ON THE ROAD TO WELLNESS. Dealing with Addiction Disease in Dentistry FINAL REPORT

Transcription

1 ON THE ROAD TO WELLNESS Dealing with Addiction Disease in Dentistry FNAL REPORT

2 ON THE ROAD TO WELLNESS OCTOBER 12-13, 2012 Dealing with Addiction Disease in Dentistry EXECUTVE SUMMARY The disease of addiction plays no favourites. Dentists, like other health care professionals, are susceptible to this disease just like others in the general population. The latest statistics from the United States have at least 15-18% of the dental profession struggling with addiction disease. There is no reason to believe that the problem is any less here in Canada. The stakes are even higher for dentists than for other individuals who are addicted. Because if a dentist s addiction is left untreated, it could not only threaten their own lives and family stability, but place patients and their practices in jeopardy too. For too long, there have been almost insurmountable barriers of shame that prevent dentists from seeking help. Society imposes stigma and its damage on addicts and their families because many of us still believe that addiction is a character flaw or weakness that probably can t be cured. Stigma is the reason there is so much social and legal discrimination against people with addictions. t explains why addicts and their families hide the disease. People who need the help are often afraid to speak up. This stigma is one of the meanest and most difficult aspects of addiction because it makes it harder for individuals and families to deal with their problems and get the help they need.

3 2 EXCECUTVE SUMMARY ON THE ROAD TO WELLNESS What am asking you to focus on is not the shame of the illness which is what you see in your daily regulatory roles but rather remember the dignity of recovery. Dr. Graeme Cunningham Wellness Consultant Royal College of Dental Surgeons of Ontario People who are victims of stigma internalize the hate it carries, transforming it to shame and hiding from its effects. Too often, people with alcohol and drug problems and their families begin to accept the ideas that addiction is their own fault and that maybe they are too weak to do anything about it. n many ways, hiding an addiction problem is the rational thing to do because seeking help can mean losing a job, your social status, the friendship of your colleagues, or even your family. Dentists with substance abuse problems could also lose more because they are usually single practitioners, and if the dentist goes down, so does the practice The profession needs to spread the word that addiction is an illness, not a moral failing, to create a culture within dentistry where no dentist is confronted by a prevailing sense of helplessness in the face of addiction. Dentists don t choose to abuse psychoactive substances or adopt abusive behaviours like gambling, sex, etc. Addiction is not the result of a lack of willpower. Addiction is an illness, not a moral weakness. Yet the stigma against people with addictions is so deeply rooted that it continues even in the face of the scientific evidence that addiction is a treatable disease.

4 3 EXCECUTVE SUMMARY ON THE ROAD TO WELLNESS We have learned more about the neural biology of addiction in the past five years that in the past 500 years. Dr. Paul Earley Medical Director State of Georgia Physicians Health Program t s puzzling why some people become addicted and others do not. No single answer has been found. t seems that people develop addictions through a mixture of factors such as: genes the way a person s brain works difficulties during childhood mental health problems stress cultural influences. While researchers continue to study the mysteries of addiction, some things are clear: nobody chooses to become addicted, and addiction is not simply due to personal weakness or character flaws. The latest scientific evidence is clear: addiction is a brain disease with underlying neurology; it is not simply a behavioural problem. t is a chronic disease. Neuroscience has substantially advanced the understanding that addiction is an organic neurobiological condition that affects perceptual, emotional and motivational processes in the brain. n addition, there are complexities involved because of the psychological, social, and economic determinants involved in the onset of addiction. The societal impact of addiction is staggering. The cost of substance abuse in Canada is estimated at $40 billion per year according the Canadian Centre for Mental Health and Addiction.

5 4 EXCECUTVE SUMMARY ON THE ROAD TO WELLNESS f you remember nothing else, remember two things after your two days here: this is an illness that is chronic and relapsing and recovery is possible with the right treatment. Dr. Graeme Cunningham RCDSO Wellness Consultant The impact of this devastating disease on individual dentist lives, practices and families is enormous. n no way do the statistics capture the human toll of family devastation, broken hearts, broken dreams and financial ruin. There is good news though. With the right support, people with addictions can lead healthy and productive lives. n fact, the current recovery rate for health care professionals is up to 90 % after five years. This incredibly positive outlook for addicted dentists was the culmination of a two-day conference on October 12 and 13 in Toronto entitled, On the Road To Wellness: Dealing with Addiction Disease in Dentistry. The conference was sponsored and organized jointly by the Canadian Dental Regulatory Authorities Federation and the Canadian Dental Association. During the conference, the nearly 80 participants gained a shared knowledge of the science of addiction and a fundamental understanding of its implications for practice and policy. The conference PowerPoint presentations and handouts are in the appendices. There were wide-ranging roundtable discussions on how to best support the well-being of the single most valuable asset in the nation s oral health care system the dentist. Other key themes of the roundtables included the appropriate role of regulators and professional associations in addressing substance abuse and what the barriers are for each group in offering assistance.

6 5 EXCECUTVE SUMMARY ON THE ROAD TO WELLNESS f you get no other take home message, is is coordination that single combination of compassion and control is what makes people shift and get better. Dr. Paul Earley Medical Director State of Georgia Physicians Health Program As the conference closed on late Saturday afternoon, it was clear that both regulators and the provincial dental associations had accepted the challenge to use the insight and knowledge gained to accept the responsibility for change. t was agreed that the right support means a reliance on a non-punitive approach to supporting the addicted health professional. Meeting the incredible challenge of reduction of barriers to dentists seeking and accessing care for addictions must be balanced with an appropriate framework to protect the public from harm. As leaders in the dental community in this country, both the regulators and the provincial professional associations agreed to shoulder the responsibility to be in the vanguard of a much-needed transformation.

7 6 EXCECUTVE SUMMARY ON THE ROAD TO WELLNESS FUTURE DRECTONS This is not a professional issue, nor a regulatory issue, it is a human issue. Dr. Rob Sutherland President, Canadian Dental Association Our ability to respond is only limited by our imagination. Dr. Peter Trainor President, Canadian Dental Regulatory Authorities Federation The two-day event wrapped up with comments from the CDRAF President Dr. Peter Trainor and CDA President Dr. Rob Sutherland as together they synthesized the roundtable discussions on how regulators and the professional associations and looked forward to the future. The key points of their joint presentation were: EDUCATON & COMMUNCATON These are the first critical steps of a successful strategy. Leaders in the dental community and the broader profession need to gain a basic understanding of the nature of the problem and the opportunities for success. COMPLEXTY By pooling and coordinating resources, the probability of success is improved. Addiction disease is a complex problem that will require complex solutions, not a one-off effort. There will need to be recognition of the geographical/language realities of the country so that some provinces are not disadvantaged. MANAGNG OUTCOMES t is important to take the strength of our existing resources and maximize them. t is critical to achieve the best outcomes in the most efficient way possible as effective solutions will be expensive. SYNERGY/TEAMWORK There is need for a synergy of commitment with a collaborative and coordinated response with defined roles for regulators and professional associations. t is important to capitalize on the current momentum to move forward together with a sense of urgency.

8 7 EXCECUTVE SUMMARY ON THE ROAD TO WELLNESS FOR MORE NFORMATON Canadian Dental Regulatory Authorities Federation rwin Fefergrad Executive Director Canadian Dental Association Dr. Benoit Soucy Director of Clinical and Scientific Affairs

9 8 EXCECUTVE SUMMARY ON THE ROAD TO WELLNESS APPENDX Tab 1 Tab 2 Tab 3 Tab 4 Tab 5 Tab 6 Tab 7 Tab 8 What is it about dentists? Health & Addiction Dr. Carolyn Thomson Anecedotal Perspectives from BC Experience of Member Counselling Support Dr. John T. Palmer Addiction in the 21 st Century: A Treatable Brain Diseases Dr. Paul Earley Addiction in Caregivers Dr. Graeme Cunningham CV of Dr. Graeme Cunningham CV of Dr. Paul Earley CV of Dr. John Palmer CV of Dr. Carolyn Thomson

10 What is it about dentists? Health & Addiction Dr. Carolyn Thomson, MD, CCFP, FCFP Co ordinator, Professionals Support Program Doctors Nova Scotia 2 Personalities Dentistry attracts people with Thinker Sensor ntrovert Perceptive ntuitive compulsive personalities unrealistic expectations unnecessarily high standards of performance require social approval and status Judgmental Feeler Extrovert 3 4 General Health Healthy Behaviours Good to excellent health 88% BUT Report poor general health 10% Poor physical state 30% Overweight 27.6% Obese 7.4% Exercise 59% Breakfast 73% Sleep 61% Snack 20% Smoking 10% Alcohol 90% Average BM 61% Myer and Myer

11 Musculoskeletal Disorders Other Health ssues High prevalence 87.2% over 12 months Low back pain (LBP most common) Shoulder pain Wrist pain Allergic contact dermatitis Respiratory sensitivity Eye injuries Auditory damage Hepatitis B: vaccine uptake 7 8 Nitrous Oxide Chronic exposure can produce serious risk Possible risks to the hematological, reproductive, hematological, hepatic and renal systems ncrease cancer risk Most common: peripheral neuropathy Usage USA and Japan 50% Denmark 45 50% UK 30 40% Ten most commonly reported minor ailments Backache or pains in the back 62.3% Nervy, tense or depressed* 60.0% Heartburn, wind or indigestion 59.4% More male Headache* 58.3% More female Difficulty in sleeping* 48.6% * Correlates with work stress Feeling tired for no apparent reasons* 48.2% More female Cough, catarrh or phlegm 38.4% Dry, itchy or tired eyes 34.4% Blocked or runny nose 32.9% Rashes, itches or other skin trouble 28.7% 9 10 Key Point Burnout and poor health are strongly related. To deal preventatively with burnout in dentistry, pay attention to physical health. How could dentists let these things happen to themselves? 11 12

12 Vulnerability Depression Genetic factors Dynamics of family of origin Personal history exposure/response to trauma Variations in brain chemistry Personality characteristics Cultural norms Religious beliefs US Lifetime prevalence 17% One year prevalence 10% Occurs more often in women and lower socio economic status Only female pediatric dentists and periodontists more depressed than male counterparts JADA What are the costs? Anxiety Personal suffering mpaired relationships Days lost from work mpact on quality of care Not the mild, brief anxiety caused by a stressful event Affects 19 million Americans Most common GAD and Panic Disorder Prevalence not increased in dentists Suicide in Dentists Suicide in Dentists Not all those with depression suicidal but most suicides linked to depression Little valid evidence that dentists are more prone to suicide than the general population Some data: female dentists more vulnerable? JADA June 2001, Roger Alexander Suicide rate among dentists higher than those of other occupations New studies required to introduce the demographic variables previous psychiatric morbidity opportunity factor stressors not related to work nternational Dental Journal, 2012 Sancho FM 17 18

13 Top Ten Suicide Rates Key Point 1. Food Batchmakers 2. Physicians and Health Aides 3. Lathe and Turning Machine Operators 4. Biological, Life and Medical Scientists 5. Social Scientists and Urban Planners 6. Dentists 7. Lawyers and Judges 8. Guards/Sales Occupations 9. Tool and Die Makers 10. Police and Public Servants Professional training and licensure do not confer immunity from the realities of our humanity and the potential to experience illness, grief, family problems, stress, trauma or depression Addiction A disease process characterized by the continued use of a specific psychoactive substance despite physical, psychological or social harm." National nstitute on Alcohol Abuse and Alcoholism Lifetime prevalence of alcohol dependence in the general population 13.3 % 12 month prevalence of addiction 4.4 % Rates in healthcare professionals similar to general population Differences related to drugs of choice Reflects familiarity with particular drugs and access Little evidence dentists at greater risk than GPs Contributing Factors The Addicted Dentist High stress Unrealistic and perfectionistic expectations of oneself Grandiose feelings of invulnerability Knowledge about and access to drugs Other stressful environments long hours excessive professional demands demands of patients and staff 80 85% addicted dentists prefer drugs over alcohol Others: tobacco stress reducers upper and downers narcotics including nitrous oxide (hardest to shake) and benzodiazepines Most common: alcohol hydrocodone N2O 23 24

14 Personality Profile of Addicted Dentist Key Points Dissatisfied with career choice Fear of causing pain Low professional self esteem Obsessive compulsive & perfectionistic behaviour High need for control (but feeling out of control) Avoidant style in interpersonal relationships Dr. Jerry Gropper Talbott Marsh Recovery Campus The onus is on the dental staff, friends and family to recognize the onset of the individual s personality changes and to encourage the affected individual to seek help. Be aware of your own risk factors. Good News: Studies indicate a better than 86% five year recovery success rate for the dental profession Why should we care? Stress Common cause of early retirement Job dissatisfaction Poor working relationships Stress can be defined as the biological reaction to any adverse internal or external stimulus physical, mental or emotional that tends to disturb the organism's homeostasis. Can be +ve or ve Stress Stress Feelings of low self esteem, depression and anxiety and hopelessness. Younger dentists more prone. Sex differences Parents Work issues Patients often create less stress for dentists than running behind schedule Minor psychiatric symptoms: 32% vs 17.8% in GP Teaching: decreased stress Myers and Myers

15 Biggest cause of stress Three Dimensions of Burnout Running behind schedule and coping with difficult, uncooperative patient. Gradual erosion of the person Emotional Exhaustion Depersonalization Loss of professional satisfaction Prevention Addressing Burnout: The 3R Approach Commitment, self efficacy, resourcefulness and hope May have to address at organizational level Cognitive behavioural strategies Exhaustion more easily treated Recognize Reverse Resilience Key Point Stigma Burnout is easier to prevent than to treat. Associated with experiencing personal difficulties Feelings of shame or guilt can be a self imposed stigma Powerful deterrent People often shun what they don t understand Common view of mental illness Recovery profound feelings of personal frustration and failure Depressed people seek treatment in only 40% of cases 35 36

16 Stigma n Closing High proportion of depressed dentists are not receiving treatment for their illness. We need to understand ourselves better so we can better help our colleagues. Can address their need for help, while allowing them to maintain their professional image and reputation

17 Anecdotal Perspectives from the BC Experience of Member Counselling Support Dr. John T. Palmer Director, Dental Professional Advisory Program British Columbia Dental Association 2 UBC ntake Survey Fall 2011 Medical and Dental 3 4 How well would you say that you know yourself? A. Extremely well B. Quite well C. Not sure D. Not very well E. Hardly at all Learning about Self A. Self reflection B. Dialogue with others C. Objective feedback D. Using stories or fables as a template E. Comparing myself with others survey responses 5 6

18 Test Goals? The kind of subjects you prefer When studying for an examination, usually aimed to get 100%. A. Agree strongly B. Agree C. Uncertain/no opinion D. Disagree E. Disagree strongly m drawn toward subjects where the right answer is always clear: where there s less room for teacher bias to affect my evaluation. A. Agree strongly B. Agree C. Uncertain / no opinion D. Disagree E. Disagree strongly 7 8 Your Current Theory of ntelligence Mindset ndicate your degree of agreement with the following statement: You can learn new things, but you can t really change your basic intelligence. A. Agree strongly B. Agree somewhat C. Disagree somewhat D. Disagree strongly 9 10 Experiencing Failure Research on Coping Styles The challenge of learning from failure. Theory of intelligence (Entity or ncremental) highly correlated with how we deal with failure. f you believe intelligence is fixed, you re at higher risk for having a maladaptive response to failure (e.g using secondary strategies to cope). Primary and secondary responses to coping with failure Both approaches involve attempts to repair impact on self esteem experienced when we fail. Secondary means are ineffective in producing a better outcome going forward. (Dweck) 11 12

19 Personal strengths Here's what you said about your personal strengths What strength word would you choose to best describe what personal quality has brought you to succeed in your application to dental school? When asked about what they would value most in practice What You Value in Colleagues What strength would you value most in a professional colleague? We asked what you think patients value What you think patients will value in you What strength would patients value most in a treating physician or dentist? 17 18

20 Strengths that can tumble into liabilities ndependence (grandiosity) A need to be in control either actively, by competitiveness, aggressive control or passively by opting out. Perfectionism An anxiety driven quest to be perfect in the eyes of others (or ourselves). Can be technically productive but interpersonally damaging. Harsh selfshaming. Tendency to hyper focus (obsess) and lose the bigger picture. Specific contributors in substance use clients High anxiety levels + low trust Black and white (categorical) thinking Shame Tendency to isolate How do we help? Respect personhood Foster trust Minimize shaming

21 Addiction in the 21st Century: A Treatable Brain Disease Paul H. Earley, M.D., FASAM Presentation Outline Addiction in the 21 st Century: A Treatable Brain Disease Paul H. Earley, M.D., FASAM Earley Consultancy, LLC and Medical Director, Georgia PHP, nc. Atlanta, Georgia USA Part : History of the Addiction Concept Part : Addiction Characteristics Part : Addiction Neurobiology Part V: Effective Addiction Treatment Historical Perspective Part History of the Addiction Concept Paul H. Earley, M.D., FASAM Earley Consultancy, LLC Atlanta, Georgia USA Late 1800s nebriety was thought to be a primary medical illness. Various medical & spiritual remedies we tried with marginal success. 1930s With the emergence of psychoanalysis, alcoholism was viewed to be a symptom of other psychiatric diseases AMA declares alcoholism a primary disease. 1960s Alcoholism treatment centers emerge to treat the illness. Historical Perspective Historical Perspective 1970s The addiction movement had to define and differentiate itself in order to promote itself as a primary illness. 1980s The addiction concept was slowly redefined from problematic drinking to a disease caused be certain chemicals and behaviors. Our initial understanding of the brain circuits of addiction evolve. Addiction is differentiated from physical dependence. 2000s The neurobiology of addiction comes into sharp definition. The exact neural circuitry of addiction is demarcated. Additional addictive processes (compulsive sex, gambling and food binging) are discovered to exhibit the same abnormalities with the neural circuitry of chemical addiction. 2010s A few medications appear that help with the primary focus of addiction: craving and relapse prevention. Portions of this material are copyrighted. Page 1

22 Addiction in the 21st Century: A Treatable Brain Disease Paul H. Earley, M.D., FASAM Symptoms and Drug Use Accepting Addiction as a Disease Symptom Drug Use Prime mover according to Psychodynamic Theory Much more critical for initial abstinence and recovery Multigenerational culture bias Behaviors of addicts and alcoholics Failure of early treatment efforts nitial marginalization of addiction treatment Addiction is an nternational Health Problem Part Addiction Characteristics Paul H. Earley, M.D., FASAM Earley Consultancy, LLC Atlanta, Georgia USA Ten percent of all people become addicted throughout their lifetime in western cultures (lifetime prevalence). Addiction-related disease accounts for one-third of all hospital days. Addicts and addiction related crimes are the largest cause of nonviolent crime and incarceration. Addiction Nomenclature Addictionists use the term addiction to refer to alcohol and drug dependence and less technical terms, such as: alcoholism, chemical dependence and drunkenness as well as the behavioral addictions (e.g. gambling and sexual addiction) The term Addict is often used to describe the drug addict or alcoholic. Physiological Dependence versus Addiction Physiological Dependence Occurs in all individuals s a characteristic of certain drugs Craving occurs during drug withdrawal Addiction Occurs in 10% of the population s a characteristic of certain people with certain drugs Craving is tied to many emotional and cognitive triggers, occurring long past the withdrawal time Portions of this material are copyrighted. Page 2

23 Addiction in the 21st Century: A Treatable Brain Disease Paul H. Earley, M.D., FASAM The Etiology of Addiction The Cycle of Addiction Genetic Proclivity Earlier Life Trauma Addiction Acute reinforcing stage (ntoxication) Personality and Psychiatric Disease Environment and Access Preoccupation & Anticipation Withdrawal & Negative Affect Koob & Le Moal (2005) Plasticity of reward neurocircuitry and the 'dark side' of drug addiction. Nature Neuroscience. 8: The Using/Shame Cycle Urge to change strong affect Using Consequences & Guilt Part Addiction Neurobiology Shame Paul H. Earley, M.D., FASAM Earley Consultancy, LLC Atlanta, Georgia USA Addicting Molecules Nicotine Alcohol Heroin Cocaine s there a single pathway to addiction? Drugs of abuse have very different structures and neurotransmitter targets in the brain, but they all exhibit: acute reward chronic reward sensitization negative withdrawal symptoms associative cue learning incentive motivation (relapse) A progression from impulsive to compulsive drug use (which defines the progression from abuse into addiction). Nestler, EJ. Nature Neuroscience 2005; 8(11): Portions of this material are copyrighted. Page 3

24 Addiction in the 21st Century: A Treatable Brain Disease Paul H. Earley, M.D., FASAM Dopamine Reward Circuit Neurochemistry of Wanting Nucleus accumbens Ventral tegmental area (VTA) Nestler, EJ. Nature Neuroscience 2005; 8(11): Neural Adaptation to Drug use Normal Dendrites After extended drug exposure Nestler, E., Malenka, R. The Addicted Brain. Scientific American 290(3): 78 (2004) 22 Cue-induced Craving Amygdala not activated Anterior Amygdala activated Part V Effective Addiction Treatment Posterior Watching a Nature Video Watching a Cocaine Video Paul H. Earley, M.D., FASAM Earley Consultancy, LLC Atlanta, Georgia USA Portions of this material are copyrighted. Page 4

25 Addiction in the 21st Century: A Treatable Brain Disease Paul H. Earley, M.D., FASAM The Addictionectomy Substance Abusing Patient A Desirable Model Continuing Care / Monitoring Early Detection of Relapse Treatment Hospital Detox. Residential Rehab OP Rehab Outpatient Cont Care AA & Tele Monitoring Non-substance Abusing Patient Courtesy of A. Thomas McLellan, Ph.D. Modified from A. Thomas McLellan, Ph.D. Taper (and increase) Treatment as needed ntensity Current treatment Time Best practice treatment Elements of Effective Treatment Viewing addiction though same lens as other chronic diseases. Combination of effective initial intervention and disease management using contingency contracting. ntervene on co-morbid psychiatric and life issues simultaneously. Judicious use of non-addicting medications. Knowing that one size does not fit all. Long term disease management. Education and Consultation Contact Dr. Earley: Web site: by phone: (404) by paulearley@earleyconsultancy.com Portions of this material are copyrighted. Page 5

26 References Addiction in the 21 st Century Anton, R; O Malley, S; Ciraulo, D; Cisler, R; Couper, D; Donovan, D; Gastfriend, D; et al Combined Pharmacotherapies and Behavioral nterventions for Alcohol Dependence: The COMBNE Study: A Randomized Controlled Trial JAMA, May 3, 2006; 295: Bechara, A. Decision making, impulse control and loss of willpower to resist drugs: a neurocognitive perspective. Nature neuroscience. 8 (11), (Nov 2005) Bechara, A; Damasio, H; Damasio, A. Role of the amygdala in decision-making. Annals of the New York Academy of Sciences. 985, (Apr 2003) Berglind, W., et. al. Dopamine D1 or D2 receptor antagonism within the basolateral amygdala differentially alters the acquisition of cocaine-cue associations necessary for cue-induced reinstatement of cocaine-seeking. Neuroscience. 137 (2), (2006). Everitt, B.; Cardinal, R.; Parkinson, J.; and Robbins, T. Appetitive Behavior: mpact of Amygdaladependent Mechanisms of Emotional Learning. Annals of the N/Y/ Academy of Sciences. 985: (2003). Goldstein, R; Volkow, N; Wang, G; Fowler, J; Rajaram, S. Addiction changes orbitofrontal gyrus function: involvement in response inhibition. Cognitive Neuroscience and Neuropsychology 12(11) 8 August Kilts, K, et al. Neural Activity Related to Drug Craving in Cocaine Addiction Arch Gen Psychiatry. 2001;58: Hall, F.S., et al., Molecular mechanisms underlying the rewarding effects of cocaine p Hyman, S. Addiction: a disease of learning and memory. Am J. Psychiatry 162: (2005). Koob, G, Le Moal, M. Plasticity of reward neurocircuitry and the dark side of drug addiction. Nature Neuroscience 8: Nov Nestler, EJ. s there a common molecular pathway for addiction? Nature Neuroscience 2005; 8(11): Schoenbaum, G., M.R. Roesch, and T.A. Stalnaker, Orbitofrontal cortex, decision-making and drug addiction p See, R, et al. Drug addiction, relapse, and the amygdala. Annals of the New York Academy of Sciences. 985, (Apr 2003) Stocker, S. Studies Link Stress and Drug Addiction. NDA Notes. Volume 14, Number 1 (April, 1999) Sugase-Miyamoto, Y; Richmond, BJ. Neuronal signals in the monkey basolateral amygdala during reward schedules. J Neurosci Nov 30;25(48):

27 Addiction in Caregivers Graeme M. Cunningham, MD, FRCPC RCDSO Wellness Consultant 2 Caregiver mpairment Prevalence One who is unable to practice giving care with reasonable skill and safety to patients because of physical or mental illness, including deterioration through the aging process, characterologic or psychiatric difficulties, excessive use of alcohol or other drugs and sero positivity for HV and Hep C. 10% were daily drinkers 9.3% had 5 drinks a day at least once in past year 17.6% had self prescribed benzodiazephines in past year 17.6% had self prescribed opiates in past year 8% reported dependency in their lifetimes Hughes PH, Brandenburg N., Prevalence of Substance Use Among US Physicians. JAMA 1992;267: Prevalence in Dentists Psychological Characteristics of Caregivers Alcohol 12 19% Opiates hydrocodone and oxycodone 37% Nitrous Oxide almost exclusively in dentists 5% Nicotine Street drugs cocaine 10% Dedication/Focus Delayed Gratification Workaholics Guilt Prone Exaggerated Responsibility Limited Emotional Expressiveness Regularly Suppress Anger 5 6

28 Psychological Characteristics of Caregivers Female MDs/Dentists Obsessive/Compulsive Traits Perfectionist Demanding mpatient Hyperconscientious Difficulty with Fun (it s OK if we make work of it!) am my Work Just as compulsive, but value relationships more than male MDs/Dentists 75 80% do own housework Frequently feel guilty Try to be Superwoman 7 8 Risk factors for Caregivers ssues Specific to Professionals Genetic tendency solation Specialty Childhood tapes Enablers Smoking Pedestal profession Terminal uniqueness Difficulty in patient role Tendency to intellectualize Severe guilt and shame Entrenched denial Tendency to self medicate Threatened loss of licence Return to work issues 9 10 Homewood Experience Work related ssues Drugs used in order of frequency: Nicotine Alcohol Opioids codeine, morphine, dilaudid, percocets, oxycontin Benzodiazepines Cocaine Antihistamines ncorrect narcotic counts Alteration of narcotic vials Patient complaints of ineffective pain relief Large volumes of wastes Discrepancies in orders,progress notes and mars Many corrections on narcotic records 11 12