Alcoholic and Drug Addicted Physicians:
Raymond
Alcoholic and
Drug Addicted Physicians:
The Scope of the Problem
During the last 15 years there have
been a number of studies on the mental
health of physicians
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SUMMARY
Alcoholism and drug addiction are
occupational hazards in the practice of
medicine. Reports from Canada, the U.S.
and U.K. show a higher incidence of these
problems in physicians than in the general
population. This article reviews some
characteristics of addicted doctors,
including their backgrounds and reasons
for starting the habit. The need for
treatment to start as soon as the problem is
discovered is emphasized. The prognosis
for both alcoholism and drug addiction is
good if the conditions are diagnosed early
and treated vigorously. (Can Fam Physician
26:851-853, 1980).
Dr. Gilbert is director of the
detoxification unit at Royal
Alexandra Hospital in Edmonton,
and a professor of medicine at the
University of Alberta. Reprint
requests to: Royal Alexandra
Hospital, 10240 Kingsway,
Edmonton, AB. T5H 3V9.
PHYSICIANS HAVE ALWAYS
been associated with health. However,
it has long been recognized that
the practice of medicine carries certain
health risks. In earlier times, tuberculosis
was frequent amongst pathologists,
1 ionizing radiation took a toll of
its pioneers2 and a decade ago hepatitis
was frequent in physicians working in
renal dialysis units.3 The association
between the practice of medicine and
the development of coronary artery
disease is less clear.46
During the last 15 years there have
been a number of studies on the mental
health of physicians. 7-13 These reports-
from the United Kingdom, the
United States and Canada-show a
disproportionately high incidence of
alcoholism and drug addiction in physicians
.
Alcoholism
Alcoholism is a long recognized
health problem in Canada, where it is
currently a leading cause of death, and
along with suicide, one of the most
rapidly increasing. It is estimated that
alcohol is used by 70% of the U.S.
adult population of whom some six to
ten percent are alcoholics."4 A U.S.
study shows that the incidence among
physicians may be as high as 18%.15
The precise cause of alcoholism remains
unknown; genetic, sociological
and psychological factors are probably
all involved. Alcoholics conform to no
specific personality type and vary from
normal to frankly psychotic.
CAN. FAM. PHYSICIAN Vol. 26: JUNE 19081 8
Murray,16 who followed up alcoholic
doctors treated in a London hospital,
found that they had undergraduate
records comparable to
non-alcoholic physicians, varying
from dismal failure to outstanding success.
He also suggested that the alcohol
habit may be started where there is
a permissive attitude toward drinking
or when masculinity is thought to be
measured by the ability to hold liquor.
In most instances the physicians
started drinking heavily between the
ages of 40-50, and attributed it to such
factors as a need to relax, inability to
sleep, overwork, and to increase sociability.
Connelly"7 noted two age peaks for
alcoholism, as well as drug abuse in
doctors: the first, between 30-40, before
developing a successful medical
practice. This group tended to have severe
psychopathology. The second
peak was at 50-65 years, after practice
was well-established, but before midlife
crises or depression developed.
The studies show a different incidence
of alcoholism in various specialty
groups: Murray found that of
physicians admitted for psychiatric
care, the highest incidence was
amongst those in general practice and
surgery, whereas Bissel and Jones14
found psychiatrists and family practitioners
had the highest incidence.
Physicians develop the same organic
and social sequelae to their
drinking as does the general population.
They are in no way immune to
potentially fatal central nervous system
complications, alcoholic cardiomyopathy
and cirrhosis of the liver, as
well as suicide, which are given as the
main reasons for the alcoholic's ten to
12 year reduction in life expectancy.
17, 18 They are also not free from
impaired driving or broken marriages.
Bissel and Jones"4 reported 219 arrests
and 170 jailings amongst 98 alcoholic
physicians they studied.
Drug Dependence
Drug dependence also seems to be
an occupational hazard for physicians.
The Medical Board of California believed
that one to two percent of its
members abused drugs, and as long
ago as 1958 was dealing with 125
cases annually.19 New York State
quotes an incidence of 0.5% amongst
its physicians compared with one in
3000 in the general population.20 21
852
Figures from the U.K., U.S., Holland
and France suggest that 15% of all
drug addicts are physicians.19
In a high percentage of cases it
either precedes or is associated with alcoholic
abuse. Narcotics, particularly
morphine and meperidine, are the
most frequently abused. 22, 23
Physician addicts were often sickly
as children, suffering from abdominal
cramps or asthma, and seldom excelled
or even took part in sports.22
They report that their sex life is unsatisfactory.
Their fathers were either
passive or domineering, and 50% of
them were alcoholics. Mothers were
excessively neurotic, religious and
sickly, as well as domineering in some
cases. Eighty-five percent of them
were said to have 'unusual' personalities.
The physician addict differs from
the usual drug abuser. A study from
Virginia22 showed the mean age of the
drug abusing physician is 40-45 and he
has been in practice for 18 years. He
has a good home and is married with a
family. The precipitating factors most
frequently mentioned include physical
pain, usually from a chronic illness,
death of a wife or child, and an addicted
wife.
In contrast, the nonphysician addict
is generally 19-30 years old, unmarried,
poorly educated and a member of
a minority group. Drug abuse is an end
in itself and he steals to support his
habit.
Management
Doctors feel somewhat frustrated in
handling alcoholics, and particularly
alcoholic colleagues, probably because
of a lack of training. The curricula
of most medical schools gives
the impression that alcoholism is an
uncommon disorder, scarcely worthy
of curriculum time. I find it unusual
that neither the Royal College of Physicians
and Surgeons of Canada nor
the American College of Physicians in
the last ten years has seen fit to devote
one postgraduate course specifically
on the fourth leading cause of death on
this continent.
How have we dealt with the physician
we've known since his student
days as a heavy drinker at cocktail parties
and other social events? His work
standards are now beginning to slip a
little-nothing serious-but into general
deterioration. Have we taken him
aside and told him of our concern?
No. We've turned a blind eye, hoping
the problem will go away or waiting
until he makes a serious mistake
with which we may confront him.
But at that point, he changes from
being a friend and colleague to a fiend.
We review his hospital work-it was a
little substandard and find also that he
really contributed little to committees.
He is brought before the hospital board
and dismissed. We feel a little uncomfortable,
even guilty. After all, he is
one of us and we have let him down.
The watchword should be immediacy.
The prognosis for addicted physicians
is good if the condition is diagnosed
early and treated vigorously. Of
the 41 doctors in Murray's study who
had been drinking from six months to
25 years before treatment, many were
severely alcoholic and nine suffered
from delirium tremens.
Principles suggested for management
of the alcoholic physician24 can
also be applied to the drug-addicted
doctor:
1. At the first sign of continual
heavy drinking, the physician must be
warned by a colleague of its dangers.
Few realize that daily consumption of
more than 50 ml of ethanol puts them
at risk. There must be no delay or
waiting for further developments-a
course of therapy and counselling, and
membership in Alcoholics Anonymous
should be started immediately.
2. If he commits a major offence
such as appearing intoxicated in the
operating room or while giving a lecture,
he must be confronted immediately,
suspended by the hospital board,
and brought to the local college. He
must not be treated as a criminal but as
a friend and colleague who is in trouble.
He should be given all the help
available, both in his rehabilitation and
preserving his practice. There is no
place for a 'holier-than-thou' attitude.
On the other hand, the greatest hazard
to his recovery is granting him special
patient status. He has a serious disease
which will require psychiatric help.
3. He must not return to work until
he is well. Addiction and medical
practice do not mix.
4. Following his return to work, he
will need to be under surveillance for
two to three years by a physician willing
to assume this responsibility.
Some colleges use 'three wise men',25
others appoint a single senior physician.
Society, including the police, has
CAN. FAM. PHYSICIAN Vol. 26: JUNE 1980
been sympathetic towards the impaired
physician, but it is apparent that the
constabulary is increasingly less tolerant
of his behavior than are his colleagues.
14 An increasing number of
impaired physicians is being 'managed'
by the law rather than by the
profession.
Finally, no physician should ever
write himself a prescription or give
himself an injection which will either
relieve severe pain or alter his mood.
The solo practitioner in a rural setting
is particularly vulnerable.
Prognosis
The prognosis for the alcoholic physician
depends on a number of factors,
not the least of which is the severity of
his addiction and the support from his
local community and peers. Goby,
Bradley and Bespalec26 recently
quoted a figure of 67% recovery,
which is rather better than my own experience
but a realistic goal to be
aimed for. The fate of those who fail to
respond is well documented by Murray.
16 Of 36 physicians followed up
for an average of 63 months, seven
died-two suicides and two probable
suicides-ten continued their drinking
habits intermittently and nine continued
dependent drinking. Five were totally
abstemious, two became normal
social drinkers and 17 required further
inpatient psychiatric care. Of the 29
alive, only eight were practicing, six
with varying degrees of incompetence,
three had retired voluntarily, two retired
under compulsion, and the names
of four did not appear in the subsequent
issue of the medical registry.
Drug addiction shows comparable
variability, with success quoted as 27-
72%.22, 27, 28 These depressing statistics
make the need for early diagnosis
and treatment more important. (
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Full information available on request.
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