Medical Student Substance Abuse Intervention: A Case Report and Literature Review

  • Daniel M. Avery
  • Gabriel H. Hester
  • Rane McLaughlin
  • and Gregory E. Skipper
  • Journal of Medical Regulation
  • September 2009,
  • 95
  • (3)
  • 27-35;
  • DOI: https://doi.org/10.30770/2572-1852-95.3.27

ABSTRACT

Alcohol and drug abuse and addiction among medical students have been reported extensively. This is an important topic because substance abuse can lead to impairment, which affects the well-being of many, including medical students, and because it compromises physician competency. Education and clinical training regarding substance use disorders (SUDS) has been severely neglected, especially in relation to their incidence, not only among health professionals but also among patients. Students know little about SUDS and little regarding identifying a colleague in trouble. This article presents a case of a peer medical student intervention with a successful outcome as a proximate result of a brief educational program for medical students and argues for more education regarding SUDS, professional impairment, and how to deal with a peer who has a problem. To our knowledge, peer medical student intervention for a fellow student addicted to alcohol or drugs has never been reported in the English language.

INTRODUCTION

Alcohol and drug abuse and addiction among medical students have been reported extensively.1–79 Studies suggest that the lifetime prevalence of substance use disorders (SUDS) among U.S. physicians is in excess of 10 percent.16,21 Alcohol and substance abuse causes physician impairment and compromises patient care.14,18 Physician abuse and addiction is important because it not only affects the life of the physician but the patients he cares for as well.17 Substance abuse among physicians not only creates health risks and physician impairment but creates huge social and financial problems.28,35 It is postulated that alcohol and drug abuse may make physicians less concerned about drug abuse and addiction in their own patients.29 According to a 1985 study by the AMA, more than 90 percent of physicians in this country believe that alcohol abuse is a problem but less than 28 percent felt adequately trained to treat it.72

Some have identified SUDS as the number one health problem in the United States.72,80 The prevalence of drug and alcohol use and abuse in this country is astounding. The United States has 6 percent of the world's population but consumes 60 percent of the world's illicit drugs.81 An estimated 40 percent of hospital admissions are related to addiction.40 An estimated 50 million people use cocaine regularly in the United States and 50 million people are addicted to drugs. Addiction is use not compatible with the goals of treatment. Addiction to nicotine may become “the greatest health risk to the developing world, surpassing malnutrition and communicable diseases.”10 Alcohol abuse is a worldwide phenomenon.44 A characteristic of chemical dependence is the compulsive use of substances despite adverse consequences.15 It is a disease in which the individual is so consumed by drugs that they take on excessive importance in a person's life.82 For centuries, man has used substances to obtain euphoria8 and has subsequently struggled with substance abuse since time began.51

CASE REPORT

An educational endowment in alcoholism and addiction education and physician impairment was established at the University of Alabama School of Medicine in Tuscaloosa in 1994 by a former patient who was a recovering alcoholic. The founder recognized that medical students, residents and most attending physicians knew very little about alcoholism and drug abuse and addiction and even less about physician impairment. The program was expanded in 2006 to a one-week series of lectures for medical students, including the natural history of drug and alcohol abuse, the disease concept of addiction, physician impairment, assessment, rehabilitation, return to education and work, contracts, monitoring, support groups, Caduceus and Alcoholics Anonymous. The lectures also include work-hour restrictions, fatigue and exhaustion, urine drug screening and employment of recovering physicians. Students are presented with clinical scenarios involving alcohol, substance abuse, prescription writing and what to do if a colleague is suspected of abusing alcohol or drugs. The students are provided with confidential contact resources both at the medical school and the physician health program. Students are educated on identification of health care professionals who may possibly be impaired.

Following the course, two medical students presented to the office of one of the authors (DA) asking for assistance for a medical student in trouble. One of the students stated that the student accompanying him was an alcoholic and needed help. He described the fellow student's excessive use of alcohol daily that had escalated to the point that his colleagues and friends did not want to be around him. This student had been involved in two recent automobile accidents, both related to alcohol. The last accident was a single-car accident near his family's home. A group of concerned medical students and friends organized and staged an intervention on the impaired medical student. The intervention impressed the impaired student about the need for getting help. The involved student admitted to one of the authors (DA) that he was in trouble with alcohol. He understood that his friends had become worried about his excessive drinking, especially after the two recent automobile accidents. He agreed to cooperate with notification of the state physician wellness program, which was called immediately. The director of the program interviewed the impaired student on the telephone and arranged for a meeting between them the following day. The student met with the medical school administration and the medical center's physician health officer. A physician health program and state medical society approved evaluation and assessment was carried out with the recommendation of residential treatment for alcoholism. A leave of absence for medical treatment was approved by the medical school. Approved residential treatment was completed. A contract with the physician health program was signed. The student subsequently returned to medical school to continue studies under contract with the physician health program and the medical school with appropriate aftercare and monitoring. The student has to date continued to do well and is in recovery.

ALCOHOL AND DRUG ABUSE AMONG PHYSICIANS, RESIDENTS AND STUDENTS

Airline pilots, railroad engineers, law enforcement personnel, firemen, nurses, attorneys and corporate leaders must be accountable and responsible to society because their fitness for duty affects the well-being of many; physicians are no different.25,83 Medical students, residents, fellows and attending physicians appear to be as susceptible to SUDS as the rest of society.5,12,46,48,58

A recent review by Mangus, et al describes concern over physician addiction to alcohol, cocaine and morphine dating back to 1869.9,17 Alcohol abuse by physicians appears unchanged for the past 50 years and approximates that of the general population, despite education and research into alcoholism and addiction.9,12,14 However, drug use other than alcohol by physicians has significantly increased since the 1960s.76 Many feel that narcotic addiction is the most prevalent addiction among physicians after alcohol addiction.14 Cocaine5 benzodiazepine, stimulant and marijuana abuse is also a major cause of physician impairment. Many medical students do not see drug and alcohol abuse and addiction as a disease.36

Self-treatment of pain and fatigue is the common reason that physicians get into trouble with drugs.70,73,76,84 Stress places physicians at risk for substance abuse and addiction.7,14 Many impaired physicians relate their initial substance abuse to stress in medical school.70,78 A family history of alcoholism is the most consistent predisposing factor for alcoholism.17 Some hospitals randomly screen their physicians for drugs and alcohol.14

ALCOHOL AND DRUG ABUSE AMONG MEDICAL STUDENTS

Medical students worldwide abuse alcohol and drugs.3,11,31,41,56 In 1973, the American Medical Association published a statement describing concern over drug and alcohol abuse among medical students.5 Studies of alcohol and drug abuse and addiction in medical students are difficult to assess because of confidentiality concerns and requests for anonymity.12,15,41 Actual numbers are difficult to obtain and under-reporting or non-responses to questions regarding SUDS are frequent because of students' fear of consequences; however, the available data approximate the lifetime risk of a physician for SUDS.12,15,69

The National Clearing House for Alcohol and Drug Information (NCADI) reports that anonymity is the essential component of reliable self-reporting.14 If a medical student uses alcohol or substances excessively before entering medical school, he or she will probably continue to do so after entering medical school.12

Alcohol is the substance used most often by medical students.12,14,31,36 A 1990 study showed that 11 percent of medical students self-reported heavy drinking and 18 percent of those met the criteria for impairment, most commonly reporting blackouts and fighting while drinking.1 In this study, 18 percent of the class met the criteria for alcohol abuse defined as “student self-report of alcohol-related impairment during medical school.”1 In one study 87.5 percent of medical students reported alcohol use within the past month, 10 percent cocaine use and 10 percent marijuana use.2 In another study, alcohol use by medical students approximated that of the general population for college age individuals.7 Other studies have suggested that medical students use less drugs and alcohol than age-matched peers.12 In a United Kingdom study in 2000, almost half the class self-reported drinking alcohol beyond a safe level.6 Percentages of alcohol use have been reported as high as 95 percent.60

Medical students consume excessive amounts of alcohol comparable to their age group, despite their knowledge of adverse consequences.11,28 In a United Kingdom study, the majority of students reported their first drink of alcohol before the age of 12; the earlier the age of consumption, the greater the risk of heavier consumption.11 Many students were already drinking alcohol excessively and trying illicit drugs before starting college.11 In another study, 86 percent of the students drank alcohol and approximately half of those drank excessively.13,28

Alcohol abuse in medical school is predicated by a family history of alcoholism, alcohol abuse before beginning medical school,1,2 availability of controlled substances, stress and emotional problems.96,85 A 1993 study examined alcoholism in parents of medical students and found that 27 percent of the students had parents that abused alcohol.18 This rate is twice that of the general population.18,46 Students attending church frequently usually use less alcohol.83 One article reported an increase in alcohol abuse with the beginning of the clinical years.24,38 Alcohol and drug abuse among medical students may affect care and safety of patients.30 A prominent 1986 study by McAuliffe in the New England Journal of Medicine implied medical student use of drugs “should not be a cause for great alarm”73; over time, this has proven not to be the case.

Medical students often report drug abuse and dependence.2 A third of medical students used illicit drugs; the most commonly used illicit drug was marijuana.13,28,31,48 A minority of medical students believe marijuana and even cocaine should be legalized.3,48,57 A 1972 study acknowledged there was a significant difference in opinions between medical students and attending physicians about marijuana.34 Medical students report less substance use than comparable age-related groups except for alcohol, tranquilizers and psychedelics other than LSD.2 Medical education is stressful78,86 and may account for increased use of tranquilizers.2 Medical students using cocaine and other drugs of abuse before medical school will often continue during medical school.5,12 A 1966 study raised the question regarding whether it is coincidental that the percentage of medical students using illicit drugs is about the same percentage as attending physicians who are addicted and impaired.32

In a 1989 study of medical students, more than a third reported use of cocaine.6 About half of medical students in 1989 reported use of stimulants to stay awake to study and take call.6 In the same study, marijuana was the most commonly used illicit drug and almost half of the students had at least tried it.11,12 Another study reported that medical students abused fewer drugs as they progressed through medical school.12 Illicit drugs and alcohol are associated with recreational use while therapeutic drugs tend to be associated with stress.70,78 “Club” drugs such as cocaine, lysergic acid diethylamide and cocaine have been reported to have been used by 17 percent of medical students.27 Surgery residents used less substances than did other residents with the exception of alcohol; alcohol use is thought to be related to stress and fatigue.14 Students, however, entering surgical residencies used more substances than did residents.14

PHYSICIAN HEALTH PROGRAMS

Approximately half of the physician health programs (PHPs) in the United States officially work with medical students. In many cases medical schools provide financial support to the PHP for the services. PHPs are a heterogenous group of agencies, typically one in every state (five states don't have officially recognized PHPs at this time: California, Wisconsin, Georgia, Nebraska and North Dakota). PHPs provide a “clinical arm” for regulatory boards to encourage early referral and treatment of physicians with problems related to impairment. The goal is to detect problems prior to overt impairment. The PHPs market their approach to the medical community by providing education to hospitals and others. Their goal of early referral is greatly enhanced when they can offer confidential supportive care. In all states where confidential care of physicians is encouraged and permitted there are predefined limits to confidentiality, such that participants are reported to the regulatory board if they refuse recommendations to stop work and obtain needed treatment or if they relapse. Thorough evaluation and treatment are usually followed by long-term monitoring for years. Evidence exists that behavioral problems among medical students is predictive of problems later in practice. Working with medical students is completely consistent with PHPs' goals of early detection, treatment and long-term monitoring.

TREATMENT PROGRAMS FOR PHYSICIANS, RESIDENTS AND STUDENTS

Comprehensive assessment and treatment programs are available for medical students, residents and physicians.85,87–97 Intervention and treatment in most states is overseen by a state impaired-physician committee or a physician health program under the auspices of the medical society and/or the state regulatory board. These programs designate and approve assessment and treatment programs. Most assessments are multidisciplinary and take three to four days to complete. Rehabilitative treatment can last from six weeks to three or more months. The success rates for physicians are high, due to the effective utilization of contingency management with long-term monitoring with real or tacit threat of loss of license for failure. Most physicians return to successful and rewarding practices. Recidivism rates are low. Most states require aftercare contracts, usually for five years but sometimes longer. Some malpractice insurance carriers require indefinite monitoring. Most physician wellness programs are rehabilitative and not punitive in nature.98,99

Aftercare following treatment usually involves a contract with the PHP for a specified number of years along with random drug screen monitoring. Most malpractice insurance carriers require PHP advocacy, including urine drug testing for as long as one is covered by that company. Group therapy, individual counseling, marital therapy, aftercare groups, treatment center revisits, local physician monitors, quarterly assessments, psychiatric and psychologic evaluations are all part of the recovery program. Twelve Step programs like Alcoholics Anonymous (AA), Cocaine Anonymous and Caduceus for Recovering Physicians are usually required. Ninety AA meetings in 90 days has been a time-honored successful program for those new in recovery.

HISTORY OF ALCOHOL AND DRUG ABUSE EDUCATION FOR STUDENTS

Physicians know very little about addiction; medical students know even less.36,101,102 They know even less about physician impairment and identifying those colleagues at risk. Medical schools have traditionally not educated medical students about alcoholism and drug addiction.101 In 1990, less than 25 percent of medical schools had policies for impaired students and only half of those had programs to assure and oversee treatment of those students.5 Before the early 1990s, there was little data on medical student substance abuse.2

This lack of knowledge limits understanding of the disease concept of addiction and subsequently of timely patient diagnosis and treatment.35,101 Students often have negative attitudes regarding addicted patients.101 Medicine has done a poor job educating physicians about alcohol and drug abuse.35,37 Although primary care providers are those most often confronted about abuse, they know the least about it and are the least helpful to patients and families.35

A need exists for education in medical school about alcoholism and drug addiction.11,12,35,36,37,40,56,72,73,76,77,101 A United Kingdom study in 2000 suggested that current education for medical students on addiction is inadequate.11,12 Medical school courses in both the basic sciences and during the clinical years are needed to better educate medical students about the risks of SUDS, and these courses must keep up with current trends.6,27,45 It is also important that medical education emphasize facts about professional impairment and how it can compromise patient care.19 Education for medical students would increase the likelihood that physicians could provide better information for patients about abuse and addiction.13,28,29,37 Students are exposed to the medical aspects of alcoholism but not the psychological, social and spiritual.103 It is important to educate medical students about Alcoholics Anonymous because most physicians and students do not have positive attitudes or much knowledge about the program.33 Education about drugs before students graduate may reduce inappropriate prescribing to patients.32,37

Medical student participation in substance abuse treatment clinics may help educate students about the risks and consequences of drug experimentation, abuse and addiction.104 Ideally, more medical schools and teaching hospitals will hire faculty specializing in addiction medicine who can conduct teaching rounds with students. This type of activity would bring more stature and signal more importance to this activity. Drug and alcohol abuse education should be part of the regular medical school curriculum.33,35,37,41,43,44,46,84 Medical students can do a better job taking a social history and asking about alcohol and drugs if they are honest with themselves about their own alcohol and drug use.38

MEDICAL STUDENT INTERVENTION FOR DRUGS AND ALCOHOL

Many medical schools over the years have simply not known what to do with addicted students. They have dealt with the problem in a traditional manner with disciplinary action and even suspension from school, when a nontraditional approach of rehabilitation and return to school may be needed.67 Other schools have not acknowledged the fact that a problem even exists.68 Medical students need to know how to respond when they are concerned about a fellow student or colleague. Only a minority of medical students acknowledge that there is a policy for substance abuse at their medical school.2 A 1990 study suggested that interpersonal intervention with alcohol abuse may meet with resistance.1 Most medical students want students dependent on alcohol and marijuana to receive treatment, but termination from school for those dependent on illicit drugs.2 Students are reluctant to report a classmate for fear of disciplinary action rather than confidential treatment.12

Medical schools need programs specifically aimed at medical students for intervention and harm reduction.36,37,39,43,56 Schools need clear-cut written guidelines and policies that conform to the Liaison Committee on Medical Education.42 As of 2005, 48 states and the District of Columbia have physician health programs.98

Dalhousie University Faculty of Medicine in Nova Scotia developed one of the first medical student support programs in North America in the early 1980s.20,21,22 This program was designed for early intervention and has served as a model for subsequent programs worldwide.20,21,22 The program is called the PIETA Program (Pieta means compassion).20,21,22

The first program in the United States for identifying and treating medical students addicted to drugs was developed at the University of Tennessee in 1983.15,16 The program is called the AIMS Program (Aid for the Impaired Medical Student) and was designed “to provide confidential treatment for chemically dependent medical students, to assure that recovering students are able to resume their education and to protect patients and others from the harm that may be caused by impaired students.”15,16 The AIMS Council, composed of health professionals and elected medical students, run the program.15 The success of such programs depends on the qualities of the student representative, support of administration and faculty, assistance from the state physician health program and cooperation with treatment programs.15,16 The goals of the AIMS program include:15,16

  1. To provide compassionate assistance to chemically dependent students before they are irreversibly harmed;

  2. To provide help in a way that fully protects the rights of impaired students to receive treatment in strictest confidence;

  3. To assure that recovering students are able to continue their medical education without stigma or penalty; and

  4. To protect patients and others from the harm that may be caused by chemically dependent students.15

In this program, evaluation of students by self-referral or intervention is performed by addictionologists through an extensive assessment and the recommendation of appropriate care.15 Aftercare is managed by the state's physician health program, which provides ongoing advocacy for the student.15 This program has been approved by the American Medical Association and other such programs around the country have been modeled after the AIMS Program.15 Obstacles to the development of this program have been:15

  1. Belief that SUDS is not a problem at that school;

  2. Belief that chemically dependent students should be dismissed from school;

  3. Belief that student identification and treatment will not be confidential;

  4. Willingness of students to identify classmates that may be chemically dependent; and

  5. Reluctance of medical students to report the personal affairs of other students.15

The University of Sherbrooke Faculty of Medicine in Quebec developed a program in which medical students received weekend training as peer-counselors and were accessible to other classmates for problems.20

Medical schools need programs to identify students with SUDS.5,57 Intervention needs to be encouraged with compassionate, confidential policies that aid impaired students.5 Self-reporting needs to be encouraged in a way that is not punitive.5 Early identification, assessment, treatment services and rehabilitation are important for medical students.29,30,46

SUMMARY

According to a 1990 study, more than half of medical students with alcohol problems seek help.7 Although treatment for abuse and addiction are possible, the real answer is prevention by education.8 Education of medical students about the disease concept of addiction, treatment of abuse and addiction in their patients and prevention of their own abuse and addiction is critical and must be improved.

Medical schools need educational programs to identify those students at risk for abuse and addiction, information on the disease concept of addiction, screening mechanisms, referral sources, treatment capabilities, counseling and support to complete medical school in a confidential, compassionate manner.12 Medical students need a mechanism to complete treatment that is satisfactory with the medical school and state physician health program, but also affordable. Students need to be made aware that those who satisfactorily complete treatment have a good prognosis and practice satisfying careers.12,17,84 The success rate is high and most physicians are motivated by the threat of losing their license. Medical students with an addiction can usually continue their education after satisfactorily completing treatment and practice medicine.

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Journal of Medical Regulation

Vol. 95, Issue 3

1 Sep 2009

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