Megan Cadman and James Bell
MJA 1998; 169: 419-421 Abstract -
Introduction -
Methods -
Results -
Discussion -
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References -
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©MJA1998
Abstract |
Objective: To describe the characteristics and
outcomes of doctors whose drug authorities were withdrawn as a result
of self-administering opioids for non-medical purposes. Design: Retrospective review of New South Wales Health Department information relating to all doctors whose authorities to possess, supply, prescribe or administer drugs of addiction had been withdrawn in the period 1985 to 1994 as a result of confirmed self-administration of opioids. Outcome measures: Age, sex, geographical location and practice category at the time of intervention; drugs used; period of opioid use before authority withdrawal; means of detection; and registration status as at August 1995. Results: From 1985 to 1994, 79 doctors had their drug authorities withdrawn (0.4% of the NSW medical profession in 1994). The groups significantly over-represented were general practitioners and those aged 30-39 years. Pethidine was the main drug used (66 doctors; 84%). Drug use for more than two years before detection was reported by 34 (43%) doctors. Community pharmacists were the source of reports leading to detection of 28 (35%) doctors. As at August 1995, 27 (34%) of the study group were not practising; 10 (13%) had died. Conclusion: Outcomes for these doctors were poor. There was substantial attrition from practice and a high mortality rate. |
Introduction |
Medical practitioners have been shown to have a higher rate of drug
abuse, mental illness and suicide than either matched controls or the
general population.1-4 It is claimed that in the
United States up to 10% of physicians at some time during their careers
become dependent on psychoactive drugs or alcohol to an extent where
their practice is impaired; about 1% become
opioid-dependent.5 For these doctors, if placed
in highly structured and strictly monitored programs, treatment
outcomes are substantially better than for other opioid-dependent
people.6,7
Few data have been published on the prevalence of drug misuse among Australian healthcare professionals, and even less on the problems experienced by drug-dependent doctors and the extent of their professional impairment. Two studies of doctors with serious drug dependency brought to the attention of the Victorian Medical Board, in 1964-1984 and 1984-1990, indicated a prevalence of about 0.5%.8,9 By comparison, in a recent anonymous survey of 1125 doctors in New South Wales, 1% of those surveyed reported drug abuse problems, a figure closer to estimates from other countries.10 Accurate reporting of the prevalence of drug misuse in healthcare professionals is often undermined by the tendency of colleagues to either protect or ignore the impaired individual, and by treating doctors often anxious to avoid "labelling" a colleague with a potentially damaging diagnosis. Our study uses official records to examine the characteristics, and the limited information about outcomes, of those doctors in NSW whose opioid use had triggered official intervention. |
Methods | |
Data collection |
The study group comprised all doctors whose authorities to possess,
supply, prescribe or administer drugs of addiction (Schedule 8
authorities) were withdrawn by the NSW Health Department as a result
of confirmed self-administration of opioids in the period 1985 to
1994, inclusive.
The data for this study were obtained from files held by the Pharmaceutical Services Branch of the NSW Health Department. Information relating to sex, geographical location and main type of practice or specialty at the time of intervention, use of other drugs, period of opioid use before authority withdrawal, means of detection, and reports of psychiatric consultations, was collected from these files. Data relating to date of birth and registration status as at August 1995 were obtained from the NSW Medical Board, and data on the age, sex, specialty and geographical location of all medical practitioners in NSW were obtained from the Workforce Planning Unit of the NSW Health Department. |
Analysis | To determine whether any groups were over-represented in the study group, demographic characteristics of the subjects were compared with those of the profession as a whole in NSW. Where available, data for 1990 were used in comparisons, as this represented a mid-point in the study period. For the number of medical practitioners and general practitioners in NSW, 1994 data were used. Confidence intervals and the c2 test were used in the analysis of the data. |
Ethical approval | The study was approved by the New South Wales Health Department. Strict confidentiality was maintained throughout the study. |
Results | In the period 1985 to 1994, 79 doctors relinquished their Schedule 8 authorities as a result of confirmed self-administration of opioids. This represents 0.4% of the medical profession in NSW in 1994.11 |
Demographic characteristics |
The main characteristics of doctors in the study group at the time
their Schedule 8 authorities were withdrawn are shown in Table 1.
Ages of doctors in the study group at the time of authority withdrawal ranged from 26 to 69 years (mean, 39 years; 95% confidence interval, 36.8-41.2 years). Fifty-six per cent of the group were aged 30 to 39 years, a significant over-representation of this age group (Table 1). Rural practitioners were significantly over-represented in the group according to the chi-squared test (chi-squared, 4.67; P = 0.031) (Table 1). Four practice categories were identified in the study group: general practice (64; 81%), anaesthetics (3; 4%), psychiatry (3; 4%), and hospital salaried staff (9; 11%). Compared with the profession as a whole for 1994, general practitioners were significantly over-represented; anaesthetists and psychiatrists were not. Comparative data for hospital salaried staff in NSW were not available. Five of the nine doctors employed in salaried positions in hospitals were working in emergency departments. |
Drugs used | Pethidine was the main drug used (66 doctors; 84%), with 31 (39%) apparently using nothing else. Commonly, doctors initially obtained pethidine, and to a lesser extent morphine, from their doctor's bag emergency supply, with prescriptions and surgery or hospital stock accessed as drug use escalated. Other drugs used included mixed opioids, barbiturates, ketamine and benzodiazepines. A concurrent alcohol problem was reported by 13 (16%) doctors, and eight (10%) admitted illicit drug use. All of the illicit drug users were men aged 30 to 43 years. |
Period of drug use | Thirty-four (43%) doctors reported using opioids for more than two years before intervention, with four individuals admitting drug use for more than 10 years (Table 2). Two of these four also reported illicit drug use dating from their late teens. |
Means of detection |
Community pharmacists were the primary source of reports (Table 3), often alerted by a large number of
opioid prescriptions written by a particular doctor. Common
scenarios included prescriptions written for patients being either
picked up personally from the pharmacy by the doctor, or requested to
be delivered to the doctor's surgery, or patients being asked to
collect opioids from the pharmacy and take them to the doctor's
surgery, where one or two ampoules were administered to the patient
and the balance retained by the doctor for personal use.
Other reporting sources were routine inspections of community pharmacy records by departmental officers, and reports by colleagues and by the doctors themselves. Self-reports occurred in 14 cases (18%); most of these were due to the prompting of a treating psychiatrist or therapist as part of a rehabilitation program. Thirty-one doctors (39%) denied self-administration at first contact by the department. Of this group, 15 stated that the drugs were for use by others, usually relatives; 11 denied self-administration, with no other explanation offered; and five insisted that the drugs were used to treat a medical condition. At subsequent interviews, all admitted to self-administration for non-medical purposes and relinquished their drug authorities. |
Morbidity and mortality |
Twenty-eight (35%) doctors reported having consulted a
psychiatrist before initial contact by the department. Twelve of
these had consulted a psychiatrist for a drug abuse problem, the other
16 had consulted for non-drug related problems. Eight individuals in
the study group reported that they had taken antidepressants.
Ten (13%) of the doctors (nine men) are known to have died in the study period. Three of these are known to have committed suicide, one died of an overdose, two died in motor vehicle accidents, one died of a heart attack, and the cause of death of three individuals is not known. There were also five known suicide attempts by subjects during the study period. |
Registration status |
Only 54 (68%) of the subjects remained on the medical register as at
August 1995 (Table 4). Two of these, although still on the
register, were known to have left the profession. Including these two
individuals, there was an overall loss from the medical profession in
NSW of 27 (34%) individuals.
Twenty-two doctors had continuing conditions placed on their registration by the Medical Board. These included, in addition to the continued withdrawal of the drug authority, requirements such as ongoing treatment by a psychiatrist, regular assessment and monitoring including urinalysis, supervised employment, and regular Board review, in line with the Board's Impairment Program protocols. |
Discussion |
From 1985 to 1994, 79 doctors had their authorities to possess,
supply, prescribe or administer drugs of addiction withdrawn as a
result of confirmed self-administration of opioids. Pethidine was
the main drug used, and 43% of the doctors had been self-administering
drugs for more than two years before detection.
There are several limitations to the data in this study. The data were obtained from a retrospective review of file notes, which had been compiled by different interviewers, and did not follow a systematic data collection format. Data on several variables, including the extent of illicit drug use and period of drug use, relied on self-reporting and therefore introduced a "recall bias", either deliberate or inadvertent. A number of confounders may have influenced detection rates during the study period. These include the frequency and areas of prescription monitoring by the department, and changes in awareness and/or diligence of the reporting groups, such as community pharmacists and medical colleagues, who may have been influenced by articles in professional journals or by mailings by the Doctors' Health Advisory Service, as occurred in 1988. These factors may have varied between regions and over time. Another limitation of the study is that the subjects represent a subset of all drug-using doctors -- those who were detected. The data indicate that some doctors can self-administer drugs for prolonged periods without detection, and it is quite likely that sufficiently careful medical practitioners may self-administer opioids regularly and never be detected. Few doctors in the study sample surrendered their Schedule 8 drug authorities on their own instigation. Since detection of a problem was often based on observations by others, particularly community pharmacists, this could introduce systematic bias. Geographical isolation has been identified as a "marker" for substance abuse.12 However, the apparent correlation between rural practice and drug use may simply indicate that a doctor with a drug problem has a greatly increased chance of detection in a rural town than in the relative anonymity of the city. Among doctors detected self-administering opioids there is considerable attrition from medical practice. Of the 79 doctors in the sample, there was a loss of 27 individuals from the profession, with 10 of these known to have died in the study period. In recent years, the NSW Medical Board has adopted policies aimed at rehabilitating doctors who misuse drugs, while maintaining them in practice wherever possible. These policies include placing conditions on registration, such as supervised employment, restrictions on possessing and prescribing drugs of addiction, attendance for treatment and assessment, urine testing, and regular review by the Board. After a period of such supervision, practitioners who comply satisfactorily may return to full registration.11 There are no published data on the outcomes of these interventions. Attrition from the profession is taken as a poor outcome, but this may be an erroneous assumption. One hypothesis concerning medical practitioners who self-administer opioids is that they are ambivalent about medical practice,13 and this was confirmed by four subjects, two of whom had sought psychiatric treatment. It may be, therefore, that leaving practice was an appropriate decision for some individuals. The misuse of opioids described in this study should be seen within the wider context of the overall medical and psychological needs of medical practitioners. |
Acknowledgement | The authors acknowledge the assistance of Pia Salmelainen, Policy Analyst (Research Officer), Pharmaceutical Services Branch, NSW Health. |
References |
(Received 11 Nov 1997, accepted 23 Jun 1998) |
The Langton Centre, Surry Hills, NSW.
James Bell, BA, FRACP, Director.
Reprints will not be available from the authors.
Correspondence:
Ms M Cadman, Pharmaceutical Services Branch, NSW Health, PO Box 103,
Gladesville, NSW 1675.
E-mail: mcadm@doh.health.nsw.gov.au
