The impact of licit (i.e., alcohol and nicotine used legally), illicit, and nonmedical prescription drug abuse and dependence in the United States is a well-documented matter affecting many individuals in the general population. A substantial number of patients served daily by pharmacists in community, hospital, and other health care facilities are therefore abusing or are dependent on alcohol, other drugs, or a combination (AOD). Despite this, a recent report concerning substantial abuse of prescription medication in the U.S. reported that many pharmacists are poorly trained to deal with alcohol or drug abuse.1
As one of America's most trusted professionals, the public expects pharmacists to respect the proper use of the medicines that they dispense to their patients.2 Just as in their patients, though, alcohol and other drug abuse and dependence are affecting the lives of a number of pharmacists, leading some researchers to call pharmacists our society's "drugged experts."3 In reality, while pharmacy students and pharmacists report somewhat higher lifetime and past-year prevalence of prescription drug use of opioids and anxiolytics than comparable groups of college students or the general population, respectively, lifetime and past-year prevalence of illicit drug use overall is less likely to be reported by pharmacy students and pharmacists. 4,5
Although not a widely discussed or well-researched topic, the issue of pharmacists impaired by prescription, illegal, and legal drug abuse needs to be addressed. Beginning in pharmacy college, some students may develop an air of invulnerability and immunity to addiction, perhaps because of an advanced understanding of drug action. What begins as recreational college AOD use may, for some individuals, develop into a complicated pattern of AOD abuse or dependence intended to produce a "sense of well-being" without an overt manifestation of intoxication or side effects.6,7 This concept of balancing drug effects, also called titration, refers to a practice in which pharmacists use their pharmacological knowledge to balance drug actions and reactions by "enhancing, neutralizing, or counteracting specific drug effects through ingesting multiple types of drugs."8
When a pharmacist experiences drug impairment, the responsibility to protect the public ultimately falls upon the pharmacy profession, as represented by the licensing boards and professional societies. The pharmacy practice act of each state describes the parameters of professional activity. When a pharmacist violates these laws, he or she is subject to punitive board action, such as license suspension or revocation. In addition to board prosecution, state pharmacy professional organizations can organize, sponsor, or support a pharmacist recovery network (PRN) program. These programs offer confidential support and assistance to pharmacists who are impaired by drug or alcohol abuse or dependence, and/or emotional or mental health problems.9
Whether through board action or collegial PRN intervention, the impaired pharmacist is taken out of practice until the impairment is resolved. Furthermore, since AOD abuse and dependence exists in nondistinct shades of gray, pharmacists (and other health care professionals) are often ill-prepared to deal effectively with AOD abuse and dependence by patients, others in the profession, or themselves.10
Scope of the Problem
The National Survey on Drug Use and Health in 2004 reported that 22.5 million Americans ages 12 years and older abused or were dependent on AOD during the year before the survey.11 This rate of abuse or dependence equals 9.4% of the U.S. population. Additionally, more than six million individuals reported using nonprescribed psychotherapeutic agents.
While pharmacists may be at greater risk of using prescription drugs than the general population, there is currently no evidence that total lifetime or past-year drug use by pharmacists significantly exceeds that of other major groups of health care professionals or the general population. 12 However, it appears that the greatest threats to pharmacists are nonmedical opiate, stimulant, and antianxiety drug use (due to easy availability), as well as legal drugs, alcohol, and nicotine. 12 Most nonprescribed opioid and antianxiety drug use by pharmacists is taken for self-diagnosed ailments, while most stimulant use is taken to facilitate performance.13 Consistent with previous research, a study found that the majority of pharmacists who used these drugs initially did so after leaving college.14 In addition, 40% of pharmacists reported that they had used a prescription drug without a physician's authorization, and 20% reported that they had done so five or more times in their lifetime.14
What Are Chemical Abuse, Dependence, and Addiction?
The terms abuse , dependence, and addiction appear to be confusing to the public and health care professionals since there is both a colloquial (which is how we will be using these terms) and a diagnostic use of the terms for alcohol or any other substance overuse. The term substance abuse is commonly used as a substitute for any use of an illegal substance. However, since there is no substance that is not a chemical or drug, the term substance is problematic. In contrast, treatment professionals limit the use of the term substance abuse to describe the symptoms of individuals who meet the specific criteria for a medical diagnosis of abuse as listed in the Diagnostic and Statistical Manual of Mental Disorders, as discussed below. 15 Substance (i.e., drug, chemical) abuse is a pattern of AOD overuse that produces many adverse results during continual use of the chemical. The diagnostic characteristics of chemical abuse include at least one of the following behaviors determined to be present in a 12-month period by a qualified assessment professional:
•Failure to carry out obligations at home or work.
•Recurrent social or interpersonal problems.
•Continual use of the drug in circumstances that present a hazard (e.g., driving a car), and legal problems, such as arrests.
•Use of the drug is persistent, despite personal problems caused by the effects of the chemical on oneself or others.
The term AOD dependence , on the other hand, has been medically defined as a group of behavioral and physiological symptoms that indicate the continual, compulsive use of chemicals in self-administered doses, despite the problems related to the use of the drug.15 The diagnostic characteristics of dependence, popularly called addiction, include the presence of at least three of the following behaviors in a 12-month period, as determined by a qualified assessment professional:
•Signs of withdrawal (vary by drug class).
•Use of larger amounts of the drug or for a longer period of time than intended.
•Persistent desire or unsuccessful efforts to cut down or control use.
•Continual use despite adverse consequences.
•An excessive amount of time and effort spent obtaining the drug.
•Social, occupational, or recreational activities given up or time spent doing them reduced.
Tolerance is evident when the same amount of drug results in a diminished effect or increased amounts of the drug are needed to achieve the desired result or level of intoxication. Withdrawal signs and symptoms signify physiological and psychological changes that occur when the body's concentration of the chemical declines in a person who has been a heavy user. Given the neurophysiological changes occurring with chronic AOD abuse, withdrawal symptoms are typically actions opposite to those of the drug. For example, alcohol's sedative effect results in increased autonomic hyperactivity when alcohol is withdrawn. When signs of tolerance or withdrawal are seen, the AOD abuser is said to be "physiologically dependent."
Pharmacy's Role in Drug Abuse Prevention and Education
Generally, pharmacists receive inadequate education on drug abuse.16 More specifically, pharmacy students and pharmacists are insufficiently trained to identify, intervene, or treat patients and coworkers with drug abuse problems. 17,18 In a study published by the Center on Addiction and Substance Abuse (CASA) in 2005, only 48% of the 1,030 registered pharmacists surveyed had received any training in preventing drug diversion.1 Moreover, only 49% had received training in identifying abuse or dependence since graduation from pharmacy college. The perception by practicing pharmacists is that proficiency in drug abuse prevention, education, and even treatment options must be addressed in pharmacy college.16 The CASA study also revealed that only about half of the pharmacists surveyed rated the substance abuse education and training they received in college as good or excellent.
In addition to drug abuse education and training before and after graduation from pharmacy college, opportunities for specialization in residency programs should be provided, and pharmacist involvement in community service and drug abuse treatment research should be encouraged.19 In 2003, the American Society of Health-System Pharmacists published a position statement, noting that pharmacists have a distinct opportunity to have a fundamental role in drug abuse prevention, education, and assistance.20 Given the extent and consequences of potential chemical abuse in the workplace, pharmacy must accept a responsibility for educating its own profession. As health care professionals with an abundance of drug knowledge and responsibility, pharmacists should shoulder the responsibility of leading drug abuse prevention and education efforts. Pharmacists are also needed to assist in patient care, employee health, and community activities. The most important activity the profession can facilitate is promoting the understanding of drug abuse and dependence among pharmacy students and pharmacists.
Educating Pharmacists and Pharmacy Students About Drug Abuse and Dependence
Pharmacy colleges in several states have begun to more proactively educate the profession in this long-neglected area. While guidelines have been published for including this topic in pharmacy education, the suggestions have been mostly ignored. 21 Several exceptions are the 20 hours of core content on drug abuse and dependence offered at the University of Maryland School of Pharmacy and the eight hours of core content in the main pharmacotherapy course at the University of Texas College of Pharmacy, which also offers a five-hour orientation program on the disease of chemical dependence, intervention, and resources for students entering the college. In addition, the University of Nebraska College of Pharmacy includes six hours of core content in its pharmacotherapy course and offers a substance abuse elective that approximately 80% of its students complete. The university provides a brochure to all students and faculty annually that details its chemical dependency assistance program and local resources, and it provides a program overview during new student orientation.
In 2000, the Texas State Board of Pharmacy approved four policies for implementation: (1) to support the concept of more training in chemical dependency for Texas pharmacists; (2) to support the attitude that such training is needed to protect the public; (3) to encourage Texas colleges of pharmacy to offer required lectures on chemical dependency; and (4) to move toward setting minimum standards for certification of pharmacists trained in chemical dependency. While the final policy has not yet been implemented, the University of Texas School of Pharmacy has produced 12 hours of chemical dependency training ("Because They Trust Us" continuing education videotapes) and a micro-Web C.E. learning series, "Neurobiology of Addiction."22
The Basics: What Pharmacists Need to Know About AOD Abuse and Dependence
All health care professionals are being called to action in the effort to address the problems of drug abuse and dependence in the U.S.23 At a minimum, pharmacists should be able to screen for these problems, assess their severity, refer individuals to appropriate levels of care, and provide appropriate counseling for those in recovery. To perform these activities, pharmacists should be educated about them and possess an ethic that promotes the necessary deployment of skills. For instance, pharmacists need logistical support in their practice environment to provide these services. This entails sufficient time to engage patients in counseling and an area that affords privacy and confidentiality. Pharmacy owners and managers, as well as dispensing pharmacists, need to make workplace accommodations that demonstrate the commitment to this professional activity.
Screening patients for substance abuse disorders is essential. Consider the number of prescriptions dispensed with an auxiliary label that warns patients against the use of alcohol "while taking this medication." For individuals who are dependent on alcohol, such advice would be difficult to follow. The pharmacist who advises, "If you find that you are unable to refrain from alcohol use during the period of prescription therapy, I strongly recommend that you seek assistance," may spark a turning point in the life of an individual who otherwise feels in total control of alcohol.
Pharmacists also practice in varied settings. For those in clinics, it may be practical to follow up a positive drug screening with assessment questions that estimate the dose, frequency, and duration of AOD overuse. A patient's responses to these questions will reveal information that will affect the treatment of other conditions (e.g., diabetes, hypertension, anticoagulation therapy) and perhaps suggest the need for treatment of an AOD abuse or dependence disorder. Clinical pharmacists can easily become frustrated when the dependent patient displays nonadherence to medication regimens and disease management advice. Until the chemical dependence is diagnosed and treated, the adverse effects of a patient's substance abuse on medication adherence and treatment outcomes for other illnesses are likely to continue.
In community pharmacy practice, assessment is less practical. Unless the pharmacist has made a concerted effort to spend time with patients in confidential counseling, the exigencies of dispensing leave little time for assessment. The advent of medication therapy management may provide sufficient incentive for community pharmacists to make the necessary arrangements to routinely engage in more therapeutic conversations with patients regarding their pharmacotherapy. 24
Pharmacy practice necessitates educating students and pharmacists on the identification of abusing and dependent patients, referral to evaluation and support resources for individuals affected by AOD use or those concerned about them, common prescription scams such as patient claims of "lost" or "stolen" narcotic analgesics and prescription forgeries, and serving as a resource for assistance-related materials and other information (patient resources). Updating the paradigm of pharmacy as the gatekeeper to include pharmacy as the educator includes enhancing the role of the pharmacist in supporting addiction recovery. For example, pharmacists can counsel on the use of addicting and mood-altering medications, provide appropriate counseling about what is not addiction, and counter "addiction phobias" for those patients (e.g., hospice patients) who require significant pain control but fear becoming addicted to the prescribed medication.
A multitude of resources exists to treat AOD abuse and dependence disorders. The major treatment options available in the community are listed in table 1, and the currently available medications for alcohol and opiate dependence treatment are listed in table 2. The thorough assessment is a critical prerequisite to a proper referral. Little is gained when needs and services are mismatched. Much time and money are wasted by individuals who minimize the severity of their AOD abuse or dependence and participate in an inadequate level of care.
Taking Care of Our Own:
Pharmacy Profession Response to Chemical Abuse and Dependence in Pharmacists
The goals of ethical standards and licensing laws in the health professions include protecting the public and establishing the boundaries of professional conduct. Stepping outside the standards of conduct and violating practice regulations expose errant practitioners to sanction. However, nonpunitive options increase the likelihood that pharmacists will refer themselves for intervention and that other pharmacists will refer an impaired colleague. Employee assistance programs (EAPs) utilize a rehabilitative approach to chemical abuse and dependence in the workplace. For over 50 years, these programs have offered assistance to workers with various problems, such as AOD overuse, that negatively affect their job performance.25 This approach offers confidential assistance to employees who request help. Workers who enter an EAP are afforded an opportunity to deal with a substance use disorder in a therapeutic setting while the worker's supervisor relies solely on job performance criteria for making decisions about continued employment.
The PRN providers use the
rehabilitative approach to assist pharmacists who abuse or are dependent on a
drug. PRN programs limit their outreach and intervention services to
pharmacists, pharmacy students, and pharmacy technicians. Umbrella programs
offer assistance to multiple professions for various problems, including
psychoactive substance dependence assistance, through a central provider. Both
programs are modeled after EAPs and identify individuals for rehabilitative
intervention, rather than punitive action.
PRN services, available in all 50 states, offer an alternative to board of pharmacy license sanctions when dealing with a pharmacist who has AOD problems.26 Pharmacists who need and want confidential help can contact their state PRN. Organized in 1982 by the American Pharmacists Association (APhA, formerly the American Pharmaceutical Association), the program is dedicated to the early identification, intervention, and treatment of drug-affected pharmacists, pharmacy students, and technicians. Pharmacists who have an AOD problem can call their state PRN to ask for confidential advice and assistance. Information is collected and the individual is referred for follow-up to a counselor or a chemical dependency assessment and treatment specialist. Early discovery of such individuals preserves both professional health and public safety.
Identifying Drug Problems in Coworkers
Most corporate chain store retailers and hospital pharmacies use statistical analysis to determine worker access to specific drugs on a periodic basis (e.g., monthly). If a particular employee appears to consistently access controlled drugs more often than his or her peers without sufficient cause, a more formal investigation is begun, perhaps instituting the use of video cameras or auditing the site. Behaviorally, however, there are several signs and symptoms of AOD abuse that coworkers may notice (table 3). In fact, some of these markers may indicate the type of impairment. For example, unexplained work absences may indicate an alcohol abuse or dependence problem, since home is the more convenient place to store and access alcohol. In contrast, consistently volunteering to work overtime or work with controlled substance inventory, and arriving at work at unscheduled times, provides an impaired coworker the opportunity to access controlled substances that are not available at home. Unfortunately, such symptoms are more easily identified in hindsight than before a coworker is identified to have an AOD disorder.
Probably one of the most difficult
professional decisions a pharmacist can make is to confront a coworker with an
AOD problem. Given the seriousness of dependence disease and its treatment,
intervention can be awkward. More importantly, pharmacists should consider
that in retrospect, many colleagues feel that an intervention probably saved
their life.8 Also, while these individuals may have been devastated
at the time of their discovery, the reality is that the majority do
successfully return to work, which will be detailed shortly. Furthermore,
given the shortage of pharmacists, it is probable that many of these
individuals will be allowed to resume their profession if they cooperate with
treatment, which may include compensation to the employer for the diverted
drugs in cases of criminal diversion.20
Recovery Assistance Programs, Risk Factors for Relapse, and Treatment Success
Once an individual's AOD problem surfaces, treatment decisions are generally tailored to his or her needs (tables 1, 2). While discussing the diverse treatment options available in a meaningful way is beyond the scope of this article, certain basic goals of treatment include matching the patient to the correct level of care, such as deciding whether an individual is better suited for inpatient versus outpatient treatment.27 Beyond placement, the fundamental facets of treatment include individual and group therapy, pharmacotherapy when appropriate, urine drug screens, and 12-step facilitation. Twelve-step programs include Alcoholics Anonymous, Narcotics Anonymous, Caduceus (for health care professionals), International Pharmacists Anonymous (a psychosocial support group specifically for pharmacists), and International Doctors in Alcoholics Anonymous (a support group that now includes pharmacists in its membership, regardless of pharmacy degree).
There is inadequate research assessing risk factors for relapse or treatment success of recovering pharmacists. In a retrospective cohort study of 292 health care professionals, including pharmacists enrolled in Washington state's Physicians Health Program, only about 25% of the study population had one or more relapses. 28 The risk of relapse was significantly higher in health care professionals who used a major opioid, had a coexisting psychiatric illness, or reported a family history of an AOD disorder. Coexisting risk factors and previous relapse also increased the likelihood of relapse.
In 1988, a survey examined pharmacist assistance programs in all 50 states and the District of Columbia. 29 The survey reported that only 20% of impaired pharmacists in these treatment programs voluntarily disclosed their chemical use problem. Most importantly, just over 88% successfully completed treatment and returned to practice. These studies suggest that the goal of returning a recovering pharmacist to practice with the proper aftercare and monitoring program is realistic and almost always successful.
Since 1982, APhA has worked to adopt and institute a policy of treatment, prevention, and rehabilitation of pharmacists who use AOD. For over 20 years, APhA has actively supported the pharmacy section of the Utah School on Alcoholism and Other Drug Dependencies in Salt Lake City. The purpose of this annual weeklong program is to bring together pharmacists and pharmacy students with various state PRN coordinators, state administrators, industry representatives, and interested individuals from around the country to listen to updates on various aspects of AOD intervention and treatment.
The Health Professional Students for Substance Abuse Training (HPSSAT) is a project of the Physician Leadership on National Drug Policy that is free to join.30 The goal of this organization is to have all graduating health professional students develop the skills to screen, diagnose, and provide appropriate intervention for patients with an AOD problem. Through HPSSAT, students can be advocates for local and national educational reform of substance abuse education and treatment training.
Agencies such as the Drug Enforcement Administration, state departments of health, boards of pharmacy, state pharmacy associations, and colleges of pharmacy should coordinate discussions about AOD use among patients, as well as pharmacists and pharmacy students. Dissemination of information (e.g., continuing education opportunities) relating to the warning signs of drug abuse and sources of help for those affected by AOD should be continual goals of these agencies. Colleges of pharmacy should pay particular attention to providing instruction on the neurobiological and psychological processes of AOD dependence and, in particular, the threats posed by alcohol, nicotine, opioids, stimulants, and antianxiety drugs, since these are the drugs most associated with abuse, dependence, and health problems. Efforts to dissuade pharmacists and pharmacy students from using AOD may not immediately produce visible results. Ultimately, however, academic and governmental agencies need to make every reasonable effort to educate both future and practicing pharmacists about these issues.
While the rates of AOD abuse or dependence among pharmacists are no greater than in the general population, the consequences of any impairment can have adverse effects on patients. People entrust their personal welfare and safety to those in the health professions. The profession, in turn, has an ethical obligation to ensure that its practitioners can discharge their duties with skill and safety. Policies should promote early discovery of professionals who overuse AOD in order to minimize the period of time that patients are at risk of being harmed.
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