Issues and Data Associated With Addictive Disease in Pharmacists

Release Date: November 1, 2013

Expiration Date: November 30, 2015

FACULTY:

W. Cross, RPh, MHS, CADC
Pharmacy Program Coordinator
Professionals Addiction Treatment Program
Presence Behavioral Health
Chicago, Illinois

S. Bologeorges, MPH
Senior Analyst
Community Health Strategy
Presence Behavioral Health
Chicago, Illinois

D. Angres, MD
Director
Professionals Addiction Treatment Program
Presence Behavioral Health
Chicago, Illinois

FACULTY DISCLOSURE STATEMENTS:

The authors have no actual or potential conflict of interest in relation to this activity. Postgraduate Healthcare Education, LLC does not view the existence of relationships as an implication of bias or that the value of the material is decreased. The content of the activity was planned to be balanced, objective, and scientifically rigorous. Occasionally, authors may express opinions that represent their own viewpoint. Conclusions drawn by participants should be derived from objective analysis of scientific data.

ACCREDITATION STATEMENT:

Pharmacy
acpePostgraduate Healthcare Education, LLC is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
UAN: 0430-0000-13-031-H01-P
Credits: 2.0 hours (0.20 ceu)
Type of Activity: Knowledge

FEE INFORMATION:

Payment of $6.50 required for exam to be graded.

TARGET AUDIENCE:

This accredited activity is targeted to pharmacists. Estimated time to complete this activity is 120 minutes.

Exam processing and other inquiries to:
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DISCLAIMER:

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients' conditions and possible contraindications or dangers in use, review of any applicable manufacturer's product information, and comparison with recommendations of other authorities.

GOAL:

To generate a comprehensive depiction of addictive disease in pharmacists with respect to sobriety outcome following a formal and individually tailored treatment program.

OBJECTIVES:

After completing this activity, the participant should be able to:

  1. Define the prevalence of addiction in the pharmacy profession.
  2. Outline factors associated with the risk for addiction in pharmacists.
  3. Describe both success and relapse rates in pharmacists.
  4. Describe the factors associated with relapse in recovering pharmacists.
  5. Summarize the use of naltrexone in increasing success rates in pharmacists.


ABSTRACT: The aims of the present study were 1) to determine pharmacists' success rates with ongoing abstinence posttreatment and 2) to pinpoint factors associated with relapse in order to identify at-risk pharmacists. Data were collected prospectively from 116 pharmacists entering an addictions-treatment program over a 14-year period. Pharmacists were followed 2 years postdischarge to determine abstinence rates. The 2-year success rate was 87.1%. These data can help identify at-risk pharmacists and be of use to treatment providers, monitoring programs, employers, and pharmacy boards to aid early intervention.

Pharmacy consistently ranks among the top two most-trusted professions by the public.1,2 Pharmacists are in a unique and centralized setting, enabling them to influence public health through the provision of population-based care and disease prevention. Among healthcare professionals (HPs), this level of accessibility coupled with clinical expertise is rare.3 Pharmacists are not immune, however, to addictive disease (AD); in fact, the demands of the pharmacy work setting itself present high risk for the development of addiction. It is this paradox that warrants much-needed attention. Pharmacists who have developed AD pose a threat to public safety, their own health, and the reputation of the pharmacy profession.4 It is estimated one in nine pharmacists will potentially suffer from AD at some point in his or her career, and AD remains the most serious illness to afflict pharmacists in their first 15 years of practice.5 While the demands of the profession present a high degree of risk, there exists a paucity of literature concerning AD in pharmacists despite the burgeoning attention given to other HPs with AD.6,7 Extant research on pharmacists has been limited to descriptive and precipitating factors of AD, both creating significant disparities in its treatment and prevention and perpetuating a problem that endangers public health. The present investigation seeks to address this gap.

As previously stated, the pharmacy work setting presents potentially the highest-risk work setting for any HP. Unquestionably, pharmacists have far greater exposure to addictive medications than any other HP.8-10 Many community pharmacists are responsible for filling upward of 400 prescriptions daily, which is extremely stressful given that pharmacists are keenly aware that this also affords them more than 400 opportunities each day to make a mistake and potentially jeopardize public health. Pharmacists have a proclivity for Schedule III opioids, which are neither as closely monitored nor regulated as Schedule II opioids, making detection of AD far more difficult. Given the additional factors of less available help, longer work hours, shift work, and greater tendencies toward self-medication, the pharmacy work setting presents a precarious environment for AD.10,11

Numerous studies of HPs as a whole (including pharmacists) have sought to identify specific factors that may place some individuals at greater risk for AD than others in their profession. These studies have largely been cross-sectional self-reports and been retrospective in nature. Pharmacists have, for the most part, been grouped together with other HPs and have only constituted a small percentage of the total samples studied. Aggregating findings from such studies of the general HP population, the factors listed below have been identified as describing a high-risk profile. Identifying these factors may assist in early recognition of an addiction in a pharmacist and promote successful entry into treatment.

  • A genetic predisposition to AD, defined by a family history of dependence
  • Environmental stressors (shift work, high level of job responsibility, job dissatisfaction)
  • Inadequate education and training on AD regarding the psychological aspects of addiction, criteria for addiction, and recovery from addiction
  • Feelings of invincibility, or the belief that knowledge of the pharmacodynamics of potentially addictive medications will ensure safety from AD
  • Greater accessibility to potentially addictive medications
  • Social factors, including a lack of peer, academic, or occupational discouragement for prescription diversion
  • Peer reinforcement of self-medication practices.5,8-10,12-14

In addition to socioenvironmental variables, the presence of comorbid diagnoses can pose significant challenges for intervention and treatment for an addicted HP. Comorbidity refers to the existence of two or more diseases, disorders, illnesses, or health problems and is commonly referred to as a dual diagnosis in the addiction literature. Specifically with regard to mental health, psychiatric comorbidity with chemical dependency is often inadequately assessed, diagnosed, and treated or is overlooked altogether.15 This is particularly problematic given the high prevalence of mental health comorbidity with AD. Mental health comorbidities such as depression or bipolar disorder increase the risk for the initial development of AD, increase the potential for self-medicating practices, and, if undertreated or undiagnosed, can greatly increase the potential for relapse.16

Comorbid mental disorders involving personality disorders also have serious implications for AD.17,18 Prevalence rates of mental health comorbidity with AD specifically in pharmacists have not been ascertained, nor has tailored mental health treatment in conjunction with AD been studied in relation to outcome.

Also overlooked as risk factors for the development of AD in HPs are comorbid medical disorders.19 Specifically, medical disorders related to chronic pain (e.g., chronic migraine headaches; back, foot, knee, or ankle pain; chronic disc disease; Crohn disease) often lead to self-medication practices with Schedule III opioids over time, ultimately contributing to AD.20 Knowing the full diagnostic history is therefore paramount in both identifying risk factors and tailoring treatment.

Curiously, despite similar prevalence rates, the literature on AD issues in pharmacists continues to lag significantly behind the available literature on AD in physicians and nurses. Few studies exist that relate AD to treatment outcome; the majority of outcome research in pharmacists has been limited to retrospective, self-reported data, often wherein addiction criteria have been loosely defined and outcomes have not been linked to a formal treatment program specifically tailored to HPs. Given this dearth, current treatment practices and guidelines concerning pharmacists are largely guided by studies of other HPs.

Recently, there have been pharmacologic advances in treatment warranting longitudinal investigation. Given the high prevalence of pharmacists who divert opioids for personal use, this dynamic lends itself well to the use of naltrexone, an opioid antagonist, as an adjunctive pharmacologic treatment of opioid addiction. While not yet studied in pharmacists, the use of naltrexone has been found to be profoundly helpful in increasing success rates in anesthesiologists.21

The present investigation seeks to address the characteristics that significantly differentiate pharmacists from other HPs. Using a prospective and longitudinal design with comprehensive monitoring and observational tracking as well as an examination of multiaxial DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) diagnostic information, this study seeks to generate a comprehensive depiction of AD in pharmacists with respect to sobriety outcome following a formal and individually tailored treatment program. Specifically, this study aims to accomplish the following: to determine the efficacy of tailored addictions treatment on longitudinal maintenance of sobriety over a 2-year posttreatment interval; to investigate both unique characteristics of the work setting and risk factors for chemical dependency in pharmacists; and to identify biologic, psychological and social factors differentially associated with relapse.

METHODS

Institutional Review Board (IRB) approval of this study, No. 2010-11, was obtained from St. Joseph Hospital in Chicago, Illinois, prior to its initiation. All investigators completed training on the protection of human subjects through the National Institutes of Health, and certificates were on file with the IRB.

Participants

The study sample consisted of 116 addicted pharmacists who voluntarily entered a treatment program for professionals in Chicago, between 1994 and 2011. The gender breakdown was 77.6% male (N = 90) and 22.4% female (N = 26). The mean age was 40 years, 7 months. Sample demographics are depicted in TABLE 1.

table 1

Procedure

Pharmacists with AD (N = 116) completed an addictions-treatment program for professionals that was theoretically driven by the disease model of addiction, abstinence-based, 12-step–oriented, and in a residential partial-hospitalization setting. Random urine screens were routinely conducted one to two times per week. Treatment was tailored to both the individual patient's needs as well as those of the pharmacy profession by assigning the patient to a primary therapist with an extensive background and license in pharmacy. Length of stay averaged 8 to 10 weeks. Collateral information was obtained, with consent, from any of the following applicable resources: patient's employers, referral sources, state monitoring programs, employee-assistance programs, pharmacy licensing boards, attorneys, probation officers, and close family members. For opioid-addicted pharmacists who were returning to a high-risk work setting and had no contraindicated situations or conditions, naltrexone was prescribed as a condition of returning to a pharmacy setting with access to opioids. All pharmacists were given the postdischarge requirement of attending at least three 12-step meetings (e.g., Alcoholics Anonymous [AA] or Narcotics Anonymous [NA]) per week.

Following program completion, pharmacists participated in a counselor-facilitated Caduceus (for healthcare professionals) After-Care group, which met for 90 minutes per week for 104 weeks (2 years). Throughout the aftercare program, random urine monitoring was conducted at an average of three times per month based on patient progress and need. The pharmacist clinician was also in contact with the appropriate state monitoring program to communicate progress and recommendations at a minimum of once a month throughout the 2-year interval. At the end of the 2-year period, participants were classified as either continually abstinent or relapsed based on their self-disclosure patterns, clinician reports, and biologic confirmation through urine monitoring.

As part of the treatment program, participants gave consent to researcher review of clinical charts and collateral information. Over the course of 14 years (1996-2009) data were collected prospectively on pharmacists from their date of admission through discharge from primary treatment and throughout the course of their 2-year aftercare programs (data collection ended in 2011). The clinician in the patient's chart documented all assessment, treatment, and aftercare information. Data were kept strictly confidential and were deidentified by the clinician before being transferred to the researcher for data entry. Data were entered and analyzed with SPSS version 18.0.

MEASURES

Longitudinal Outcome: As mentioned earlier, participants were classified as either continually abstinent or relapsed at the end of the 2-year follow-up interval. Abstinence was defined as the absence of use of any addictive substance (except nicotine) for the 2 years following program completion. Relapse was defined as any use of an addictive substance in the same interval. Outcome determination was based on documentation from frequent and random urine toxicologies specific to the drug(s) of choice overseen by state pharmacy-assistance-monitoring programs, most commonly referred to as PRN (Pharmacy Recovery Network) programs. The determination was corroborated by observational and clinician interview reports at aftercare groups and through ongoing collaborative discussions with referral sources and pharmacy monitoring programs.

Drug(s) of Choice: Drug(s) of choice had to meet the full DSM-IV-TR dependence criteria for inclusion. Drugs were classified into the following categories: oral stimulant, oral opioid, injectable opioid, alcohol, illegal (e.g., marijuana, cocaine, heroin), and other (e.g., benzodiazepines, sedatives, hypnotics).

Dual Diagnosis: Dual diagnosis (coexisting psychiatric disorders) was assessed throughout the duration of treatment (average 8-10 weeks) by the program psychiatrist in conjunction with clinician reports. Final diagnoses were presented in multiaxial diagnostic form, and all diagnoses had to meet DSM-IV-TR criteria for inclusion. Data were coded in binary as the presence or absence of a dual diagnosis.

Naltrexone: Opioid-dependent pharmacists returning to a work setting with access to prescription opioids were assessed for the appropriateness of an oral naltrexone regimen. Exclusion criteria included contraindicated conditions, such as severe (but not moderate) chronic pain, adverse reactions severe enough to discontinue use, diagnosis of a personality disorder creating instability, a psychiatric diagnosis of refractory to treatment, or simply identification as an individual with low likelihood of program compliance. Data were coded in binary as whether or not an individual was prescribed naltrexone as a condition of returning to work. Naltrexone XR (extended release) injectable suspension did not carry an indication for opioid dependence until shortly after the study end date; therefore, all participants were on the oral regimen.

Twelve-Step Involvement: Twelve-step involvement was assessed in the follow-up interval while patients were in aftercare. At the end of the 2-year period, a classification was made as to whether pharmacists were continuously and actively invested in a 12-step program (e.g., AA, NA) based on their consistent attendance at a minimum of three meetings per week, investment in a "home group," and having a sponsor with whom they interacted with regularity.

Known Family History: Family history was coded as a binary classification of whether the patient had a known family history of addiction.

Prior Treatment History: Treatment history was coded as a binary classification of whether the patient had previously been in treatment for addiction. All patients in the study who had a history of relapse had also had prior treatment.

Work-Related Variables Assessed: Binary classifications were made regarding the presence or absence of legal charges incurred related to addiction; involvement of the Board of Pharmacy in the patient's case; involvement of a formal pharmacy assistance program; and whether the patient was diverting medications from his or her workplace. The patient's job status at the end of treatment (terminated vs. still employed) was also included.

table 1

RESULTS

At the end of the 2-year follow-up interval, 87.1% (N = 101) of pharmacists had remained abstinent, as confirmed by random urine screens, clinician observation, and participant self-reports. Fifteen pharmacists had relapsed.

Demographic and Treatment Variables as Predictors of Recovery Outcome

Between-group comparisons of descriptive indicators using Pearson chi-squares were made between pharmacists who had remained abstinent and those who had relapsed during the study duration to ascertain the relative effect of indicators on longitudinal sobriety outcome. For each indicator variable level, the relative risk of relapse was calculated where possible. TABLE 2 shows the variable levels, percentage of the sample for whom data could be used in analyses, the raw numbers of pharmacists per variable level who were classified as either sober or relapsed, the chi-square statistic, significance level, and relative risk of relapse. Single marital status carried a significantly higher risk of relapse than a marital status of married/domestic partnership (P = .027, relative risk [RR] = 2.94). Pharmacists who had a personality disorder had a higher relative risk of relapse (P <.001, RR = 6.75). Having a prior treatment history increased the likelihood of relapse over the course of the 2-year follow-up interval compared to those without a prior treatment history (P = .007, RR = 5.47). Pharmacists who were not invested in a 12-step recovery program throughout the follow-up interval were significantly more likely to relapse than those who were committed to a 12-step program, (P <.001, RR = 17.83). There were no significant between-group differences for the effects of gender, race, dual diagnosis of psychiatric disorders (with the exception of personality disorders) or complicating medical conditions, or known family history.

table 2

Characteristics of Addictive Disease and Relationship to Follow-up Outcome

The percentage of the sample meeting criteria for addictive disease is presented by drug group in FIGURE 1 and accounts for the distribution of all substances meeting dependence criteria in the study. Dependence on oral opioids was met by 70.69% of the sample, indicating these medications are the predominant substance of dependence for pharmacists. Alcohol was the second-highest drug class, with 22.41% of the sample meeting dependence criteria.

fig1

When broken down by drug of choice, the majority of pharmacists, 66.4%, preferred oral opioids. Alcohol was the drug of choice for 12.1%, oral stimulants for 6.0%, illegal drugs for 6.0%, and injectable opioids for 2.6%. Other drugs were the drug of choice for an additional 6.9% of the sample.

TABLE 3 examines the relationships of drugs meeting dependence criteria and presents these findings and the relative risk of relapse for each drug group. Only for alcohol dependence did the relative risk of relapse increase significantly: P = .016, RR = 3.03.

table 3

Associations of Pharmacy Variables to Outcomes

Variables related to the pharmacy profession and their associations with longitudinal sobriety outcome were tracked and calculated. Formal involvement with a pharmacy-assistance program (PRN program) for monitoring and advocacy was protective of relapse; P <.001, relative risk = 0.10. Of the three pharmacists who did not engage with a pharmacy-specific assistance program in the follow-up interval, all three relapsed. The relative risk of relapse if not involved in a pharmacy-assistance program was 10.18 times greater than if involved. The presence of pending legal charges, Board of Pharmacy involvement in the follow-up interval, job status, and workplace setting were not related to longitudinal sobriety outcome.

Interestingly, job status was associated with workplace setting. Pharmacists who worked in community pharmacy settings (most notably large chains) were far more likely to be terminated than pharmacists who worked in either a hospital setting or other settings; P <.001. Subsequent to identification of their addiction, 74.7% of community pharmacists (65 of 87) had been terminated from their jobs, compared to 29.4% of hospital pharmacists, 16.7% of students, and 50.0% of pharmacists in other settings.

Additionally, 85.3% (N = 99) of the sample reported diverting their drugs from the workplace. Of those not diverting (N =17), 10 were alcohol users only, 3 used alcohol and an illegal drug, and 4 were illegal drug users only. All of the stimulant, opioid, and other drug users reported diverting from the workplace.

Commitment to 12-Step Recovery Program

As depicted in TABLE 2, engagement in a 12-step recovery program throughout the follow-up interval was the single strongest predictor of long-term abstinence; the relative risk of relapse was 0.06% for those who were invested in 12-step programs, indicating a protective effect on sobriety outcome. For those who did not engage in 12-step recovery, the relative risk of relapse jumped significantly to 17.83%; all nine of the pharmacists who did not engage in such a program relapsed. Upon further examination, Pearson chi-square statistics were calculated for variables that could potentially affect 12-step involvement. The presence of the dual-diagnosis personality disorder predicted lack of investment in 12-step recovery. Of the eight pharmacists with personality disorders, five relapsed compared to 10 of the 108 without personality disorders; P = .001.

Naltrexone

Neither disulfiram or acamprosate were used by participants in the study; however, the adjunctive use of naltrexone in the follow-up interval displayed promising findings to support both its continued use and subsequent lines of inquiry. Of the entire sample, the first 21 pharmacists to enter the study were excluded from analyses involving the use of naltrexone, as its prescription in the initial phases of the study was difficult to institute as a routine element of care for opioid dependence. Further, urine screening for naltrexone compliance was prohibitively expensive at that time, given that a separate screen for naltrexone was required in addition to the regular, all-inclusive panel. As a result, its investigation was a later-introduced secondary aim of the study. Of the eligible 95 pharmacists, 59 were prescribed naltrexone for use in the follow-up interval. The remaining 36 were not prescribed either because contraindications were met or because their specific drugs of dependence were not appropriate for its prescription. All 59 of those who were prescribed naltrexone met criteria for opioid dependence. A minimal number of pharmacists (five) reported adverse reactions or side effects to oral naltrexone. Of the reactions reported, none were severe enough to discontinue use, all were transient in nature, and all were described by patients as short-lived and manageable. Most common were gastrointestinal issues, i.e., mild anorexia or diarrhea. There was the potential for underreporting adverse reactions, as return to work, for many, was conditional on their ability to tolerate naltrexone. As illustrated in TABLE 2, the effect of naltrexone was significant, with only 2 of the 59 on an adjunctive naltrexone regimen relapsing. Further, naltrexone has a protective effect against relapse, since those for whom it was prescribed had a relative risk of relapse equaling 0.12%.

The relative risk of relapse is more than eight times greater for pharmacists not prescribed naltrexone: RR 8.19. As evidenced herein, naltrexone appears to be both safe and effective as an adjunctive pharmacotherapy.

DISCUSSION

The present investigation found the 2-year recovery success rate for chemically dependent pharmacists to be 87.1%. Strengths of this investigation include a prospective and longitudinal design, use of clearly defined and objective outcome measurement, and use of a tailored treatment program with components similar to those recommended in prior studies of other health professionals.7,12 This indicates that a treatment program tailored specifically to the pharmacy profession has promising results for returning addicted pharmacists to work. This study suggests that after 2 years of abstinence, a recovering pharmacist poses minimal additional risk to a potential employer compared to a randomly selected member of the general population. Findings suggest the effectiveness of a tailored and multifaceted monitoring program, including collaboration with employers and assistance programs; of advocacy with the licensing Board of Pharmacy; of random urine toxicology screenings; of treatment and management of dual diagnoses; of a foundation in the 12-step model; and of a structured aftercare program and contract. Further, this study reveals the importance of addressing return-to-work issues, as the workplace itself is high risk. A strength of the present study's treatment approach was its emphasis on the unique stressors inherent in the pharmacy profession along with engagement of recovering pharmacists in weekly group therapy.

Factors associated with the highest relative risk of relapse in this study were a comorbid personality disorder (PD); alcohol as a drug of choice; failure to invest in a 12-step recovery program; and prior history of relapse. That PDs were associated with a seven times greater relative risk of relapse is consistent with prior literature.12,18 Other comorbid diagnoses (e.g., depression, chronic pain) were not related to relapse, perhaps suggesting that these additional comorbidities were receptive to the comprehensive treatment modality received.

Interestingly, although alcohol is not the drug of choice for most pharmacists, it carried a three times greater risk of relapse for abusers than for those who did not abuse it. Use of oral opioids, the drug of choice for nearly 71% of pharmacists in the study, did not impact the risk of relapse significantly. In terms of returning an addicted pharmacist to work, this finding along with a naltrexone regimen suggests increased safety and decreased likelihood with regard to potential medication diversion.

Of greatest note is the importance of 12-step programming in ongoing recovery. Engagement in 12-step programs at least three times per week was a protective factor; failure to invest in 12-step programs was associated with an 18 times greater relative risk of relapse. This finding highlights the importance and success of 12-step programs (e.g., AA, NA) in the maintenance of recovery.

Although not the primary line of inquiry, findings also provide preliminary evidence for the use of naltrexone. For opioid-addicted pharmacists seeking to return to work, naltrexone seems to be an effective adjunctive treatment option to help prevent relapse. While data collected in this study concerning the use of naltrexone did not constitute a comprehensive drug study, they highlight possibly valuable ancillary findings for potential employers, Boards of Pharmacy, PRN programs, and treatment providers.

Despite the prevalence of addiction in pharmacists (one in nine), a well-documented problem remains the lack of education about addiction in pharmacists' formal training. Pharmacy schools tend to center on the characteristics and pharmacology of addicting drugs and drugs used to treat addiction, but little education is offered on the psychological aspects of addiction, including signs, symptoms, and criteria. Little information is given about potentially helping a patient or colleague who is suffering from addiction. Findings from this study highlight critical warning signs and triggers of AD in the workplace (e.g., diverting) that may aid others in the identification of at-risk pharmacists and assist in getting them into treatment. Further, pharmacists educated on addiction improve the facilitation of the healthcare system.3,5

ResourcesFor the purposes of this article, the terms dependence(cy), addiction, and addictive disease are used interchangeably and refer to individuals who exhibit the full criteria for substance dependence as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).22 (The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5] was published shortly after this article was submitted for publication.)

The authors would like to thank Jeff Baldwin of the University of Nebraska and Norm Katz of the University of Illinois for their input into the development of this article.

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