Correspondence about impaired pharmacists

I have been engaged in a vigorous correspondence with pharmacists around the country on the subject of impaired pharmacists. The first article ("Does stress up R.Ph.s' substance abuse?) originally appeared in Drug Topics. "Show no mercy" was a letter that I wrote in response which was published in the October 4th issue. The rest are emails, more letters from Drug Topics and articles from other sources. I welcome all views. Interesting viewpoints will be added to this page.

This was an article written by Carol Ukens that appeared in the August 2nd issue of Drug Topics.

Does stress up R.PH.s' substance abuse?

The pharmacist was working 60 to 70 hours a week. After work, she'd pop benzodiazepines to help her sleep and then fall into bed. A few hours later, she'd get up and gulp down phenteramine just to rev up her engine so she could do it all over again.

This frazzled pharmacist is one of a growing number of stressed-out R.Ph.s whose self-medication spirals downward into substance abuse, according to David Marley, R.Ph., executive director, North Carolina Pharmacist Recovery Network Inc. His organization's case load jumped from five impaired R.Ph.s per year in 1996 to 26 cases in 1998 and a projected 30 cases this year. And the impaired R.Ph.s are no longer just young practitioners who continued a habit they picked up in college. More cases involve older R.Ph.s in their late 20s and 30s with no history of drug abuse.

"Increased stress on the job is going to cause more people to become addicted," said Marley. "In today's practice environment, chemical dependency disease among pharmacists is as much an occupational hazard as black lung is to the coal miner. Consistently we hear the same things: long hours, no breaks, high stress, not enough pharmacists, use of drugs to get going or keep going."

Nowadays, more pharmacists who abuse substances get started because they're trying to do a better job or to keep up with the flow. They take drugs to speed up or analgesics for the pain that can come with the job. As an example, Marley points to stress as the root cause of the five cases so far this year of R.Ph.s who were taking Fioricet for migraines.

Those pharmacists would be at work with a massive headache," Marley said. "They'd reach for two Fioricet tablets. Two years later, they're taking 20 to 25 tablets a day. Opiates usually start out with a bad back or muscle strain. There may be eight hours left in a 12-hour day, and the pharmacists stay on the job instead of going home. They take two hydrocodone products and discover that not only doesn't their back hurt, they don't care as much about the insurance company driving them crazy or the SOB across the counter. Tomorrow they'll take four just in case they do have a backache. That's how easy it is to get started."

Dave Cranmer reported that the New Mexico PRN program he heads is still seeing younger R.Ph.s. But the latest pharmacist to enter the Kentucky recovery program is a hospital R.Ph. in her 30s who was stealing methylphenidate, said Brian Fingerson, R.Ph., who sees stress as a factor in the program he oversees. "She denies any previous problems or experimentation with substance abuse," he said. "She found herself burning the candle at both ends and tried to keep her energy up. Now she's wondering how it all happened."

The American Medical Association estimates that 12% to 16% of health-care professionals will suffer from substance abuse or dependence over the course of their careers. Yet, very few states have fully funded, full-time programs for impaired R.Ph.s. North Carolina's PRN gets $86,000 from the state board, which charges each licensee $10 to support the program. "Pharmacy as a whole has lagged pathetically behind the other professions in setting up impairment programs," said Marley. "Only two or three states have legislation similar to ours. Most states have informal programs. They bum out and no one steps in to take their place."

For a listing of state pharmacist recovery programs, visit: www.aphanet.org/APhA/development/prnprgms.html

Reprinted with permission of
DRUG TOPICS, Medical Economics Co.

Show no mercy

I am writing in regard to your unbelievable story “Does stress up R.Ph.s’ substance abuse?”

As a pharmacist for the past 32 years, I have worked in many practice settings: hospitals, community pharmacies, medical centers and am currently pharmacy manager for a large chain. “…long hours, no breaks, high stress, not enough pharmacists…” as David Marley lists as the apparent reasons for increased substance abuse have always been around. In fact, with computerization and on-line claim processing, pharmacy is a much less stressful environment than it used to be.

A pharmacist is NOT addicted when he/she takes the two Fioricet tablets for the headache, just stupid, unethical and a knowing lawbreaker. As pharmacists, we know the actions of drugs. As pharmacists, we know the laws, both federal and state, concerning illegal drug use. We see the junkies come in with their pathetic forgeries and either kick them out of the store or call the cops. Do these innocent impaired pharmacists victimized into their addiction give any or all of their customers whatever drugs they ask for?

PRN programs aid this “victimization” because they work under the assumption that the recovered pharmacist will be restored as a useful professional. It won’t wash! These people have not made an innocent mistake, they willfully and knowingly violated the core values of the profession to which they were admitted. Pharmacy is not their profession, because they repudiated their professionalism. And to charge honest professionals a fee to encourage these charlatans and mountebanks to be recognized as professionals is an outrage.

Pharmacy was, is and always will be a high stress profession. We are dealing with our customers’ lives with every decision we make. I, for one, wouldn’t hire one of these retreads, they’ve proved they can’t cope. Kick them out! They can’t claim ignorance, only the inability to take responsibility for their actions and accept the consequences. We are better off without them and their woeful apologists.

Bob Shubert, R.Ph.

Reprinted with permission of
DRUG TOPICS, Medical Economics Co.

L. A. Lloyd (of the Arizona State Board of Pharmacy) responded in the November 1st, 1999 issue.

Counterpoint

To pharmacist Shubert, whose letter (Oct. 4) relevant to "impaired pharmacists" and "pharmacy recovery programs" left little doubt about his position, I make no apology for my diametrically opposed position.

Having a science-based education, I am prone to favor scientific findings on issues that are frequently influenced by personal opinion and/or bias. Nearly 10 years ago, I shared Mr. Shubert's position about chemical (drug) addiction; that, however, was prior to attending the University of Utah summer school program on alcoholism and other drug dependencies. That program changed my thinking forever on the subject. Scientific studies present strong evidence favoring the "disease concept" of chemical dependency. More recently, genetic research has produced data establishing a "genetic link" to chemical dependency. I believe the evidence is sufficient to establish chemical dependency as a "disease." Our colleagues in medicine recognize it as such and have established a medical specialty of "addiction medicine."

One could cite numerous articles and references in defense of this position. Rather, I elect to reference real-life stories. I have known more than 100 "recovering pharmacists." Of these, 90% are productive, sensitive, caring, professional, practicing R.Ph.s. They have come to grips with their disease and are serving their patients and their communities as health-care professionals. Most have told me that having been afforded a second chance has had a dramatic impact on their personality, their empathy for patients, and their zest for life. I wish I could say as much for many of the other pharmacists I know.

I understand that not all R.Ph.s will share my position relevant to "recovering pharmacists" in the workplace. I wish that I could convince the doubters to attend that University of Utah program. It is held annually for one week in June, and I'll guarantee that anyone wanting to learn about chemical dependency will experience a unique educational opportunity

L A. Lloyd, R.Ph.

Reprinted with permission of
DRUG TOPICS, Medical Economics Co.

I replied to Mr. Lloyd on November 17th. The second reply was sent November 22nd and crossed Mr. Lloyds response to my letter.

Dear Mr. Lloyd:

Whether we are speaking of alcoholism or chemical dependency (either licit or illicit drugs) or tobacco, great care must be used to prevent misunderstandings. You speak of a "genetic link" to chemical dependency, but I hope you agree with me that such a link means that a person has a greater or lesser propensity towards developing a chemical dependency. To mean otherwise implies an inevitability which denies the possibility of treatment and/or cure. If someone, by dint of a bad throw of the genetic dice, is destined, despite their best intentions, to be "diseased", than by what power can that destiny be overcome? And if there is such a power to overcome the inevitable, than the genetic link is not, in fact, inevitable. I concede that because of genetic makeup, some people are at greater risk, but I hope you will likewise concede that the genetic influence is merely one of many risk factors.

Perhaps I didn't make my point clear enough in my letter, but my ire was focussed on the tone of the original article that took the view that, of course if you have a headache or a backache or need some help sleeping or need something to get you back up in the morning that you have the perfect right as a pharmacist to grab something off the Rx shelf without a prescription. This, from people who are supposed to know about the uses and effects of drugs. Maybe my point of view is old-fashioned, but I think that is still considered felonious behavior. When Brian Fingerson was quoted as saying of the hospital R.Ph. who started taking methylphenidate to "...keep her energy up. Now she's wondering how it all happened." I think it is fair to question how much the young woman learned in both her schooling and in her practical experience. You know, I am sure, as well as I, how it happened. Methylphenidate can be addicting. And the young lady was NOT addicted to the drug before she started taking it. And before she started taking it I am reasonable sure that she would not have stolen it to give to her brother, husband, friend, sister or any other acquaintance who asked for it because she would have told them that it is a potentially dangerous substance that can cause a debilitating addiction ("disease") if not used under proper supervision and, furthermore, such diversion was illegal. And if she discovered that one of her pharmacist co-workers was diverting such drugs to someone else, she would do all in her power, up to calling in the legal authorities, to put a stop to it.

A comment that was repeated in the original article was that the problem of chemical dependency was not restricted to young pharmacists. "More cases involve older R.Ph.s in their late 20s and 30s..." and "the latest pharmacist...is a hospital R.Ph. in her 30s..." were the relevant quotes. In my letter to Drug Topics, I asked (this was edited out) "...if pharmacists in their late 20s and 30s are considered older, what does that make those of us in our 50s and 60s? Dinosaur dirt?" Although I don't have hard evidence (and perhaps with your experience with more than 100 "recovering pharmacists" you could substantiate or refute me), I suspect that the incidence of chemical dependency among pharmacists of my generation (I'm 56) was much lower than it is now. If that is so, how can that be explained by a disease model?

In your letter, you cite your experience that 90% of "recovering pharmacists" are productive, caring, professional, practicing pharmacists. As a manager of a multi-million dollar department who will be giving the keys to the narcotic lockup to my new hire, what assurance will I have that I won't get one of the 10%? It may seem that I am being unfair when I won't give the 90% the break to resume their professional life, but I can't afford the 10% risk. Of the more than 100 that you have known, how many have been processed through the judicial system and incarcerated for their felonious use of drugs as the street kid in the ghetto would be? I suspect you will be forced to agree that there is a dual system of justice, which is, in fact, not justice at all.

Another complaint I have is with the concept of PRN programs that are supported through mandatory fees for all pharmacists. Assuming the "disease concept" of chemical dependency, why is it my responsibility, as a "disease-free" pharmacist, to support the treatment of the afflicted. After 30 plus years in retail pharmacy, where is the profession to pay for the treatment of my hemorrhoids? That disease is more directly traced to my working environment than any chemical dependency, and when they flair up, I am, indeed, "impaired"! David Marley says that "Pharmacy...has lagged pathetically behind the other professions...." His program gets $86,000 from the state board for a projected case load of 30. My math tells me that these impaired pharmacists are getting just under $3,000 worth of services that is paid for by their honest brethren for kicking a habit they got themselves into. I don't quite see the fairness in that.

My experience with chemical dependency is not as extensive as yours. Twenty-five years ago I stopped a 14 year smoking habit. I know I am a nicotine addict and will be for the rest of my life. Like the alcoholic who cannot have one drink, I know I cannot have even one cigarette. But it was only the understanding that my rational being could (and must) overcome the physical dependency that allowed me to quit. What troubles me is that the construction of the "disease model" grants the status of victimhood upon the addict and obviates the necessity for that person to take full responsibility for their own actions.

I await your views.

Sincerely,

Bob Shubert, R.Ph.

Dear Mr. Lloyd

I think our disagreement concerning recovering pharmacists stems, not from a disagreement about the nature of addiction, but rather from our differing perspectives.

You may argue that my admission of nicotine addiction supports your position. I recognize that my addiction is present and will be until I die. I am, I believe you would argue, in exactly an analogous situation to that of a recovering pharmacist. I understand what I need to do to avoid lapsing and have demonstrated my ability to do so for 25 years. My response is that my addiction was caused by a perfectly legitimate activity, smoking cigarettes. Furthermore, at no time did the cause or continuation of my addiction impair my professional ability or violate the law and/or the ethics and trust of my profession. As a recovering nicotine addict, it is relatively easy for me to maintain physical separation from cigarettes. I would have to make a positive action to acquire them (i.e., get in line and buy a pack.) As the maintenance of my addiction was always a legal activity, it would be unthinkable that I should change my attitude and now say that I could just steal a pack.

For your recovering pharmacist, the situation is quite different from mine. The initiation of the addiction and its maintenance (especially those cases that were outlined in the original Drug Topics article that started this dialog) were most probably accomplished through a violation of state and federal laws and a frustration of the ethics and trust of the profession.

George Bernard Shaw once said: "Marriage is so popular because it combines the maximum of temptation with the maximum of opportunity." And so we return the recovering pharmacist to the scene of the crime. We allow them virtually unlimited access to the object of their addiction (please note, I agree that the addiction is a disease and not a moral failure, but that does not lessen my insistence that the ability to control the addiction is the responsibility of the individual. Failure to control the addiction is a shirking of that responsibility for which the individual must pay the consequences) and understanding that their previous behavior did not have the moral restraint that precluded illegal activity, we expect the leopard to change its spots? I think you are overly optimistic. You stated that the recovery rate is 90%. In Moyers on Addiction (the PBS series), the recovery rate was listed as 80%. That is for the average person who would not have daily at hand access. And whether the failure rate is 10% or 20%, why should a businessman not feel put upon when told that this recovering pharmacist is perfectly fine?

The Gallup Organization has consistently rated pharmacists as "the most trusted profession." Our customers give us that trust 3 billion times a year. I do not understand why you insist on returning to the profession those who have demonstrated a lack of trustworthiness and who, by your admission, only have a 90% chance of being trustworthy. Our customers deserve better.

Bob Shubert

Dear Mr. Shubert,

I trust that I have not unintentionally misled you to believe that philosophically I think that an impaired pharmacist (or other health care professional) is immune or exempt from punishment for criminal or civil violations. Boards of pharmacy routinely punish impaired pharmacists. Boards that embrace the concept of rehabilitation frequently punish either in conjunction with mandatory participation in structured programs of rehabilitation or independent of a program. In today's models rehabilitation is a five year program, at the expense of the participant, with a required appearance before the board of pharmacy pursuant to completion of the program and requisite to reinstatement of a license in good standing.

Please also allow me to clarify that even though I have a philosophy that is not in lock step with your's, I am savy enough to realize that not everyone is going to share my position...I readily recognize that you are of a different pursuasion...and I'm okay with that. I'm not committed to pursuading you to embrace my position, conversely I'm sure you realize that I am not likely to embrace yours.

Having said more than I planned on in this regard, allow me to address some of the issues you raised in your email letters. I'm reminded of a line that Jack Benny once used when being given a award, "I don't deserve this award, but I have arthritis and I don't deserve that either." A recovering pharmacist receiving his/her license following successful completion of a rehabilitation program could say that about their license and their disease. A freind of mine (recovering pharmacist) said when I asked if 'will power' was a factor in impairment/recovery. His reply, "It's similar to having diarrhea...I haven't had much success in controlling diarrhea with willpower".

One of the reasons impaired healthcare professionals have a higher success rate in recovery is the strong desire to maintain their license to practice. And before I'm told that not all healthcare professionals are altrusisticlly driven to serve patients; there definately are those that are dedicated professionals and suffer from addictive diseases. Regardless, it a fact that the recovery rate is greater than the population at large.

I can only speak authoratively about the pharmacist recovery program in Arizona; the Arizona program is partly funded by a license surcharge, the money is not used to pay for a participants required recovery program but does subsidize the administrative costs of providing a program. Your comments focus mostly on prescription drug abusing pharmacists, interestingly our program has included a number of 'pure' alcoholics, pharmacists that practiced regularly with out diverting controlled substances for their personal use...somewhat akin to the 'tobaccoholic' you referred to in your emails.

You should know that just because boards of pharmacy (or other public health protection agencies) embrace rehabilitation of impaired licensees they likewise embrace punishment for those unfortunate individuals that are 'constutionally' unable to enbrace recovery...they fail to follow the rigid principles of recovery and in Arizona their licenses are revoked or they become so despondent with their inability to follow the program and they take their own lives...regrettably three Arizona pharmacists have chosen this avenue in the past 18 months.

I could go on for pages if I had the time and the inclination, I choose instead to conclude by saying, prior to grasping the disease/rehabilatation concept of addiction in healthcare professionals I advocated showing no mercy and giving no quarter. In 1989 I attended the University of Utah Summer School on Alcoholism and Other Drug Dependencies. I left there enlightened, not because it is their mission to make converts but because I embraced the precepts and scholarship of addiction that I had not been exposed to previously. I also learned more about "me" at that school, I learned that I might possibly help a human being deal with a disease that if untreated would eventually kill them, that I could reach out to a fellow pharmacist in compassion not condemnation and offer them an opportunity to regain their health and their dignity and pursue their profession. Regardless of what others think, I know in my heart that I have done the right thing, for the right reason and the rewards have been multiplied to me a hundred fold.

Thanks for indulging me in this commentary of my personal encounter. There really isn't anything else I can say on the subject except, but by the grace of God there go I.

Sincerely,

L.A. Lloyd

Dave Marley (Executive Director of North Carolina Pharmacists Recovery Network, Inc.) reponded in a letter published in the November 15, 1999 issue of Drug Topics.

Give the addicted a break

I would like to take a moment to respond to Mr. Shubert's comments on the article "Does stress up R.Ph.s' substance abuse?" (Drug Topics, Aug. 2), in which I was quoted. First, let me say that neither I nor any of my colleagues in the field of pharmacy or addiction would condone self-medication with controlled substances or, for that matter, any other "legend" product (that includes ibuprofen 800mg). The point I was making was that when any persons with a genetic predisposition to addiction choose to self-medicate with a mind-altering substance, they have then lost the ability to choose whether or not they will become addicted. The evidence-based research for genetic predisposition to substance abuse is well published in a number of peer-reviewed medical journals and is easily obtainable by a Medline search.

I'm afraid that if we permanently removed every pharmacist who has ever taken a prescription drug without authorization, we would shrink our ranks by 85%-100%. As members of the profession Mr. Shubert feels so strongly about, we have a responsibility to respond to problems within our profession and to seek solutions that will allow, if possible, for the pharmacists in questions to again become productive members of that profession.

Dave Marley, R.Ph.

Reprinted with permission of
DRUG TOPICS, Medical Economics Co.

Dear Mr. Marley:

Your response to my letter in Drug Topics (November 15, 1999) leaves the distinct impression that you feel you were misquoted. As you are well aware, you were not.

One note. Throughout this letter, any reference to substance abuse or impairment specifically refers to the illegal use of prescription drugs (usually, controlled substances.) Although alcohol abuse can cause impairment, the two cases must be separated. Alcoholic beverages are a legal substance whereas the improper abuse of controlled substances is not legal. Furthermore, a pharmacist who abuses alcohol does so as any other citizen. Pharmacist abuse of prescription drugs is a special case because it makes a mockery of the core values of our profession.

In your letter, you state the evidence of a genetic predisposition to substance abuse, a point also taken by L. A. Lloyd in his November 1st letter. I think you may be surprised to know that I agree with the concept of a genetic predisposition.

You state in your letter that "...when any persons (sic) with a genetic predisposition to addiction choose to self-medicate with a mind-altering substance, they have then lost the ability to choose whether or not they will become addicted." as if that absolves any persons from further responsibility for that action. As you know, it doesn't work that way. Your scenario reminds me of the wholesome, innocent teenager who takes one puff of a marijuana joint in Reefer Madness, and is instantly metamorphosed into a raving, depraved junkie. It was wrong then, and it's wrong now. Addiction occurs upon repeated exposure. Genetic predisposition means that those people so affected require less exposure, but one slip does not an addict make. You talked about the pharmacist with the bad back or muscle strain and 8 hours left on a 12 hour shift taking two hydrocodone products and discovering that not only does their back not hurt, but they don't care about the insurance company driving them crazy or the SOB across the counter (with an attitude towards customers like that, do you consider this a "productive member of our profession?" Remember, at this point this pharmacist is NOT addicted, he's only taken two tablets!) He then takes four tablets the next day just in case he does have a backache. That is not the action of a person who has lost the ability to choose, but a person who consciously (with full awareness of the possible outcomes of his action--this is, after all, a pharmacist who has spent 5 or 6 years studying the actions of drugs. And if he claims ignorance, how the hell did he graduate and get a license? We are not talking about the average guy on the street who knows diddley-squat about pharmacology) chooses a self-destructive (irregardless of whether or not he is genetically predisposed) behavior.

In the original Drug Topics article, you were quoted as saying "Increased stress...is going to cause more people to become addicted." and "...chemical dependency disease among pharmacists is as much an occupational hazard as black lung is to coal miners." Now you take the genetic predisposition disease line. You make it sound as though addiction is inevitable. First, let me say that neither I nor any of my colleagues in the field of pharmacy, nor, I suspect, any of the "clean" pharmacists of the great state of North Carolina who are coerced by mandatory charges by the state board of pharmacy into paying your salary would agree. To imply that inevitability, perforce, denies the possibility of treatment and/or cure, for if someone, by dint of a bad throw of the genetic dice, is destined, despite their best intentions, to be "diseased", then by what power can that destiny be overcome? And if there is such a power to overcome the inevitable, then the genetic link is not, in fact, inevitable and the fact of the addiction devolves from an individual's free choices for which they must be held responsible.

L. A. Lloyd stated that he knows more than 100 recovering pharmacists, of which "...90% are productive, sensitive, caring professional pharmacists." In the PBS series Moyers on Addiction, the recovery rate was listed as 80%. Professor A. Thomas McLellan, Ph.D., of the University of Pennsylvania's Center for Studies of Addiction, says that physicians, other treatment providers, and the public need to adjust their attitudes about addiction treatment. A realistic goal is patient improvement; an expectation of "cures," unrealistic. Treatment outcomes for addiction, he says, are about as successful as treatment of other chronic disorders. Relapse is more the rule than the exception when it comes to addiction, and shouldn't be viewed as a treatment failure, he adds. And whether the failure rate is 10% or 20%, in view of Dr. McLellan's assessment of expected relapses, why should a businessman not feel put upon when told that this recovering pharmacist is perfectly fine? The Gallup Organization has consistently rated pharmacists as "the most trusted profession." Our customers give us that trust 3 billion times a year. I do not understand why you insist on returning to the profession those who have demonstrated a lack of trustworthiness and who, by the best estimates, only have a 90% chance of being trustworthy. Our customers deserve better.

In your Drug Topics letter, you state "I'm afraid that if we permanently removed every pharmacist who has ever taken a prescription drug without authorization, we would shrink our ranks by 85%-100%." This is, as you full well know, nothing more than a bogus strawman. I do not condone (did you have to waffle and say you "would [not] condone"-you work with these people on a daily basis, it's not a conditional "would/would not" type of question depending on the circumstances-do you or do you not condone) unauthorized self-medication with either controlled or non-controlled prescription drugs, but I did not say, or mean, that anyone who did should be removed from the profession and you were unfair to imply that I did.

You state that we have a responsibility to respond to problems within our profession and I agree. You further state that we have a responsibility to seek solutions to allow, if possible, impaired pharmacists to again become productive members of the profession and you are absolutely wrong. I and my colleagues have NO responsibility for the irresponsibility of others. I did not contribute to their impairment any more than they contributed to my hemorrhoids (a condition which is much more an occupational hazard of the profession and to which no one in the profession feels any responsibility for assisting my treatment.)

The problem within our profession is not that we have "...lagged pathetically behind the other professions in setting up impairment programs" but impaired pharmacists and the destruction of the trust with which the public holds our profession that they cause. My response to the problem within our profession is quick and does not infringe, through coerced fees, on the liberty and freedom of the non-impaired: get rid of them.

Sincerely,

Robert A. Shubert, R.Ph.

I spent the morning reading the North Carolina PRN website and responded to Mr. Marley

Later that morning (December 10th), Mr. Marley sent the following fax. An envelope containing several copies of the NCPRN newsletter and reprints of other articles about addiction as a disease state arrived a few days later.

Dear Mr. Shubert,

I am sending along as promised, a number of articles that address addiction as a whole, as well as addiction within the health care professionals. I hope that you will find them informative, and enlightening.

Let me say that nobody resisted the disease precept of addiction stronger than I did almost eleven years ago. God willing, come January 3, 2000, I will have been in successful recovery from cocaine and alcohol addiction for 11 years. Prior to seeking help, I too incorrectly believed that I was of “weak character.” The shame and guilt that went along with that mindset nearly resulted in my death by suicide. However, having a science based education and background, I was unable to refute the irrefutable evidence that addiction truly is a brain chemical disease, once it was presented to me.

I take from your comments that since I was eventually able to stop using, it must not truly be a disease. This is like saying a person never really had cancer if the chemotherapy was able to eliminate any cancer cells. I am inclined to describe that as “contempt prior to investigation.” I have come to expect that philosophy from a lay person, but am truly surprised that someone with a science based education would also be of that mindset.

Addiction is a bio-psycho-spiritual disease. Essentially, if you take 1. Genetic predisposition, 2. Environmental stress, and 3. Ingestion of chemicals in that order, you will in every case, create an addict. In order to treat, you first need to eliminate the chemicals for, the body, which will stop the initial cycle of dependency (Bio). Much like you need to taper a person from prednisone to get the body to produce cortisol again. Second, you need to address the underlying pathology that lead to a person seeking the drugs to begin with, i.e. low self-esteem, family of origin issues etc. (Psycho). Third you need to provide the tools necessary to develop a higher self esteem than was originally in place. This is where spirituality and 12 steps come in to play (Spiritual). As you can see, abstinence alone does not equal recovery, which is why many people relapse.

I trust that after reading the articles enclosed, you will have a greater understanding of this disease. I will say that I can only provide the materials, I can’t force you to accept the precepts contained within. Much like a bumper sticker I saw recently, “A mind is like a parachute, it only works when open.” I can only shudder to think where we would be if everyone chose to place their personal biases ahead of proven scientific facts.

Should you choose to continue not to agree with me, I can respect that. In such case we will simply agree to disagree.

Sincerely

David Marley
Executive Director

In the December 6, 1999 issue of Drug Topics, there were two letters published.

Understanding addiction

In response to the letter in Drug Topics, Oct. 4, entitled "Show no mercy," I am a recovering pharmacist, and I hope the RPh. who wrote that letter has more compassion toward his patients with other diseases than he does toward us. He seems not to understand that addiction/alcoholism is a disease also. He, as well as others like him, must be educated. Like a diabetic in need of insulin, addicted RPh.s need help.

Hopefully, with help from magazines such as yours, with articles on addiction, and the help that is out there for the pharmacist, we're off to a good start.

Name withheld by request

Reprinted with permission of
DRUG TOPICS, Medical Economics Co.

We are saved by grace and mercy! Not anything of our own actions! In reference to Mr. Shubert's letter in Drug Topics, Oct. 4, I want to totally agree that we "charlatans and mountebanks" do not deserve to practice in our profession again. it is only because of the grace and mercy extended to addicts in recovery by our exemplary North Carolina Board of Pharmacy and the fine pharmacy community in the state of North Carolina that we are given a second chance.

My family and I are so appreciative of this chance and all the thankless work of the North Carolina Pharmacy Recovery Network (N.C. PRN) in assimilating a mentoring and monitoring program dedicated to the early identification and intervention of impaired pharmacists. It has allowed me, and countless others, a way back from self-destruction to become the humble servant our profession desired. Contrary to Mr. Shubert's belief, I did take responsibility for my actions and accepted the consequences with much encouragement from N.C. PRN. I returned from a 10-year dead-end road and the loss of almost everything I cherished to the road of recovery and the profession of pharmacy

As pharmacists, we have a responsibility to constantly update our knowledge base on disease states and therapeutics. Today, more than ever, does the analogy apply-that a drug addict unable to correctly process drugs resembles the diabetic being unable to correctly process sugar. We are at a point, with the research being done in the field of addiction, that it is professionally irresponsible to recognize drug addition and alcoholism as anything other than a chronic, progressive, and treatable disease.

I am grateful that I was extended a hand of forgiveness and love by others who have "been there." I am even more grateful that our state board of pharmacy is progressive in its thoughts and views, especially in the area of chemical abuse and addiction.

B. Scott Dinkins, R.Ph.
Chairman, Board of Directors
North Carolina P.R.N.
Monroe, N.C.

Reprinted with permission of
DRUG TOPICS, Medical Economics Co.

On December 16, 1999, I sent a letter to Drug Topics for publication. It has not been published as of January 1, 2000.

Lest I become the poster boy for unenlightened prejudice and the scrooge of the profession, I should like to respond to several writers to this space.

For over twenty years, I have argued strenuously for the decriminalization of drug use. I did so for many reasons, by no means least being that the only effective strategies for the "war on drugs" were education and treatment. This was based on my belief then, as it still is now, that addiction is a treatable medical condition.

In the subsequent letters that have attacked my October 4th letter, a consistent comparison is made of addiction with diabetes. I feel that is unfair to diabetics. Addiction doesn't appear out of the blue, but only after repeated exposure to the addicting substance. Except for crack babies, we are not born with an addiction-some have a predisposition that is greater than others, but the initiation of the addiction is by choice and free will. It is that choosing that, I believe, disqualifies a pharmacist from the profession, not the fact of his or her ultimate addiction. I differentiate between alcoholics, who were using a legal substance which is not under their professional control, and controlled substance addicts whose use violates every legal and professional ethic of the profession.

As professionals, we have been granted a special trust. To my impaired brothers and sisters, I offer my encouragement for successful treatment. Understand, however, that your choice, as pharmacists, to engage in unprofessional and unlawful behavior which led you down the path to your unfortunate disease broke that trust. And trust, like a fine crystal bell, is a fragile thing which once shattered can never be fully restored.

For those who question my compassion, I would only respond by saying you are expecting me to be more compassionate to you, just because you entered my profession, than to my customers who trust and rely on me. I am not expected to subsidize treatment for every disease that any of my customers have, but you coerce me to subsidize treatment programs for impaired pharmacists through mandatory fees collected at licensure. If addiction is only a disease like diabetes, blood pressure and, yes, hemorrhoids (a greater occupational hazard), why is it the only disease granted such a privilege?

I welcome dialog from those who agree or disagree with my views. Please address email: alpenmic@attbi.com

Bob Shubert, R.Ph.
Valpariso, IN

From the December 1999 issue of PRN Journal, the newsletter of the North Carolina Pharmacist Recovery Network.

Self Medication
By Dave Marley, RPh.
Executive Director

The profession of pharmacy has evolved through the years from one of apprenticeship, to now requiring a six-year Doctorate degree for entry into the profession. We have come from a role that was once primarily of prescription compounder and seller of product, to one of dispensing necessary drug/health care information. One area of practice though that has remained consistent is our false believe that we as pharmacists can somehow diagnose and treat our own illnesses.

So as not to offend anyone, I will say that not all pharmacists are guilty of self-medication. When I speak of self-medication though, I'm not just talking about controlled substances. I mean all drugs that contain the federal legend on the stock bottle, which states, "Federal law prohibits dispensing without a prescription."

First and foremost, self-medication is irresponsible, unethical, and dangerous pharmacy practice. Our colleagues in the filed of medicine would say that "a doctor who treats himself has a fool for a patient, and even bigger fool for a doctor." It is important to also note that we pharmacists do not posses the legal ability to diagnose and dispense, making self-medication a felonious offense.

This combination of knowledge and drug availability can lead health care professionals to a false sense of confidence. It has been said that this is a "paradox of familiarity" where pharmaceutical knowledge, minus an accurate understanding of the risks, leads to the belief of immunity from prescription drug abuse. In most pharmacies it is only a couple of inches difference between reaching for 800mg of ibuprofen (also a legend drug), and if that doesn't work for whatever ails you, then grabbing the hydrocodone products.

To date, I have not seen a study that addresses the issue of self-medication as whole. When it comes to addressing self-medication with controlled substances, this issue first appeared in an 1888 issue of The Apothecary, which stated, "the bane of drug clerks (today known as staff pharmacists) is a tendency to have two great besetting vices - tippling, and opium eating."

In 1987, McAuliffe et al's study, "Use and Abuse of Controlled Substances by Pharmacists and Pharmacy Students," looked at 312 pharmacists and 278 pharmacy students. Their results showed that 46% of the pharmacists, and 62% of the students had reported using a controlled substance at some time without a prescription.; 19% and 41% , respectively, used one within the previous year. One has to ask if this many pharmacists and students are willing to violate the Federal Controlled Substances Act (CSA), how many more are willing to violate the federal Food Drug and Cosmetic Act? While both are federal crimes, the CSA generally has more serious punishment.

The purpose for making self-medication an issue is two-fold. First, is the very serious potential for bad outcomes when one is involved in diagnosing and treating one's own illnesses. The other is to hallmark an important point that is often missed when addressing addiction within the profession, this being that self-medication is a choice, while addiction is a disease.

I have yet to meet an addict who has consciously chosen to "become an addict." Many pharmacists make a choice to experiment or self-medicate. If McAuliffe's numbers are correct, almost half of the profession of pharmacy has chosen to take a controlled substance without authorization. If that person happens to have the genetic predisposition to addiction, then any choice about addiction is lost. They have no more control over becoming an addict than the diabetic has over becoming diabetic.

This now raises a couple of questions: 1. Do we punish someone for having a disease? I think not 2. Do we punish someone for breaking the law? What we as a profession need to do is first recognize that self-medication is a problem. Addressing this issue in the schools of pharmacy is part of the solution. Boards of Pharmacy also need to take action when the self-medication is discovered. Self-medication by itself is easy enough to reprimand.

Recognizing that there may be a concomitant disease process (addiction) also occurring requires action as well. Society's approach to criminalizing drug use is outdated, ineffective and doesn't address the underlying pathology. Mandating treatment in lieu of prosecution is an approach that is having success. Many jurisdictions are now implementing drug courts, rather than traditional jail time.

If we are serious about addressing impairment within the profession of pharmacy, we need more states to implement fully funded impairment programs. But we also need the schools of pharmacy, the professional societies, and Boards of Pharmacy to start talking about self-medication as well.

On January 1, 2000, I sent the following questions about the article "Self Medication"

Hi Dave

Thank you for sending the December '99 PRN Journal.

I agree with much of what you wrote in the lead article, but I have some questions.

When you write "If that person happens to have the genetic predisposition to addiction...", it appears as though you are saying that some people may become addicted because of their genetic predisposition and others won't. I believe that the predisposition among individuals runs a full spectrum. Some people are more easily addicted than others, but everyone would become addicted to a drug such as cocaine upon repeated exposures. If so, then the consideration of choice being lost is inaccurate. Granted, some are more at risk than others, but we are all at risk. A diabetic will develop the disease no matter what his lifestyle is; a diet which imposes stress on the system may accelerate the progression of the disease, but it will still occur in someone who eats properly. I have never heard of a person who became addicted to cocaine if they never took it. Please, the diabetic analogy just doesn't hold water.

Since I graduated from pharmacy school in 1967, I didn't realize how much the educational standards of the schools has dropped. You talk about the situation where "...pharmaceutical knowledge, minus an accurate understanding of the risks, leads to the belief of immunity from prescription drug abuse." Pharmaceutical knowledge minus an accurate understanding of the risks IS NOT PHARMACEUTICAL KNOWLEDGE!!!. If that is what the schools are passing off today, then we are in worse shape than can be imagined. When I went to school, I was taught the risks. What the hell are they taught now?

You pose two questions: "1) Do we punish someone for having a disease? I think not." That is absolutely the correct answer. The second question you ask is: "Do we punish someone for breaking the law?" I don't know whether to agree or disagree with your answer, because, quite frankly, you didn't answer the question. The answer should be: Yes! To even consider briefly that because we wear the white coats means that we shouldn't be treated exactly the same as the poor ghetto kid makes a mockery of the American system of justice. Yes, you are correct that our system of criminalizing drug use is outdated, ineffective, etc... I've been saying that for more years than I care to count. However, it is the system we have and though we can try to change it for everyone, we can't claim any special privileges.

Personally, I feel much more obligation to the profession, which I can manifest by doing the best job I can for the health and well-being of my customers, than I do for the impaired pharmacist. They are the ones who have turned their backs on the ethics of the profession and think nothing of bringing disrepute upon the profession. Looking at it from the disease mode, why is THIS disease the only one that needs implementation of fully funded impairment programs and why should the state fund programs for pharmacist impairment and not for, say, bricklayer's impairment? If you wish to voluntarily contribute, more power to you, but by what right do you claim justification in coercing others to pay for your pet program.

In the article on pp.6-7 of the journal, the conspiracy of silence is discussed. It is explained that the profession fears loss of respect and embarrassment to the society. Well, why not try a little simple honesty. The impaired pharmacist is a cancer on the profession. He has the same right to get healthy, and readjust to a life away from drugs as anyone else, but not any more than anyone else just because he's a pharmacist. These are educated people who can give back to society, but NOT behind the prescription counter.

Bob

Mr. Marley's response on January 3rd did not address the questions I raised, but questioned my personal motives:

I responded the same day by trying to answer his questions with my understanding of the importance of integrity in the profession and get him to define his position.

No addicts or alcoholics at all (to the best of my knowledge--that is, if there were, I was not aware of their status.)

My feelings are very strong because this profession has been very good to me and, I hope, I to it. Perhaps you never thought about it, but it is a profession because we profess to something. We profess to use the knowledge that we have solely for our customers best interests. We profess to recognize the limits of our knowledge so that we don't guide our customers falsely. We profess, when all is said and done, to the TRUTH. Through our studies, and by making that profession, we have been granted a trust that is based solely on our adherance to the ethics and values of pharmacy. When a pharmacist starts down the road to addiction because he or she feels superior to the truth, that pharmacist has broken that trust. And every time that trust is broken, my reputation is diminished, especially when the profession says that these are really good guys who are just victims of some terrible disease. Yes, addiction is a disease, but, dammit, they brought it on themselves. Nobody strapped them down and injected dangerous drugs into their system until they were victimized into the disease.

Please answer three questions:

1) Do we punish someone for breaking the law? Specifically, when a pharmacist is involved in the felonious theft of controlled substances, does he or she deserve any different punishment than the ghetto kid who knocks over a pharmacy for a couple thousand hydrocodone?

2) Since addiction is merely one disease among many, why do you feel justified in calling for a tax on non-impaired pharmacists to pay for the treatment of their brethren who are afflicted with it and not any other disease?

3) When a pharmacist puts his selfish hungers above the ethics and values of the profession, why do you feel that he should be allowed back to a position of trust, a trust which he demonstrated means little or nothing to him?