Substance Use Disorders in Health Care Professionals

Introduction

The impact of licit (i.e., alcohol and nicotine used legally) and illicit (including nonmedical prescription) drug use, abuse, and dependence in the United States is well documented in the general population. Overall, a 2006 survey reported that an estimated 20.4 million Americans 12 years of age or older were current illicit drug users, meaning they had used an illicit drug—defined as “marijuana/hashish, cocaine (all forms), heroin, methamphetamine, hallucinogens, inhalants or psychotherapeutics used nonmedically”—during the month prior to the survey interview. This estimate represents 8.3% of the population 12 years of age or older. More specifically, an estimated 5.2 million persons were current nonmedical users of prescription pain relievers, up from an estimated 4.7 million in 2005.

A recent report of abuse of prescription medication in the United States reported that many health care professionals are poorly trained to deal with alcohol or drug abuse. A substantial number of patients served daily by health care professionals in various health care facilities are abusing or dependent on alcohol and or other drugs. On the other hand, the public expects health care professionals to understand the proper use of the medicines they prescribe, dispense, or administer to their patients. Just as in their patients, though, alcohol or drug use also affects the lives of a number of health care professionals.

Starting in college, some health care students develop an attitude of invulnerability and immunity to addiction, fueled by their advanced understanding of the mechanisms of drug action. What begins as recreational college alcohol or drug use may, for some, develop into a complicated pattern of alcohol or drug abuse or dependence intended to attain a “sense of well-being” (p. 17) without an overt manifestation of intoxication or side effects. This concept of balancing drug effects, also called “titration,” or “walking a chemical tightrope,” refers to a practice whereby students or health care professionals use their pharmacological knowledge to balance positive and negative drug actions and reactions by “enhancing, neutralizing or counteracting specific drug effects through ingesting multiple types of drugs” [Dabney D (1997) A sociological examination of illicit prescription drug use among pharmacists. University of Florida, “An Unpublished Dissertation”].

Health care professionals have a significant responsibility that comes with the privilege of using medications to treat patients. Although most health care professionals engage in appropriate prescribing, dispensing, and administration of medication, reports of exceptional cases often receive public attention. A North Hollywood, California, physician, for example, was charged with conspiring to distribute 406 prescriptions of hydrocodone and oxycodone over 2 months after he surrendered his license to the US Drug Enforcement Administration (DEA) in May 2008. This pain management specialist was also being investigated regarding a role that his prescriptions might have played in the deaths of six patients over the past 3 years. A Virginia pharmacist was caught with hundreds of phentermine capsules when he was apprehended by law enforcement authorities, and a Maryland pharmacist was trading sex for drugs. Medication errors caused by substance-impaired pharmacists have been cited as posing a direct and serious threat to the public. Moreover, nurses were reported to be alcohol or drug impaired while committing “dozens of errors leading to patient deaths in Illinois” (p. A1).

Whether by virtue of their drug access or socioeconomic status, most evidence supports the notion that a small but significant proportion of health care professionals do experience personal problems with the use of alcohol and other drugs, which can result in serious consequences to themselves and to the public [Valentine N (1991) Stress, alcohol and psychoactive drug use among nurses in Massachusetts. Brandeis University, Boston, MA, “An Unpublished Dissertation”]. Not only can the economic costs of substance use disorders in health care professionals be considerable, but early identification is essential because patient and provider well-being may be at risk. Given the increasingly stressful environment due to manpower shortages in the health care system in general, alcohol or drug use and misuse among health care professionals has been projected to grow. Treatment of alcohol or drug disorders by health care workers was a policy issue recognized years ago by the professional organizations, and the Joint Commission requires hospitals to monitor and identify matters of health including substance use and abuse by physicians and other health care professionals.

The aim of this chapter is to provide perhaps the most comprehensive review of the problem of drug abuse by health care professionals to date. In addition, although covered in greater detail in other chapters in this book, we also briefly discuss the behavioral signs and symptoms of addiction in health care professionals, the treatment of substance use disorders in this special subpopulation, and the prognosis of sustained recovery and efforts needed to enlighten the various health care professional programs and groups.

Epidemiology of Alcohol and Other Drug Use by Health Care Professionals

The current literature regarding the prevalence of substance use and dependence in health care professionals is limited in both its scope of generalizability and methodological rigor. Lack of empirical data have contributed to an air of skepticism regarding the actual prevalence of substance abuse (abuse as referred to colloquially, not a Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition [DSM-5] diagnosis) and dependence by health care professionals. In fact, evidence of the extent of medication diversion, considered to be the major source of nonprescribed drug abuse by health care professionals, is based primarily on retrospective accounts [Dabney D (1997) A sociological examination of illicit prescription drug use among pharmacists. University of Florida, “An Unpublished Dissertation”], although the actual size of the diversion problem is largely unknown. As a result, the prevalence of inappropriate substance abuse and chemical dependency among health care professionals is inconclusive and, like the extent of prescription opioid drug diversion in the United States, for example, is impossible to estimate at the present time. The fact that the behaviors being measured represent illegal or inappropriate behaviors compounds the problem, as it is difficult to obtain accurate estimates of sensitive variables such as substance use.

A glimpse of the lack of epidemiological knowledge in the field is best illustrated by contradictory prevalence estimates found in the literature. For example, reports have suggested that narcotic addiction in US physicians was as much as 30–100 times the rate found in the general population, but these data were based on data from Germany in the 1950s. In addition, the lifetime estimate of combined substance abuse and dependence among health care professionals was reported by Kessler et al. to be at a rate nearly equal to that of the general population, or 26%. Similarly, estimates from other studies of health care professionals have reported a lifetime prevalence of substance dependence ranging from 3% to 20%. Although the literature provides limited studies of substance use by dentists, Hedge has estimated that up to 15%–18% of dentists could be addicted to drugs and alcohol. In contrast to these rates, however, another report concluded that physicians were at a “greater lifetime probability of developing a substance-related disorder than the general population” (p. 7).

Such statements clearly demonstrate the confusion and misinformation surrounding a meaningful discussion of alcohol or drug use by health care professionals. These generalizations have not only contributed to the uncertainty about the prevalence of substance use, but also to the confusion with regard to risk factors that contribute to substance use among health care professionals. For example, although referring to pharmacists as “drugged experts” (p. 102), Dabney used a measure of questionable reliability and validity to assess substance use in a nationwide sample of pharmacists. Specifically, the measure assessed redundant drug use items, categorized unauthorized use of nonnarcotic medications as addictive drug use, and provided no direction to participants regarding exactly which drugs were included in each drug category. Moreover, as also noted by Baldwin, the frequency data reported by Dabney contained no time frame for reported substance use and were, therefore, not useful in estimating the prevalence of substance use. Although Dabney claimed that the onset of potentially addictive drug use in pharmacists occurred upon becoming a professional, such a conclusion was essentially impossible without longitudinal data or some specific items assessing age at the onset of regular use. The methods were strongly defended by the author ; however, these issues contribute to a suspect interpretation of the data.

Overgeneralizations from methodologically questionable data also exist in the limited amount of literature describing substance use by the dental profession. Except for reporting the number of disciplinary actions taken against Oregon dentists from 1979 to 1984, no known empirical prevalence data for substance use had ever been reported for practicing dentists until recently. However, Chiodo and Tolle, drawing on nonrepresentative disciplinary action data, inaccurately concluded that dentists, like physicians, were at higher risk for substance use and abuse than the general population, and also concluded that the literature had consistently reported higher rates of chemical dependency in health care professionals, a notion unsupported by quantitative self-reported data.

In a series of important analyses, McAuliffe et al. assessed alcohol or drug use by both physicians and pharmacists, and Valentine [Valentine N (1991) Stress, alcohol and psychoactive drug use among nurses in Massachusetts. Brandeis University, Boston, MA, “An Unpublished Dissertation”] assessed alcohol or drug use by nurses. Lack of generalizability to other practitioners outside these two disciplines was a major limitation of these studies. In addition, these studies were conducted in the Northeast, where past-year alcohol or drug use has been reported to be higher than in other areas of the United States. Subsequently, to address some of the methodological shortcomings of these studies, Hughes and colleagues (p. 2333) compared a national sample of physician use of alcohol or drugs with that of the general population. They reported that when compared with the general population, physicians were more likely to use alcohol, benzodiazepines, and minor opioids but less likely to use street drugs such as marijuana and cocaine. Furthermore, contrary to the suggestion made by Chiodo and Tolle, that the literature consistently reported disproportionately higher rates of chemical dependency in health care professionals, Hughes et al. reported that only 7.9% of physicians identified themselves as substance abusers, while the corresponding rate for the general population at that time was 15%–18%. Hughes et al. also noted, however, that physicians were as likely as their age and gender peers to have experimented with illicit substances in their lifetime, an observation also affirmed more recently. Although methodologically rigorous, Hughes et al. acknowledged the narrow focus of their study to physicians alone that subsequently limited their findings due to the lack of comparable national data across other similar professions. In recognition of this limitation, the authors concluded that any comparisons between physicians and other health care professionals in “similar socioeconomic strata may have yielded different results” (p. 2337). Complicating these issues is stigma that accompanies alcohol or drug use in any population, which leads to underestimates of problem use.

Etiology of Substance Use Disorders in Health Care Professionals

Many etiologic factors have been reported to contribute to substance use in health care professionals, such as a family history for drug or alcohol use, college substance use, or age at first alcohol or drug use ; psychological factors such as “pharmacological optimism,” access to prescription medications, self-prescribing, socioeconomic status, and additional factors such as gender (male), lack of religious practices, and social influences.

Drug Access

Drug access, and in particular easy drug access, is generally recognized as a principal factor contributing to substance use by health care professionals. Certainly, studies show that access to prescription medications would explain the higher rates of use of these drugs among health professionals than in the general population. Although research on drug use in the working population in general has been inconclusive, Mensch and Kandel have suggested that drug use by workers was due less to the workplace than to the workers themselves. Clearly, however, a substantial foundation of research indicates that health care professionals are at considerable risk due to their working environment. Drug access is related directly to the job of being a health care professional. As such, the working condition related to medical practice is an important contributing factor enhancing one’s exposure to addicting drugs.

To illustrate this point, dentists have historically had easy access to nitrous oxide, an inhalant commonly kept in dental offices, and a known drug of abuse for dentists. Although the data are now dated (1979–1984), 7.1% of 109 impaired dentists in a study that took place in Oregon were sanctioned for abusing nitrous oxide. The authors concluded that nitrous oxide in particular posed a serious hazard for dentists. Although dentists have access to nitrous oxide for procedures, access to other drugs such as minor opioids and anxiolytic drugs is limited. For example, dentists were the only health care professional group who did not report personal use of samples; the study, nonetheless, indicated that they found other sources for addicting prescription medications.

Different researchers have developed measures to assess the impact of drug access by health care professionals on drug use [Dabney D (1997) A sociological examination of illicit prescription drug use among pharmacists. University of Florida, “An Unpublished Dissertation”]. A pilot study by Trinkoff and Storr suggested that easy access to drugs contributed to misuse. This was more firmly supported in a later, more extensive study of nurses ( n = 3917), wherein the ease of access correlated positively with past-year misuse. Three workplace dimensions were measured (availability, frequency of administration, and workplace controls), and, summed as an index, nurses with easy access on all dimensions were most likely to have misused prescription-type drugs (odds ratio = 4.18; 95% confidence interval [CI] 1.70–10.30). Furthermore, access continued to show the same correlation to misuse, even when knowledge of substances was also controlled in the analysis, thereby showing that access was not explained by nurses’ knowledge of substances used.

In a survey study performed comparing alcohol or drug use by pharmacy and nursing students and with pharmacists and nurses, predictors of lifetime illicit drug use by pharmacists and nurses included having a family history of drug problems, greater amount of past-month alcohol use, lack of religious affiliation, and notably greater access to drugs. Predictors for use of an illicit drug (any Schedule I or unprescribed drug use) by pharmacy and nursing students included a family history of drug problems, less drug access, and cigarette use in the past year. Of interest, lower drug access was a significant predictor for lifetime illicit substance use by pharmacy and nursing students, suggesting that when substances were unavailable in the workplace, students were more likely to obtain them elsewhere. Despite a reassurance of anonymity, students may also have been reluctant to admit to such behavior due to the fear of being discovered. In support of this notion, none of the students in the study reported diverting any medications from where they work, yet a greater number of pharmacy and nursing students in the same sample reported use of prescription medications than among the general population. We know that various sources for drug use include the home and friends [Dabney D (1997) A sociological examination of illicit prescription drug use among pharmacists. University of Florida, “An Unpublished Dissertation”], but we also know that sources include the workplace as well [Dabney D (1997) A sociological examination of illicit prescription drug use among pharmacists. University of Florida, “An Unpublished Dissertation”].

Where pharmacy students worked did not appear to be related to disproportionate drug use; however, a greater number of retail pharmacists reported illicit drug use than pharmacists in other pharmacy practice areas. When parsing out comparisons of individual drugs, except for marijuana, consistent with the data from Hughes et al. a higher proportion of the general population reported use of street drugs such as cocaine, hallucinogens, and inhalants. A greater number of health care professionals and students, however, reported use of drugs to which they typically had access, such as opioids and anxiolytics. In sum, quantitative and qualitative studies have all demonstrated that increased drug access in an unrestrictive environment provides an important substrate permissive of drug use by health care professionals. The available studies are consistent for studies of nurses, pharmacists [Dabney D (1997) A sociological examination of illicit prescription drug use among pharmacists. University of Florida, “An Unpublished Dissertation”], certain types of physicians, and health care professionals in general that report drug access to be a key element leading to drug misuse and abuse in health care professionals. Efforts to restrict drug access in every setting, as well as increased vigilance to monitor drug procurement and drug disposition by clinicians who dispense from their offices, should be considered a priority.

Family History of Alcohol and Drug Use

Without a doubt, the greatest concern for health care professionals, as for the public, are alcohol use disorders. Lifetime prevalence of alcohol abuse in the United States is 17.8% and alcohol dependence is 12.5%. Past 12-month prevalence of alcohol abuse is 4.7%, while alcohol dependence over the same period is 3.8%. Alcohol dependence is significantly more prevalent among men, whites, and younger unmarried adults, and lifetime alcohol abuse is highest among middle-aged Americans.

Twin studies of alcoholics have highlighted the possibility of genetic components of alcoholism while other researchers have also sought genetic markers for individuals with a positive family history for alcoholism. Studies have demonstrated that first-degree relatives (parents, siblings, or offspring) are more likely to use alcohol, become alcohol dependent, and are at substantially higher risk of developing problems with alcohol at some point during their lives. Family history of alcoholism has been estimated to be approximately 38% in the United States.

A retrospective review of substance use and addiction in medical students, residents, and physicians suggested that the most predictive factor for alcoholism in physicians was a positive family history for alcoholism. Kenna and Wood reported that significant bivariate correlations between positive family history and pattern of alcohol use ( r = 0.31), as well as positive family history for drug problems and current drug use ( r = 0.55), existed for physicians alone. There is the possibility that there were genuine relationships between those physicians reporting a positive family history for alcoholism and their alcohol use and between a positive family history for drug problems and drug use. Physicians are trained diagnosticians and can putatively accurately assess the presence or lack of alcohol and drug use problems by family members. These diagnoses may have led to a more accurate assessment of family members, thereby reducing measurement error in this particular group.

Numerous studies also demonstrate that first-degree relatives are at substantially higher risk of developing problems with alcohol at some point during their lives. Coombs proposed that the health care professions attract “people vulnerable to drug abuse because of emotional impairment due to alcoholic and emotionally abusive parents” (p. 192). Several studies of dental students previously speculated that many dentists perhaps come from dysfunctional families or families with a history of alcoholism or chemical dependency. Sammon et al., for example, reported that 35%–39% of students at two dental schools had an alcoholic parent or grandparent, and Sandoval et al. reported that 15% of all dental students at the University of Texas had a family history of alcoholism and 17% of illicit drug use. In a more recent study, however, dentists reported the fewest family members with alcohol problems of any health care professional group, suggesting that there is little evidence that dentists are at greater risk than other health care professionals to report a family history of alcohol problems.

Several other studies have also reported high rates of positive family history for alcoholism for health care students and health care professionals as well. For example, in a comparison of chemically dependent and nondependent nurses, Sullivan reported that 62% of chemically dependent nurses reported an alcoholic family member, compared with 28% for nonchemically dependent nurses. In addition, in a sample of recovering pharmacists, Bissell et al. reported a positive family history for alcoholism rate of 55%–58% in recovering pharmacists, slightly higher than the 47.4% prevalence estimate reported by Kenna and Wood in a survey. What of course must be considered between the two rates are the differences between the two study populations: one clinical and the other population based. In college students, Tucker et al. reported a positive family history for alcoholism in 28.1% in a sample of pharmacy students, and Kriegler et al. established that a positive family history for alcoholism was reported by 38.3% of nursing student respondents. In a measure including eight close relatives (other studies typically included parents, grandparents, and siblings), Kenna and Wood reported a positive family history for alcoholism in 46% of pharmacy students and 74.5% of nursing students surveyed.

In a follow-up study of 479 licensed health care professionals (68.7% response), researchers sought to ascertain whether positive family history for alcoholism and positive family history for drug problems were more prevalent among nurses than among dentists, pharmacists, and physicians and if an association between positive family history for alcoholism or positive family history for drug problems and current alcohol or drug use, respectively, existed. Nurses reported a significantly higher prevalence of positive family history for alcoholism than other groups of health care professionals ( P < 0.001) ( Fig. 68.1 ), and nurses also reported a significantly higher prevalence of positive family history for drug problems than dentists and physicians ( P < 0.01), but not pharmacists ( Fig. 68.2 ). The study also demonstrated that positive family history for alcoholism in nursing was not associated with either amount of current alcohol use or abstinence. On the other hand, as noted previously, among physicians alone, relationships between alcohol use and positive family history for alcoholism as well as between drug use and positive family history for drug problems were significant. The results of this study support the notion that positive family history for alcoholism and positive family history for drug problems differ across groups of health care professionals.

While speculated, no one truly understands why a significant number of people with a positive family history for alcoholism appear to select nursing as a profession. Some have suggested that the desire to go into nursing emanates from the family of origin and that nurses assume parental roles taken on in childhood. For example, in a study of the characteristics of chemically dependent nurses, 48% indicated that while growing up, they had acted in some type of parental role compared with only 22% of nondependent nurses. In order to delineate the association between nursing and family history of alcoholism, more research into the familial dynamics or individual differences of nurses and nursing students needs to be performed.