Source: British Medical Journal Authors: John Strang, Michael Wilks, Brian Wells, Jane Marshall Contact: Pubdate: Sat, 07 Feb 1998 Edition: BMJ No 7129 Volume 316 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. 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