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1348
Am
]
Psychiatry149:1
0,October1992
ResidentPhysicianSubstanceUse,bySpecialty
PatrickH.Hughes,M.D.,DeWittC.Baldwin,Jr.,M.D.,DavidV.Sheehan,M.D.,ScottConard,M.D.,andCarlaL.Storr,M.P.H.
Objective:Thisstudycomparessubstanceusebymedicalspecialtyamongresidentphysi-
cians.
Method:TheauthorsestimatedtheprevalenceofsubstanceuseofI1medicalspecialties
f
romanationalsampleof1,754U.S.residentphysicians.Results:Emergencymedicineandpsychiatryresidentsshowedhigherratesofsubstanceusethanresidentsinotherspecialties.Emergencymedicineresidentsreportedmorecurrentuseofcocaineandmarijuana,andpsy-chiatryresidentsreportedmorecurrentuseofbenzodiazepinesandmarijuana.Contrarytorecentconcerns,anesthesiologyresidentsdidnothavehighratesofsubstanceuse.Family/gen-eralpractice,internalmedicine,andobstetrics/gynecologywerenotamongthehigherorlowerusegroupsformostsubstances.Surgeonshadlowerratesofsubstanceuseexceptforalcohol.Pediatricandpathologyresidentswereleastlikelytobesubstanceusers.Conclusions:Theauthors
‘
previousresearchindicatesthatresidentsoverallhavelowerratesofsubstanceusethantheiragepeersinsociety.Yetresidentsubstanceusepatternsdodifferbyspecialty.Residentsinsomespecialtiesaremorelikelytousespecificclassesofdrugs,touseagreaternumberofdrugclasses,andtobedailyusersofalcoholorcigarettes.
(Am
J
Psychiatry1992;149:1348-1354)
T
hereadyavailabilityofdependence-producingsub-stancesposesanoccupationalrisktophysicians
andother
healthprofessionals,butthisriskdoesnot
appearto
beevenlydistributedamongthemedicalspe-cialties.Datafromdrugtreatmentprograms,medicallicensingboards,andsurveysofphysicianssuggestthatmembersofcertainspecialtiesareatgreaterriskofsub-stanceuse.StudiesoftreatedpopulationsincludeBisselletal.’sfollow-upof98maleand95femalephysicianmembersofAlcoholicsAnonymous(1,2).UsingknownspecialtydistributionsforU.S.physicians,Bisselletal.foundmaleandfemalepsychiatriststobeovenrepresentedandobservedasimilartendencyforfemalephysiciansinemergencymedicine.Surgicalspecialtieswereunder-represented.Morseetal.(3)reviewed73chemicallyde-pendentphysicianstreatedattheMayoClinicandfoundthatfamily/generalpractitionersand,toalessen
Presentedinpartatthe143rdannualmeetingoftheAmericanPsy-chiatricAssociation,NewYork,May12-17,1990.ReceivedOct.23,1991;acceptedFeb.20,1992.FromtheInstituteforResearchinPsy-chiatry,UniversityofSouthFlorida,Tampa;andJamesA.HaleyVet-eransHospital,Tampa.AddressreprintrequeststoDr.Hughes,3515EastFletcherAve.,Tampa,FL33613.SupportedbytheDivisionofMedicalEducationResearchoftheAmericanMedicalAssociationandbygrantDA-04877fromtheNa-tionalInstituteonDrugAbuse.TheauthorsthankJackF.Samuels,Ph.D.,forstatisticalconsulta-tionandKristineM.Williamsforeditorialassistance.Copyright©1992AmericanPsychiatricAssociation.
extent,anesthesiologistswereoverrepresented.Talbottetal.(4)described1,000physicianstreatedatSmyrna,Ga,92%ofwhomhadaprimarydiagnosisofchemicaldependence.Anesthesiologists,thoracicsurgeons,emergencymedicinepractitioners,plasticsurgeons,andfamily/generalpractitionerswereoverrepresented.Pe-diatniciansandpathologistswereunderrepresented.Statelicensingboardsareanothersourceofdataonphysiciansubstanceabuse.Inastudyof34physiciansdisciplinedbytheOregonboard,Shore(5)reportedthatpsychiatristswereoverrepresentedwhencompared
to
theexpectedrateamongregisteredphysiciansinthatstate.IkedaandPelton(6)studied247physiciansen-rolledintheCaliforniaDiversionProgram;over90%werebeingtreatedforsubstanceabuse.Threespecial-ties-anesthesiology,emergencymedicine,andfamily!generalpractice-wereoverrepresented.Surveyresearchershavealsoinvestigateddruguseinmedicalspecialties.SethiandManchanda(7)inter-viewed240residentphysiciansinIndiabutdidnotcomparedruguseratesbyspecialty.McAuliffeetal.’squestionnairesurvey(8)of489physiciansselectedfromtheMassachusettsMedicalSocietymembershipfoundpsychiatriststohavemuchhigherratesofuseforalltypesofsubstances,followedbyanesthesiologists.Madduxetal.
(9)
foundpsychiatryresidentsataTexasmedicalcentermorelikelythanresidentsinotherspe-cialtiestoreportbenzodiazepineuseinthepastyear.MyersandWeiss(10),inasurveyof1,805internsand
HUGHES,BALDWIN,SHEEHAN,ETAL.
Am
]
PsychiatryI49:10,October1992
1349residentsinOntario,Canada,foundthatanesthesiol-ogyandpsychiatryrankedamongthefirstfiveofIIspecialtiesforeachofthreepatternsofsubstanceuse.Communityhealthresidentswereleastlikelytousesubstances,followedbyresidentsinemergencymedi-cine,surgery,andpediatrics.Mooreetal.(II)followed1,014graduatesofJohnsHopkinsSchoolofMedicineandfoundnostatisticallysignificantdifferencesinratesofalcoholabuseinthemajorspecialties.
In
theprecedingstudies,physiciansinanesthesiology,emergencymedicine,family/generalpractice,andpsy-chiatrywerefoundtobeathigherriskofsubstanceuseorabusethanphysiciansinotherspecialties,butthesefindingswerenotconsistentacrossthevariousstudies.Thisraisesthequestionofpossiblebiasesduetomade-quateornonrepresentativesamples,especiallywhenstudiesareconfinedtophysiciansinasinglemedicalcenter,state,ortreatmentprogram.Tofurtherexploredrugusedifferencesbymedicalspecialty,
weexamineddatafromanationalsurveyof
U.S.residentphysicians(12).Thesurveyprovideddata
ondrugusepatternsin
I1medicalspecialties.TheaimwastoidentifythosespecialtieswhichwereatgreatestriskofI)unsuperviseduseofspecificdrugclassesortypes,2)multipledruguse,and3)dailysubstanceuse,aswellas4)legitimateuseofcontrolledsubstancesun-derthesupervisionofanotherphysician.Backgroundvariableswereexaminedtodetermineifobserveddif-ferencesinsubstanceusepatternsmightbeexplainedbyfactorsotherthanspecialtystatus.
METHOD
ThestudysamplewasdrawnfromtheAmericanMedicalAssociationphysicianmasterfile,whichisconsideredthemostcomprehensivelistingofU.S.phy-siciansavailable.Thesamplingframeconsistedof15,814U.S.physiciansintheirthirdyearofresidencytrainingwhohadgraduatedfrommedicalschoolin1984.The3,000subjectswereastratifiedrandomsam-pleselectedtoensurethattheirdistributionbymajorspecialtyreflectedthatofthemasterfile.TheIIspe-cialtieswereanesthesiology,emergencymedicine,fam-ily/generalpractice,internalmedicine(includingsub-specialties),obstetrics/gynecology,pathology,pediatrics,psychiatry,radiology,surgery(includingsubspecial-ties),andacategoryforthosewhowereinanotherspe-cialtyorwhowereundecided.
In
thespringofI987,eachsubjectwassentananony-mousquestionnaire,acoverletterwitha$1incentive,andaresponsepostcard(withsubjectidentificationnumber)tobereturnedseparately.Theeight-page,multiple-choicequestionnairewasdesignedforanop-ticalmarkreaderandtook15-25minutestocomplete.Uptotwofollow-upquestionnairesweresenttosub-jectswhosepostcardswerenotreturned.
Q
uestionscovereddemographiccharacteristics,medi-calspecialty,workactivities,anddruguse.Respondentswereaskedhowfrequentlytheyhadusedeachof11typesofdrugsintheirlifetime,inthepastyear,andinthepast30days.Substancecategoriesincludedcigarettes,alcohol,marijuana,cocaine,LSD,otherpsychedelicdrugs,heroin,andprescriptiondrugtypesincludingamphetamines,bar-biturates,benzodiazepines,andopiatesotherthanheroin.
Q
uestionsonprescriptiondrugsincludedthephrase“withoutadoctortellingyoutousethem.”Thequestions
were
basedontheNationalInstituteonDrugAbuse’sMonitoringtheFuturestudyattheUniversityofMichiganInstituteforSocialResearchinAnnArborinordertoallowcomparisonwithasampleofsimilarage(13).Drugusequestionshadbeenfieldtestedonmedicalstudentsinearlierpilotwork(14,15).Theoverallresponseratewas60%(N=1,785).Ofthese,1,754indicatedcurrentspecialtyandwereusedforthisanalysis.Distributionofspecialtiesamongme-spondentsreflectedtheactualdistributionofresidentsinspecialtytrainingprogramsfortheyearofthesurvey
(
I6).Thedruguseprevalencerateofeachspecialtywascomparedtothatofallotherscombined.Statisticalsig-nificancewasevaluatedbyusingthechi-squaretestforstratifiedsamples(onedegreeoffreedom)and
95%
confidenceintervals.
RESULTS
AreResidentsinSomeSpecialtiesMoreLikelytoUseSpecificTypesofSubstances?
Theproportionofresidentsineachspecialtywhohadeverused10ofthe11substancesintheirlifetimeap-pearsintable1
.
Heroinusersweretoofewtodrawfirm
conclusionsregardingspecialtydifferences,andthere-
fore
thedataarenotshown.
Useofnonprescribedsubstances.
Littlevariationwasobservedacrossspecialtiesinrelativerankingofthelegalandillicitsubstancesused.Thistrendheldforbothlife-time(table1)andpastyear(figure1)substanceuse.Resi-dentsinallspecialtiesreportedalcoholasthemostwidelyusedsubstance.Oven90%ofresidentsineachspecialtyreportedhavingusedalcoholintheirlifetimeandinthepastyear,andmorethan80%ineachspecialtyreporteduseinthepastmonth.Amongthenonprescribedsub-stances,marijuanawasthesecondmostfrequentlyusedsubstanceforallthespecialties,cigaretteswerethird,do-cainefourth,andpsychedelicsfifth(figure1).Thefollowingfivespecialtieshadsubstanceuseratesclosetothemeanforallresidents:anesthesiology,in-tennalmedicinewithitssubspecialties,surgerywithitssubspecialties,radiology,andthosesignifying“other.”Psychiatryandemergencymedicineresidentsshowedhigherratesofdrugusethandidotherspecialties.Psy-chiatryresidentshadthehighestratesforlifetime-everuseofmarijuana(pnevalence=80.7%,
95%
confidenceinterval=72-89,p=O.OO2),cigarettes(prevalence=65.S%,
95%
confidenceintenval=SS-76,p=O.OO8),cocaine(prevalence=45.S
%,
95%
confidenceinterval=35-56,p=0.001),LSD(pnevalence=30.7%,
95%
confidenceinterval=21-40,p=O0001
),
andotherpsychedelicsub-
RESIDENTPHYSICIANSUBSTANCEUSE
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Psychiatry149:10,October1992
TABLE1.LifetimeUseofPsychoactiveSubstances
Reported
by1,754ResidentPhysicians,bySpecialty
AlcoholMarijuanaCigarettesCocaineBenzodiazepinesAmphetamines
Specialty%CIa%CIa%CIa%CIa%CU’%CIa
AnesthesiologyEmergencymedicineFamily/generalpractice98.396-10110096.594-9968760-7779.668-9i’59.6
5466d
59.150-68SS.i41-69
49.243-55
34.526-4338.0
25-52
17.6
1322d
22.6
32.020.8
15-30
19-4516-26
29.6
26.014.5
21_38d
14-38
10-19d
Internalmedicine97.496-9964.360-6949.645-5428.725-3323.620-2720.317-24
Obstetrics/gynecology98.296-10162.053-7142.733-5226.618-3519.312-2723.916-32
PathologyPediatrics10093.890-97’62.7
50-76
55.949-63’
58.845-72
47.440-55
19.69-31
24.718-31
19.6
16.4
9-31
11_22d
27.5
19.0
15-40
13-25Psychiatry97.795-10180.7
7289d
65.5
5576d3556d
50.0
40-60d
31.8
222d
Radiology
Surgery
95.892-100
98.998-100
74.766-84
66.260-72
57.047-67
50.244-S6
37.928-48
35.129-41
30.5
16.4
21-40
1221d
20.018.312-28
14-23
Undecided/other10071.461-8253.642-6528.618-3925.716-3624.6
15-35
Alltrainees97397-9865.163-6751.549-5429.227-3122.721-2520.819-23
a95%
confidenceinterval.bOtherthanheroin.
CNOt
includingLSD.
dSigficantdifferencecomparedtoallothertraineesforthatsubstance(pO.OS,chi-squareanalysis).
stances(pnevalence=30.7%
,
95%
confidenceinterval=21-40,p=O.0001
).
Psychiatryalsohadthehighestper-centageofmarijuanausersinthepastyear(preva-lence=34.1%
,
95%
confidenceintenval=24-44,p=0.0001
).
Emergencymedicinehadthehighestmateofcocaineuseinthepastmonth(pnevalence=8.0%,
95%
confidenceintenval=1-16)andthepastyear(preva-lence=14.0%,
95%
confidenceinterval=4-24)andhighuseratesinthepastyearformarijuana(pnevalence=28.6%,
95%
confidenceinterval=16-41,p=OO3)and
cigarettes(pnevalence=16.3
%,
95%
confidenceinter-val=6-27).Specialtieswithlowerratesofnonprescnibedsub-stanceuseincludedfamily/generalpractice,obstetnics/gynecology,pediatrics,andpathology.Family/generalpracticeresidentshadthelowestrateofevenhavingusedcocaine(pnevalence=17.6%,
9S%
confidencein-tenval=13-22,p=O.0001)andpsychedelicsubstances(otherthanLSD)intheirlifetime.Obstetnics/gynecol-ogyhadthelowestlifetime-evennateofcigaretteuse.Pediatricresidentshadthelowestlifetime-everuseofmanijuana(pnevalence=SS
.
9%
,
95%
confidenceinter-val=49-63,p=O.OO6)andalcohol(prevalence=93.8
%,
95%
confidenceinterval=90-97,p=O.0O2).Pathologyresidentsdroppedfromthethirdhighestmateoflife-time-evencigaretteusetothelowestnateinthepastyearandpastmonth.Pathologyresidentsalsoreportedthelowestrateofpastyearuseofcocaineandman-juana.
Unsuperviseduseofprescriptiondrugs.
Littlecross-specialtyvariationwasalsoobservedinrelativerank-ingoftheprescriptiondrugtypesbylifetime(table1)onpastyear(figure2)use.Residentsinallspecialtiesreportedhigherratesofunsuperviseduseofbenzodi-azepinesandamphetaminesthanofbarbituratesandprescriptionopiates.Ratesofamphetamineandpne-scniptionopiateuseinthepastyearwerelow(4.7%orlowerforallspecialties),andpastyearuseofbanbitu-rateswasnegligible.Benzodiazepines,however,wereclearlythepreferredtypeofprescriptiondrugforallspecialties;9.4%ofallresidentshadengagedinunsu-perviseduseofbenzodiazepinesintheirlifetime.Specialtiesthatshowedhigherratesofunsuperviseduseofprescriptionsubstancesincludedanesthesiology,withthesecondhighestlifetimeuseofamphetamines(pnevalence=29.6%,
95%
confidenceinterval=21-38,p=0-02),andpathology,withthehighestlifetimeuseofprescriptionopiates.Psychiatryhadthehighestlifetimeandpastyearratesforbothbenzodiazepineandam-phetamineuse(benzodiazepines:lifetimeprevalence=50.0%,
95%
confidenceinterval=40-60,p=O.0001;pastyearprevalence=27.3%,
95%
confidenceinterval=18-37,p=0-0001
).
Emergencymedicineresidentswerethesecondmostlikelytohaveusedbenzodiazepinesintheirlifetimeandinthepastyear,buttherateswerenearlyhalfthoseofpsychiatry.Surgeonstendedtore-portlowerratesofuseforallprescriptionsubstancesandwereamongthespecialtiesleastlikelytohaveusedbenzodiazepinesintheirlifetime(pnevalence=16.4%,
95%
confidenceinterval=12-21,p=OOO8),alongwithpediatricresidents(prevalence=16.4%,
95%
confidenceinterval=11-22,p=O.OO8).Pathologyresidentstendedtohavelowerratesofuseinthepastyearforallprescnip-tiondrugsexceptbenzodiazepines.
AreResidentsinSomeSpecialtiesMoreLikelytoBeMultipleDrugUsers?
Themeannumberofdrugtypesusedbyrespondentsineachspecialtywascalculatedforpastmonth,pastyean,andlifetimeuseinordertoaddressthisquestion.All11substancetypeswerecounted,includingalcoholandcigarettes.Table2presentstheseresultsinrankorder,beginningwiththosespecialtiesthatreportedlifetimeuseofthefewestnumberofsubstances(i.e.,family/generalpracticeresidents).Littledifferencewasobservedinpastmonthandpastyearmeansacrossthespecialtiesexceptforemergencymedicineandpsychia-tryresidents,whotendedtousemoresubstancesthanresidentsinotherspecialties.
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