Thomas M Canfield, MD
Dru addiction of health Plrofessionals
The problem of drug abuse among professional health care deliverers is a closely guarded and supressed secret. Physicians and nurses are entrenched in a hierarchy that almost preempts a prompt and appropriate response to the professional abuser. Failure of the professionals to regulate and maintain appropriate order within themselves will most certainly lead to bureaucratic governmental interference with the practice of medicine; thus, we must police ourselves. As a practicing clinician in the emergency room of several hospitals and the medical officer of several police departments, I have seen and
Thomas M Canfield, MD, is pathologist and director of laboratories, Montrose Memorial Hospital, Montrose, Colo, and director, Regional Forensic Sciences Laboratory, Montrose. He is also an agent for the Colorado Bureau of Investigation, police surgeon for the Montrose Police Station, and deputy coroner, Montrose County Coroner’s Office.A fellow of the American Academy of Forensic Sciences, he holds MD and BS degrees from the University of Minnesota, Minneapolis. This paper is based on his presentation at the 1976 AORN Congress in Miami.
treated many disasters resulting directly and indirectly from drug abuse. I have treated the abuser for both his direct drug-related problem and the indirect damage done to himself or others because of the drug abuse. As a coroner’s pathologist and medical examiner, I have had to determine the cause and manner of many drugrelated deaths as well as to investigate the source and type of drugs involved. As a commissioned law enforcement officer, I have investigated and probed illicit drug abuse. As the director of a forensic science laboratory, I have examined hundreds of items pertaining to drug-related crimes. Thus, I have observed a spectrum of illegal drug use and its results. Why should I direct my remarks to you, the operating room nurse and supervisor? As practicing operating room nurses, you are in a unique position to observe health care deliverers at unusual hours and at times of maximum stress. As active practitioners, you have responsibility and accountability for your conduct and that of your professional colleagues in the health care delivery system. Thus, if you know of or have valid grounds to suspect drug abuse by a peer, colleague, or supervisor and do nothing, you may be held morally or
AORN Journal, October 1976, Vol 24, No 4
665
I
dentification of a professional who abuses drugs is difficult.
legally responsible for the consequence of acts by that professional if damage occurs resulting from the effects of his or her drug abuse. Depending upon the circumstances, you may be held civilly liable in a torts claim or criminally liable as an accessory in a criminal action. Your professional standing and code of conduct include accountability for competence of yourself and your peers. Finally, your personal selfesteem must suffer if you allow abuse to continue while it will rise if you prevent abuse or its consequences. The problem of drug abuse includes, but is not limited to, opiates, dangerous drugs, and alcohol. As one of their earliest actions, abusable drugs tend to affect the judgment of the abuser. The professional judgment of a health care deliverer is the single most important gift he has; t o lose that judgment is tantamount t o losing his most precious skill in caring for the patient. No one can afford loss of judgment in his or her care of the patient. Identifying a drug abuser who is a professional is difficult because of what it may do to his reputation and because of the response by the professional and lay community if the information becomes public. The problem lies not in the good or evil of the situation but in the response of the patients and the professional. Many may rise to the defense of the accused and object to his criticism o r to limit-
666
ing the privileges of one who has helped so many in the past. Pressures from both the professional and lay community may be intense. However that judgment, which was keen in the past, may well be lost in the future with the interference of drugs. In addition, the high cure rate and return to professional service of the treated professional drug abuser indicate we do a service by identifying him. What is the extent of the problem? No one really knows. The data is suppressed and limited. Health care professionals who abuse drugs are not discussed. Defining the problem becomes fraught with difficulties in the semantics of the terms abuse, addiction, habituated, experimental, and sporadic use. No one ever plans to become habituated or addicted to opiates, drugs of abuse, or alcohol. The occurrence of the problem is minimal when one recognizes the stress of health care delivery and the professional’s access to drugs. However, it is a problem that is significant; thus, to maintain our professionalism, we must not tolerate any level of drug abuse in our midst. In reviewing the professional literature, I came to two conclusions. One, there is very little written in the professional journals about the problem. Secondly, essentially all the articles that quote incidences, rates, or other statistical data state their data is most likely incomplete and probably underestimates the extent of the problem.
AORN Journal, October 1976, Vol 24, No 4
Some of the data on the extent of the problem is summarized below. The American Medical Association’s Council on Mental Health, in discussing the scope of the problem among physicians in the United States, England, Germany, Holland, and France, indicated that about 15% of known drug addicts are physicians. An additional 15%are members of the nursing and pharmacy profession.’ Rasor and Crecraft in the Journal of the American Medical Association noted that nearly 50% of meperidine addicts admitted to the United States Public Health Service facility Lexington, Ky, over a three-year period were physicians, nurses, or others involved in health care delivery systems. Garb in Anesthesia and AnalgesiaCurrent Researches reported a n abuse rate of 49 per 100,000 registered physicians. This is about 300 physicians a year who became addicted to meperidine alone and represents only those brought to “official a t t e n t i ~ n . ” ~ A’Brook, Hailstone, and McLaughlin in the British Journal of Psychiatry stated that of physicians with behavioral problems, 32.8% were considered drug addicts with about one-third using opiates, one-third alcohol, and one-third dangerous drugs. Those using meperidine accounted for only 11%of the total drug abuser^.^ Pescor in 1942 reported in Diseases of the Nervous System that physicians
who voluntarily seek aid have a n average 13-year history of drug abuse prior to their seeking aid.5 Monnerot-Dumaine in the New Medical Press (Nouvelle Presse Medicale) noted physicians use sedatives, alcohol, and narcotics 30 to 100 times more frequently than the general public.6 Murray, in discussing psychiatric illness, stated in Lancet that physicians are especially prone to drug dependence and called the risk a n occupational hazard of the medical profession. He estimated the frequency of narcotic addiction to be 30 to 100 times that of the general population.’ Poplar in the American Journal of Nursing reported that drugs abused most by nurses are, in descending order, Demerol, morphine, paragoric, codeine, and Darvon.8 I found few references to nurse addicts in the literature; most reference to the nurse is included in the general professional categories. No references speak to the operating room nurse as a special category. Glatt in Lancet stated that physician-alcoholics clearly out-number physicians who abuse other drugs. In his studies, between W o to almost 4% of known alcoholics in England were physician^.^ A’Brook and colleagues in the British Journal of Psychiatry noted the ratio of alcohol to other drugs used by professionals was about 50/50.1° Vincent, in the Canadian Medical As-
AORN Journal, October 1976,V o l 2 4 , No 4
667
D
ocument your suspicions and report any incident to your immediate supervisor.
sociation Journal, also reported a ratio of about 50/50 of alcohol to other drugs. In several studies reported by Vaillant and others in the New England Journal of Medicine, the ratio of ffhigh drug use” was 36% to 40%0 of physicians who used mood-altering drugs to the extent they had problems.12 An editorial in the Canadian Medical Association Journal viewed drug abuse by physicians as a major problem with about 0.3% of physicians abusing drugs at that time. The editorial called the data incomplete and pointed out increasing cannabis use among medical students.13 Smith and Blachly in the Journal of Medical Education discussed the extent of amphetamine usage by medical students and noted that 44% of students had used the drug.14 Farnsworth in the New England Journal of Medicine discussed increasing drug use by medical students.15 In 1970, Watkins in the Southern Medical Journal reported that over 75% of medical students in his study had used amphetamines for nonmedical reasons.16 Thus, it may be that the problem is not decreasing but perhaps increasing. Statistics are difficult to deal with, and most of the above figures do not, by their own admission, indicate the true rates, incidences, or total impact of the problem. If we take the data of Garb, who states the rate of
668
meperidine abuse alone is about 0.05% of physicians sampled per year, and note the proportion of meperidine abuse in A’Brook’s studies is about lWo of the total opiates, dangerous drugs, and alcohol abused, one can calculate a yearly rate of 0.5%. Noting the average professional practices from between 30 to 40 years at a rate of 0.5% a year, his or her statistical chance of having a problem with drug abuse calculates to between 15% to 20% in his lifetime. Obviously, it does not account for the individual who may have multiple problems in his career. Although the statistical analysis appears correct, the actual number of professionals involved is smaller due to multiple offenders. The above statistical manipulation is somewhat verified by two separate state boards of medical examiners whose experiences are reported by the American Medical Association’s Council on Mental Health in the Journal of the American Medical Association. They found that about 5% of practicing physicians officially had alcohol and other types of drug abuse problems over a ten-year period.” If 5% have a problem in 10 years, the figure of 0.5% per year appears valid. Thus, over a lifetime of practice, the statistical incidence of alcohol, opiate, and dangerous drug abuse is between 15% and 200/0.
The above data are from statistics gleaned from professional literature,
AORN Journal, October 1976,Vol24, No 4
published data, and so-called official statistics. My experience comes from four distinct responsible areas of drug information. First, due to my interest and work in drug abuse, I am often requested by supervisory and responsible persons who know of a possible drug abuse situation to give advice. As the director of a forensic sciences laboratory, I and my staff are responsible for analysis of suspected tempered or diluted medications. Further, because of my law enforcement and medicolegal background, I am consulted and requested to give advice on security problems and thefts in limited access areas where drugs have been found missing. Finally, as a law enforcement officer, I a m aware of and consulted in cases of professionals who become subjects of official investigations relating to drug abuse at a local, county, state, or federal level. Based upon these experiences, it is my opinion that the yearly incidence of 0.5% and the lifetime risk of 15% to 20% are valid and reasonably correct figures. It is obvious we must be on constant and objective guard to prevent the problem from affecting critical areas of health care delivery. We must continue strict self-regulation and maintain our high standards. Because of the extent of federal bureaucratic interference with health care delivery systems, it is clear if we do not maintain a constant vigilance and policing of our ranks, the interventionists will
do it for us. For instance, drugs critical to health care delivery may be removed from our armamentarium. It has already been recommended that certain opiates be limited or deleted.l8 What should we do when we are confronted with a situation which may be drug abuse? Positive assertive behavior is mandatory. First document your suspicions on paper as, or immediately after, they occur and keep a written personal log. Your records, as well as the official records of your institution, are mandatory when the problem comes up for action. Report any incident or suspicion to your immediate supervisor. That person then becomes responsible for the problem, and you have fulfilled a significant part of your responsibility. The system, then, can more easily respond and take the heat generated when the phenomena is brought before the administration. Protect yourself when reporting suspicions of drug abuse because although the hierarchy of your system may support you, it may also attack you. Always discuss your knowledge or suspicion with a reliable adviser or counselor who may later be called upon to defend your responsibilities and the manner in which the problem was handled. If you suspect hostility will be directed toward you for raising the problem of a potential drug abuser, consider hiring legal counsel. Your reputation and job may be in jeopardy,
AORN Journal, October 1976, Vol24, No 4
669
D
o not confront the individual you suspect.
and you may be threatened or actually sued. You may also be attacked on a moral, ethical, licensure, or personal issue. In the investigatory phase of a colleague whom you suspect and have reported, you should consider the advisability of contacting law enforcement personnel. I suggest this not to set up an arrest of the suspected abuser but to get the tools and expertise of an experienced professional investigator. In addition, if you are certain you are correct in your suspicion, it may be legally required in your state to report criminal behavior. Certainly, you have a moral obligation to do so. Having advised you on positive assertive action, I will also advise you on what not to do. Do not confront the individual you suspect. This should be done at the proper time by a responsible person at least one rank above you or the person who reported the incident. Do not let the hostility focus on yourself or any other person as an individual. Any hostility should be focused toward the system to avoid as much as possible any personal risks to the reporting individual. Do not gossip about your suspicion but certainly listen for statements by others relating to your suspicion. Do not attempt to provide therapeutic services to the suspected drug abuser. Your motivation may be commendable, but your results are most apt to be disastrous.
670
Treatment must come from a recognized professional in drug abuse therapy. This person can be objective and professionally, not personally, attached in a patient relationship. Do not become involved in the problems of the drug abuser for you may compromise your status by becoming an indirect or direct source of drugs. Then you may become an accessory to criminal behavior by assisting or allowing illegal access to drugs either passively or actively. What should you expect if you report or are a supervisor involved in detecting and reporting professionals with drug abuse problems? You should expect trouble. Even if you are supported by your system, you may well be singled out as a troublemaker. If you are not supported by your hierarchy, you may be attacked by your system, supervisor, and peers. You then may face possible loss of your job, and harassment from your peers as well as physicians and administration officials. Many persons in the upper echelon do not want drug problems exposed. They erroneously believe the danger of publicity outweighs the danger of a professional who abuses drugs. Finally, you may find yourself involved in lawsuits against your system or yourself or both. To meet these problems, always attempt to maintain a professional and ethical approach when dealing with the problem of drug abuse among professionals.
AORN Journal, October 1976, Vol24, No 4
Finally, what will happen to the individual professional who is identified as one who has drug abuse problems? Help for these professional patients is hard to find. There is resistance on the part of the professional to seek help because of the stigma attached to the problem. Further, there is the risk of loss of license if he or she is exposed. Thus, there are few who voluntarily request help.l9 The professional who has a drug abuse problem is more likely to be a so-called sociologic addict as opposed to the psychological addict on the street. The sociologic addict tends to use drugs so he or she can continue to perform in the face of pain, fatigue, or disease.20 The sociologic addict is more prone to basic psychiatric disease. The sociologic addict has a well-developed coping mechanism, and his potential for cure is extremely high. The cure rate of Starkey’s program in Denver is over 95% in his professional patient group.21 The cure rate reported from a study in California was 920/0.~~ In summary, you do your profession, the patients, yourself, and, probably most important, the abuser a service in identifying professionals who are drug abusers. By policing your profession, you maintain a high standard of care, avoid bureaucratic interference, and provide a service to all concerned.
0 Notes 1. American Medical Association: Council on Mental Health, “The sick physician,” Journal of American Medical Association 223 (Feb 5, 1973) 684-687. 2. R W Rasor, H J Crecraft, “Addiction to meperidine (Demerol) hydrochloride,” Journal of the American Medical Association 157 (1955) 654-657. 3. G Garb, “Drug addiction in physicians,” Anesthesia and Analgesia-Current Researches 481 (1969) 129-133. 4. M F A’Brook, J D Hailstone, I E J
McLaughlin, ”Psychiatric illness in the medical profession,” British Journal of Psychiatry 113 (1967) 1012-1023. 5. M J Pescor, “Physician drug addicts,” Diseases of the Nervous System (June 1942) 173174. 6. Monnerot-Dumaine, “Doctor cure thyselfneurosis and depression among physicians,” Nouvelle Presse Medicale 2 (March 10, 1973) 663-664. 7. R N Murray, “Psychiatric illnesses in doctors,” Lancet 1 (June 15, 1974) 1211-1213. 8. J F Poplar, “Characteristics of nurse addicts,” American Journal of Nursing 69 (1969) 117-119. 9. M M Glatt, “Alcoholism among doctors,“ Lancet 2 (Aug 10, 1974) 342-343. 10. A’Brook, Hailstone, McLaughlin, “Psychiatric illness,” 1013. 11. M 0 Vincent, E A Robinson, L Latt, “Physicians as patients: Private psychiatric hospital experience,” Canadian Medical Association Journal 100 (March 1, 1969) 403-412. 12. G E Vaillant, J R Brighton, C McArthur, “Physician use of mood altering drugs,” New England Journal of Medicine 282 (Feb 12, 1970) 365-370; G E Vaillant, N C Sobowale, C McArIhur, “Some psychologic vulnerabilities of physicians,” New England Journal of Medicine 287 (Aug 24, 1972) 372-375. 13. Canadian Medical Association, “Physician drug abuse a major manpower problem,” Canadian Medical Association Journal 106 (June 24, 1972) 1353-1354. 14. S N Smith, P M Blachly, “Amphetamine usage by medical students,” Journal of Medical Education 41 (1966) 167-170. 15. D L Farnsworth. “Drug dependence among physicians,” New England Journal of Medicine 282 (Feb 12, 1970) 392-393. 16. C Watkins, “Use of amphetamines by medical students,” Southern Medical Journal 63 (1970) 923-929. 17. American Medical Association, “The sick physician.” 18. Garb, “Drug addiction in physicians.” 19. M M Glatt, “Doctors with a drinking problem,” Lancet 1 (Jan 25, 1975) 219-225. 20. S Garb, “Narcotic addiction in nurses and doctors,” Nursing Outlcok 13 (November 1965) 30-34; S Herbert Peyser, “Children of the poppy,” New Republic 152 (Feb 13, 1965) 19-20. 21. G H Starkey, personal communication, Denver General Hospital, 645 Bannock St, Denver, Colo 80204. 22. L E Jones, “How 92% beat the dope habit,” Bulletin Los Angeles County Medical Association 88 (1958) 19; 37-40.
AORN Journal, October 1976, Vol24, No 4
671
Dru addiction of health Plrofessionals
The problem of drug abuse among professional health care deliverers is a closely guarded and supressed secret. Physicians and nurses are entrenched in a hierarchy that almost preempts a prompt and appropriate response to the professional abuser. Failure of the professionals to regulate and maintain appropriate order within themselves will most certainly lead to bureaucratic governmental interference with the practice of medicine; thus, we must police ourselves. As a practicing clinician in the emergency room of several hospitals and the medical officer of several police departments, I have seen and
Thomas M Canfield, MD, is pathologist and director of laboratories, Montrose Memorial Hospital, Montrose, Colo, and director, Regional Forensic Sciences Laboratory, Montrose. He is also an agent for the Colorado Bureau of Investigation, police surgeon for the Montrose Police Station, and deputy coroner, Montrose County Coroner’s Office.A fellow of the American Academy of Forensic Sciences, he holds MD and BS degrees from the University of Minnesota, Minneapolis. This paper is based on his presentation at the 1976 AORN Congress in Miami.
treated many disasters resulting directly and indirectly from drug abuse. I have treated the abuser for both his direct drug-related problem and the indirect damage done to himself or others because of the drug abuse. As a coroner’s pathologist and medical examiner, I have had to determine the cause and manner of many drugrelated deaths as well as to investigate the source and type of drugs involved. As a commissioned law enforcement officer, I have investigated and probed illicit drug abuse. As the director of a forensic science laboratory, I have examined hundreds of items pertaining to drug-related crimes. Thus, I have observed a spectrum of illegal drug use and its results. Why should I direct my remarks to you, the operating room nurse and supervisor? As practicing operating room nurses, you are in a unique position to observe health care deliverers at unusual hours and at times of maximum stress. As active practitioners, you have responsibility and accountability for your conduct and that of your professional colleagues in the health care delivery system. Thus, if you know of or have valid grounds to suspect drug abuse by a peer, colleague, or supervisor and do nothing, you may be held morally or
AORN Journal, October 1976, Vol 24, No 4
665
I
dentification of a professional who abuses drugs is difficult.
legally responsible for the consequence of acts by that professional if damage occurs resulting from the effects of his or her drug abuse. Depending upon the circumstances, you may be held civilly liable in a torts claim or criminally liable as an accessory in a criminal action. Your professional standing and code of conduct include accountability for competence of yourself and your peers. Finally, your personal selfesteem must suffer if you allow abuse to continue while it will rise if you prevent abuse or its consequences. The problem of drug abuse includes, but is not limited to, opiates, dangerous drugs, and alcohol. As one of their earliest actions, abusable drugs tend to affect the judgment of the abuser. The professional judgment of a health care deliverer is the single most important gift he has; t o lose that judgment is tantamount t o losing his most precious skill in caring for the patient. No one can afford loss of judgment in his or her care of the patient. Identifying a drug abuser who is a professional is difficult because of what it may do to his reputation and because of the response by the professional and lay community if the information becomes public. The problem lies not in the good or evil of the situation but in the response of the patients and the professional. Many may rise to the defense of the accused and object to his criticism o r to limit-
666
ing the privileges of one who has helped so many in the past. Pressures from both the professional and lay community may be intense. However that judgment, which was keen in the past, may well be lost in the future with the interference of drugs. In addition, the high cure rate and return to professional service of the treated professional drug abuser indicate we do a service by identifying him. What is the extent of the problem? No one really knows. The data is suppressed and limited. Health care professionals who abuse drugs are not discussed. Defining the problem becomes fraught with difficulties in the semantics of the terms abuse, addiction, habituated, experimental, and sporadic use. No one ever plans to become habituated or addicted to opiates, drugs of abuse, or alcohol. The occurrence of the problem is minimal when one recognizes the stress of health care delivery and the professional’s access to drugs. However, it is a problem that is significant; thus, to maintain our professionalism, we must not tolerate any level of drug abuse in our midst. In reviewing the professional literature, I came to two conclusions. One, there is very little written in the professional journals about the problem. Secondly, essentially all the articles that quote incidences, rates, or other statistical data state their data is most likely incomplete and probably underestimates the extent of the problem.
AORN Journal, October 1976, Vol 24, No 4
Some of the data on the extent of the problem is summarized below. The American Medical Association’s Council on Mental Health, in discussing the scope of the problem among physicians in the United States, England, Germany, Holland, and France, indicated that about 15% of known drug addicts are physicians. An additional 15%are members of the nursing and pharmacy profession.’ Rasor and Crecraft in the Journal of the American Medical Association noted that nearly 50% of meperidine addicts admitted to the United States Public Health Service facility Lexington, Ky, over a three-year period were physicians, nurses, or others involved in health care delivery systems. Garb in Anesthesia and AnalgesiaCurrent Researches reported a n abuse rate of 49 per 100,000 registered physicians. This is about 300 physicians a year who became addicted to meperidine alone and represents only those brought to “official a t t e n t i ~ n . ” ~ A’Brook, Hailstone, and McLaughlin in the British Journal of Psychiatry stated that of physicians with behavioral problems, 32.8% were considered drug addicts with about one-third using opiates, one-third alcohol, and one-third dangerous drugs. Those using meperidine accounted for only 11%of the total drug abuser^.^ Pescor in 1942 reported in Diseases of the Nervous System that physicians
who voluntarily seek aid have a n average 13-year history of drug abuse prior to their seeking aid.5 Monnerot-Dumaine in the New Medical Press (Nouvelle Presse Medicale) noted physicians use sedatives, alcohol, and narcotics 30 to 100 times more frequently than the general public.6 Murray, in discussing psychiatric illness, stated in Lancet that physicians are especially prone to drug dependence and called the risk a n occupational hazard of the medical profession. He estimated the frequency of narcotic addiction to be 30 to 100 times that of the general population.’ Poplar in the American Journal of Nursing reported that drugs abused most by nurses are, in descending order, Demerol, morphine, paragoric, codeine, and Darvon.8 I found few references to nurse addicts in the literature; most reference to the nurse is included in the general professional categories. No references speak to the operating room nurse as a special category. Glatt in Lancet stated that physician-alcoholics clearly out-number physicians who abuse other drugs. In his studies, between W o to almost 4% of known alcoholics in England were physician^.^ A’Brook and colleagues in the British Journal of Psychiatry noted the ratio of alcohol to other drugs used by professionals was about 50/50.1° Vincent, in the Canadian Medical As-
AORN Journal, October 1976,V o l 2 4 , No 4
667
D
ocument your suspicions and report any incident to your immediate supervisor.
sociation Journal, also reported a ratio of about 50/50 of alcohol to other drugs. In several studies reported by Vaillant and others in the New England Journal of Medicine, the ratio of ffhigh drug use” was 36% to 40%0 of physicians who used mood-altering drugs to the extent they had problems.12 An editorial in the Canadian Medical Association Journal viewed drug abuse by physicians as a major problem with about 0.3% of physicians abusing drugs at that time. The editorial called the data incomplete and pointed out increasing cannabis use among medical students.13 Smith and Blachly in the Journal of Medical Education discussed the extent of amphetamine usage by medical students and noted that 44% of students had used the drug.14 Farnsworth in the New England Journal of Medicine discussed increasing drug use by medical students.15 In 1970, Watkins in the Southern Medical Journal reported that over 75% of medical students in his study had used amphetamines for nonmedical reasons.16 Thus, it may be that the problem is not decreasing but perhaps increasing. Statistics are difficult to deal with, and most of the above figures do not, by their own admission, indicate the true rates, incidences, or total impact of the problem. If we take the data of Garb, who states the rate of
668
meperidine abuse alone is about 0.05% of physicians sampled per year, and note the proportion of meperidine abuse in A’Brook’s studies is about lWo of the total opiates, dangerous drugs, and alcohol abused, one can calculate a yearly rate of 0.5%. Noting the average professional practices from between 30 to 40 years at a rate of 0.5% a year, his or her statistical chance of having a problem with drug abuse calculates to between 15% to 20% in his lifetime. Obviously, it does not account for the individual who may have multiple problems in his career. Although the statistical analysis appears correct, the actual number of professionals involved is smaller due to multiple offenders. The above statistical manipulation is somewhat verified by two separate state boards of medical examiners whose experiences are reported by the American Medical Association’s Council on Mental Health in the Journal of the American Medical Association. They found that about 5% of practicing physicians officially had alcohol and other types of drug abuse problems over a ten-year period.” If 5% have a problem in 10 years, the figure of 0.5% per year appears valid. Thus, over a lifetime of practice, the statistical incidence of alcohol, opiate, and dangerous drug abuse is between 15% and 200/0.
The above data are from statistics gleaned from professional literature,
AORN Journal, October 1976,Vol24, No 4
published data, and so-called official statistics. My experience comes from four distinct responsible areas of drug information. First, due to my interest and work in drug abuse, I am often requested by supervisory and responsible persons who know of a possible drug abuse situation to give advice. As the director of a forensic sciences laboratory, I and my staff are responsible for analysis of suspected tempered or diluted medications. Further, because of my law enforcement and medicolegal background, I am consulted and requested to give advice on security problems and thefts in limited access areas where drugs have been found missing. Finally, as a law enforcement officer, I a m aware of and consulted in cases of professionals who become subjects of official investigations relating to drug abuse at a local, county, state, or federal level. Based upon these experiences, it is my opinion that the yearly incidence of 0.5% and the lifetime risk of 15% to 20% are valid and reasonably correct figures. It is obvious we must be on constant and objective guard to prevent the problem from affecting critical areas of health care delivery. We must continue strict self-regulation and maintain our high standards. Because of the extent of federal bureaucratic interference with health care delivery systems, it is clear if we do not maintain a constant vigilance and policing of our ranks, the interventionists will
do it for us. For instance, drugs critical to health care delivery may be removed from our armamentarium. It has already been recommended that certain opiates be limited or deleted.l8 What should we do when we are confronted with a situation which may be drug abuse? Positive assertive behavior is mandatory. First document your suspicions on paper as, or immediately after, they occur and keep a written personal log. Your records, as well as the official records of your institution, are mandatory when the problem comes up for action. Report any incident or suspicion to your immediate supervisor. That person then becomes responsible for the problem, and you have fulfilled a significant part of your responsibility. The system, then, can more easily respond and take the heat generated when the phenomena is brought before the administration. Protect yourself when reporting suspicions of drug abuse because although the hierarchy of your system may support you, it may also attack you. Always discuss your knowledge or suspicion with a reliable adviser or counselor who may later be called upon to defend your responsibilities and the manner in which the problem was handled. If you suspect hostility will be directed toward you for raising the problem of a potential drug abuser, consider hiring legal counsel. Your reputation and job may be in jeopardy,
AORN Journal, October 1976, Vol24, No 4
669
D
o not confront the individual you suspect.
and you may be threatened or actually sued. You may also be attacked on a moral, ethical, licensure, or personal issue. In the investigatory phase of a colleague whom you suspect and have reported, you should consider the advisability of contacting law enforcement personnel. I suggest this not to set up an arrest of the suspected abuser but to get the tools and expertise of an experienced professional investigator. In addition, if you are certain you are correct in your suspicion, it may be legally required in your state to report criminal behavior. Certainly, you have a moral obligation to do so. Having advised you on positive assertive action, I will also advise you on what not to do. Do not confront the individual you suspect. This should be done at the proper time by a responsible person at least one rank above you or the person who reported the incident. Do not let the hostility focus on yourself or any other person as an individual. Any hostility should be focused toward the system to avoid as much as possible any personal risks to the reporting individual. Do not gossip about your suspicion but certainly listen for statements by others relating to your suspicion. Do not attempt to provide therapeutic services to the suspected drug abuser. Your motivation may be commendable, but your results are most apt to be disastrous.
670
Treatment must come from a recognized professional in drug abuse therapy. This person can be objective and professionally, not personally, attached in a patient relationship. Do not become involved in the problems of the drug abuser for you may compromise your status by becoming an indirect or direct source of drugs. Then you may become an accessory to criminal behavior by assisting or allowing illegal access to drugs either passively or actively. What should you expect if you report or are a supervisor involved in detecting and reporting professionals with drug abuse problems? You should expect trouble. Even if you are supported by your system, you may well be singled out as a troublemaker. If you are not supported by your hierarchy, you may be attacked by your system, supervisor, and peers. You then may face possible loss of your job, and harassment from your peers as well as physicians and administration officials. Many persons in the upper echelon do not want drug problems exposed. They erroneously believe the danger of publicity outweighs the danger of a professional who abuses drugs. Finally, you may find yourself involved in lawsuits against your system or yourself or both. To meet these problems, always attempt to maintain a professional and ethical approach when dealing with the problem of drug abuse among professionals.
AORN Journal, October 1976, Vol24, No 4
Finally, what will happen to the individual professional who is identified as one who has drug abuse problems? Help for these professional patients is hard to find. There is resistance on the part of the professional to seek help because of the stigma attached to the problem. Further, there is the risk of loss of license if he or she is exposed. Thus, there are few who voluntarily request help.l9 The professional who has a drug abuse problem is more likely to be a so-called sociologic addict as opposed to the psychological addict on the street. The sociologic addict tends to use drugs so he or she can continue to perform in the face of pain, fatigue, or disease.20 The sociologic addict is more prone to basic psychiatric disease. The sociologic addict has a well-developed coping mechanism, and his potential for cure is extremely high. The cure rate of Starkey’s program in Denver is over 95% in his professional patient group.21 The cure rate reported from a study in California was 920/0.~~ In summary, you do your profession, the patients, yourself, and, probably most important, the abuser a service in identifying professionals who are drug abusers. By policing your profession, you maintain a high standard of care, avoid bureaucratic interference, and provide a service to all concerned.
0 Notes 1. American Medical Association: Council on Mental Health, “The sick physician,” Journal of American Medical Association 223 (Feb 5, 1973) 684-687. 2. R W Rasor, H J Crecraft, “Addiction to meperidine (Demerol) hydrochloride,” Journal of the American Medical Association 157 (1955) 654-657. 3. G Garb, “Drug addiction in physicians,” Anesthesia and Analgesia-Current Researches 481 (1969) 129-133. 4. M F A’Brook, J D Hailstone, I E J
McLaughlin, ”Psychiatric illness in the medical profession,” British Journal of Psychiatry 113 (1967) 1012-1023. 5. M J Pescor, “Physician drug addicts,” Diseases of the Nervous System (June 1942) 173174. 6. Monnerot-Dumaine, “Doctor cure thyselfneurosis and depression among physicians,” Nouvelle Presse Medicale 2 (March 10, 1973) 663-664. 7. R N Murray, “Psychiatric illnesses in doctors,” Lancet 1 (June 15, 1974) 1211-1213. 8. J F Poplar, “Characteristics of nurse addicts,” American Journal of Nursing 69 (1969) 117-119. 9. M M Glatt, “Alcoholism among doctors,“ Lancet 2 (Aug 10, 1974) 342-343. 10. A’Brook, Hailstone, McLaughlin, “Psychiatric illness,” 1013. 11. M 0 Vincent, E A Robinson, L Latt, “Physicians as patients: Private psychiatric hospital experience,” Canadian Medical Association Journal 100 (March 1, 1969) 403-412. 12. G E Vaillant, J R Brighton, C McArthur, “Physician use of mood altering drugs,” New England Journal of Medicine 282 (Feb 12, 1970) 365-370; G E Vaillant, N C Sobowale, C McArIhur, “Some psychologic vulnerabilities of physicians,” New England Journal of Medicine 287 (Aug 24, 1972) 372-375. 13. Canadian Medical Association, “Physician drug abuse a major manpower problem,” Canadian Medical Association Journal 106 (June 24, 1972) 1353-1354. 14. S N Smith, P M Blachly, “Amphetamine usage by medical students,” Journal of Medical Education 41 (1966) 167-170. 15. D L Farnsworth. “Drug dependence among physicians,” New England Journal of Medicine 282 (Feb 12, 1970) 392-393. 16. C Watkins, “Use of amphetamines by medical students,” Southern Medical Journal 63 (1970) 923-929. 17. American Medical Association, “The sick physician.” 18. Garb, “Drug addiction in physicians.” 19. M M Glatt, “Doctors with a drinking problem,” Lancet 1 (Jan 25, 1975) 219-225. 20. S Garb, “Narcotic addiction in nurses and doctors,” Nursing Outlcok 13 (November 1965) 30-34; S Herbert Peyser, “Children of the poppy,” New Republic 152 (Feb 13, 1965) 19-20. 21. G H Starkey, personal communication, Denver General Hospital, 645 Bannock St, Denver, Colo 80204. 22. L E Jones, “How 92% beat the dope habit,” Bulletin Los Angeles County Medical Association 88 (1958) 19; 37-40.
AORN Journal, October 1976, Vol24, No 4
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