By Christopher Guadagnino, Ph.D.

Published March 1997

• React to this article in the Discussion Forum.

Abraham J. Twerski, M.D., is founder and medical director of Gateway Rehabilitation Center and associate professor of psychiatry at the University of Pittsburgh School of Medicine.

PND: Why is drug abuse so prevalent among physicians?

AT: Physicians are as vulnerable as any other professional, and the problem of chemical abuse—which includes both alcohol and drugs—is an equal opportunity destroyer. Although stress in itself is not the cause of drug abuse, the person who has the propensity towards drug abuse in a high stress position has an increased reason for recourse to drugs. Physicians have easy accessibility. They can prescribe drugs for a long time before it is picked up that they are prescribing illegally for themselves. No on knows for certain, but the statistics that are usually kicked around is that anywhere between 10-15 percent of physicians are addicted to either alcohol or drugs.

PND: How can such addiction be detected?

AT: Unfortunately, early on there is virtually no detection means, because people who use drugs can continue to function to all appearances at high level until they take enough that it begins to impair either actual functioning or memory, which they somehow manage to cover up.

PND: What should physicians do for colleagues whom they suspect are addicted?

AT: Physicians who know that a colleague has an alcohol or drug problem should talk with the family of the physician, and they should either confront the physician themselves or contact their local physician’s health program. In that way, it’s possible to intervene at an earlier stage before the disastrous consequences occur.

PND: Is it a physician’s professional responsibility to intervene?

AT: It’s a responsibility for two reasons: a responsibility toward the colleague who has a condition which is out of his control and which is going to destroy him and his family, and it’s also a responsibility that the medical profession has towards the public, the consumer, because a physician who continues with chemical abuse is ultimately likely to produce something harmful to the patient. We have a responsibility towards our patients.

PND: How can a colleague intervene without threatening the loss of that physician’s license?

AT: If an untreated addiction is not picked up, the loss of license is going to come about in a much worse fashion than it could possibly come as a result of identification and treatment. We now have an advocacy system in which, if the physician who is identified as having a problem accepts proper treatment and monitoring, his license is not jeopardized. The state Medical Society has an agreement with the licensing board that if they identify the problem and if they can assure that the physician has received proper treatment and adequate monitoring to prevent a recurrence or relapse, then the license board does not intervene.

PND: What does the treatment program entail?

AT: If necessary, there may have to be a period of detoxification which sometimes requires inpatient treatment to withdraw the person from whatever drug he is on. Then we usually recommend some sort of program, whether it’s inpatient or outpatient, which deals with the issues of addiction: denial, rationalization and protection—all the games that the addict plays. He needs to increase his coping skills and self-confidence, because invariably people who use drugs are very low on self-esteem and self-confidence. Strangely enough, this is most intense and most severe in people who are the highest qualified and most gifted. So, a doctor who is maybe chief of his department and is a nationally known authority may have a great deal of self-confidence in himself as a professional, but as a person does not feel any self-worth. So what we need to do is help the individual with getting a feeling of self-esteem and self-worth because, ultimately, if you know that you are beautiful and valuable, you won’t do anything to damage an object that is beautiful and valuable.

PND: Do treatment programs reduce the level of the physician’s medical practice responsibility?

AT: That has to be an individual decision. An interesting example was a person who was my personal physician, who was a surgeon and eventually began to show signs of deterioration and memory lapses. Eventually it was picked up that he was prescribing for himself, and he came in for treatment. He did very well, and when he went back after treatment to the hospital, the chief of the department called me and said, "Do we need to monitor him?" And I said, "I don’t understand you. At the times that he was putting away 15 Valiums a day, he was doing surgery and nobody monitored him, nobody supervised him. And now when he is perfectly clean, now you’re going to supervise his work?" For the first time in years he was functioning at a much higher level and he did not need supervision as far as his work is concerned. What he needed was supervision as far as his drug use is concerned. Now, sometimes we may suggest that the person not be exposed. Sometimes we will not allow an anesthesiologist go back into the operating room for a period of time until we feel that it is safe for them, because they can get all the drugs and are not accountable for them. So it really has to be an individual evaluation.

PND: How is monitoring done?

AT: I use random urine samples rather than scheduled urine samples, which means that I tell the physician you can receive a call anytime, day or night, 7 days a week. When you receive that call, you have exactly 12 hours to report to a laboratory. He may receive that call twice within a week or he may receive it at three-week intervals. The other option is a urine sample three times a week. That becomes an ordeal, which is really not necessary.

PND: Which agency handles the monitoring?

AT: It can be worked out with almost anyone. Usually the rehabilitation center handles the monitoring, the outpatient follow-up. We get all the legal necessities, the releases for communication. We do exchange of information so that everybody knows that we are in touch with the physician’s health group and the state Medical Society. We are in touch with the practice, we are in touch with the hospital. So the doctor knows that any positive urine is going to be quickly reported to the necessary group.

PND: Are patients made aware that their physician is undergoing treatment?

AT: No, we don’t tell patients. It’s surprising, though, how patients sometimes find out that the doctor is addicted. There is a difference in the doctor’s prescribing pattern because he is not as free to give addictive medications as he was before. The other surprising thing is that the loyalty to the doctor is still very strong, and they’ll continue going to him even while he is addicted before treatment. After treatment we have not ever had, to my knowledge, any doctor who has lost patients as a result of the discovery.

PND: What signs of addiction should colleagues look for?

AT: Changes, atypical behavior. Unexplained mood swings. That doesn’t mean that he’s using drugs, but it may. Sudden changes in irritability. Missed appointments, not showing up when he is supposed to. Difficulty in getting in contact with him. How many times can your beeper batteries go low? Loss of memory. If he is supposed to have been there, and he doesn’t show up for the appointment, didn’t show up for the surgery. It’s certainly possible that a doctor falls asleep at a meeting if he had a bad night. So if this happens once in a while, it’s something else. But if the doctor is frequently falling asleep at meetings, that would be a red flag.

PND: How successful is treatment?

AT: The recovery rate is extremely high. There is an enormous amount of investment when the person knows that his career depends on his towing the line. The person who is a laborer does not have that kind of risk that his alcoholism or drug addiction is going to destroy his career. Physicians, precisely because of the sensitivity of their position, are much more vulnerable. This works in their favor.