Because of their knowledge of opioid analgesics and their unique
access to such medications, physicians may be at greater risk for
abusing prescription painkillers than those with less access. This
risk notwithstanding, physicians are also patients who have a right
to expect adequate treatment if they experience acute or chronic
pain.
The 1992 Physician Substance Use Survey (PSUS) polled 9,600
physicians about their own use of psychoactive substances. The PSUS
found that 8 percent of physician respondents had a lifetime
occurrence of a substance use disorder, but because the PSUS relied
on physician self-reporting, it may have underestimated actual
rates of physician substance use.
The PSUS and other studies have found that anesthesiologists and
emergency medicine physicians are at greater risk than other
physicians for developing substance use disorders. The PSUS also
found that physicians were more likely than non-physicians to
misuse prescription analgesics and tranquilizers, but less likely
than non-physicians to use illicit drugs.
A large proportion of physicians who reported misusing
prescription drugs in the PSUS did so for reasons of "self
treatment." Self-treatment may thus represent an occupational
hazard for physicians.
Because of this risk of misuse, we strongly discourage
physicians from self-prescribing any medications, and we remind
physicians that it is a violation of Massachusetts law to
self-prescribe opioids, benzodiazepines, and other medications in
Schedules II-IV.
Physicians at risk for abusing substances may also obtain
opioids and other medications from a colleague, who may be more
likely to prescribe liberally - and less likely to implement
ordinary safeguards against misuse - for another physician.
For physicians who develop either acute or chronic pain, short-
or long-term treatment with opioids may be indicated. When this is
the case, we recommend the following procedures to reduce the risk
of misuse:
- Select one treating physician, ideally your primary care
provider, to be in charge of all prescriptions. Ask this physician
if it is safe for you to continue practicing medicine while taking
narcotic analgesics, especially during the early phase of
treatment.
- Fill all prescriptions at one pharmacy.
- Work with your primary care provider to develop a comprehensive
plan for pain management that maximizes the use of non-opioid
treatments such as NSAIDs, acetaminophen, and physical
therapy.
- Allow open communication among all treating physicians, and
always consult with a pain management specialist in cases of
chronic, non-malignant pain.
- Have your primary care physician occasionally order urine for
toxicology, to document that you are taking the opioid as
prescribed, and not taking any non-prescribed medications or
illicit drugs.
- If you have a history of substance abuse or dependence, consult
with an addiction physician or specialist with expertise in this
area, and allow open communication between that provider and all
other treating clinicians.
Common warning signs of opioid misuse include a physician who is
seeing multiple providers and receiving multiple prescriptions from
them and a physician who self-prescribes, asks colleagues who are
not treating him to write prescriptions as "a favor," or asks staff
members to fill prescriptions on his or her behalf. Other possible
signs include personality changes, bizarre or erratic behaviors,
unexplained absences, excessive ordering of drug supplies,
prolonged lunch breaks, excessive daytime naps, or significant
physical changes.
What should you do if you think you or someone you know is
abusing opioids or has developed a problem with prescription drugs?
Given the high stakes - the individual physician's health, the
well-being of the physician's patients, and the potential impact on
the physician's career - we recommend prompt intervention and
referral to Physician Health Services (PHS). PHS has internal
resources for evaluating these concerns, and PHS physicians can
also make referrals for more complete evaluations and/or treatment
when indicated. PHS can be reached at (781) 434-7404.
- J. Wesley Boyd, M.D., Ph.D., and
John Knight, M.D.
Associate Directors, Physician Health Services
