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Few problems in emergency medicine are as vexing as dealing with an impaired professional. Following the old saw “Judge not lest ye too be judged” is often harmful not only to the patient, but also to the professional in question. Depending on the nature of the impairment, available treatment can usually resolve the problem, or at least make it manageable. When lives are at stake, conspiracy of silence, although often the easier and more attractive course, is not an acceptable option.

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Impairment, defined here as a lessening of ability to perform professional duties, may be a result of several factors. In emergency medicine, most impairment is due to substance abuse. Other diseases, both psychiatric and organic, also often appear in the differential diagnosis. Age itself may be a cause. All these factors need to be considered when evaluating the impaired professional.

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This chapter addresses various causes of professional impairment, explores ways to determine the cause, and offers practical information about handling this thorny, complex, life-threatening problem.

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About 10% of all people become dependent on mood-altering substances. The incidence of addiction is higher in health professionals than in the general population: about 15% of physicians will be impaired at some point in their careers.1,2 Other sources report that substance abuse in physicians mirrors the general population: 6% to 8% with substance abuse disorder and 14% with alcohol use disorder.3 Given that physicians make decisions that impact the health of others, they are held to a higher standard. For this reason, the scope of the problem is larger for health professionals than for the general population.

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Physicians at greatest risk for addiction appear to be anesthesiologists, who have the easiest access to addictive substances.4 Emergency physicians may well have the next highest risk.3 Emergency medicine residents have higher rates of substance abuse than other residents.5 Emergency services personnel, including physicians, nurses, and paramedics, have ready access to addicting drugs and the opportunity to use them, and thus are at greater risk than the general population for developing the disease of chemical dependence. The demand for qualified emergency medicine practitioners makes professional mobility easy, and thus detection of the disease difficult. Since nearly all emergency physicians will need to deal with the difficult problem of a chemically dependent colleague or employee at some point in their careers, it is imperative to have as thorough an understanding of chemical dependence as with other common life-threatening diseases, such as diabetes mellitus.

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Chemical dependence, which includes alcoholism, has been recognized as a disease by the medical profession since 1953.6 Like other disease processes, chemical dependence possesses a characteristic symptom complex, clinical course, and treatment.7 Some aspects of the disorder that frustrate both those who have it and those who treat it are progression, denial, and a tendency to relapse. Victims of chemical dependence who are in the medical field are sometimes ...

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