Substance Use and Behavioural Disorders
Approved: June 25, 2008
Revised: June, 2014
Problems with substance use arise in approximately ten per cent of the population over a life time and physicians share the same rates of difficulties. Mood altering substances include alcohol, prescription and non-prescription medications and illicit drugs.
The safety-sensitive nature of a physician’s work demands a higher degree of attention to the use of substances than other, less risky occupations. When there is dependence on or significant abuse of these substances, there will be an impact on life and work, and the situation needs to be brought to the attention of the College as it can affect the professional practice. Intoxication at work is perhaps an extreme of a significant problem with substances; however, prior to that there can be an impact on the reliability, mood, attention to detail and other factors influencing both care of patients and professional conduct.
Untreated substance use can have dramatic and even life-threatening effects but, especially in the physician population, treatment and rigourous monitoring result in a very good prognosis.
Terminology: Addiction, Substance Use, Abuse and Dependence
There are a number of somewhat differing definitions for the disease of addiction, which are included below.
The Physician Health Monitoring Committee chooses to use the term Substance Use and Behavioural Disorders, as it most broadly encompasses the issues that may affect physicians with substance use and “addictive behaviour” disorders, and remains consistent with the current DSM-IV TR definitions of Substance Abuse and Dependence Disorders. Some definitions of addiction and substance dependence/abuse follow, and while there is variation in the details, there is much in common.
Canadian Society of Addiction Medicine, American Society of Addiction Medicine
Addiction – Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
World Health Organization
Addiction, drug or alcohol – Repeated use of a psychoactive substance or substances, to the extent that the user (referred to as an addict) is periodically or chronically intoxicated, shows a compulsion to take the preferred substance (or substances), has great difficulty in voluntarily ceasing or modifying substance use, and exhibits determination to obtain psychoactive substances by almost any means. Typically, tolerance is prominent and a withdrawal syndrome frequently occurs when substance use is interrupted. The life of the addict may be dominated by substance use to the virtual exclusion of all other activities and responsibilities. The term addiction also conveys the sense that such substance use has a detrimental effect on society, as well as on the individual; when applied to the use of alcohol, it is equivalent to alcoholism. Addiction is a term of long-standing and variable usage. It is regarded by many as a discrete disease entity, a debilitating disorder rooted in the pharmacological effects of the drug, which is remorselessly progressive. From the 1920s to the 1960s attempts were made to differentiate between addiction ; and “habituation”, a less severe form of psychological adaptation. In the 1960s the World Health Organization recommended that both terms be abandoned in favour of dependence, which can exist in various degrees of severity. Addiction is not a diagnostic term in ICD-10, but continues to be very widely employed by professionals and the general public alike.
DSM definitions of Abuse and Dependence:
Substance Abuse – a medical diagnosis, as specified in the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM IV TR) – A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
- recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
- recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
- recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
- continued substance use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
The symptoms have never met the criteria for Substance Dependence for this class of substance.
Substance Dependence – a medical diagnosis as specified the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM IV TR) – A maladaptive pattern of substance use , leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
- tolerance, as defined by either of the following:
- a need for markedly increased amounts of the substance to achieve intoxication or desired effect
- markedly diminished effect with continued use of the same amount of the substance
- withdrawal, as manifested by either of the following:
- the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
- the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms
- the substance is often taken in larger amounts or over a longer period of time than was intended
- there is persistent desire or unsuccessful efforts to cut down or control substance use
- a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recovering from its effects
- important social, occupational, or recreational activities are given up or reduced because of substance use
- the substance use is continued despite knowledge of having a persistent of recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induce depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)
It is the policy of the College of Physicians and Surgeons of Alberta to adhere to the current DSM definitions when mandating treatment to addicted physicians. Diagnoses consistent with the DSM should be included in any assessments performed for the CPSA.
The DSM is under revision at present. Proposed criteria for diagnosing and categorizing substance use and addictive disorders can be found at http://www.dsm5.org/ProposedRevision/Pages/SubstanceUseandAddictiveDisorders.aspx
Physicians may suffer from behavioural disorders which have a significant effect on their ability to practice safe, quality medicine. Increasingly, research and clinical evidence supports the
categorization of certain well-defined behaviours as “addictions”, when they reach a certain level of pathology.
Examples of behavioural addiction include pathological gambling, compulsive sexual behaviour, compulsive internet use, and binge or binge/purge eating.
If the College becomes aware through self-reporting or any other form of notification that a physician’s practice may be compromised as a result of behavioural addiction, the College follows the process used for assessment and management of substance use disorders.
 Ries, R., et al., eds. Principles of Addiction Medicine, 4th ed. 2009. Chapter 5 “Understanding Behavioral Addictions: Insights from Research” pp 45-63.