Last week a book I had ordered dropped through the letterbox. It’s Adam Hill’s ‘Long Walk Out of the Woods’. He’s a doctor who developed an alcohol use disorder and recovered from it. The book about his journey is next on my reading list.
The arrival of Adam’s book triggered thoughts of my own story and then of the colleagues in recovery I’ve got to know over the years. I have also been thinking of some who have died from their addiction. There is no doubt about it: doctors get addicted to alcohol and other drugs. We also get different treatment and better outcomes from that treatment compared to our patients. But what about nurses?
If you are a nurse or a doctor with a substance problem and it comes to the attention of your employer, then what happens to you in the UK really depends to a large extent on varying policies but also geographical and local political considerations, not to mention the approach of your regulatory body.
My impression is that doctors and nurses with substance use disorders often have different experiences in the UK when it comes to getting help and, although this is not scientific, I believe that, in general, doctors get a better deal here from employers than nurses.
Physicians & Nurses
I was reminded of a paper published a while back in the Journal of Advanced Nursing. Matthew Shaw and his colleagues looked at this subject. Incidentally, one of the authors is Daniel Angres. I recommend his excellent book: Healing the Healer: the Addicted Physician.
The researchers wanted to compare the experiences of doctors and nurses when they first sought help, when they went through treatment and how well they got on after treatment was complete. They hoped that such interdisciplinary comparisons in healthcare would help to “identify the distinctive risks for the development and perpetuation of these [addictive] disorders, and the obstacles to successful recovery.”
The authors make the point that the literature suggests doctors and nurses are not any more at risk of addiction than the general population. What does mark us out is the nature of our addictions (after alcohol, prescription drug dependence is most common) and where we procure our drugs (the workplace). The implications of this for patients, themselves and their families are potentially great.
Some theories to be tested were set out:
- Doctors, often working alone rather than in teams, will present later and with more severe problems
- Nurses will participate in treatment better due to their working in more collaborative environments
- Nurses will experience harsher professional sanctions due to less empowerment and advocacy
How did they go about testing these? One hundred and ninety-two people enrolled in a treatment programme dedicated to healthcare professionals in the US between 1995 and 1997 were involved. There was no control group as it would have been unethical to deny treatment to any group (though it might have been interesting to have a control group of non-healthcare professionals going through similar treatment). Data were gathered from records retrospectively and from prospective interviews.
Questionnaires were sent out to potential participants and just over half were returned. The researchers tested for the possibility of selection bias by comparing the demographics of the non-responders and the responders. They seemed to have pretty similar characteristics. Of the 105 people agreeing to participate, there were 73 physicians and 17 nurses. These made up the study sample.
There were some differences between the groups at baseline. The proportion of females was higher in the nursing group. A higher percentage of nurses were divorced or gay. Relatively more doctors than nurses had personality problems, but the doctors were functioning slightly less well. Doctors tended to be referred to treatment by physician health programmes and nurses by their employers.
Substance use pattern differed significantly. For doctors, 30% used only alcohol, 28% used only opiates and 30% used alcohol and prescription opiates, whilst 65% of nurses relied on prescription opiates only. Nurses did not go for poly-drug use, with only three using more than one substance.
There are plenty of interesting findings in the paper. What pushed the doctors and nurses to seek help? Was it breakdown of health or relationships? Was it legal issues or social disintegration? No, it was primarily because of work. Nurses and doctors rank their work over just about everything else, including emotional distress.
Both groups identified their participation in 12 step programmes as being important to their recovery, but nurses reported a greater reliance on fellowship with other people in recovery. At follow up, almost three quarters of both groups had active licenses to practise and nurses were working more hours than before recovery started and doctors less.
The rate at which nurses were placed on probation was not only higher than physicians prior to treatment, but was also disproportionately higher than doctors after treatment. Similarly, although nurses and physicians were equally likely to experience professional sanctions prior to treatment, nurses (53%) were more likely to be sanctioned after treatment than doctors (35%). In addition, nurses tended to be more distressed on multiple measures than doctors at follow up and the authors say that nurses work in situations with more triggers to relapse, though I didn’t see convincing evidence for this.
There are some obvious limitations to this paper, which the authors do acknowledge. The number and proportion of nurses makes robust comparisons difficult. Only fourteen percent of the doctors were female, but 82% of the nurses were meaning gender issues could be confounding. There was no control group of any kind and the data were all collected at a single site. These all limit generalisability though should not stifle debate.
And their hypotheses – do doctors have more problems at presentation? That supposition was supported by the data.
Do nurses engage more fully in treatment? Well in this study, doctors used more intensive support than nurses. The authors speculate that may be because doctors can afford to. Doctors reduced their working hours in recovery, but nurses increased them and there was this association with greater psychological distress. Again this may be explained by income differences.
And what about the third hypothesis: nurses will experience harsher professional sanctions due to less empowerment and advocacy? Sadly, this did seem to be supported with nurses getting a raw deal:
“Therefore, the group who can least afford to miss work appears to be most likely to be reprimanded and may be least likely to seek costly legal representation.”
An incidental finding came onto the radar. In this sample, 7% of doctors committed “sexual boundary violations” and 18% of the nurses were victims of violence. We need to view that with the lens of gender differences between the samples. This was worrying.
Of particular interest is that substance use outcomes were the same across doctors and nurses: all participants reported abstinence, although the doctors had higher average duration of abstinence than the nurses, which for me raises the question: can we expect better outcomes from the general population if they get access to the same sort of treatment that doctors normally get?
In concluding, the authors hope that these findings and others to follow: “can inform programmes developed to prevent substance use in medical environments, treat health care professionals once they become symptomatic, guide the advocacy work of professional organisations, and modify professional sanctions so as to be effective means of accountability, deterrence, and most importantly, recovery.”
Julie Worley, writing in the Journal of Psychosocial Nursing, reported that there are barriers to nurses getting substance use disorder treatment including ‘wide variability in Alternative to Discipline programmes, inconsistent funding for treatment, and lack of policies and support for nursing students.’ These same challenges face doctors, but overall I still think pathways to treatment, recovery and return to work are often easier for us.
The skills that become impaired in addicted healthcare professionals can flourish again in recovery and it is important that we are aware of the issue, can help identify it and support colleagues to seek treatment and recovery support. Stigma of course prevents many coming forward. There are more and more doctors opening up about their addiction stories in recent times which I think is immensely helpful in defeating stigma. I’m not so aware of the public narratives of nurses, but if you know of any, please post links below.
(This is an updated version of a blog from a while back.)
Continue the discussion @DocDavidM
 Shaw MF, McGovern MP, Angres DH, Rawal P. Physicians and nurses with substance use disorders. J Adv Nurs. 2004 Sep;47(5):561-71. doi: 10.1111/j.1365-2648.2004.03133.x. PMID: 15312119.
 Worley J. Nurses With Substance Use Disorders: Where We Are and What Needs To Be Done. J Psychosoc Nurs Ment Health Serv. 2017 Dec 1;55(12):11-14. doi: 10.3928/02793695-20171113-02. PMID: 29194558.