Editorial

MISSED PROBLEMS AND MISSED OPPORTUNITIES FOR ADDICTED DOCTORS

We need a special service for doctors addicted to drugs or alcohol

Every few days another addicted doctor comes to light in Britain. A report
from an alliance of health professional bodies, led by the British Medical
Association and published last month,(1) highlights the risk posed by such
doctors to the general public and calls for better preventive education and
awareness. It fails, however, to prioritise the need for improved treatment
for addicted doctors.(2) This need arises from the special problems facing
addicted doctors compared with other addicts and their special treatment
needs, which ordinary addiction services do not serve well.

Doctors are at special risk of developing addiction problems,(3-5) owing to
the strain of medical practice, erosion of the taboo against injecting and
opiates, and, particularly, access to supplies.(6) Once addicted, they pose
a particular risk to the general public, forcing consideration of whether
they need urgent removal from their work. Ordinarily, many patients with
drug or alcohol problems receive outpatient treatment while continuing to
work, but the same level of disability may be incompatible with medical
practice. In addition, since most doctors who become addicted to drugs
misappropriate them from work, removing the doctor from his or her work
environment may be necessary to protect both the doctor and the public.

Membership of the medical profession normally enhances access to treatment,
through knowledge of providers and the old boy network, but addicted doctors
face major problems in accessing effective treatment. Addiction fosters
isolation and denial: when present in a medical culture that prizes self
reliance and has deficient mechanisms for intervention and treatment, the
paradoxical consequence is impaired access to health care. Doctors find it
particularly difficult to access help for stigma bound problems, fearing
breaches of confidentiality and jeopardy to their reputation, professional
accreditation, and employment. The NHS reforms have further aggravated the
problem with their requirement for identifying patients referred outside
normal contracts.

The identification of addiction problems is often characterised by crisis -
perhaps following removal from the operating theatre or surgery after being
deemed intoxicated, complaints from patients, or discovery stealing drugs
from the workplace. The problem may be chronic, but the circumstances around
public exposure give the condition an acute on chronic character. Internal
investigations are often inefficient, protracted, and inhumane for a doctor
who essentially has a health problem. It is easy to see why addicted doctors
feel they cannot seek treatment. Nevertheless, such crises provide excellent
opportunities for healthcare intervention.

Providing treatment to the addict-doctor also poses challenges. Doctors have
difficulty accepting the role of patient. Clinical staff may deal with
addicted doctors differently - for example, treating them more as colleagues
and holding higher expectations for recovery, compliance, and participation
in treatment. Nevertheless, despite these complications, when addicted
doctors are comprehensively treated the outcome is good.(3)(5)(7)

Thus addicted doctors are deflected from obtaining help by numerous
obstacles and eventually come to light through distorted routes of referral
- - via distraught colleagues, friends, or family seeking secret consultations
or informal opinions. Existing provision, as listed in the BMA report,(1)
falls far short of an accessible and appropriate and adequate service. A
dedicated service for addicted doctors is now long overdue.

Three distinct components of care are essential. Firstly, entry routes into
treatment should be simple and well publicised and must include crisis
intervention. Responding to a crisis such as police proceedings or exposure
at work with a distant appointment is manifestly inadequate. Not only is it
compassionate to offer urgent admission; it is also valuable to capitalise
on the motivation generated by the crisis.

Secondly, though immediate admission for assessment and detoxification is
desirable, existing addiction units often have major difficulties in
providing this care. Doctors who have committed crimes and other acts
shameful to their professional standing may have difficulty sharing these
episodes with a non-medical peer group. Other patients may express outrage
at a fellow patient who is a doctor. The addict-doctor may therefore need
treatment in a dedicated unit - probably alongside other addicted healthcare
professionals.

Thirdly, special arrangements for supervision and post-treatment monitoring
are essential, especially if the recovering addict-doctor returns to work.
Progress may need to be "policed" by a supervising consultant in liaison
with the recovering doctor's employer or senior colleagues. Support systems
such as peer groups(8) and counselling are pivotal factors in maintaining
recovery.(9) Monitoring should include random collection of supervised urine
or hair samples for analysis(10) and should generally continue for some two
years.

The phenomenon of the addicted doctor may shock and offend. Nevertheless, it
must be addressed by both the profession and employers as an important cause
of impaired performance through ill health. In America, state level
"impaired physician" schemes(7)(11,12) ensure that addicted doctors are
confronted, receive adequate treatment, and return to work under
supervision. Other countries may feel less comfortable with such
interventions, but, as the BMA report illustrates,(1) greater professional
awareness at all levels and visible dedicated services will enable many
doctors to avoid the tragic consequences of drug and alcohol dependence that
can so affect their patients, their family, and their careers. The current
lack of a dedicated service leaves many addicted doctors unchallenged,
untreated, and abandoned: the BMA report's failure to deal with comment on
this point is an important shortcoming in an otherwise excellent document.
With good outcomes from treatment of this group (on whose training so much
has already been expended), there are compelling grounds for such a
development. The addicted doctor, the profession, and the general public
would all benefit.

John Strang, Professor of the addictions National Addiction Centre,
Institute of Psychiatry, London SE5 8AF

Michael Wilks, Chairman Medical Ethics Committee, British Medical
Association, London WC1H 9JP

Brian Wells, Medical director Riverside Mental Health Trust, London W6 8DW.

Jane Marshall, Consultant psychiatrist in the addictions National Addiction
Centre, Institute of Psychiatry, London SE5 8AF

References

1 Working Group on the Misuse of Alcohol and Other Drugs by Doctors. The
misuse of alcohol and other drugs by doctors. London: British Medical
Association, 1988.

2 British Medical Association. Chemical dependence in the medical
profession. London: British Medical Association, 1995.

3 Vaillant G E, Brighton J R, McArthur C. Physicians' use of mood-altering
drugs: a twenty-year follow-up report. N Engl J Med 1970;282:365-70.

4 McAuliffe W E. Nontherapeutic opiate addiction in health professionals: a
new form of impairment. Am J Drug Alcohol Abuse 1984;10:1-22.

5 Brooke D, Edwards G, Andrews T. Doctors and substance misuse: types of
doctor, types of problem. Addiction 1993;88:655-63.

6 Winick C. A theory of drug dependence based on role, access to, and
attitudes towards drugs. In: Lettieri DJ, Sayers M, Pearson H, eds. Theories
on drug abuse: selected contemporary perspectives. Rockville, Maryland:
National Institute on Drug Abuse, 1980.

7 Talbott G D, Gallegos K V, Wilson P O, Porter T L. The Medical Association
of Georgia's impaired physicians program: review of the first 1000
physicians, analysis of specialty. JAMA 1987;257:2927-30.

8 Chappel J N. (1991) The use of alcoholics anonymous and narcotics
anonymous by the physician in treating drug and alcohol addiction. In:
Miller NS, ed. Comprehensive handbook of drug and alcohol addiction. New
York: Marcel Dekker, 1991:1079-88.

9 Coombs R H. Drug-impaired professionals. Cambridge, Mass.: Harvard
University Press, 1997.

10 Strang J, Black J, Marsh A, Smith B. Hair analysis for drugs:
technological breakthrough or ethical quagmire? Addiction 1993;88:165-8.

11 Shore J H. The Oregon experience with impaired physicians on probation:
an 8-year follow-up. JAMA 1987;257:2931-4.

12 Pelton C, Ikeda R M. The California physicians diversion program's
experience with recovering anesthesiologists. J Psychoactive Drugs
1991;23:427-31.