Book Review

Drug-Impaired Professionals

N Engl J Med 1997; 337:1093-1094October 9, 1997

Article

Drug-Impaired Professionals
By Robert Holman Coombs. 351 pp. Cambridge, Mass., Harvard University Press, 1997. $39.95. ISBN: 0-674-21673-3

The medical profession — especially organizations like the American Medical Association and state medical societies — has taken a special interest in identifying and managing substance abuse among its members. However, as Robert Holman Coombs points out, physicians constitute just one of the groups of “pedestal professionals” (physicians, dentists, nurses, pharmacists, attorneys, and airline pilots) for whom drug impairment is a problem. Because each of these groups are, as he says, “trusted with our well-being,” Coombs wrote Drug-Impaired Professionals with each of these six professional groups in mind.

In the opening chapter, Coombs argues that because these professions are trusted with the welfare of patients, clients, and customers, drug impairment among them requires special attention. The professionals have an “artificial immunity” to addiction because of their high social standing and the misperception that professionals will somehow overcome these problems before they become too serious. Multiple examples are given, however, that refute this concept. Despite Coombs's effort to give an overview of the prevalence of drug use among these professions, it is apparent that few empirical data are available.

The first chapter prepares readers for the remainder of the book by inserting vignettes about individual professionals to illustrate points made in the text. These stories are about surgeons intoxicated on the job, anesthesiologists who divert controlled substances from patients, and a nurse who can't remember caring for a patient because of an alcohol-induced “blackout.” In all, Coombs interviewed over 120 professionals, most of whom were health care providers. Although health professionals may be familiar with the general concepts illustrated by the vignettes, the richness of detail Coombs gives enhances one's understanding of what it means to be an addicted health care provider. More important, these cases give a vivid sense of what drug impairment may imply for patients.

The vignettes from other professions are also powerful examples of how addiction can interfere with job performance. Among the most vivid examples are those concerning airline pilots, for whom easy access to alcohol is an occupational hazard. One tells of a pilot denied access to alcohol while stationed in Saudi Arabia during Operation Desert Storm. When he was leaving Saudi Arabia at the end of the war in a 747 with 400 troops aboard, there was an engine failure after takeoff. The pilot decided to make an emergency landing in Cairo, basing his decision on the fact that, unlike in Saudi Arabia, beer was available in Egypt.

Like the first chapter, the remainder of the book intermixes content with case vignettes. Much of the book presents generic material on addictive disorders in a way intended to make it relevant for “professionals.” For example, the second chapter (“Addiction's Defining Nature”) provides a brief overview of the effects of psychoactive drugs and details a five-stage drug-user continuum: abstainers, social users, abusers, physically dependent addicts, and physically and psychologically dependent addicts. The chapters in the “Developmental Dynamics” section include one headed “Vulnerabilities,” detailing professionals' experiences during childhood that may have promoted their subsequent addiction. The chapter on developmental stages recounts the cycle of addiction from initiation through recovery. There are several examples here of young people being given or acquiring controlled substances for the first time for legitimate or illegitimate reasons and quickly falling into a pattern of abuse and dependence. The scenario of the house officer who prescribes narcotic analgesics for himself will have a familiar ring to many health professionals.

Appropriately, the largest section of the book — “Breaking Free” — focuses on the recovery process. Like the previous sections, much of this material reads like a generic primer on addiction for nonspecialists and perhaps those who are not health professionals. The chapter entitled “Recovery Tools” covers a wide array of approaches, including motivational intervention, detoxification, drug screening, behavioral contracts, and various forms of counseling and psychotherapy. The chapter entitled “Self-Help Recovery” presents the basic principles of 12-step programs. This chapter contains some interesting information on how the specific professions have developed self-help programs for their own members, such as International Doctors of Alcoholics Anonymous, Birds of a Feather (for pilots), and The Other Bar (for attorneys).

The final chapter, headed “Formal Recovery Programs,” presents generic information on topics such as inpatient and outpatient treatment programs. The most useful information is that which is specific to the professions in question. A section headed “Diversion and Control Programs” describes how the professional societies have shifted the focus of state regulators from punishment to rehabilitation. The section on work-site programs also presents some interesting information on how large employers and professional societies have attempted to use an Employee Assistance Program model to improve access to treatment. The appendix lists the addresses and phone numbers of organizations representing each profession that have “help lines” (except nurses, who are referred to their state nurses' association).

Coombs's book provides an interesting overview of substance abuse in the “professions.” Unfortunately, there is little scientific evidence available to him concerning the cause, epidemiology, identification, management, and prognosis of substance abuse in these professions. Thus, the book relies heavily on a generic overview of substance abuse and on interviews of affected professionals. Perhaps these interviews are the main contribution of this book. Taken as a whole, they give an insightful portrait of the impact of substance abuse on the professionals interviewed and those whom they profess to serve.

Patrick G. O'Connor, M.D., M.P.H.
Yale University School of Medicine, New Haven, CT 06520