Feature Article from Peter J. Cohen, MD, JD, Chairman of MSDC’s Physician Health Committee: The Society’s Role in Physician Health

Drug dependence, a disease that afflicts all members of society, does not spare physicians.  The Physician Health Committee of the Medical Society of the District of Columbia (PHC) plays an important role in assisting physicians who suffer from this illness.  The PHC’s role in intervention, monitoring, and advocacy, is vital both for public welfare and physician health. Education of the general public and medical community is an integral component of the PHC’s activities.

Members of the PHC are available for “outreach” programs aimed at individual practitioners, hospitals, medical staffs, credentialing committees, medical negligence carriers, and the general public.  We hope that all affected (and potentially affected) groups will take advantage of this important mission.  In discussing drug dependence, we stress several significant facts.

Drug dependence in health care professionals is not new!  More than a century ago, for example, Professor William Osler chronicled, in his Inner History of the Johns Hopkins Hospital, his observations of and concerns for his friend, Professor William Stewart Halstead; this excellent description of an opiate-addicted physician, recorded in a small locked black book that was not even opened until 1969, is classic, yet rarely taught to students of medicine:

The proneness to seclusion, the slight peculiarities amounting to eccentricities at times (which to his old friends in New York seemed stranger than to us) were the only outward traces of the daily battle through which this brave fellow lived for years.  When we recommended him as full surgeon to the hospital in 1890, I believed, and Welch did too, that he was no longer addicted to morphia.  He had worked so well and so energetically that it did not seem possible that he could take the drug and done so much.

 About six months after the full position had been given, I saw him in severe chills, and this was the first information I had that he was still taking morphia.  Subsequently, I had many talks about it and gained his full confidence.  He had never been able to reduce the amount to less than three grains daily; on this, he could do his work comfortably and maintain his excellent physical vigor (for he was a very muscular fellow).  I do not think anyone suspected him, not even Welch.

Drug dependence is a disease and not a moral failing.  As with other diseases, it has specific diagnostic criteria:  Although science has not elucidated the mechanism(s) of every disease, the molecular biology of drug dependence is beginning to be understood.  

CRITERIA FOR SUBSTANCE DEPENDENCE

Substance dependence is a syndrome characterized by a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period (note that tolerance and symptoms of physical withdrawal are not necessary to make the diagnosis):

1.     Tolerance, as defined by either of the following:

        (a)    a need for markedly increased amounts of the substance to achieve intoxication or desired effect, or

        (b)    markedly diminished effect with continued use of the same amount of the substance.

• Withdrawal, as manifested by either of the following:

(a)    the characteristic withdrawal syndrome for the substance, or

        (b)    the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.

3.     Substance is often taken in larger amounts or over a longer period than was intended.

4.     There is a persistent desire or unsuccessful efforts to cut down or control substance use.

5.     A great deal of time is spent in activities necessary to obtain the substance…, use the substance…, or recover from its effects.

6.     Important social, occupational, or recreational activities are given up or reduced because of substance use.

7.     The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

Finally, regardless of one’s eventual mind-set, the following quotation is useful:

If we reject all cases of affliction which the improvidence of human beings has brought upon themselves, there will be but little room left for the exercise of mutual love and charity.  God alone punishes.  We, as we best can, must relieve.  Neither must we be too curious in respect to causes and motives, nor too vexatious in our censorship.  Hence I will state what I have observed and tried in the disease in question; and that not with the view of making men’s minds more immoral, but for the sake of making their bodies sounder.  This is the business of the physician.

If you are interested in learning more about the disease of drug dependence and the availability of the PHC to help you, your colleagues, and the public, please contact Barbara Allen at 202-466-1800 ext 103.

C. DOUGLAS TALBOTT, KARL V. GALLEGOS, DANIEL H. ANGRES, Impairment and Recovery in Physicians and Other Health Professionals, in PRINCIPLES OF ADDICTION MEDICINE 1263, 1264 (Allan W. Graham and Terry K. Schultz, Editors, Second Edition, American Society of Addiction Medicine, Chevy Chase, MD, 1998).

See, e.g., Edythe D. London, et al., Morphine-Induced Metabolic Changes in Human Brain.  Studies With Positron Emission Tomography and [Fluorine 18]-Fluorodeoxy-glucose, 47 Arch. Gen. Psychiat. 73 (1990); Nora D. Volkow, et al., Long-term Frontal Brain Metabolic Changes in Cocaine Abusers, 11 Synapse 184 (1992); Nora D. Volkow, et al., Brain Glucose Metabolism in Chronic Marijuana Users at Baseline and During Marijuana Intoxication, 67 Psychiat. Research and Neuroimaging 29 (1996).

Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (Washington, DC: American Psychiatric Association, 1994).

In his review of Darrel W. Amundsen, Medicine, Society, and Faith in the Ancient and Medieval Worlds, Johns Hopkins University Press, Baltimore, 1996 (Eric J. Cassell, 336 New Engl. J. Med. 883 (1997)), Cassell called attention to Amundsen’s final chapter—The Moral Stance of the Earliest Syphilographers—quoting Thomas Sydenham’s reply, in 1673, to those who believed that syphilis should not be treated, in order to frighten the unchaste or punish the afflicted.