Halcion

Editor's note: Names of the doctors interviewed for this article who freely talked about their past substance abuse problems are being kept confidential in order to protect their privacy.

As a director of pharmacy at a California hospital, Dr. Kevin stole Vicodin, Percocet, Demerol and morphine. He used them to get high, and there was no way for his colleagues to detect his abuse of his authority.

Dr. Kevin's deceit was an inside job. He knew that when drugs reached their expiration date they would be good for another six months to a year. When 10 pills came back from the hospital floor, he logged in that five came back. If anyone ever checked, they would find the inventory of the five pills and never miss the five he put in his pocket.

He exploited a sad reality.

A hospital's accountability doesn't work when the abuser is one of its very own. Pharmaceutical paperwork where Dr. Kevin worked required two signatures. As the supervisor, Dr. Kevin was always the last to sign off on such transactions. Even when confronted about his erratic behavior, he had a solid alibi. No drugs were missing and hospital records proved it.

"They actually would have never caught me until I died," Dr. Kevin says.

The reason: Physicians tend to be better at hiding their addictions, drug treatment experts say.

That may correspond with the findings of ACPE's Physician Behavior survey where the vast majority of respondents indicated that substance abuse was behind bad behavior in only 10 percent or less of the cases. Several survey participants noted, however, that it's often difficult to determine if a doctor has a problem with drugs or drinking.

What's more is that family and colleagues help doctors keep alcohol and drug abuse out of sight. Family and colleagues look the other way when seeing troublesome behavior, failing to report it. As a result, the disease gets a head start, sometimes making treatment more complex and difficult.

The delay getting treatment is just putting off the inevitable, says Warren Pendergast, MD, associate medical director for the North Carolina Physician Health Program, one of more than 40 treatment programs nationwide specially designed for medical professionals.

"The problem is going to come out eventually," he says.

That's what happened to Dr. Kevin.

One of his supervisors knew he was doing something, but he couldn't prove it. The supervisor watched as Dr. Kevin couldn't keep his mind focused on his job and noticed when he fell asleep at the counter. The supervisor didn't smell alcohol and cast that possibility aside. He also says he knew Dr. Kevin wasn't taking anything from the pharmacy because he had checked all of the records. Dr. Kevin laughed at those words, knowing he had duped his supervisor. In the end, it would be the first of six such confrontations.

Longtime habit

By the time Dr. Kevin started stealing drugs from hospitals, he had been abusing alcohol and drugs for years. He started drinking alcohol to fit in when he was 16. He quickly graduated to marijuana and then to opiates and tranquilizers. He used the drugs to kill the fear, the fear of the unknown. He didn't feel comfortable in his own skin until he had some alcohol or drugs in his system. On top of that, he chose a field where he would have unfettered access.

That's the primary difference when it comes to doctors and other abusers. Colleagues don't believe doctors would put their careers in jeopardy. For their part, doctors also have garnered a significant amount of respect by the time they walk through hospital doors and begin practicing medicine.

Or as Pendergast puts it: "People just don't think of doctors getting sick."

Dr. Kevin, though, was sick. He flunked out of his first treatment program, going on a five-day binge of valium, amphetamines and cocaine just days before he was set to graduate. The second time around he lasted 88 days. When he finally confronted his addiction, he freed himself of alcohol and drugs for more than two years.

But it only took one sleeping pill for him to relapse. One tiny, 0.25 milligram Halcion. That one pill set off a chain reaction that left Dr. Kevin so high he couldn't pick himself off the floor when he needed to urinate. Like most abusers, Dr. Kevin was in denial.

A recovering addict has at least one sponsor, a mentor of sorts who has experienced some of the same challenges. When Dr. Kevin's sponsor moved to another city, he convinced himself that he could be his own sponsor.

At the same time, Dr. Kevin's job was keeping him awake at night. He had been charged with completing a pharmaceutical report for the Joint Commission on the Accreditation of Hospitals, covering three years. But Dr. Kevin only had been at the hospital for two years. He spent his time fabricating information for the third year of the report. When a doctor suggested he take a sleeping pill to alleviate his bouts of guilt, Dr. Kevin's support system wasn't there. He took the sleeping pill. Then he went to get 100 more.

"To whom it may concern," he prayed, as he lay on the floor that day. "Help me or let me die."

By that time, Dr. Kevin had failed and succeeded in treatment. He had friends who knew how to help him. He turned to them, and one let him get sober at his home. That friend also gave Dr. Kevin an ultimatum--tell an administrator at the hospital about his drug abuse. Dr. Kevin obliged, turning himself in one day in December 1992.

"If I hadn't turned myself in," says Dr. Kevin, "I don't think I would be alive today."

Dr. Kevin, 47, survived, but his career didn't. His license was suspended for four years and he never returned to a pharmacy. Today, he is a courier, traveling the globe as he helps transports equipment. He has been sober for nearly 12 years.

Dr. Kevin's addiction could have taken a blow much sooner. His enablers were his family, his colleagues. No one stepped up and confronted him. They feared for his life and said nothing.

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'Quiet' addiction

There are more like him, more doctors who exhibited the tell-tale signs of abuse.

But for reasons that astound some professionals, doctors are often allowed to quietly consign themselves to addiction.

Like Dr. Kevin, Dr. Bob took his first sip of beer at age 16. When he took his last drink, some 44 years had passed. He didn't lose his job or his family, but he severely limited his achievement in medicine.

In the end, he drank every day, getting drunk on the weekends. What he got in return was a pair of shaky hands, tremors so powerful he couldn't control them. Dr. Bob, too embarrassed for colleagues to see his hand tremors, took himself out of the operating room. He even applied for and received administrative duties, casting aside years of medical training as an obstetrician/gynecologist so that he could continue to drink.

He compensated for his drinking in any way that he could. His memory lapses, for example, were so profound he wrote notes to himself, particularly at night.

"In all those years, I never saw a patient (while I was) drunk," Dr. Bob says. "I was never in the operating room drunk. But I was certainly hung over seeing patients." When confronted by family or colleagues, he was embarrassed, professed his guilt, promised to cut back. And he did, if only for a short time.

But soon the cravings would return, and Dr. Bob turned to the bottles he had hidden everywhere. He had bottles stashed in his car, in his briefcase, in all corners of the house. He drank on the way to work. He had a glass of wine with dinner. His wife went to bed and he stayed up to drink.

"It was so gradual and so insidious," says Dr. Bob, now in retirement. "My motivation was suffering. I was becoming more and more isolated."

He was passed over for a promotion, in part, because of his drinking. He left a job where he was an administrator for an HMO and went to work for a California county health department, again severely limiting his growth as a medical professional.

There, he was in a meeting one morning when a colleague smelled alcohol on his breath. The colleague suggested he seek treatment, but stopped short of reporting him to the medical board, primarily because he wasn't seeing patients at the time. He knew he had a problem, but he didn't want to seek treatment too soon. He didn't want to quit. He also was scared treatment wouldn't work. If the treatment failed, he knew there was nowhere to turn. So, he didn't go. But the idea has been planted in his head.

The fellow doctor checked up on him periodically, prodding him for answers about his treatment. He finally went to meetings, but only to manage his drinking. He figured he would cut back on his drinking, not stop. But he couldn't fight the cravings. He talked himself into having one last drink. He argued with himself that day, but he trusted his drunk self more than his sober self.

A few days later, though, his wife, who had talked to him about his drinking, smelled the alcohol. Busted for the last time and knowing he couldn't stop drinking on his own, Dr. Bob went to a 12-step program.

"There was no hope for me," he says. "I could not stop."

He hasn't had a drink since that day his wife smelled the familiar odor on his breath. That was six years ago. But Dr. Bob lamented that his drinking was tolerated at work. He called for help on more than one occasion:

* There was the time he talked with his doctor about possible liver damage and the doctor missed the clue.

* There was the time another doctor asked leading questions about his drinking. "You probably drink socially, right?" Dr. Bob recalls one asking. "Taking a history like that is worthless," he says.

Difficult diagnosis

If alcohol and drug abuse are complex diseases, diagnosing and treating doctors who suffer from them is even more so. Dr. Bob has developed his own theories about why such behavior is tolerated, especially when the risks are so high.

"I think (doctors) are in denial about the role of alcohol in their own lives," he says. "They're afraid to deal with their own (addiction) and that makes it easy for them not to deal with others."

If someone had confronted him, turned him into a supervisor and threatened to go further, Dr. Bob says he would have sought treatment sooner. "I should have been reported."

Instead, he got warnings not to let it happen again. The colleague who finally confronted him wouldn't let him off so easy.

"When I am honest with myself. I was jeopardizing patient care," he says. "I was not as attentive as I should have been and just getting by. Mostly I was giving 200 percent effort to behave normally."

The lack of normal behavior is a tip off of sorts. Another abuser, Dr. Robert, for example, scheduled his drinking around his work. He didn't have clinics for Friday afternoons, leaving time to prepare for his weekend binges. He also didn't schedule surgeries on Monday mornings, giving himself time to recuperate from the previous weekend's drinking.

Other odd behavior: Dr. Robert turned over his medical duties to others because he was incapacitated. He didn't show up for work at the scheduled time and made rounds after midnight.

"My job began to suffer," Dr. Robert says. "I worked hard to protect my right to drink. I performed as well as I could. I volunteered for the tough assignments. I tried to be as good as I could so that people wouldn't fuss with me about my drinking."

A simple rotation saved his life. Dr. Robert, a general surgeon at a west coast Naval hospital, was required to spend some time in a visiting doctor program at the hospital's treatment facility for addicts. Dr. Robert knew he was sick, confessed he should be the patient, not the doctor. He was sent home to gather his belongings. Soon he was a drug treatment patient in his own hospital.

Dr. Robert, now 64, doesn't suggest anyone do what he did. But the lack of anonymity forced him to get real with himself, his drinking and his colleagues. He has been sober for 25 years. He knows his colleagues allowed his disease to progress so that he could retain his career.

Experts say such enablers aren't really helping.

"The professional consequences get worse," says Pendergrast. "The addiction continues. By the time it's detected, it's worse. Sometimes there is a sense of needing to get negative drug screenings and not to get treatment."

Doctors also are confident, almost bullying those who question their behavior. "You can test me every day," is a phrase Pendergast has heard countless times while trying to help doctors.

The ramifications of reporting a doctor, especially a superior, sometimes have far reaching effects, particularly for clinics and some specialties.

"If you do report your boss, he may go away and the clinic will suffer." Pendergast says. Such thinking, though, is short-sighted.

The medical profession is more accepting of doctors who seek treatment. A number of programs are in place and allow colleagues to refer a doctor to treatment without putting his job in jeopardy.

Educating doctors about how to make referrals and what making a referral means will slowly change the secrecy of alcohol and drug abuse among doctors, says Marsha Epstein, MD, a service planning medical director in Los Angeles.

Epstein has successfully referred doctors to Alcoholics Anonymous. She recommends that physician executives who have a physician with alcohol or drug problems be referred to AA or another appropriate agency. Physician executives might also consider attending an open AA meeting or an Al-anon meeting to learn more about substance abuse.

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"You can't make them go. But some of them are going to go just by your doing that."

Another, more personal strategy brings similar results. Epstein says doctors are moved when they hear the stories of recovering doctors who share their experiences and show others through their stories that there is hope.

When you hear somebody tell their story, it's so inspiring."

RELATED ARTICLE

At the North Carolina Physician Health Program, one of more than 40 treatment programs nationwide for doctors, the number of physicians assessed each year has steadily increased over the last 16 years. In 1988, the program assessed 26 physicians with some sort of substance abuse or behavior problem. Ten years later in 1998, they assessed 65, and, in 2003--the last year for which statistics are available--they assessed 138 physicians. (The program assesses physicians and, if necessary, refers them to appropriate treatment programs.)

Here's a look at the types of problems the NCPHP has assessed and numbers of cases they've handled:

Monique Fields is a journalist for the St. Petersburg Times in St. Petersburg, Fla., and also an accomplished freelance writer. She can be reached through her Web site at www.moniquefields.com

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