Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole, and we have a thought leader panel for you today, and this is part one of our two-part series on Healthcare Provider Substance Use Disorder and Recovery. Joining me is Dr. Christopher Godlewski, he's a board-certified anesthesiologist, an Associate Professor in the Department of Anesthesiology and Perioperative Medicine at UAB Medicine, part of the Acute Pain and Regional Anesthesia faculty, and a physician that has been involved in recovery for over 11 years; and Dr. Sudheer Potru, he's a triple-board certified anesthesiologist, Interventional Pain physician, and Addiction Medicine specialist.

Doctors, thank you so much for joining us today in this first part. Dr. Godlewski, starting with you. Can you speak about the prevalence of substance use disorder within the healthcare community? What have you seen in the trends? And how did factors such as the pandemic contribute to burnout, substance use disorder, and feelings of exhaustion among your colleagues?

Dr. Chris Godlewski: Absolutely. Thanks for having us here. Before I answer, I just wanted to quickly say a big thank you to UAB as well as the Department of Anesthesiology for going above and beyond and allowing us to do this, and bring this important message to people.

Regarding the sort of incidence and prevalence of substance abuse in providers, I think the big challenge with medical providers is that they tend to be very intelligent. And so, these substance use disorders can go on for a long time unknown to everybody, including their family members. Specifically regarding anesthesia, it was often thought that anesthesiologists have a higher incidence, but the literature tends to support the fact that anesthesia providers have no higher incidence than your general comer, if you will.

With regards to the pandemic, there has been an uptick in SUDs during and after the pandemic in medical providers. And I think that also parallels what we've seen in the public. And I think that just comes from all the things that happened in the pandemic in terms of isolation being a big one, fear of the unknown, dealing with a deadly disease that we didn't understand that well, long work hours for some people. The acronym used for triggers of substance use disorders is HALT: hungry, angry, lonely, tired. And I think we saw a lot of that during the pandemic. So, I think that would explain the, uptick we've seen in SUDs, both in the public and in medical providers in and around the time of the pandemic.

Melanie Cole, MS: Thank you for that, Dr. Godlewski, for setting the stage for us for this discussion today. Dr. Potru, one of the biggest things that we've heard about in the healthcare community when it comes to substance use disorders are the stigma, the bias within the healthcare setting towards providers with substance use disorder, whether they cannot practice anymore, whether their colleagues are going to find out access to medications. Did they, you know, do that? Can you speak about that a little bit? You're an addiction recovery specialist in this field of Medicine. Speak about that for us.

Dr. Sudheer Potru: Absolutely. I think, luckily, that stigma is of course still there, but even amongst medical providers now, to some extent, as we see it in our colleagues, our partners, you know, different people, it's starting to change somewhat. It would be surprising, I think, especially as Dr. Godlewski and I are both anesthesiologists and we've seen this in our colleagues and we've heard stories about friends, different things like this, it's begun to shift a little bit from, "Oh, this person should not be practicing medicine" or "This person should not be in an operating room providing anesthesia" to "Okay, where are they sort of in their recovery process?"

We know that, as Dr. Godlewski alluded to, about 10-15% of healthcare professionals in general have likely abused a substance at some point, or at least have shown signs or symptoms of a substance use disorder. That's a pretty significant number, but it's actually pretty similar to the number of the general population. And people in general population, a lot of them are in recovery and eventually go back to work, and medical practitioners are not different completely, except for the fact that our jobs are sometimes a little bit more demanding, they can be a little bit more stressful, and our hours can be significantly worse, depending on what your specialty might be.

Melanie Cole, MS: Well, you're held to a higher standard as well.

Dr. Sudheer Potru: Yes, absolutely. The standards for professionalism are definitely higher, of course. the most important thing when you're thinking about whether somebody should be coming back to work as a clinician or in some other associated specialty, it's important to remember what the remission process looks like. So if you actually look at the ICD-10 codes for diagnoses related to substance use disorders for people who are in recovery, up to about the 90-day mark, three months, is what we call early remission. So, sobriety for 90 days counts as early remission, and then sustained remission basically starts after the 12-month mark.

We think that there's some process of rewiring in the brain that happens around the three-month mark in order to facilitate patient recovery process. But of course, all of the relevant things that are important to recovery, whether that's relapse prevention, avoiding triggers, finding substitute activities, all of that stuff is definitely still going to be important in that process, even after that three months and, of course, for the rest of that medical practitioner's, likely their life. And it's important to organize those plans and create those models for practitioners to return to the clinical landscape.

Melanie Cole, MS: Dr. Godlewski, as you said in the answer to your first question, you talked about how healthcare providers tend to be on the more intelligent side. Sometimes they're able to conceal this even from family and friends. So, what are the most effective screening tools and diagnostic criteria for identifying substance use disorder? How does past history, behavioral analysis play roles in this process? Is it more difficult to diagnose? And is there a code, don't tell if you know a colleague is involved in this? Is it harder to diagnose?

Dr. Chris Godlewski: That's a fairly complicated and difficult question to answer, but I would say that, at least in the Anesthesia world, a lot of the people who suffer from the SUDs were top of their class, very high achieving, very well-thought-of people. And in a way, it's almost necessary because as you're doing the very demanding job of practicing anesthesia, if your drug of choice is something that is found at the hospital or in the operating room, you're also having to craft a way to obtain and use that substance. So, it can be very complicated. It can be very demanding.

Just as a side note, a good friend of mine was an orthopedic surgeon, and he had actually figured out the computer-based algorithm by which he was going to be drug tested. So, this is not something that your average person will come up with, I would say. It is so very difficult for a variety of factors. I think that as we've talked about the stigma, being a high achiever, it's often very difficult to admit that you're fallible or that you have "fallen from grace", and you have an SUD or very often people who are high achievers like this have a lot of difficulty asking for help. So, they may very well be aware of what is going on with them and may even want to take steps to alleviate those issues, but either they don't know how to ask for help, they're not willing to. So, I think it can be a very complicated problem from that standpoint. Unfortunately, in the world of Anesthesia, most folks, they either self-report frequently or they are found intoxicated or having overdosed. And, unfortunately, the trite and cliche phrase of, you know, "I had no idea that he had this problem" comes up far too often in the world of Medicine and, in fact, in the general public as well.

To your other point about there being a code of silence, so to speak, that's a difficult one as well. I don't know that it's sort of a don't-ask-don't-tell phenomenon so much as it is that there very much is a feeling that you respect the work that somebody else has put into getting into the world of Medicine, and you don't know how to help them. And you certainly don't want to instigate a process that may devastate their career, their family, all those sorts of things.

So, I fundamentally think that everybody tends to mean well, and either people don't want to get involved with it at all for fear of the ramifications, or they just don't know what to do for this person, more those things as opposed to a more nefarious thought process of "We have to keep it silent" and that sort of thing, or "We'll deal with it internally." That certainly does happen, but I don't think it's as prevalent as the other two.

Melanie Cole, MS: You make such good points, and I really appreciate the point about that you don't want to devastate a colleague's reputation and career that they've worked so hard towards. So, I agree with you. I think it's not quite so much a nefarious code, but more of a, "I'm not going to be the one to do it. I'm not going to be the one to out this person to say these things." so Dr. Potru, based on that, how important is personalized treatment planning when you do know that a colleague, whether it's in Anesthesiology or in any healthcare setting is now somebody who is struggling with substance use disorder, and they want to get into recovery? What factors do you consider most critical when you're looking at this personalized treatment plan? Because there is career, family, all of these high expectations for this person.

Dr. Sudheer Potru: Well, looking at someone's motivation to get into recovery, whether that's seeking a detoxification program, whether that's seeking Addiction Medicine or Addiction Psychiatry clinician who can care for them on an ongoing basis, or whether that's getting help in a different location, in a 12-step group or whatever that might be. Looking at their motivation to return to the workforce, to reconcile with their family, to just generally resume to some extent the life that they had previously prior to their development of an SUD is likely the most important factor because, at the end of the day, as Dr. Godlewski will probably agree with me, you can only get better if you want to get better. If you're not interested in getting better, then you won't be able to. And it doesn't matter how "strong" somebody is. Their positive mental attitudes are helpful. But if they don't have a strong desire to recover, they will not be able to do it because recovery is a very difficult process and a difficult road for most people.

For the average healthcare professional entering these types of programs, luckily, they're extremely effective. There's what we call PHPs or professional health programs for doctors, lawyers, business people who are entering recovery. And often, it's typically 75-80% of them, or maybe even higher in some instances of the entrance into these programs who actually get better and go back to their various professions.

So, the bad news is it's rough getting there, but once you actually do get to the recovery process and try to get into it, typically they do very, very well. So, that's a positive point for these individuals who are dealing with these challenges.

Melanie Cole, MS: We're going to get into treatment strategies and planning in part two of our series. But as we wrap up part one, Dr. Godlewski, why is it so important for physicians to connect with one another? For support groups, just as Dr. Potru was just speaking about, and using these strategies such as resilience, yoga meditation, resilience training, these kinds of things, before we speak about the treatment options, speak about some of those whole body programs and things that can really help to start that journey.

Dr. Chris Godlewski: Sure. I think a lot of that ties in with what Dr. Potru was just mentioning. I think the more tailored and personalized the program can be for the individual as we talked about in the first two parts, the more likely that they are to succeed. And it's just a simple matter of loading the boat to gear things more towards things that the individual will understand or that will resonate with them. But I think the overarching point that Dr. Potru made is absolutely spot on. And that is, unless somebody is a hundred percent willing to go through the process and really identify factors that led them to where they are and do the work to have that fundamental psychic change that recovery programs talk about, a lot of it is just white knuckling or going through the motions. So, I think that the buy in from the patient is the first and foremost part. And then, I think all the factors that you mentioned can only augment the process and help that individual feel like they are part of the process and that they're in whatever way, if you like, enjoying the process, so maybe mindfulness, vis a vis yoga and meditation is something that they need, and something that they find truly beneficial, both with regards to their substance use and just life in general. So, the more alternatives or strategies that we can provide to people to get them on board and, as the 12-step groups say, keep them coming back every day to the process, that can only augment the success of the treatment plan.

Melanie Cole, MS: Thank you so much, doctors. What an enlightening and eye opening discussion that we're having here today. And that concludes part one of UAB MedCast series on provider substance use disorder and recovery. Please be sure to check out part two to get all the information that you need. And for more information, you can visit our website at uabmedicine.org/physician. I'm Melanie Cole. Thanks so much for tuning in.