Addiction among physicians: the problems may not be what you think MILAN KORCOK Easy access to drugs is usually cited as the main reason for the high incidence of narcotic addiction among physicians. But a recent stLldy from Texas suggests that emotional stress in early life and the strains and .frustrations of practice make the physician especially vulnerable. Reporting to the annual national drug abuse conference in San Francisco, Sondra Stickney, chief nurse at the clinical research unit of the Texas Research Institute of Mental Sciences, cited studies showing that physicianabusers tend to show greater-than-normal incidence of parental deprivation or prolonged or serious childhood illness - insecurities compensated for by academic overachievement, sexual inhibition and emotional hypersensitivity. Physicians have an addiction ratio of 1:400, compared to 1:4000 in the general population, she said. Medicine has become a world of specialization littered with frustrations, said Nurse Stickney. The physician finds himself confronted by patients who expect miracles, who are critical of him and who resent his fees. This pattern affects his personal life and domestic stability. Recent studies show that professionals who abuse drugs have histories of overwork, chronic fatigue, physical illness, marital problems and insomnia. They are also anxious about pending retirement and professional dissatisfaction. Among physician abusers treated at the Texas centre, one of the major issues is the professional's resentment of being regarded differently at home and at work. He often feels undervalued at home, in contrast to his work situation. Spouses appear resentful of his prolonged physical and emotional absences and his continued caring for others.
This problem becomes even more acute when both partners are professionals, says Nurse Stickney - "each feels they gave at the office." Experience with physician abusers at the Texas unit shows a vicious cycle, said Stickney: stress, leading to an increased need to be cared for, leading to resentment of the spouse, increased avoidance of the home situation, increased work and consequent fatigue, all this finally leading to more stress. One study showed that of 98 physician abusers, marital problems were rated as a significant causative factor in their addiction, yet none took steps toward divorce. Seventy-one percent of these physicians' spouses were aware of the drug abuse but took no measures to intercede. Though this high rate of addiction among physicians continues, treatment remains elusive. "Data collection is shrouded in mystery," said Nurse Stickney. "Peers are reluctant to report. In spite of the volumes of material available on the subject of drug abuse. little deals with the professional in a role other than healer." The Texas research team, trying to shed light on the scope of the problem, surveyed all state medical boards and boards of nursing. The response rate was a "disappointingly low" 22%. And 51 of the 65 responses reported no specific data on prevalence of drug abuse among professionals. There appears a reluctance among physicians to tarnish the image of the profession, suggested Stickney. Worse, nothing binds the professional morally or legally to report abuse by a colleague - and it is often the professional who reports the addiction of a colleague who feels the greatest stigma. The majority of physician abusers who come to the attention of author-
ities do so not by colleague identification but through audits of the various regulatory boards. Studies show that few physicians seek treatment without fear of legal reprisal, yet many admit to being relieved to have been caught. Stickney noted that nurses also have a high rate of abuse, but the nurse is frequently detected by employers or coworkers. Unlike the physician, who can obtain his drugs by prescription or sample supplies, the nurse abuser often steals her drugs from patients. To cover up she may administer a placebo or shortchange the medication dose. Of 113 nurses reported to the Michigan Board of Nursing during 1976, 101 were reported for diverting drugs from their patients. The ability to deal with a physicianaddict is often impeded by the therapist's tendency to treat him as a VIP, said Nurse Stickney. The "Physician heal thyself' thesis remains strong. But this can be a frustrating situation for the physician-patient, who in fact does not know all the answers. Stickney emphasized that the physician abuser is often no more able to define and eliminate his psychologic problems than any other patient. The therapist must not lose sight of the fact that the patient, even if he is a physician, is ill and deserves as good care as others receive. It is important in this situation clearly to define the physician-addict as the patient and to underline that no shortcuts will be taken in his management. Equally important, said Stickney, legal issues must be confronted. Specifically who will get the information given to the therapist, and what course needs to be taken to protect the physician-abuser patient? This may involve a forced vacation, suspension of hospital privileges, suspension of narcotic li-
CMA JOURNAL/JULY 9, 1977/VOL. 117 89
Bactrim* Roche Rx summary indlcaUons The following types of infections when caused by susceptible pathogens: * Upper and lower respiratory tract infections (particularly chronic bronchitis and including acute and chronic otitis media) * Genitounnary tract infections, acute, recurrent, and chronic cystitia, pyetonephntis, urethntis (including uncomplicated gonococcal urethritis), prustatitis, vaginitis, cervidtis, salpingitis * Gastrointestinal tract infections It is not indicated in infections due to Pseudomonas, Mycop/asma, orviruaes.
Contraindications Evidence of marked liver damage; blood dyecrasias; known hypersensitivity to tnmethopnm or sulfonamides; or marked renal impeirment where repeated serum assays cannot be carned out. Infants during thefirstfew weeks of life (espeoslly premature infants). For the time being, during pregnancy. Adverse reactions Mostfrequent: nausea; vomiting; gastnc intolerance: and rash. Less frequent: diarrhea; constipetion; flatulence; anorexia; pyrosis; gastritis; gastroenteritis; urticana; headache; and liver changes (abnormal elevations in alkaline phosphatase and serum transaminase). Occasionally reported: glossitis; oliguna; hematuria; tremor; vertigo; alopecia; and elevated BUN, NPN, and serum creatinine. Hematological changes, occurnng particularly in the elderly, are moattytransient and reversible (pnmarily, neutropenis and thrombocytopenia; less frequently, leukopenia, aplastic or hemolytic anemia, agranulocytoas, and bone marrow depression).
Precautions
As with other sulfonamide preparations, benefit should be critically appraised against risk in patients with liver damage, renal damage, urinary obstruction, blood dyscrasias, allergies, or bronchial asthma. The possibility of superinfection with anon-sensitive organism should be borne in mind. Dosage and administration Children less fhan 2 years: 2.5 ml of suspension twice a day. Children 2 ro 5 years; 2.5-5 ml of suspension twice a day. Children 6 fo 12 years; 5-10 ml of suspension twice a day. Adufts and children over 12 years otage: Standard dosage; Bactrim DS Roche tablet or 2 adult tablets, twice daily. IAnimum dosage and dosage for long-term treatment Yx Bactrim' DS Roche tablet or 1 adult tablet, twice daily. Maximum dosage (overwhelming infections). 1.i Bactrim DS Roche tablets or 3 adulf tablets, twice daily.
Supply
DS tablets, containing 160mg trimethopnm and 800mg sulfamethoxazole. Bottles 01100 and 500. Adult tablets, containing 80mg tnmathopnm and 400mg sulfamathosazole. Bottles 01100 and 500 Bactrim Roche is also available as suspension (aniseedlfavoured) 40mg tnmethoprim and 200 mg sulfamethosazole pertsp (5 ml). Bottlesof lOOand 400 ml. Product monograph available on request. * Trade Mark of Hoffmann-La Roche Limited ®Reg. Trade Mark
cence, close supervision of work performance by a responsible colleague or other controls. For narcotic use, particularly with short-acting agents such as Demerol (pethidine hydrochloride), the patient should be hospitalized and withdrawn over a 1- to 14-day period, according to Stickney. Often, hospitalization in another community is indicated. Therapy should be directed toward the elucidation and understanding of the physician' s coping problems, frustrations and anxieties about self-esteem. Reports of treatment outcome among physician addicts vary widely - from 27 to 92%, but this is considerably better than the accepted 5 to 15% for the typical abuser. The typical abuser normally becomes addicted in adolescence. The physician is usually into his mid 30s and 40s before he becomes seriously involved. He also is introduced to drugs by himself rather than by his peers, and his drug of choice is Demerol, rather than the heroin favored by nonphysician addicts. The fact that the medical system is not closed and that it is subject to social values and pressures has had a lot to do with growing involvement of physicians in treatment of addictive behaviour, a New York psychiatrist told the conference. Dr. Marc Galanter, of Albert Einstein College of Medicine, said that so long as a physician perceived his responsibility as limited to the immediate medical sequelae of alcoholism, he could justify treating alcoholic hallucinosis or gastrointestinal bleeding and ignoring the patient's addictive problem. Continued drinking appeared to be no more the responsibility of the physician, or the hospital, than was the criminality of the assailant who was injured during a criminal act. But with the growth of psychoanalysis, with a greater understanding of compulsive behaviours and with the expansion of organizations such as Alcoholics Anonymous, the generalized denial of alcoholism as an illness becomes less tenable, said Galanter. The public became sensitized to the importance of treatment for the addic-
tions, and it started to assign the physician some responsibility for treating the cause of recidivism. Said Galanter: "The physician could no longer deny that the patient had an ongoing pathologic process that extended between each of the hospital admissions. That is to say, the recidivist GI bleeder had an underlying disease, namely alcoholism." In defining what is legitimate medical practice, "we must look to the value system of society," said Galanter. There is a rooting of "our medical perspectives" in the assumptive values of the larger society. Greater physician involvement in treating addictive behaviours was also stimulated by the legitimizing of detoxification units as a treatment means and development of methadone treatment for heroin addiction - which firmly established addictive disease as a target illness for pharmacotherapy. In addition, there was growth in psychosocial interventions such as group therapy and pharmacological interventions such as disulfiram treatment. In effect, the physician had something more concrete to treat (he was not getting bogged down in exasperating moral dilemmas), his arsenal of methodologies was expanded, and there was financial recognition of his services. Further strengthening of the physician's role in treating the addictions will come with the fixing of content in undergraduate and graduate medical systems. Galanter noted that National Board examinations soon will include questions on drug abuse therapy. Galanter said that addictive diseases are becoming more prominent in the wards of general hospitals. In one report on four hospitals, 16% of ward patients were alcoholics. "The social toll of the addictions is also great. For alcoholism, it has recently been estimated at over $25 billion per year. "These reasons, in addition to the clear-cut organ pathology and the psychosocial disruption associated with the disease, make it most perplexing that it was not explicitly included in the American Medical Association nomenclature as recently as 25 years ago."E
New bill will extend support The new Social Services Act, introduced into the House of Commons last month by Health Minister Marc Lalonde, calls for the Canadian government to pay part of the cost of a wide range of provincial programs, some of which had not previously been cost shared. Services eligible for funding under 90 CMA JOURNAL/JULY 9, 1977/VOL. 117
the act include: crisis intervention, information and referral, family planning, child protection and development, day care for children and adults, rehabilitation for the disabled, home support and meals, counselling, employment help, transportation for the handicapped and community services.E
This problem becomes even more acute when both partners are professionals, says Nurse Stickney - "each feels they gave at the office." Experience with physician abusers at the Texas unit shows a vicious cycle, said Stickney: stress, leading to an increased need to be cared for, leading to resentment of the spouse, increased avoidance of the home situation, increased work and consequent fatigue, all this finally leading to more stress. One study showed that of 98 physician abusers, marital problems were rated as a significant causative factor in their addiction, yet none took steps toward divorce. Seventy-one percent of these physicians' spouses were aware of the drug abuse but took no measures to intercede. Though this high rate of addiction among physicians continues, treatment remains elusive. "Data collection is shrouded in mystery," said Nurse Stickney. "Peers are reluctant to report. In spite of the volumes of material available on the subject of drug abuse. little deals with the professional in a role other than healer." The Texas research team, trying to shed light on the scope of the problem, surveyed all state medical boards and boards of nursing. The response rate was a "disappointingly low" 22%. And 51 of the 65 responses reported no specific data on prevalence of drug abuse among professionals. There appears a reluctance among physicians to tarnish the image of the profession, suggested Stickney. Worse, nothing binds the professional morally or legally to report abuse by a colleague - and it is often the professional who reports the addiction of a colleague who feels the greatest stigma. The majority of physician abusers who come to the attention of author-
ities do so not by colleague identification but through audits of the various regulatory boards. Studies show that few physicians seek treatment without fear of legal reprisal, yet many admit to being relieved to have been caught. Stickney noted that nurses also have a high rate of abuse, but the nurse is frequently detected by employers or coworkers. Unlike the physician, who can obtain his drugs by prescription or sample supplies, the nurse abuser often steals her drugs from patients. To cover up she may administer a placebo or shortchange the medication dose. Of 113 nurses reported to the Michigan Board of Nursing during 1976, 101 were reported for diverting drugs from their patients. The ability to deal with a physicianaddict is often impeded by the therapist's tendency to treat him as a VIP, said Nurse Stickney. The "Physician heal thyself' thesis remains strong. But this can be a frustrating situation for the physician-patient, who in fact does not know all the answers. Stickney emphasized that the physician abuser is often no more able to define and eliminate his psychologic problems than any other patient. The therapist must not lose sight of the fact that the patient, even if he is a physician, is ill and deserves as good care as others receive. It is important in this situation clearly to define the physician-addict as the patient and to underline that no shortcuts will be taken in his management. Equally important, said Stickney, legal issues must be confronted. Specifically who will get the information given to the therapist, and what course needs to be taken to protect the physician-abuser patient? This may involve a forced vacation, suspension of hospital privileges, suspension of narcotic li-
CMA JOURNAL/JULY 9, 1977/VOL. 117 89
Bactrim* Roche Rx summary indlcaUons The following types of infections when caused by susceptible pathogens: * Upper and lower respiratory tract infections (particularly chronic bronchitis and including acute and chronic otitis media) * Genitounnary tract infections, acute, recurrent, and chronic cystitia, pyetonephntis, urethntis (including uncomplicated gonococcal urethritis), prustatitis, vaginitis, cervidtis, salpingitis * Gastrointestinal tract infections It is not indicated in infections due to Pseudomonas, Mycop/asma, orviruaes.
Contraindications Evidence of marked liver damage; blood dyecrasias; known hypersensitivity to tnmethopnm or sulfonamides; or marked renal impeirment where repeated serum assays cannot be carned out. Infants during thefirstfew weeks of life (espeoslly premature infants). For the time being, during pregnancy. Adverse reactions Mostfrequent: nausea; vomiting; gastnc intolerance: and rash. Less frequent: diarrhea; constipetion; flatulence; anorexia; pyrosis; gastritis; gastroenteritis; urticana; headache; and liver changes (abnormal elevations in alkaline phosphatase and serum transaminase). Occasionally reported: glossitis; oliguna; hematuria; tremor; vertigo; alopecia; and elevated BUN, NPN, and serum creatinine. Hematological changes, occurnng particularly in the elderly, are moattytransient and reversible (pnmarily, neutropenis and thrombocytopenia; less frequently, leukopenia, aplastic or hemolytic anemia, agranulocytoas, and bone marrow depression).
Precautions
As with other sulfonamide preparations, benefit should be critically appraised against risk in patients with liver damage, renal damage, urinary obstruction, blood dyscrasias, allergies, or bronchial asthma. The possibility of superinfection with anon-sensitive organism should be borne in mind. Dosage and administration Children less fhan 2 years: 2.5 ml of suspension twice a day. Children 2 ro 5 years; 2.5-5 ml of suspension twice a day. Children 6 fo 12 years; 5-10 ml of suspension twice a day. Adufts and children over 12 years otage: Standard dosage; Bactrim DS Roche tablet or 2 adult tablets, twice daily. IAnimum dosage and dosage for long-term treatment Yx Bactrim' DS Roche tablet or 1 adult tablet, twice daily. Maximum dosage (overwhelming infections). 1.i Bactrim DS Roche tablets or 3 adulf tablets, twice daily.
Supply
DS tablets, containing 160mg trimethopnm and 800mg sulfamethoxazole. Bottles 01100 and 500. Adult tablets, containing 80mg tnmathopnm and 400mg sulfamathosazole. Bottles 01100 and 500 Bactrim Roche is also available as suspension (aniseedlfavoured) 40mg tnmethoprim and 200 mg sulfamethosazole pertsp (5 ml). Bottlesof lOOand 400 ml. Product monograph available on request. * Trade Mark of Hoffmann-La Roche Limited ®Reg. Trade Mark
cence, close supervision of work performance by a responsible colleague or other controls. For narcotic use, particularly with short-acting agents such as Demerol (pethidine hydrochloride), the patient should be hospitalized and withdrawn over a 1- to 14-day period, according to Stickney. Often, hospitalization in another community is indicated. Therapy should be directed toward the elucidation and understanding of the physician' s coping problems, frustrations and anxieties about self-esteem. Reports of treatment outcome among physician addicts vary widely - from 27 to 92%, but this is considerably better than the accepted 5 to 15% for the typical abuser. The typical abuser normally becomes addicted in adolescence. The physician is usually into his mid 30s and 40s before he becomes seriously involved. He also is introduced to drugs by himself rather than by his peers, and his drug of choice is Demerol, rather than the heroin favored by nonphysician addicts. The fact that the medical system is not closed and that it is subject to social values and pressures has had a lot to do with growing involvement of physicians in treatment of addictive behaviour, a New York psychiatrist told the conference. Dr. Marc Galanter, of Albert Einstein College of Medicine, said that so long as a physician perceived his responsibility as limited to the immediate medical sequelae of alcoholism, he could justify treating alcoholic hallucinosis or gastrointestinal bleeding and ignoring the patient's addictive problem. Continued drinking appeared to be no more the responsibility of the physician, or the hospital, than was the criminality of the assailant who was injured during a criminal act. But with the growth of psychoanalysis, with a greater understanding of compulsive behaviours and with the expansion of organizations such as Alcoholics Anonymous, the generalized denial of alcoholism as an illness becomes less tenable, said Galanter. The public became sensitized to the importance of treatment for the addic-
tions, and it started to assign the physician some responsibility for treating the cause of recidivism. Said Galanter: "The physician could no longer deny that the patient had an ongoing pathologic process that extended between each of the hospital admissions. That is to say, the recidivist GI bleeder had an underlying disease, namely alcoholism." In defining what is legitimate medical practice, "we must look to the value system of society," said Galanter. There is a rooting of "our medical perspectives" in the assumptive values of the larger society. Greater physician involvement in treating addictive behaviours was also stimulated by the legitimizing of detoxification units as a treatment means and development of methadone treatment for heroin addiction - which firmly established addictive disease as a target illness for pharmacotherapy. In addition, there was growth in psychosocial interventions such as group therapy and pharmacological interventions such as disulfiram treatment. In effect, the physician had something more concrete to treat (he was not getting bogged down in exasperating moral dilemmas), his arsenal of methodologies was expanded, and there was financial recognition of his services. Further strengthening of the physician's role in treating the addictions will come with the fixing of content in undergraduate and graduate medical systems. Galanter noted that National Board examinations soon will include questions on drug abuse therapy. Galanter said that addictive diseases are becoming more prominent in the wards of general hospitals. In one report on four hospitals, 16% of ward patients were alcoholics. "The social toll of the addictions is also great. For alcoholism, it has recently been estimated at over $25 billion per year. "These reasons, in addition to the clear-cut organ pathology and the psychosocial disruption associated with the disease, make it most perplexing that it was not explicitly included in the American Medical Association nomenclature as recently as 25 years ago."E
New bill will extend support The new Social Services Act, introduced into the House of Commons last month by Health Minister Marc Lalonde, calls for the Canadian government to pay part of the cost of a wide range of provincial programs, some of which had not previously been cost shared. Services eligible for funding under 90 CMA JOURNAL/JULY 9, 1977/VOL. 117
the act include: crisis intervention, information and referral, family planning, child protection and development, day care for children and adults, rehabilitation for the disabled, home support and meals, counselling, employment help, transportation for the handicapped and community services.E
