Christopher J. Welsh M.D.

University of Maryland School of Medicine


Prepared for the Alcohol Medical Scholars Program


June 20, 2001 (updated May 27, 2002)


I. Introduction

This lecture is aimed at helping healthcare providers become more aware of the unique aspects of substance dependence in healthcare professionals.  It might be included with other lectures on substance use disorders or as part of a more general program on physician’s health (this might be during  the orientation to Medical/Nursing/etc. school).  It is probably most effective to present in conjunction with a talk from a recovering physician, a member of the local “Physicians Wellness Committee” (or an equivalent) and/or a video about substance dependence in health care professionals (such as “Wearing Masks”; Association of Anesthesia Program Directors, 1993; (708) 825-5586). Although the focus of this lecture is on physicians, most of the information about identification and treatment can be applied to any healthcare professional.  It is very important to emphasize that this is about impaired people who are professionals.


Slide 2 Want to highlight that one reason that the students are receiving this lecture is that

“statistically,  about 10-15 of you have or will develop a substance use disorder.”


Slide 3 The Key Points that will be emphasized are:

A.     Overall, the prevalence of substance use disorders in healthcare professionals appears to be about equal to that in the general population.


B.     Rates of illicit drug use for medical students are similar to age matched controls.


C.     Beginning with residency, use of controlled substances (benzodiazepines and opioids) increases in physicians relative to the general population.


D.     Identification of substance abuse and dependence in healthcare professionals is often very difficult because of extremely strong denial and the “Conspiracy of Silence.”


E.      Healthcare providers tend to have better treatment outcomes.


F.      Impaired Physicians Programs are designed to provide non-punitive help


Slide 4  Just a review of some terminology  (Assume that the medical students don’t know anything about substances use disorders).  Give a brief explanation of what the DSM IV is and how Substance Abuse and Substance Dependence are defined. Very important to highlight that this discussion will be talking about substance use as well as Substance Use Disorders (SUDs) as defined by DSM IV:

A.     Dependence

3 or more of the following in a 12-month period

1. tolerance                             

2. withdrawal

3. taken in larger amounts or over a longer period

4. inability to cut down/control use

5. considerable time spent using/obtaining/recovering from use

6. important activities given up/reduced

7. continued use despite negative consequences


            B. Abuse

                 “Less severe” than Dependence

                     1 or more of the following in a 12-month period

1.      failure to fulfill major role obligations at work, school, home

2.      recurrent use in hazardous situations

3.      recurrent substance-related legal problems

4.        continued use despite persistent social or interpersonal problems


II. History

 (This section could be deleted or shortened depending on time constraints. You may want to pick a few of these examples to highlight how this problem has been seen over the past 130 years.  It is here to help set the historical context of addiction in healthcare professionals).


Slide 5  This is William Halsted, one of the founders of American surgery, whose career and life were very severely affected by substance dependence.


The literature on substance use disorders in the health professions begins with anecdotes and progresses to more formalized studies and methods of data collection (although all of these have their own limitations as will be discussed in the epidemiology section).  The following are designed to highlight the treatment of this problem over the past 130 years. As can be seen, certain observations (such as the increased use of opioids in physicians) were made in the 1800s that continue to be made today.


A.     In 1869, in a report published on the fate of medical students, mention is made of

physicians impaired by “habits of intemperance.”(Paget, 1869)


B. In 1892, Sir William Osler wrote in his textbook The Principles and Practice of

Medicine that “the habit is particularly prevalent among women  and physicians who use the hypodermic syringe for the alleviation of pain…”  He also wrote about his concerns for a fellow physician, William Halsted, who was “addicted to morphia.”(Osler, 1892).


C. In 1894, Mattison published an article entitled “Morphinism in Medical Men” in

which he wrote “It is a fact-striking though sad-that more cases of morphinism are   met with among medical men than in all other professions combined.”

     (Mattison, 1894).


D. In 1900, an article in The American Journal of Insanity discussed reports that “10 to

20 per cent of physicians are intemperate in the use of alcohol and drugs.”(Anonymous, 1900)


E. In 1914, Dr Seale Harris  wrote that “…forty percent of the medical profession at

sometime go into some habit, either alcohol or morphine or other drug habit.”(Harris, 1914).


F. In the 1950s and 1960s, various sources reported that physicians are 30-100 times 

more likely than the general population to become addicted to “narcotics.”  The actual data for these reports are questionable (based on statistics from one reporting source in Germany and very low estimates of dependence in the general population!!)(Winick, 1961; Modlin, 1965).


G. The American Medical Association Council on Mental Health published a report

defining physician impairment as “the inability to practice medicine with reasonable skill and safety to patients by reason of physical or mental illness, including alcoholism and drug dependence.”


H.     In 1973, the American Medical Association Council on mental Health published a report on “The Sick Physician.”which recommended that:

1. state medical societies establish programs devoted to identifying and helping impaired physicians(to be discussed further below). 

2. the AMA develop legislation to amend state practice acts so that treatment could be made available (as opposed to pure punishment)(AMA, 1973).


Slide 5-second click  And to bring the picture to modern day, this is Carter from the T.V. show E.R.  (a lot of the students will know who he is).  There was an excellent story line in which he was injured, placed on an opioid by prescription and subsequently became addicted (not just physically dependent) and sent to treatment.


III. Epidemiology

It is important to highlight that all of the epidemiology data are dependent on the population being studied and the questions asked. \

Slide 6A. The data on the epidemiology of substance use disorders in healthcare professionals

are variable due to:

1. various populations being studied:

a. self report surveys (both institution-specific and national)

b. samples of physicians in specific treatment programs (reporting bias?)

c. reporting to state licensure boards

d. anecdote

All of these sources have obvious limitations.

2. imprecise and variable definitions and criteria:

 a. “use” vs “misuse” vs “impairment” vs “abuse” vs “dependence”

 b. no criterion vs DSM III vs DSM III-R vs DSM IV

3. differences over time:

a. unclear if related to actual  changes in patterns or is an artifact of      sampling, etc.

4.      bias due to concern about anonymity is a big problem with this type of data.

a. of great concern to physicians who may be afraid of losing license if they answer such questions honestly.


There are literally hundreds of  reports of various aspects of the epidemiology of substance use disorders in physicians. The following section is designed to give an overall summary of the available data and highlight some of the larger or better designed studies.  Again, it must be emphasized that the data regarding epidemiology are very variable.

Slide 7

B.     In general:

1.       controlled studies using DSM diagnostic criteria indicate that healthcare

professionals have similar rates (8-14%) of overall substance abuse and dependence to the general population (Brewster, 1986)  and slightly lower rates compared to other occupations (Anthony, 1992; Stinson, 1992).

      a. some occupations such as roofers & house painters have very high rates.

2.      there appears to be higher use of prescription opioids and benzodiazepines

than in the general population.

a.       certain specialties appear to be more vulnerable (more on this later).


It may be useful to look at substance use disorders in the various stages of medical training:

Slide 8

C. Medical Students

1.      the large study conducted by Baldwin et al in the late 1980s and published in JAMA included >2000 4th year students from 23 medical schools.

a.       the use of all drugs except “tranquilizers” tends to begin prior to medical school (Conrad, 1988; Baldwin, 1991).

            b. types of substances used tend to parallel current popular drugs of abuse       

            (alcohol and marijuana highest)( Conrad, 1988; Schwartz, 1990; Baldwin, 1991).

c.  the heaviest users in med school were the heaviest users prior to school.

            d. medical students tend to use less of most drugs than age-matched peers                 who completed high school or college (Conrad, 1988; Baldwin, 1991).

      1) in the prior 30 days: marijuana-10%,cocaine-3%, heroin-.9%, LSD-.1%

                 2. Data on alcohol use and dependence are less clear:

a.       in the large study cited above, 87% of students reported using alcohol but only 3.4% reported ever being dependent.

b.      other studies show that use and problems related to use appears to be less than in college students (Flaherty, 1990) with 6% reporting “heavy use” and 4% reporting problems from their use (McAuliffe, 1984).

Slide 9

            D. Residents

1.      various studies with variable rates of substance use disorders (2-16%).

a. probably in 10-14 % range

2.      in the largest study (published in JAMA)with >3000 PGY IIIs, compared to age-matched peers who had graduated high school or college (Hughes, 1991):

a.        self reports of illicit drug dependence very low

b.      illicit drug use lower than for age matched peers who had graduated

c.       slightly higher alcohol use than peers (but not abuse).

d.      slightly higher (not statistically significant) use of opioids and benzodiazepines in male residents.

3.      the use of all substances except benzodiazepines and opioids is more likely to have begun prior to residency.

a.       largely reported as “self treatment” and not “recreational.”

b.      the controlled substances were self-prescribed in most cases

Slide 10

E. Physicians in practice

1.      although it is widely believed that physicians and other healthcare professionals have a higher overall prevalence of substance use disorders than the general population (with older reports of prevalence30-100 times that in the general population), most recent studies do not demonstrate this. 

The prevalence of alcohol or illicit drug dependence appears to be between 8-12% (which is the same for the general population) (Brewster, 1986).

a. Nevertheless, given that there are >680,000 physicians in the U.S. alone, a significant number of lives are affected (60-75,000 physicians).

2.      rates of alcohol abuse and dependence appear to be similar to the general

population (Bissell,1984) though a few studies have reported rates higher than the general public (Glatt, 1976;  Murray, 1975; Stimmel, 1984).

3.      some reports do indicate that the use and misuse of prescription opioids and

benzodiazepines is higher among physicians, with figures of up to 5 times higher than the general population (Gallegos,1988; Hughes, 1992).


Slide 11

            F . By Medical Specialty

Just to emphasize again, these data are difficult to interpret because of various types of populations studied, definitions used and questions asked.

1.      highest use:

a.       Emergency Medicine

1). higher prevalence in most studies

      2). higher prevalence of marijuana and cocaine use

b .Psychiatry

                  1). higher prevalence in most studies

            2). higher prevalence of benzodiazepine use

            c. Anesthesiology

            1). overall substance use is not consistently higher across all studies

2). one 30 year survey of anesthesia residents in one program found 16% considered themselves to abuse substances during training (Lutsky, 1991).


d.      Family Medicine

1). higher prevalence in some studies

2.      highest abuse or dependence:

a.       Emergency Medicine (12.4%)

b.      Psychiatry (14.3%)

c.       Anesthesiology

1).  Potentially more fatal due to typical substances used and route of use:

2). a study (Menk, 1990) of 113 anesthesiology residencies from 1975-‘89 found:

a). 180 out of 8,810 residents had drug dependence

b). 26 of the 180 died of drug-related reasons

c). 70% of the self-injectors completed residency succesfully

d). Substances used: Fentanyl>>>other opioids>diazepam>alcohol

d.      still appear to be similar to rates seen in general population

3.lowest use:

a.       Obstetrics/gynecology

b.      Pathology

c.       Radiology

d.      Pediatrics


IV. Time-Course and Patterns of Substance Use Disorders

Slide 12 A. Three main patterns of use (not necessarily abuse or dependence):

1.      recreational use

a. seen more in students

2.      performance-enhancement

a. seen more in ER physicians (not surgeons)

3.      self treatment of pain, anxiety, depression

a. seen more in residents and practicing physicians


B.Initiation of substance use similar to general population; late teens-early 20s.


C.Use of prescription opioids generally starts in late medical school or residency.


 Slide 13

D. Consequences of use have a typical progression (Bissell, 1984; Vaillant, 1983):

                        1. family, community, finances, spiritual/emotional health, physical health, work
Clinical performance is often one of the last things to be affected!
E.Typically does not enter treatment until 40s (reasons to be discussed further later).



V. Contributing Factors

From this point on, we will be talking about substance use disorders (not use).

Need to emphasize that the following are generalizations and that each person must be looked at on an individual basis; any of these things can be primary in a given individual).

 Slide 14

A.     Traditional “wisdom” has been that long hours, stressful work conditions and easy access to drugs are the main factors that predispose physicians to substance use disorders. There are, however, few data to support this.


B.     Various studies report different predisposing factors (McAuliffe, 1987; Gallegos,

1988; Vaillant, 1992): history: (of substance use disorders or mental illness)

2.personality Characteristics:

a. over-confidence, sensation-seeking, externalizing

4. health: (chronic fatigue, >1 ppd cigarette use)


C. Suggestion that the reaction to the work environment is more important than the stressful job conditions themselves (Jex, 1992).


D. Stress appears to be significant only in the presence of other mediating factors (as in C above).  It appears that personality characteristics are more important; the vast majority of physicians under very stressful work conditions do not develop substance dependence..


E. It appears that increased access to controlled substances does not generally affect the overall prevalence of substance dependence in physicians but rather the types of substances used.


VI. Identification

It should be emphasized here that the signs of dependence  are universal and not unique to healthcare professionals. 

Slide 15

A.     Urine drug screening

1.      pre-employment (or pre-school)

2.      random

3.      detects use, not necessarily disordered use

a.       though, if someone knows that they are likely to have a drug screen and is unable to stop long enough for the screen to be negative, there is probably a higher likelihood that there is a problem with the use.


B.     Job/School Applications

1.      need to be mindful of laws around asking this information


C.  Screening by a physician is less likely to happen when the patient is also a physician


D. Physician’s (or Student’s) Assistance Programs (to be discussed more later)

1.      institution-based or State-sponsored

2.      non-punative

Slide 16

E. Some “warning signs” of substance abuse in professionals (Breiner, 1979)

(similar with medical students). It is important to remember that these should raise suspicion but do not necessarily mean that a substance use disorder is present. None are necessary or sufficient to indicate that a substance problem exists.  Some of these may seem very obvious but they are often overlooked.

1.      social or professional isolation

2.      friction with colleagues

                        3.   disorganized schedule

                        4.   inaccessibility to patients and staff

                        5.   frequent absences

                        6.   rounding on patients at odd hours

                        7.   decreased work and chart performance

                        8.   large quantities of drugs ordered for “stock”

                        9.   inappropriate orders

10. forgotten verbal orders (given during a black out)

11. slurred speech during off-hours phone calls for orders

                        12. heavy drinking at hospital functions

                        13. vague letters of reference

                                14. pharmacist notices prescriptions being written for family members


                        16. suicide attempts


So given these fairly obvious signs, why the delay in detection?

Slide 17 E. Reasons for delay in detection:

                        1. fewer formal controls such as “supervision”

                        2. relative independence of various professions

                              3. denial particularly strong

a.       sometimes referred to as “Malignant Denial

b.      extremely difficult for people who are used to controlling things to admit that they can not control substance use

4.  feeling in healthcare professionals that “I can take care of myself.”

a.       strong tendency to self diagnose and treat

b.      disease understanding does not equal disease acceptance

5. fear of consequences

a.       for many physicians who have devoted many years of training,

loss of license = loss of identity

                        6. “conspiracy of silence”

Slide 18                       a. reasons for the “Conspiracy of Silence” in the family:

                                                1). family’s reputation in the community

                                                2). financial status

b. reasons for the “Conspiracy of Silence” in staff:

                                                1). financial dependence

                                                2). intimidation by “more prestigious” physician

                                                            a). also see with medical students

c. reasons for the “Conspiracy of Silence” in fellow physicians:

                                                1). practice’s reputation

                                                2). practice’s income

                                                3). strong sense of community in medical specialties

                                    d. reasons for the “Conspiracy of Silence” in patients:

                                                1). don’t want to think that their doctor has a problem

                                                2). think that doctors are “immune” to addiction


VII. Reporting

Need to highlight that the actual laws pertaining to this vary by state, but that the ethical issue of reporting a health-care professional who may be endangering the public should supersede the law.

Slide 19

A. Ethical obligation to report a physician who you feel may be endangering the lives of

others through their impairment

1.      a result of the 1972 American Medical Association House of Delegates


B. In 1974, the Disabled Doctors Act urged:

1. mandatory reporting of incompetent physicians

2. evaluation and treatment with restoration to practice after successful treatment

3. removal from practice of “incurable”

4. immunity for “whistleblowers”


            C. Federal law requires an institution (or individual) to report to the state licensing board

and the National Practitioner Data Bank only when disciplinary action is taken against that physician’s license.


D.Requirements for reporting vary by state and by profession (eg M.D.s vs nurses).

1. only @ 20% of states have laws mandating reporting of  impaired colleague

2. everyone should be encouraged to find out about laws in their particular state.

a. available through the State Medical Society or licensing board.


E. Laws regarding self-prescribing (and prescribing to family members) vary by state.


            F. Most states provide “immunity” from civil suit for the reporter.


VIII.        Engagement  In Treatment

This section can be omitted or mentioned only briefly, depending on the focus of your talk. This could be just mentioned as a way that is often needed to get an impaired healthcare professional into treatment or you could give some detail on how an intervention is set up and conducted.

A.     Important to emphasize that the goal is actually to have the person evaluated for their need for treatment.


B.     This is very important given the above statements about the difficulty in identifying

healthcare professionals in need of help.  They tend to be less likely to come to treatment on their own because of denial.


C.     “An Intervention”

1.      use a team approach

2.      use a trained and experienced leader

3.      include other physicians on the team

4.      use a non-threatening, quiet place

5.      allow plenty of time

6.      rehearse what everyone will say

7.      have clear and consistent goals, choices and consequences


IX. Treatment

Slide 20 Continuing to sound like a broken record, the data for treatment outcomes are also plagued by variability in the populations studied, methods used, duration of follow-up and outcomes measured. Reported recovery rates vary from 27-92% however:

A.     Most data show that physicians have better outcomes than general population.

1. probably closer to 70-90% abstinence rates

                        2. the vast majority are able to return to the practice of medicine.

3. no correlation with the substance of abuse.

                  4. the length of the initial treatment may not be particularly important.

Slide 21

B.     Goals of treatment (not an exhaustive list)

1.      abstinence

2.      understanding and acceptance of the disease concept

3.      identification of triggers

4.      development of non-chemical coping skills

Slide 22

C. Factors important in aftercare:

1. duration of aftercare (seems to be most important)

                        2. frequent contact with Physician Health Program

            a. typically monitor for a minimum of 5 years

3. family involvement

4.12-step program involvement

a. although this is not formal treatment, it is clearly helpful for many patients.

                  5. witnessed urinalysis

a. one study showed that 96% of physicians “improved” when monitored (urinalysys & program involvement), as compared to 64% who were not monitored (Shore, 1987).


D. Contingency Contracting  (Crowley, 1986)

1. uses the professional’s license as an incentive for changing behavior

2. typically, the impaired physician signs a contract that instructs the treating therapist to mail a license-surrendering letter to the medical board if a urine sample is positive for a drug of abuse.

3. this helps make the loss of license as predictable as the reinforcing effects of the drug.

4. this also helps relieve the therapist from the divided duties to the impaired professional-patient and the safety of the professional’s patients.

Slide 23          

E.Some factors that make treating impaired physicians particularly difficult:

            1. feeling of uniquiness

            2. role reversal

      a. extremely difficult for helpers to accept help

3.over identification with work/performance

a. on the part of the patient

            4. identification

a.       on the part of the treating professional

b.      may be more likely to overlook warning signs because of this

5.medical knowledge

a. more adept at “fooling” urinalysis (such as with self catheterization)

Slide 24

F. Is a treatment designed specifically for physicians necessary or useful?

1.      there are programs (Talbott Recovery Center in Georgia, Farley Center in Virginia) that work exclusively or primarily with impaired health professionals. 

2.      the literature is not clear as to whether  patients who attend these programs   have better long-term outcomes.

3.      many areas have 12-step meeting specifically for physicians and other healthcare professionals (“Caduceus Meetings”)

4.      there are pros and cons to this:

Pros:   identification with others with similar training

identification with others with similar consequences of relapse

            understanding of difficulties inherent in work (eg. shift work, etc)

Cons:   implication that dependent health care professionals are different

                        than other people with chemical dependency

            5. probably best to combine approaches (“Peer-Blend Therapy”)

Slide 25

G.”Re-entry” (Gallegos, 1989)

1.      most return to the practice of medicine

2.      some change to a “less high-risk” specialty (eg. anesthesia to internal med)

3.      some may have imposed limits on dispensing and prescribing

4.      some alter work schedule (eg. no more night shifts)

5.      some recovering healthcare professionals find it helpful to work with other patients with addiction and may specialize in the treatment of addiction.


X. Prevention

Need to highlight that much of the following are forms  of secondary and tertiary prevention that are aimed at trying to reduce harm.  In most cases, the substance use disorder will be present prior to these interventions.  One exception to this is the role of education about the misuse of prescription drugs by health care professionals.

Slide 26

A. Detection in medical school

1.      medical schools are required by the Higher Education Act of 1965 to establish policies and programs that address substance abuse among their students.

2.      surveys during the late 1980s showed that most schools violated these


This might be a good place to mention that you will tell the students how they can access help for substance use disorders or other problems at your institution.


B.     Medical school education

1.      lectures (such as this one) on chemical dependence in healthcare professionals highlighting the increased risk with controlled substances.

2.      lectures on general health and coping skills for medical students and

physicians (given that the response to stress seems to be very important).

This might be a good place to talk about some issues such as  attending to personal needs during school, rest, exercise, talking with family members, etc.

3.      no studies have been done to evaluate the effectiveness of medical education

on later substance use patterns.


C. State Impaired Physicians Programs

1.  also known as Physician Health Programs (or Services or Committees)

2.  present in all 50 states

3.  a result of The Disabled Doctors Act of 1974.

a. the first one was started in Georgia in 1975

                  4.  they have two main functions:

            a. to protect the public from impaired physicians

b. to “rehabilitate” chemically dependent or mentally ill physicians

5.  they typically provide:

a.       confidential assistance

b.      reporting to the medical board only if physician is uncooperative or a threat to safety of patients

c.       education/prevention programs

d.      confidential reporting process

e.       intervention teams

f.        referrals to treatment

g.       contracting and monitoring

h.       advocacy and assistance with “reentry” to work

i.         financial assistance

6.  they are generally run  either by the state licensing/disciplinary board or an

independent state medical society. 

a. it is felt by many that the programs administered by medical societies are more effective because they encourage earlier, non-punitive self-reporting.


D. As of January, 2001, the Joint Commission on Accreditation of Healthcare

Organizations (JCAHO) has required that all JCAHO accredited hospitals establish “a process to identify and manage matters of individual physician health that is separate from the medical staff disciplinary function.”

Slide 27


A.     Overall, the prevalence of substance use disorders in healthcare professionals appears to be about equal to that in the general population.


B.     Rates of illicit drug use for medical students are similar to age matched controls.


C.     Beginning with residency, use of controlled substances (benzodiazepines and opioids) increases in physicians relative to the general population.


D.     Identification of substance abuse and dependence in healthcare professionals is often very difficult because of extremely strong denial and the “Conspiracy of Silence.”


E.      Healthcare providers tend to have better treatment outcomes.


F.      Physicians Assistance Programs are designed to provide non-punitive help


Slide 28 This might be a good  place to have the phone number where students should call to get help for substance-related problems or other mental health issues.


 (The following are just brief comments on substance abuse and dependence in some of the other healthcare professions; if there are time constraints, this can be deleted.  Otherwise, it is probably good for students to be familiar with some of the issues specific to other healthcare workers as they will be treating them in the future).


XII. Nurses

When talking with medical students, emphasize that they should be aware of these issues in nursing staff because of the amount that they will work with the nurses during clinical rotations and to help safegaurd against substance abuse in their future office practice.

Slide 29 A.Overall rates probably similar to the general population

B.Higher rates of benzodiazepine and opioid use.

1. more parenteral use (Gallegos, 1988)

C. Higher rates in trauma center and critical care nurses.

D. Clues to “diversion” of medications:

                        1. extreme interest in giving medications and carrying narcotics keys

                        2. being on the unit when off duty

                        3. use of maximum p.r.n. doses when other nurses use less

                        4. patient complaints of not receiving meds when record indicates they were given

                        5. physical changes of multiple dose vials indicating substitution with saline

                        6. frequent wastage such as spillage

                        7. emergency room supplies appear missing

                        8. frequent trips to bathroom (especially with purse)

                        9. entire stock of drug from pharmacy (as well as sign out sheet) is missing


XIII. Dentists

Slide 30A. Little good data


B. More use of inhaled anesthetics such as nitrous oxide

                        1. use is minimally regulated

2. one study reported 20% of pharmacy students reported recreational use (Rosenberg, 1979)

3. in 1987, the deaths of 2 dentists and a dental student were attributed to nitrous       oxide.

4.extremely difficult to monitor abstinence because there is no urine toxicology


C. One report of prevalence of alcoholism at 8% (Bissell, 1986)


XIV. Pharmacists

Slide 31 A. Estimates of substance dependence from 10-18% (McAuliffe, 1987)

                        1. 46% reported using a controlled substance without a prescription

                                    a. 19% on a regular basis

                                    b. primarily for self medication

2. 62% of students reported using a controlled substance without a prescription

                                    a. 41% on a regular basis

                  b.primarily for recreational purposes


B.May have a higher use of stimulants than other health care professionals:

1.      35% in treatment reported using stimulants illicitly(Gallegos, 1988).


C. Less parenteral use than other healthcare professionals (Bissell, 1989).


XV. Veterinarians

Slide 32A. Very little good data


B.  More use of ketamine.


C.  More use of higher potency opioids


D.  More use of inhaled anesthetics



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