Physician impairment: Referral


The three keys to a successful intervention are a thorough investigation, an experienced intervention team, and rehearsed intervention plan. These factors are well discussed in the review by Silverstein et al. and summarized as follows. The investigation, which may take weeks, is ideally performed confidentially by an experienced team drawn from the human resources, employee assistance, or risk management departments or physician well-being committee of the medical center, with a representative from the anesthesia department. The purpose of the investigation is not to make the diagnosis of substance misuse, substance abuse, or chemical dependency but to gather sufficient evidence of behavioral changes, drug diversion, or drug use to mandate an evaluation. No intervention should be attempted based only on suspicion without evidence.

The intervention team should consist of two or more members with experience in confronting people who deny their problems. If behavioral changes are the only evidence of suspected drug misuse, the team cannot assume that drug misuse is the problem. Rather, the team should accept that the evidence suggests it is reasonable and necessary for the individual to have an evaluation before he or she is allowed to return to work. It is the purpose of the subsequent medical and psychiatric evaluation to determine the cause of the behavioral changes. There should never be a one-on-one intervention. The gender and cultural makeup of the team is important to avoid charges of harassment or assault. Ideally, one team member should be someone who is either a certified addictionologist or a former impaired professional. A spouse or family member could be motivated to either facilitate or sabotage the process. Advice from an experienced interventionalist is recommended to determine his or her suitability as a member of the intervention team. Interventions take time, sometimes hours, if diversion is to be successfully accomplished. It is important for team members to devote their full attention to the intervention by turning off their beepers and cell phones and canceling all other commitments until the intervention is completed.

The intervention plan should include preparation for immediate drug testing, inpatient admission to a hospital or treatment center, accompanied transfer to testing site and inpatient facility, and contingency plans if the suspect refuses to accept testing and evaluation. The purpose of the intervention is not to accuse the individual of a crime or to make the diagnosis of drug misuse. It is to convince the health professional colleague to submit to drug testing and an evaluation. Drug testing should be required as a routine part of institutional policy and procedure related to risk management of untoward events or inappropriate or unaccountable behavior. Because the suspect may become physically hostile, security personnel should be alerted to be in the vicinity of the intervention, but they should remain out of sight unless needed to avoid the perception of an impending arrest. Finally, an individual once confronted must be regarded as a suicide risk and not be left alone until he or she has been admitted to an evaluation center or accompanied by a responsible individual away from the medical center if he or she refuses evaluation and leaves against medical advice.

Key Points

1. The incidence of opioid abuse among anesthesia trainees is 1%.

2. Addiction is a treatable chronic, relapsing disease.

3. Vulnerability to addiction has a genetic component.

4. Seventy-five percent of addicts declare themselves by age 27 years.

5. Most addicts have psychiatric comorbidities.

6. The addicted brain is a reorganized brain.

7. The key to detection of dependence is recognition of subtle changes in behavior and performance.

8. Interventions must be carefully researched, planned, and rehearsed.

9. The earlier the intervention, the greater the chance for successful treatment.

10. Improvements in the treatment of addiction have reduced relapse rates.

11. Reentry requires a contract between the dependent colleague and the employer.


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