November 25, 2003

     "Ok guys", exclaimed the esteemed Pathology professor one day, " your assigned reading is from Chapters 11 to 16 for the discussion and pretest tomorrow"... Now how in the world am I supposed to read six freakin’ chapters in one night, I thought? Caffeine doesn’t seem to work anymore. By the third year of Torture College my average coffee intake was at least 6 mugs a day (and three Red Bulls). Hmmm…it seemed tempting to use something stronger to perk me up. Why not some prescription medications, the thought crossed my mind. Shhh…or maybe "over the street" drugs? Certainly my Pharmacology teacher said that with some of this stuff I could stay awake virtually forever. It makes people feel good too. Hey, I know some residents use it, I know a school mate who OD’d from it, and I’ve seen how shabu keeps some acquaintances awake for 72 hours straight so they can keep hanging out in Mission Road or DB Ledesma. Hell, I’ve even seen surgeons operate drunk or stoned. So why can’t I use?

     Sounds familiar?

"Studies show that most medical students who admitted to drug abuse started the habit before med school and the heaviest users were the worst users prior to medicine. The estimated alcohol use in medical students is 87% and those who admitted to alcoholism is 3.4%."

     We’ve all probably gone through this thought process. Some gave in and some didn’t and some are probably still hooked. There are those who are now regretting the day of submission and didn’t "Say NO to drugs" and alcohol. Because of that fateful day, the consequences may have been a lost degree, a lost specialty, a lost relationship, a lost patient, or a lost self-respect. And if you’re still hooked to drugs or alcohol and practicing medicine, you are a sick doctor and need help.

     The thing is, you are not alone.

     Studies have shown that substance abuse rates among healthcare professionals is about 8 to 14%, and one in every six residents will develop a substance use disorder at one time or another.

     Now, many of us drink Pale Pilsen (still my fav) and we get to take prescription controlled substances occasionally. However, there is a thin line separating "dependence" and "abuse" from simply being in the Barracks, Sandpipers, or Tatoy’s too often. Besides, shabu and marijuana is cheap everywhere and it is easy to steal hospital narcotics or self prescribe. If you kept up with the Psychiatry professor on DSM IV, you can, during your rare sober moments, remember that if drinking, or using, causes 3 out of the 4 of the following then you are a certified junky or alcoholic: tolerance, withdrawal, using more or longer and inability to control use (especially if it causes problems in your work, health, home or relationships).

     Why do doctors and doctors-to-be become alcoholics or drug abusers? The easy traditional alibis are: long hours and stressful conditions AND easy access to drugs. Broken down, docs do it for: recreational use, performance enhancement, or self-treatment of pain, anxiety or depression.

     Actually, statistics show that average rates for junky docs are similar to the general population. The sad thing about it, we are supposed to be the healers and role models and should know better. But then ALL of us go through the rigors of training and the stresses of practice and get subjected to the same kind of tribulations, but the vast majority do not become drunks or addicts. OK, it’s "multifactorial" as the Psychotherapist will say for each individual is unique. Therefore, the buck stops at you, the individual. Personality has everything to do with it. The stressors are significant but how you react to them is more important. It is how you cope with the problem: religion, friends and family, getting busy, or psychotropic substances.

     If it is due to stress, when does "stress" begin? My Ericksonian inculcation says it begins way before. In fact, the risk for abuse is higher in those already using before the onset of medical school (duh). Studies show that most medical students who admitted to drug abuse started the habit before med school and the heaviest users were the worst users prior to medicine. The estimated alcohol use in medical students is 87% and those who admitted to alcoholism is 3.4%.

     Observing residents on the other hand, when I was under their tutelage, it seemed that they were worse, or so I thought. A large published study pegged the rates to be about 10 to 14%! The subjects reasoned that the drinking and drugging were "self-treatments" and not "recreational" (as opposed to non medical people) and the drugs were often self-prescribed or written by a consenting colleague. Again the alibi is stress and long hours plus easy access to drugs. It is not uncommon to see cacophonous docs in throngs in Breakthrough or Caesar’s Court. Not that this is evil, but it may raise a warning sign.

     Warning signs to the supervising consultants was the thought. But how can the warning signs be noticed if they are also into it? Between 8-12% of physicians in practice are also estimated to be alcohol or illicit drug dependent. Of course, it is easy to recognize a prominent physician driving by a street corner to buy drugs, and therefore the most commonly abused drugs are prescription opioids and benzodiazepines. The statistics don’t even include the newer party drugs like Ecstasy.

     Does the specialty have any bearing on this problem? Perhaps. The top three are: Psychiatry (14.3%), Emergency Medicine and Anesthesiology. The OR guys inject more often, overdose most often and die more frequently. Least likely specialists to abuse: Pediatrics and Radiology.

     So what are we supposed to do about it? Shall we do mandatory drug testing like the LTO? (Which by the way, they said can be bought for as low as P500). That sounds like martial law, but they actually do it in US residency programs. If anything should be done, it should be non-punitive (except in gross negligence cases) and done in a spirit of support for the sick doctor who needs help to overcome the addiction. There is of course, a conspiracy of silence among us physicians because it is our friends and colleagues we are talking about. But if neglected, it will lead to harm for everybody including the patients. Therefore, cases should be individualized and those suspected should be reported, tested AND helped. We all have an ethical obligation to do this. Once identified and treated, alcohol or drug dependent physicians have better recovery rates than the general population (70-90%).

     Here is a reprint of the warning signs of substance abuse in healthcare professionals (applies to nurses and techs too):

• Social or professional isolation
• Friction with colleagues
• Disorganized schedule
• Inaccessibility to patients and staff
• Frequent absenteeism
• Rounding on patients at odd hours
• Decreased work and chart performance
• Large quantities of drugs ordered for "stock"
• Inappropriate orders
• Forgotten verbal orders (given during being high or drunk)
• Slurred speech during phone calls (or any other time!)
• Heavy drinking during hospital functions
• Vague letters of reference (making up stories)
• Lots of prescriptions for "family members" (or for self)
• Overdose
• Suicide attempts

     It might be a good place to start prevention in Roxas Hall through closer contact with advisers and telling students that help is available. Hopefully, the mentors would be the role models, not drunk or stoned themselves. If only training can be "de-stressed" just a little bit and trainees guided on how to cope with stress, it will make a world of difference. Reminding ourselves not to neglect the rest of our lives may help untangle us from the binds of substance abuse for there is more to life than the four walls of the classroom and the University Hospital.

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