Addicts in the OR?

It was a lifetime ago, specifically at the time of the Vietnam War. I was working in the pharmacy of a military hospital, and, on a routine check, it was found that the cocaine supply had been adulterated with lactose. The Military Police investigated, and, based on polygraph examinations, nearly accused the wrong person. In the end, the drug abuser turned out to be one of the pharmacists, who claimed to have fooled the lie detector with yoga exercises. He was transferred to the hospital's admissions department and gave up his pharmacy license.

A few years later, I was working in a civilian hospital where, once or twice a month, the hospital administrator would walk into the pharmacy, take a bottle of dextroamphetamine tablets from the controlled drug stocks, and return to his office. When I asked about this, I was assured that, under hospital rules, department heads weren't required to pay for their medications. As long as the issue of payment was covered, nothing else seemed to matter.

Years after that, a group of us sat watching a surveillance tape of the drug cabinet in the operating room of a different hospital. A figure in a scrub suit approached the camera. Just as it seemed the figure was coming close enough to be recognizable, something, probably a cap, was thrown over the camera. A supply of ketamine was taken from the stocks, but no one was ever identified as having taken it.

Avoiding the Issue

Because people are reluctant to discuss the problem, the extent of drug abuse by healthcare workers is hard to evaluate. In my experience, there have always been rumors and gossip. Sometimes the talk is prompted by a house officer, who leaves before her residency is completed. Sometimes it's sparked by a hospital visit from the Drug Enforcement Administration inspector – not to inspect, but "simply to chat" while he's in the building for "other reasons."

With 10 to 15% of all healthcare professionals misusing drugs at some time in their careers, the statistics on drug abuse by professionals seem to show a pattern similar to the general population. The literature on the subject is strongly biased toward the United States, so it is hard to estimate the extent and nature of the problem in other nations. Even so, reports from Canada and Israel seem to show similar patterns. But while healthcare professionals abuse drugs at about the same rate as the general population, their choice of drug is different. Healthcare professionals tend to use benzodiazepines and opiates – no doubt because they are more inclined to use the drugs they routinely work with. Use of the traditional recreational drugs, such as marijuana and cocaine, is lower than among the population as a whole.

Drug abuse by healthcare professionals may also be more difficult to detect than among the general population. A nurse, Don, in the drug abuse forum of RNWeb, wrote: "I would just like to say that there are a lot more of us out there than people realize …." (Don did not respond to a request for an interview for this article.)

One reason healthcare professionals may not be detected as drug abusers is that their job performance often seems to be the last thing affected by their drug abuse. In the general community, employers are advised to look for early signs of drug abuse, such as increased rates of absenteeism or decline in job performance, which doesn't seem to be the case with healthcare professionals. Those in healthcare will alienate their families, destroy their finances, drop out of their usual recreations, and only then have their problems show up on the job. Just possibly, impaired healthcare professionals are less likely to miss work simply because they get their drugs on the job.

In addition, according to Dr. Christopher Welsh of the University of Maryland, although the rate of drug abuse among physicians is about the same as the general population, the rate of use (falling just short of drug abuse) of benzodiazepines and opioids is about five times higher than among non-professionals. This implies that physicians set a double standard – one set of rules for their patients, another for themselves.

Also, healthcare professionals who may be quick to spot signs and symptoms of alcoholism or drug abuse in their patients may turn a blind eye toward the same symptoms in their professional colleagues. It's hard to say whether this attitude stems from concern that they may alienate somebody whom they deal with daily or if it's from a sort of professional pride that leads to denial.

Who, When, and Why

A study by the Department of Psychiatry at Dartmouth Medical School in Hanover, New Hampshire found distinctions between female and male physicians in their reasons for drug misuse. Although the sample size in this study was too small to be conclusive (n = 73), the findings appear to justify further study using a larger sample. Women were more likely to turn to alcohol than to prescription drugs, were better at hiding their addiction, and less likely to ask for help until their chemical dependence became severe. At the same time, when women did join 12-step recovery groups, they were more likely to develop a supportive network and make a good recovery.

Among physicians, drug misuse occurs more in some areas of specialization than in others. Factors include access to drugs, type of personality that these specialties attract, and amount of job stress. Emergency medicine specialists, psychiatrists, and anesthesiologists have the highest rate of drug abuse, while pediatricians, pathologists, radiologists, and obstetrician/gynecologists have the lowest.

The stories told by nurses seem to follow a different pattern. Few of them use drugs or alcohol as a coping measure for job stress. On the RNWeb message board, Alan wrote: "I became addicted to Vicodin after numerous knee surgeries four years ago," and Jenny told her own story: "I became addicted to Darvocet that I was taking for an injury received while water skiing in 1990." And Deb, writing on the Nurses in Recovery message board, tells of becoming addicted to narcotics following three back surgeries.

Facing the Consequences?

Perhaps because of differences in the drugs used, impaired healthcare professionals are more likely to be treated as patients than as criminals. In its January 2001 standards, the US Joint Commission on Accreditation of Healthcare Organizations (JCAHO), states: "The purpose of the process [of identifying and treating impaired physicians] is assistance and rehabilitation rather than discipline, to aid a physician in retaining or regaining optimal professional functioning, consistent with protection of patients." In Australia, the Nurses & Midwives Board of New South Wales has also developed a system to separate the medical aspects of substance abuse from the potential criminal liability – in other words decriminalizing drug abuse by healthcare professionals. In the United States, more and more State Boards governing the health professions are taking this approach.

Once a healthcare professional enters into a treatment program, the chances are good for a complete recovery. This seems to be independent of any other factor, including the nature of the drug dependency, the profession, or the area of specialization within the profession. Success rates, measured by the ability of the professional to return to work, have been as high as 90% in some studies, although it is often recommended that the impaired professional return to work in an area of reduced stress and reduced access to abuse potential drugs.

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