Doctors should be able to seek help with confidence that their colleagues will be supportive
MJA 1998; 169: 404-405
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What causes apparently successful young doctors to decide one day to inject themselves with pethidine? In how many cases and how rapidly does such drug abuse escalate? How much harm is done to these doctors, their families and the community? What risk does this pose to patients? A renewed search for answers to these questions should be stimulated by the article by Cadman and Bell1 in this issue of the Journal. It is a valuable reminder of a continuing problem for the self-regulating medical profession: doctors who self-administer drugs of dependence. The report focuses retrospectively on a cohort of 79 New South Wales doctors confirmed to have self-administered opioids. In keeping with earlier studies, the doctors were mostly male, predominantly in their thirties, and favoured pethidine. At the end of the 10-year survey period (1985-1994), 13% had died and only 54 (68%) remained on the medical register. Of these 54, 22 had conditions on their registration. The NSW study found an over-representation of general practitioners. Rural doctors were also over-represented and the authors postulate that in rural practice drug abuse may be harder to conceal. This interesting finding warrants further study, as there are other possible factors to consider, including the stress and isolation of rural practice, the attitude of rural pharmacists and the level of survey of pharmacies by drugs of dependence inspectors. This NSW experience indicates a prevalence of drug abuse among the medical profession of 0.4%, similar to an earlier Victorian estimate of 0.5%,2 but it is likely that this is an underestimate. Information from anonymous questionnaires3 and the experience of increased notifications which followed the mandatory reporting provisions of the Victorian Medical Practice Act 19944 suggest that opioid abuse among doctors may occur at twice this prevalence. It has also been suggested that doctors familiar with the recreational use of illicit drugs may be more prone to self-administration of narcotics.5 If this is correct, recent graduates may prove to be at greater risk. What should the profession do? What is it doing at present? An ideal strategy would encompass prevention, early detection, treatment and rehabilitation. Prevention should include education and deterrence. The trends towards later entry into medical school, more sophisticated student selection procedures, and curricular content directed at personal and professional development of student doctors, augur well. Education in this subject should continue in postgraduate training programs. Deterrence through strict uniform laws relating to drugs of dependence combined with extensive surveillance of misuse is currently as well developed as is practical. We do not support tougher penalties or tighter surveillance as they might simply lead to the emergence of alternate self-destructive behaviours. The medical profession needs to be aware of, and open about, this problem, appreciative of the impairment and rehabilitation model and supportive of colleagues in trouble.6 Doctors need to recognise their vulnerability to addictive behaviours, predisposed as many are through personality traits,7 stressful work and ready access to drugs. Doctors in trouble should be able to seek help without stigmatisation and with confidence that our profession will support their rehabilitation. Where prevention has failed and drug abuse has been detected, the next step is to provide effective treatment and rehabilitation. Although self-administration of drugs of dependence is a criminal offence, medical boards deal with the problem wherever possible as an illness, and regard such doctors as impaired, rather than subject them to a disciplinary process. There may be some procedural variation from State to State, but provided the community is protected from harm, medical boards generally seek voluntary acceptance of treatment with agreed enforceable conditions on practice (including psychiatric treatment, restricted access to Schedule 8 drugs, and strict urine screening), which may be progressively lifted. While some programs aim to keep narcotic-dependent doctors at work without interruption, the experience of the Medical Practitioners Board of Victoria has indicated that an initial brief period away from practice during drug withdrawal is critical. Relapse in the first 12 months is common and is not a sign of a poor prognosis. Provided there is no comorbidity such as major psychosis or severe personality disorder, the prognosis for recovery is good. Of 38 doctors notified to the Victorian Board and confirmed to be self-administering during 1994-1997, 29 are currently practising (25 with conditions), five are suspended from practice and four have allowed their registration to lapse. Any improvement in recovery figures will require the development of better treatment and rehabilitation programs, with professional support dedicated to the care of drug-dependent doctors. Such programs have been pioneered in several United States and Canadian jurisdictions, and have involved specialised treatment and rehabilitation programs, with the capacity to accept both voluntary referrals and referrals mandated by medical boards.8 Such programs could also undertake research and play a role in undergraduate and postgraduate education of doctors. The report by Cadman and Bell is timely. The topic of impairment and drug dependence is a key item on this year's annual meeting of Australasian medical boards to be held in Brisbane in November, where the US experience will be described by an invited expert, and the existing Australian and New Zealand impaired practitioner programs will be compared. The topic of the mental health of doctors is also of increasing concern to the Australian medical colleges. The Committee of Presidents of Medical Colleges has established a widely representative mental health working party to give guidance to the Colleges on this topic. With the establishment of prevention and early intervention programs for the profession, perhaps we can dare to hope that in the next 10 years, the prevalence of self-administration of drugs of dependence will decline. Kerry J Breen John M Court
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