: The same addictions exist among physicians as among everyone else, but the availability of the addictive substance virtually drives the addictive disease. The more readily available an addictive substance is, the more it is taken, the higher the dosage, the more addicts there are. And now, in contrast to others, there are some addictive substances that are simply more accessible to medical professionals. Alcohol is accessible to everyone. They can buy it 24 hours a day at the gas station. To get drugs, patients have to go from one doctor to another, we talk about doctor shopping. Doctors are simply closer.

medinlive: Besides availability, what other factors can you identify specifically for physicians that can result in addiction?

Musalek: An addictive disease never develops on its own. There is no addiction disease where other mental illnesses or pronounced psychosocial problems do not also play a role. We know that there are people who are attracted to professions that require a high value system and who make high demands on themselves, such as medical professions. The people who choose such professions are more predisposed to overextend themselves. And then there are also occupational areas in which overstraining — both psychologically and physically — is the order of the day, so to speak. We see this particularly in the case of medical professionals, physically, for example, due to the night duty situation and the constant expectation of availability from outside, and psychologically due to the massive pressure of having to reckon with possibly drastic consequences in the event of mistakes. Accordingly, these people are under enormous pressure.

medinlive: In the past, you have spoken out in favor of an anonymous, inpatient facility for the treatment of addicted physicians. Why?

Musalek: The necessity becomes clear when you consider that we have a professional group here that is medically very poorly or under-supplied, because the threshold to go into treatment is exorbitantly high, and unfortunately we do not have an inpatient facility in Austria that specializes in this. It would be good to have clinics here where you can have inpatient treatment without it already being clear for what reasons you are going into treatment, or that it is not known that you are going into treatment. Attempts that I have started here have unfortunately not been successful. There is such a model in South Tyrol in Bad Bachgart. This is an addiction clinic that is also a burnout clinic.

You can be admitted there for burnout and be treated for addiction at the same time. This is a common combination anyway and would therefore be a good way to go. In this model, other mental illnesses that are already substantially more recognized by the public will then also be treated. The most widely recognized illness today is burnout. Depression, which often occurs in the context of burnout, is already much less recognized. The disease that is the least recognized of all is addiction. This goes so far that some even think it is not a disease at all. For example, addictive disease is explicitly excluded in all private insurance policies — a relic of a time when addictive disease was seen as self-inflicted rather than a disease.

The other would be a clinic that is hermetically sealed, where there is almost no way for data to get out. Addiction treatment could be financed by the clinic itself, or it could be given a financial budget from the public purse, without having to disclose personal data. Such facilities exist in Spain and Norway, for example. They are for physicians and other underserved groups who are in the public eye or work in neuralgic areas such as politicians. For these professional groups, there are fewer overall treatment options available and they therefore have a much poorer prognosis.

medinlive: Are there projects in Austria that address this problem?

Musalek: There is a project in Lower Austria that tries to treat people anonymously, but it is not an inpatient project. I can also treat patients in the burnout outpatient clinic in the Rudolfinerhaus, but it is not a comprehensive outpatient clinic, but a very specialized one and only on a private basis. Anonymity is also only guaranteed to a certain extent here, because a personalized medical record has to be created. If you go to the Anton Proksch Institute, it is absolutely clear that you have an addiction disease, because otherwise you cannot be admitted there. And you can’t expect doctors to be admitted as patients and meet all their patients there. But you could certainly also set up a burnout ward in a conventional addiction clinic, or an inpatient facility for work addiction. It has been suggested and discussed several times, but it has not yet been possible to implement it.

medinlive: If you now look at models from abroad. How great is the danger of losing one’s license to practice medicine if a physician were to be admitted there?

Musalek: The idea behind the facilities is that you can be admitted and treated without informing the responsible authorities, chambers or institutions that could say something negative. The withdrawal of the license to practice medicine is not related to the addiction, but to what one does in the context of an addiction. Doctors are not disbarred because they are addicted, but when they have committed acts that endanger patients. The Austrian Medical Association makes a precise distinction here. The main problem, however, is that addiction is a highly stigmatized disease, and this is particularly the case among physicians. If the patients know that the doctor is addicted, then this certainly does not promote trust.

medinlive: Which doctors are more inclined to become addicts?

Musalek: As a rule, very good physicians become addicted because they place very high demands on themselves, easily overtax themselves and then need the appropriate doping agents to be able to get through these overtaxes. Many addicts are excellent, high-performing people in their profession. It is an extreme loss to the medical system not to treat these people in a targeted way.

medinlive: Did the situation change in the Corona pandemic? Has there been a change in the type of addiction, for example?

Musalek: What we can already say is that alcohol consumption is increasing and, by the way, so is nicotine consumption. This is also shown by the data from an online survey conducted for this purpose. If consumption increases, then problem consumers and addicts will also increase. A statistical evaluation of the number of alcoholics does not make much sense at present, because it takes a certain latency before one becomes addicted. One does not become addicted to alcohol within a few months. It takes years of consumption to become addicted, so we won’t see these effects until later. But what we also see is that people no longer come to outpatient treatment on a regular basis. Here we know that there is a direct correlation between the frequency of relapse and the regularity of treatment.

If someone goes to treatment regularly, then the chance that he will stay abstinent is about 80 percent. If he doesn’t, the chance of lasting abstinence is only about ten percent. This means that we have to expect that there will be many more relapses of the disease if patients do not continue treatment regularly. And that is also what we see in clinical practice. Patients stay away because they withdraw, in general, or because they are afraid that they might get infected in an outpatient clinic. This usually accentuates and exacerbates the problem of addiction.

Despite their knowledge of the risks and treatment options of substance use disorders, physicians are not immune to them. On the contrary, a number of studies have shown that physicians have an increased risk of burnout, depression, and dependency disorders, especially abuse and dependence on alcohol and medications, due to the psychological and physical stresses of their jobs. In addition, the relatively uncomplicated access to psychoactive drugs, especially hypnotics, analgesics and benzodiazepines, results in a higher proportion of addicted physicians compared to the general population. However, the prognosis is good. According to figures from the medical associations in Germany, three quarters of those affected for the first time can be helped while retaining their license to practice medicine and their jobs. (Addictive disorders in physicians 2020)

medinlive: What do you see as an obstacle and motivation for physicians to seek help?

Musalek: The problem is that wherever an illness leads to extreme consequences, there are no appropriate treatment options or such treatment is not accepted. Attempts are then made to conceal the disease, which also affects the patient’s environment. A step towards destigmatization could be a treatment facility that focuses on anonymity.

medinlive: Are future doctors prepared for this topic — for example, during their studies?

Musalek: Unfortunately, the stresses to which physicians are exposed, or how to deal with them, are not a topic of study. That would be something that should definitely be integrated into the studies. Namely, that one becomes better acquainted with a goal-oriented approach to this profession, which ultimately often endangers itself. Like every craftsman, for example, learns how to deal with moments of danger in his profession. In the medical field, however, it is usually just learning by doing. You think: You’re psychologically so strong anyway that you can take it all. But just being confronted with death or severe suffering on a daily basis, or having to constantly give people bad news, requires a special kind of psychological stability and knowledge: How far can I push myself, when do I notice that I am overburdened and how can I counteract this? And above all, prophylactic measures are needed.

The second is that we need facilities where people can get specific help when they are under stress. I think there is also a need for facilities, doctors for doctors. And what has been said here also applies to nursing staff in particular. There is also a need for more opportunities for supervision and targeted preventive measures. And last but not least, we need facilities for those who have failed. This trio would be ideal. An addictive disorder practically never arises out of a joke. Addiction always starts with a disastrous development or a severe overload. This can be a life event, but mostly it is a chronic life situation that can no longer be coped with.

medinlive: The topic of addiction is already present in your studies.

Musalek: Studying is a great challenge, in terms of the amount of material, but also in terms of the subject matter itself. If you’re constantly dealing with diseases, there’s hardly anyone who doesn’t suspect they have one, and you have to learn how to deal with that, too. If you are confronted with it every day in your professional life, you need mechanisms to deal with it. Simply negating “I don’t get sick, only the patient gets sick” is not an effective way to prevent suffering. If one does nothing against chronic suffering, then it becomes stronger and stronger. Addictive substances are then used as a quick remedy. Because addictive substances — we must not forget — are outstanding in their effectiveness, which is what makes them so dangerous. They only help in the short term, but in the long term the suffering comes back like a boomerang, in the form of the addiction.

medinlive: What signs in the daily routine of a practice or clinic could indicate an addictive disorder?

Musalek: The central phenomenon is the loss of control. When I can no longer control the intake and it becomes regular. For example, with alcohol: If it becomes regular, if you don’t have alcohol-free days, if you resolve to drink less but don’t manage it, then a danger factor is to be expected. The same applies to medication. If I notice that I need the medication regularly in higher and higher doses, then I am already at the beginning of the development of addiction.

medinlive: Do doctors perceive addiction differently because of the professional approach?

Musalek: That varies greatly from person to person. Most addicts can pinpoint very precisely when they were no longer able to handle the addictive substance in a controlled manner. In this situation, they themselves try to gloss over their consumption. Then comes a phase where you know: This isn’t working, but I can’t manage to go into treatment. With alcohol, this period lasts between three and eight years on average. Unfortunately, the threshold for treatment is very high and particularly high among medical professionals. We have to distinguish between three stages here: When did the addiction start, when do you admit it to yourself, and when do you go into treatment. If we now had a special facility, we could shorten this second phase considerably. The first phase is related on the one hand to the attitude “only others get sick” and on the other hand to the high level of stigmatization. Education and anti-stigmatization measures would help to shorten it

medinlive: Which addictions would you most likely locate in the medical profession?

Musalek: Alcohol is the number one drug and also the number one among physicians. Nicotine addiction is still more common, even though the numbers here have declined significantly. In addition, medications also play a role because of their easy access, as do opiates for a much smaller group. With cocaine, the number of unreported cases is extremely high. In private practice, I treat an abundance of addicted physicians, mainly because they know that there is a great deal of anonymity here. Alcohol and drugs play the biggest role for them, cocaine and morphines rather a marginal role. We estimate that there are 300,000 alcoholics and 200,000 to 250,000 drug addicts in the Austrian population. Where we have the most reliable data, because almost everyone who is addicted comes into treatment sooner or later, is in the area of opiates. We have to assume that there are about 30,000 addicts in Austria. Among physicians, the percentage of opiate addicts will be a bit higher compared to the general population, because of the better availability of the addictive substance. As a doctor, you can prescribe it yourself, so to speak, and thus have direct access to the addictive substance, while non-physicians are almost exclusively dependent on the illegal black market.

medinlive: Are there mechanisms or programs in the area of self-prescription to control the prescription of drugs?

Musalek: According to the Narcotic Drugs Act, every prescription and every use must be recorded, and this is also strictly controlled. But the chance of preventing addiction via control is not very great. You can curb the availability somewhat, but to prevent something completely with control mechanisms is not possible. Even during Prohibition, when alcohol was banned, people drank. The number of alcoholics decreased, but criminalization increased accordingly.

medinlive: Do addictive diseases manifest themselves differently in the medical profession than in the general population? For example, that suicides are more frequent as a consequence?

Musalek: Suicides or suicide attempts are more frequent in the group of physicians, anesthesiologists and psychiatrists are the top group here. Of course, this is due to the fact that these are particularly stressed occupational groups. But it also has to do with the fact that anesthesiologists have many suicides with fewer suicide attempts because they choose particularly safe methods. With psychiatrists it is related to the fact that this topic is a permanent one in their specialty. Thus, it is not something foreign that is not even considered. In addition, the chance of suicide is much higher when suicides occur in the environment. This phenomenon is also called the Werther effect (when more suicides occur as a result of a suicide known from the media, literature or film, note). Someone who constantly has to deal with suicide attempts is thus at higher risk. Under chronic alcohol influence, the risk of suicide is increased ten to 15 times, because alcohol is a depressogenic and at the same time disinhibiting substance. Unfortunately, this is an ideal prerequisite for suicide. When inhibitory mechanisms fall away and a depressive mood prevails, this is unfortunately an ideal breeding ground for suicide attempts.

medinlive: What recommendations would you give to medical professionals to seek help for which signs?

Musalek: The first thing is to accept that you can also become mentally ill yourself. This is an essential basic attitude that everyone should be taught, even during their studies. There is a need for appropriate teaching content, where future doctors learn how to deal with this. The second thing is to take the early signs seriously, not only in patients, but also in oneself. The third thing is, if you notice that you are mentally ill, you should go to a specialist facility where you know that the problem will be treated professionally but also discreetly, ideally anonymously, where you can open up and start treatment. Today, this is quite possible in the private outpatient sector, but it is much more difficult in public outpatient clinics because anonymity can usually no longer be maintained here, and in the inpatient sector in Austria it is virtually impossible.

medinlive: What would you like to see in general with regard to this topic?

Musalek: What I would wish is that mental illness in general and addiction in particular is simply seen as any illness. It would be nice if addiction were put on the same level as all other illnesses, be they physical or psychological. It would be nice if we in our society could simply see addiction as a chronic disease like any other,

One successful program in the U.S. is the Bradford inpatient clinic in Alabama, where doctors from all over the U.S. make pilgrimages. Dr. Michael Wilkerson, Bradford’s medical director, explains this by saying that other doctors are treated as well. One of the biggest challenges for any drug or alcohol addict is overcoming the guilt and shame associated with addiction. “Physicians generally have high expectations of themselves. They need to know they are not alone,” he said. Sharing a house with 15 other doctors and supporting each other at group meetings reinforces this. The addiction clinic works hand-in-hand with state programs that provide five years of drug testing, and because doctors can lose their licenses if they relapse, the program is especially effective. Physician health programs are typically funded by physician licensing fees, grants, and private donations.

The Viennese psychiatrist and psychotherapist Michael Musalek is internationally regarded as one of the most renowned addiction experts. He was medical director of the Anton Proksch Institute and is now full professor of general psychiatry, the medical faculty of Sigmund Freud University in Vienna, head of the Institute for Social Aesthetics and Mental Health at Sigmund Freud Private University in Vienna and Berlin, and chairman of the expert committee “psychosocial advisory board” of the Supreme Sanitary Council of Austria

* Estimates of prevalence in Germany are based on the results of North American studies (US study by Hughes et al. 1992 and Canadian study by Brewster et al. 1994) from the late 1980s early 1990s, as stated by the German Medical Association in mid-May of this year.

The Medical Chamber of Lower Austria supports addicted physicians in strict confidence in the immediate initiation of qualified inpatient or also outpatient withdrawal and detoxification treatment, information on possible reimbursement of costs for outpatient or inpatient therapy and in finding a practice substitute. https://www.arztnoe.at/arzt-sucht

In Germany, according to a 2019 survey by the German Medical Association (BÄK), all 17 state medical associations offer a structured intervention program for addicted physicians, as the German Medical Association explained in mid-May when asked. However, the uptake of the intervention programs in the state medical associations varies greatly. However, according to the chamber, the results would show that the intervention programs are more successful compared to general data of the addiction help system; the success rate would be between 60 and 100 percent. The survey also showed that chambers that have a structured assistance program and actively publicize it receive a higher than average number of SARs. In 2019, the 122nd German Medical Congress focused intensively on the topic of physician health. The papers on the agenda item can be viewed here. The German “Ärzteblatt” also addressed the issue.

The “Integrated Care Program for Physicians with Mental Illness” (PAIMM — Programa d’Atenció Integral al Metge Malalt), founded in Catalonia in 1998, is considered one of the first intervention programs for physicians with mental illness in Europe. The program is anonymous and is funded 80 percent by the Catalan government and 20 percent by the medical society. It includes interventions at a therapy facility in Barcelona, day hospital services, and outpatient care. In Norway, Villa Sana, a prevention program specifically for health professionals, has been established. Health professionals can participate in individual counseling sessions, group therapy over several days, lectures and activities. The program is funded by the Norwegian Medical Society. In the UK, an anonymous support program for medical practitioners was recently launched by the National Health Service (NHS). Under the Practitioner Health Programme, doctors with mental health problems, anxiety or depression can contact specialists in confidence for specialist help.

There is an increased suicide rate among physicians. A U.S. study in 2000 found a suicide rate of between 28 and 40 per 100,000 — compared to 12.3 in the general population. According to this study, physicians commit suicide more than twice as often as the U.S. population. It also showed how addictive behavior subsequently correlates with suicide: According to the study, 40 percent of suicides among physicians are related to alcohol dependence and 20 percent to drug abuse. Other studies from Western countries have even found that the suicide rate among female physicians is about five times higher than in the average population; and among male physicians twice to three times higher than among female physicians.

Experts emphasize that each suicide or suicide attempt is due to a variety of causes. There are a number of points of contact for people in crisis situations and their families:
Emergency numbers and first aid for suicidal thoughts can be found at www.suizid-praevention.gv.at.
Telephone help in a crisis is also available from.
● Telephone counselling 142, daily, from 0 a.m. to midnight.
● Crisis Intervention Center 01/406 95 95 (Monday through Friday, 10 a.m.-5 p.m.);
also personal and e-mail counseling: www.kriseninterventionszentrum.at.
● Social psychiatric emergency service / PSD daily, 0 a.m. to midnight, tel.: 01/31330.
Relatives can find information and materials at www.suizidpraevention.at