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12/5/2003

Recovery Assistance Programs Help Pharmacists with Substance Abuse Problems

Donna Young

The first time Oklahoma pharmacist Kevin R. Rich took a controlled substance without a prescription to relieve a headache, he told himself that, because he was an experienced practitioner with knowledge of pharmacology, he knew what he was doing.

Before long, however, Rich began taking hydrocodone on a daily basis to “make it through” his long, stressful workdays in the pharmacy.

He continued to justify to himself that he was in control and refused to acknowledge his dependency on the potent drug.

But eventually, Rich was caught by his employer stealing controlled substances from the pharmacy and was fired.

Between 8% and 12% of health care workers have chemical dependencies, according to the National Institute on Drug Abuse (NIDA).

Health care professionals may be at increased risk of prescription drug abuse because of their easy access to medications, including controlled substances, according to NIDA.

After surrendering his license to his state board of pharmacy, Rich sought help from Oklahoma Pharmacists Helping Pharmacists (OPHP), a nonprofit volunteer-run organization that assists pharmacists with substance abuse problems in getting treatment for their dependencies.

Rich successfully completed his treatment and recovery program—he has been sober since June 1994—and is again a practicing pharmacist.

State programs. Most states have recovery assistance programs for pharmacists who are dependent on prescription medications, alcohol, or other drugs.

It is critical for pharmacists with substance abuse problems to have the availability of a pharmacist recovery program that provides a peer-structured support system, said pharmacist Nan Davis, cofounder of International Pharmacists Anonymous.

Many pharmacists in recovery are surprised to discover that “they are not the only one” with a chemical dependency problem, she said.

It can make a big difference in a recovering pharmacist’s self-image to know that he or she has support from peers that have experienced chemical dependency and have successfully completed a treatment program, Davis said.

When a pharmacist has been fired or has had his or her pharmacy license suspended, “they need to know it is not the end of the world,” said Michael D. Quigley, president of Ohio’s Pharmacists Rehabilitation Organization Inc. “There is help.”

For more information about pharmacist recovery assistance programs, go to usaprn.org.

Many of the programs are open to pharmacy students, but because most state boards of pharmacy do not regulate pharmacy technicians, few of the programs serve that group.

The Washington Recovery Assistance Program does accept technicians into its program, said Michaelene Kedzierski, associate director of counseling services for the University of Washington’s office of academic and student programs and a clinical associate professor in the department of pharmacy.

Some of the recovery assistance programs for pharmacists are supported by state licensing fees or other funds appropriated by state governments or boards of pharmacy.

The Kansas Pharmacists Association (KPhA) Committee on Impaired Pharmacy Practice, which contracts services to an umbrella organization—Heart of America Professional Network, which provides services to many types of health care workers—receives about $30,000 from state licensing fees.

The Kansas program also serves pharmacists who have other mental impairments, including Alzheimer’s disease and bipolar disorder, said Jenith Hoover, KPhA’s associate director.

Maryland’s recovery assistance program, the Pharmacists Education and Assistance Committee, received $89,000 this year.

But many of the programs are run by volunteers and funded by monthly fees charged to clients. Local pharmacy organizations also aid in supporting some of the programs.

Pharmacist assistance programs do not provide drug abuse treatment to pharmacists but do assist with the referral process, monitor pharmacists’ recovery and compliance, and act as a support structure for the person in recovery.

A recovery assistance program can also serve as an advocate for a pharmacist who has been summoned before the board of pharmacy.

Several states have passed laws that protect recovery assistance programs from liability.

Liability laws are necessary to protect assistance program volunteers or employees who are involved in an intervention, said Rich, who is president of OPHP.

“When we intervene on someone, denial is a great big issue that keeps people from getting help, and a lot of times when we go in, we don’t know what we are going to deal with,” he said. “Many times when we’ve gone in, people are ready to get help, but many times we come up against somebody that’s pretty angry. If they have any money left at that point, they might threaten legal steps. Through the pharmacy practice act there are some pretty good protections.”

A good success rate. Many of the pharmacist recovery programs reported that they have about an 85% success rate.

KPhA’s Hoover said of the 117 referrals since 1988 to her state’s program, 36 were self-reported and 31 were reported by the state’s board of pharmacy. The other pharmacists referred to the program were directed there by an employer (34) or by colleagues or family members (16).

However, of the 117 referrals, 14 were cases that were unsubstantiated, she said.

The program has closed 89 cases, Hoover added.

Oklahoma’s volunteer-run program, first established in the early 1980s, has assisted 141 pharmacists since its inception, Rich said. The program has 49 active cases.

Pharmacists seeking services from recovery assistance programs are generally required to sign a contract, which obligates the person to comply with certain rules, including completing a treatment program, random drug testing, consistent contact with an assigned person who acts as a monitor, and regularly attending support groups meetings, such as Alcoholics Anonymous.

Most programs require a five-year contract, but some boards of pharmacy may request a longer or shorter contract.

Pharmacist recovery programs interviewed reported that contracts are confidential and if a person is self-referred and has successfully completed a rehabilitation program, the pharmacist’s board of pharmacy is not notified about the person’s substance abuse problem.

However, if a pharmacist is noncompliant after entering a contract with an assistance program, most state pharmacy practice acts require an assistance program to report the impaired pharmacist to his or her board of pharmacy.

Seeking treatment. Most boards of pharmacy and state prosecutors are “compassionate” and supportive of treatment for pharmacists versus taking strict disciplinary action by revoking a pharmacist’s license, said pharmacist Merrill Norton, director of the recovering pharmacist program at the Talbott Recovery Campus in Atlanta, Georgia.

But, he said, because pharmacy is a profession that is highly esteemed, pharmacists have difficulty seeking treatment and often wait until their substance abuse problem is discovered by an employer.

“If something is wrong with the perfectionist pharmacist, which most [of] the pharmacists are perfectionists, and they fall off the platform, they feel this overwhelming shame,” said Norton, a nationally certified addictions counselor and certified clinical supervisor. “Pharmacists do not like being told what to do. They think they’ve got to have control, and some of that is their training, and a lot of that is their personality. But in recovery, you have to surrender to win. You have to give up control in order to get it back.”

According to the Substance Abuse and Mental Health Services Administration’s 2002 National Survey on Drug Use and Health, 26% of people who are drug dependent and 24% of people with an alcohol abuse problem reported that they do not seek help because of the stigma associated with receiving treatment.

“I have pharmacists coming believing it was a lack of willpower, some of them believing they didn’t have enough religion, and some believe it is just because they were a bad person,” said Norton. “It has nothing to do with that. It has to do with brain chemistry. We are the ones who are supposed to know the pharmacology, neurobiology, pharmacokinetics of what our central nervous system is about.”

Lack of education. Pharmacy has failed, he said, to “appropriately train” boards of pharmacy, pharmacists, pharmacy students, and the general public about the “disease of dependency.”

“We will talk about diabetes, high blood pressure, and HIV [and] AIDS, but guess what is destroying most of our kids and most of our profession? It’s the disease of dependence, not high blood pressure,” said Norton, who recently produced a six-hour DVD series for the Georgia Counsel on Substance Abuse titled From Disgrace to Grace: The Neurobiology and Pharmacology of Dependence, Shame, and Recovery. “We all have got to work harder in our own ranks because I’m seeing some tragedies.”

Some pharmacy schools are doing an “adequate” job of including substance abuse in their curriculum, he said.

“I don’t see it as a priority,” said Norton. “I think because of the conservatism of pharmacy they still want to put this in their back pocket and kind of cover it up.”

Pharmacy associations, he said, need to conduct regular surveys asking pharmacists and schools of pharmacy about what is known about substance abuse in the profession, and what needs are going unmet.

Pharmacists should participate in, or contribute to, the development of substance abuse and prevention and assistance programs within health care organizations, ASHP declared in its Statement on the Pharmacist’s Role in Substance Abuse Prevention, Education, and Assistance (October 1, 2003, AJHP).

Practitioners should also be involved in public drug abuse education and prevention programs, the policy states.

University of Washington’s Kedzierski, a licensed addictions counselor, said her pharmacy school is one of a few that has included courses about chemical dependency issues in its curriculum.

Anthony Tommasello, associate professor at the University of Maryland (UM) School of Pharmacy in Baltimore, said his school includes 30 credit hours of substance abuse-related studies in its curriculum.

Tommasello, director of UM’s office of substance abuse studies, recently coauthored a report outlining recommendations for implementing effective substance abuse education in pharmacy practice for the Association for Medical Education and Research in Substance Abuse.1

But many colleges of pharmacy lack qualified faculty to teach courses about chemical dependency, said Jeffrey N. Baldwin, associate professor of pharmacy practice at the University of Nebraska College of Pharmacy and cochair of the Nebraska Pharmacists Recovery Network.

Baldwin served as chair of the American Association of Colleges of Pharmacy’s Substance Abuse Education and Assistance Special Interest Group from 1988 to 1997 and coauthored a survey in 1994 of substance abuse content in pharmacy schools.2

Another reason pharmacy schools do not include substance abuse in their curriculum is that “nothing is driving or forcing them to do addiction education,” he said.

If substance abuse education was included in pharmacy board examinations, Baldwin said, more pharmacy schools would include courses about the topic in their curriculum.

“Tests drive study,” he said. “That is the tail that’s wagging the dog.”

The Utah experience. Many schools of pharmacy, including the University of Nebraska Medical Center in Omaha, encourage faculty and students to attend the University of Utah’s School on Alcoholism and Other Drug Dependencies, a weeklong summer seminar about chemical dependency held in Salt Lake City, Baldwin said.

Some schools provide scholarships for students, he added.

Several state pharmacy assistance programs also encourage pharmacists in recovery and members of boards of pharmacy to attend the 53-year-old program, which is the longest-running school of its kind.

The school’s pharmacy section is the largest of the 16 group section programs, said the school’s director, Claude Grant, clinical director of the university’s alcohol and drug abuse clinic.

Those attending the conference can earn continuing-education or university credits, he added.

In addition to attending seminar courses, Grant said, conference participants have an opportunity to observe therapy sessions at a local recovery facility.

Baldwin said that, even with programs like the University of Utah’s, it’s been an “uphill battle” to educate the profession and the public about the problem of substance abuse in health care workers.

Every health-system pharmacist at some time in his or her career, he said, will “deal with an addicted colleague or is going to have to work with somebody who is in recovery and needs to understand a little bit about those folks’ recovery program and how you behave around them.”

Employer support. One group that has recently shown more support, Baldwin said, is employers.

If an employer knows a pharmacist who is in recovery is being monitored and must regularly submit to urine testing, the employing company can be assured that the employee will more than likely not misuse prescription drugs, he argued.

Eckerd Corp., a community pharmacy chain headquartered in Clearwater, Florida, with stores in 21 states, instituted a policy in late 1999 that gives pharmacists with substance abuse problems a second chance.

If any Eckerd pharmacist with a chemical dependency problem comes forward or the problem is discovered by a manager, the company will not fire or prosecute the pharmacist if he or she agrees to seek help from a state-sponsored recovery assistance program and signs a contract with the program within seven days, said Lori Toenjes, senior director of regulatory compliance for the company.

The pharmacist may return to work at Eckerd as long as he or she is in good standing with the state board of pharmacy and meets certain criteria outlined by the company, she said.

However, Toenjes noted, the pharmacist is not guaranteed that he or she may return to the same store location where the employee worked before seeking treatment.

Eckerd must also report any loss of controlled substances to the Drug Enforcement Administration, and the pharmacist is required to pay any restitution for any stolen drug products, she said.

Pharmacists who divert products and sell or give the drugs to others are not eligible for the program, Toenjes added.

The goal of recovery, said KPhA’s Hoover, is to “not only protect the public, but also to restore the pharmacist’s career, get them back on track. It’s not necessarily punitive or disciplinary, but tough love. A firm structure of support.”

1. Dole EJ, Tommasello AC. Recommendations for implementing effective substance abuse education in pharmacy practice. Subst Abuse. 2002; 23S:263-71.

2. Baldwin JN, Dole EJ, Levine PJ et al. Survey of pharmacy abuse course content. Am J Pharm Edu. 1994; 58:47S-52S.