When Health Professionals Abuse Drugs and Alcohol: Personal Problems and Public Health Consequences

Howard Markel, MD, PhD

Disclosures

June 29, 2004

Every Thursday morning, in a nondescript office building on the outskirts of Ann Arbor, Michigan, a group of recovering alcoholics and addicts meet with their social worker. What's decidedly different about this substance abuse treatment program is that all of the people attending are practicing nurses, pharmacists, dentists, and physicians.

The treatment is rigorous. Those enrolled are closely monitored by addiction counselors, drug-screened on a random basis, and will risk losing their licenses permanently if they relapse. Unlike many other substance abuse treatment programs that have a 66% or higher relapse rate, the programs dedicated to keeping health professionals clean and sober have been remarkably successful for those willing to enroll. Approximately 95% of the health professionals participating stay alcohol- and drug-free for at least 5 years, and are allowed to return to the practice of medicine.

Tom, a dentist in the Ann Arbor program who has been sober for more than 2 years after 35 years of "drinking and drugging that was abruptly interrupted by a substance abuse intervention," explains that "the most difficult thing I had to learn how to do is ask for help." One of his fellow sobriety group members, Donna, a nurse who has been undergoing treatment for addictions to alcohol, opiates, and benzodiazepenes for more than 9 years, agreed: "I've had to learn that I am an addict first, not a nurse, not a mother -- I have to pay attention to that fact in order to stay sober and to perform these other functions. But it is hard because as a nurse, I am used to, I am trained to think of helping others first."

No one is quite sure how many doctors, nurses, pharmacists, or other health professionals actually abuse alcohol and other substances, although a 1992 study, published in JAMA,[1] conservatively estimated the number at about 8%. Alcohol remains the leading drug of abuse, although the accessibility of narcotics, benzodiazepenes, and other prescription drugs remains a concern. Illicit drugs, such as cocaine, marijuana, and heroin, appear to be less abused by health professionals when compared with the general public.

In 1974, the American Medical Association began to encourage state licensing boards to develop confidential and nonpunitive programs for health professionals with substance abuse problems as a means of both protecting patient safety and enhancing these individuals' health. Today, every state has special programs legislated for substance abusing health professionals. These programs are entirely voluntary, provided there were no legal or malpractice consequences associated with the substance abuse problem, and are paid for through the fees all health professionals pay each year to renew their license to practice.

Although there are some variants to these programs from state to state, such as whether services are contracted through private physicians or clinics, the basic requirements are similar. After an initial inpatient detoxification, the health professional signs a confidential contract with the state-sponsored health professional recovery program. The contract requires that person to undergo 3 years of monitoring and random, computer-generated drug screens 3-10 times a month, depending on the severity of the individual's addiction and his or her history of compliance. Each day, the health professional must call an 800 number, enter a code, and is told whether or not and where he or she must go to give a urine sample.

The impaired health professional is also required to attend weekly group therapy meetings conducted by a trained substance abuse counselor, in which issues ranging from coping with recovery to scheduling vacations are discussed. In addition, the health professional must have regular sessions with an addiction physician, 3 or more 12-step meetings a week (including special meetings held exclusively for health professionals), and form a steady relationship with a "sponsor" to help advise them on recovery issues. Finally, each individual is required to identify a work-site monitor, typically a supervisor, who knows the individual's situation and can communicate with the state's health professional recovery program.

George Vandel, an addiction counselor for the Wyoming state health professionals recovery program, explained the high success rate rather bluntly: "When you have someone's license to practice in escrow, that person tends to be very compliant. It's a carrot and a stick, but it works. If you don't comply, you don't practice."

Jeff, an intensive care nurse who formerly abused narcotics while on duty, has been a member of the Ann Arbor sobriety group for almost 2 years. "I didn't exactly want to go into this program, but it's been the best thing for me. I could say I just want to quit being a nurse, but I can't. It's part of me, it's what I do, it's my life's work," he said.

"A key aspect of treating impaired health professionals is the linkage to credible sanctions," explained Dr. Michael M. Miller, the director of the treatment program at the Meriter Hospital in Madison, Wisconsin. "This means that the health professional treatment programs have a clear relationship with the state government's licensing authority. We try to keep the individual in a treatment track and offer them appropriate rehabilitation services instead of punishment, but there is always the understanding that if they refuse treatment or drop out, we can contact the licensing body, which has the ability to intervene with a heavier hand."

Dr. Marvin Seppala, an addiction psychiatrist and Vice President of Medical Affairs at the Hazelden Foundation, said, "There is a fine line between protecting the public from potential mistakes that can be made by impaired health professionals and treating and advocating for these people who have a treatable disease. We have to respect and consider both of these charges."

One question surrounding these tightly controlled programs is how well patients do once they are no longer monitored. "Most of the success of these programs is the unrelenting requirement of accountability on the part of the licensee," said Dr. Bobbe J. Kelley, the medical director of the Michigan Health Professional Recovery Corporation. "It is not infrequent that a licensee will successfully complete their monitoring agreement, but once out from under the intense scrutiny, they relapse and come back. Most, however, have been able to internalize the principles of recovery and continue as nonimpaired, well-functioning healthcare professionals."

Is the hospital the worst place for addicted health professionals to work given the easy availability of substances of abuse and their ability to prescribe them? Dr. David McDowell, an addiction psychiatrist at Columbia University College of Physicians and Surgeons, New York, NY, believes that before health professionals start thinking about the physical access to narcotics and similar drugs, all must contend with something he calls psychologic access. "If you think about how often these people prescribe or talk about medications, such as opiates or tranquilizers, how often they hear their patients tell them about enjoying them, this situation inspires a curiosity and makes substance abuse more likely," said Dr. McDowell.

However, Dr. Abraham Verghese, an internist at the University of Texas at San Antonio and author of The Tennis Partner, a book about his friendship with a cocaine-abusing physician who ultimately died from his addiction, said the following: "I think the problem is only partly access. My sense is that it relates to the peculiar dysphoria and dysfunction that can be part of a successful health professional's career. Physicians learn, in response to the carnage they see every day, to distance themselves almost as a safety mechanism. In the macho culture of the hospital, no one is encouraged to talk about this, and the great danger is that they begin to disconnect from their emotional states. In essence, they deny their problems, focus on symptoms of sadness, self-medicate, and this is often the genesis of their addiction."

"It can be frustrating when the substance abusing health professional chooses to fight the treatment rather than work with us," said Dr. Maher Karem-Hage, an addiction psychiatrist and medical director of the Chelsea-Arbor Addiction Treatment Program in Ann Arbor. "But it is usually very gratifying to see these patients restore their health and spread the message about recovery to other health professionals, patients, and the public."

Kathe Dylan, a social worker and substance abuse counselor who conducts the weekly Thursday meetings in Ann Arbor and treats many health professionals for substance abuse, said, "It's important to emphasize that this is not just about not drinking or using drugs. It's about how to find a healthier way of life."

One of her patients, Nicole, a nurse who has been in recovery for almost a year, agrees. "Of course I want to keep my license to be a nurse. But I know that I have to want to be sober for myself. The recovery itself needs to be the reward," she said.

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