Introduction

Misuse of alcohol and other drugs is a growing problem in Western society, and doctors and medical students are at least as susceptible to it as the rest of the population.

This booklet reviews the evidence in this area, and makes recommendations from a Christian perspective.

The scale of the problem

Alcohol consumption in doctors and medical students

In 1976, admission rates for alcoholism among doctors in Scotland were over twice those for broadly comparable professional groups.[1] In 1986 the Royal College of General Practitioners informed its members that 'medical practitioners have a death rate from cirrhosis three times that of the general population'[2] and a 1985 study in Oxford showed that 12% of male GPs and 45% of female GPs were drinking dangerous quantities of alcohol.[3] In fact, during the mid 1980s, it was estimated that there were 2-3,000 alcoholic doctors in England and Wales alone.[4]

More recent evidence is a little less damning. An article in JAMA in 1992 found that 10% of doctors used alcohol daily, but only 0.6% had more than five drinks each day.[5] However, this is still significantly higher than the rates for the general population, especially for women. One review found figures in the profession nearer the population figure of 6-10%.[6] The standard mortality ratio for cirrhosis in 1991 showed a fall to 110 (cf 100 national average), but it has been as high as 300 in recent years.[7] (It should be noted here that alcohol is not the only cause of cirrhosis and doctors have greater exposure to other causes such as hepatitis B and C.)

Medical students also drink heavily. In a 1989 study of London medical students, 23% of male and 22% of female students were drinking more than suggested maximum safe levels.[8] Other studies put this figure at 25-33%.[9,10] Moreover, in the London study, 43% of female and 34% of male students were drinking more than they themselves thought was safe.[8] A similar study revealed that 'almost half the students admitted to having had a hangover at least once in the preceding year, and 15% were worried that they might be drinking to excess'.[11] A review in Medical Education quoted a range of between 11% and 20% of students abusing alcohol.[12]

Although some studies [13,14] disagree with these high estimates and favour levels of consumption by doctors and medical students comparable to the general population, all agree that women are drinking at levels comparable to men.

Drug misuse by the medical profession

Although doctors use 'drugs' less than they do alcohol, misuse is also a significant phenomenon. Of those with an alcohol problem, a significant proportion go on to develop a drug habit.

In the USA it was found that 'half of all alcoholic physicians eventually develop drug addiction'.[15] In the UK the figure is thought to be nearer a third, although studies agree that true figures are very hard to measure. Some doctors also become addicted to drugs without preceding alcohol addiction. Over 10% of doctors studied in India and Venezuela were thought to be taking hypnotics[16] and 8% of those surveyed in an American study had abused substances at some time.[5]

Anaesthetists are generally over-represented in studies; about 2% being drug dependent in one report.[17] A study of American medical students found about 12% using at least one drug on a daily basis.[18] In Hungary illicit drug use was found in 5% of students.[19]

Again, some researchers disagree and claim that medics misuse drugs no more than the general public. Whoever is correct, even levels close to the national average are too high for safety and national average levels are continually rising. The problem is beginning to attract serious attention in the profession. The BMA News Review in July 1996 called for the BMA and the Royal Colleges to take action, quoting a possible figure of 13,000 doctors suffering from addiction.[20]

Which drugs are most commonly misused? Research shows that doctors and students take more amphetamines, benzodiazepines and opiates than non-medics but smaller quantities of non-prescribed drugs.[5,21] They are also more likely to use more than one drug at the same time.[22] Many doctors claimed to be self-prescribing, although one study suggested that recreational use is also high.[5]

Students generally used drugs for recreation, with the exception of amphetamines which were used to enhance performance.[9,21] Most students had experimented with drugs before starting medical school, especially in the USA where medical students are generally older.[18]

As a large percentage of the drugs abused are benzodiazepines and minor opiates which have been self-prescribed, the appropriateness of this practice should be questioned. Doctors are not generally as objective about drug and dose when dealing with themselves as they are when dealing with patients. Conventional medical wisdom warns against prescribing for self or close family.

Interestingly, a study which correlated behaviour and religion found that doctors who professed no faith had higher levels of drug and alcohol abuse than colleagues who did.[23]

In all these studies, it is important to remember that the figures often come from self-reported questionnaires or from proven illness, and therefore the true rates of abuse and addiction are likely to be higher.

The consequences for patient care

What effect does this number of doctors with an alcohol or drug problem have on patient care?

The attitude and practice of doctors regarding substance use in themselves is rather different from their attitude about its use in patients.[16,24] Patients who misuse alcohol and drugs come to the attention of medical practitioners because of the medical or psychiatric complications. The unconscious youth brought into casualty, the terminal cirrhotic patient on the ward round, and the HIV-positive drug misuser are common sights.

Yet beyond these stereotypes is a vast array of other conditions where alcohol or drugs are a major aetiological factor. It is thought that alcohol is involved in 20-50% of general hospital admissions.[24] In the chaos of the busy clinic or ward round it is hard to have sympathy for those who are thought to have a self-inflicted illness. Even so, looking at the evidence, it is apparent that many medics know the clinical features of alcohol and drug abuse not only from textbooks and patients but from personal experience. Is the tendency not to look beyond the stereotypes both protecting us from admitting our own problems and preventing us from recognising substance-related illness in our patients?

Hypocrisy will damage the profession. If we do not take the problem seriously in ourselves, how can we expect our patients to comply with our advice?

As well as affecting our behaviour towards patients, substance use affects our competence in diagnosis and treatment. Signs such as withdrawal; disinterest; uncharacteristic, anti-social or impulsive behaviour; unreliability; irritability; tardiness and overprescription are common. 'Alcohol problems are one of the most common causes of a doctor's inability to practise competently. In any one year, a little under one half of those cases considered by the penal committee of the General Medical Council resulted from abuse of alcohol.'[2]

Impairment due to drug misuse in America accounts for approximately 15-20% of all those unfit to practise, and the overall percentage of US physicians reported for impairment due to alcohol or drugs is approximately 2%.[5,14]

Apart from damaging the doctor-patient relationship, the health implications for the individual medics involved cannot be ignored. Misusing alcohol and drugs is harmful and many will end up seriously ill.

Why do people develop alcohol and drug problems?

People misuse alcohol and drugs for a variety of different reasons. Identifying these reasons helps us to understand, overcome and prevent the problem.

Much recent research on the cause of alcoholism has centred on inheritance, which is thought to account for a considerable amount of morbidity.[13] Even more weight is placed on the effects of growing up in a household with one or more alcoholics, where children are liable to begin drinking early and heavily. Other childhood events such as parental marital breakdown have also been implicated.

Tobacco smoking has frequently been associated with subsequent addiction to alcohol or drugs.[8]

People with certain kinds of personality may be more vulnerable to dependence on alcohol or other drugs. Traits which have been suggested include: a tendency towards depression, impulsiveness, low tolerance to frustration, poor coping skills and denial of problems.[7,18,22] Other aspects of personality, such as the need to achieve and the fear of being stigmatised for admitting psychological problems, may push people into using substances in order to cope.[14,16] Some studies have cited a narcissistic personality (one which 'endorses the exploitation of others'), a history of poor relationships, and current lack of social supports as partly responsible.[13,25]

A more subtle factor in the development of addiction is the time needed for a habit to become an addiction. The insidious nature of alcohol addiction, which may not show up for years, lets its victims believe their behaviour is neither harmful nor disruptive. For instance, one study showed that American medical students who drank excessively had levels of academic performance comparable to those of their classmates.[26]

The stressful life of the doctor is often cited as a reason for substance abuse, where it can become a maladaptive coping mechanism. Stress levels measured in medical students in some studies are significantly higher than in the rest of the population, one study [9] quoting 31.7% as fitting the category 'emotional disturbance' on Goldberg's general health questionnaire. Those most distressed drank the most. 88% of GPs in a recent survey thought stress in the profession had increased in the last five years.[27]

Women doctors, more than any other women in society, have patterns of drinking like those of their male colleagues. This may be a consequence of women emulating men to compete in what is in some ways still a male-dominated profession. The stress of balancing family life with work has also been suggested as a reason.

Drug availability is another factor. The higher rates of drug misuse in anaesthetists may be due to their increased access to drugs.[17] The availability theory is also supported by the high use of prescribed drugs as opposed to street drugs.[5,21]

In the USA, anaesthetists, general practitioners and psychiatrists [22] have higher rates of addiction than other doctors. Researchers have attributed this to working in isolation as well as to ready access to drugs.

Many study authors cite lack of teaching about alcohol, drugs and addiction in both undergraduate and postgraduate programmes as a significant factor in subsequent misuse.[2,9,21,22] Teaching given is aimed at detecting problems in patients rather than in themselves. The problem is compounded by the profession seeing alcohol as a normal and acceptable part of socialising.[28] Those overindulging are generally tolerated, and using alcohol to relax is thought to be entirely reasonable. If a problem is detected, little or nothing is done for fear of damaging a colleague's career. Even if alcohol misuse doesn't lead to job loss, the longer the problem goes unnoticed, the worse the prognosis both medically and in terms of future work. There is also a lack of knowledge amongst doctors about the steps that could or should be taken in such cases. The problem must often reach crisis point before coming to light.[16]

People are slaves neither to their genetic makeup nor to environmental influences. There is always an element of choice and everyone is ultimately responsible for their own actions. Doctors are in a position of privilege, trust and responsibility and should act accordingly. However they are also human and subject to human failings.

The Christian View

Doctors are under the authority not only of the General Medical Council, but also of God. Medical standards and ethics have historically been based on biblical principles and although in recent times Christians have no longer made up the majority of the profession, these standards still apply.

Perhaps the principles of our society, where anything is acceptable if you like it, are partly to blame for the state we are in. A return to the biblical idea that 'everything is permissible - but not everything is beneficial'[29] might well help in the fight against substance abuse.

What does the Bible say about alcohol and drugs?

The Bible has a great deal to say about alcohol. Wine, for example, is mentioned 214 times. It is important to understand the context. In biblical Israel, water was not always plentiful and was often unsafe to drink. Wine was drunk with meals and for refreshment much as we drink tea and coffee.

It is not surprising then that the consumption of wine and other alcoholic drinks is not discouraged in either Testament. In fact, its presence is regarded as a sign of God's blessing, symbolic of a good harvest.[30] Wine was an integral part of offerings and sacrifices to God.[31] Priests were allotted wine as part of their 'portion' from the people, a living allowance.[32] It is also advocated as a medicine,[33] as a dressing for wounds,[34] for refreshment,[35] and as a commodity to trade. In the life of Jesus alcohol takes on greater significance as he turns water into wine [36] to endorse the celebrations at a wedding, and as the symbol of his blood at the Last Supper.[37]

There are, however, restrictions on the use of alcohol. The Old Testament priests were forbidden to drink it before serving in the inner court of the temple.[38] Wine was not allowed during a religious fast. Those in leadership were told not to indulge in excessive drinking as it would cloud their judgement in ruling the people.[39] However, total abstinence was only encouraged for specific groups. These included the Nazirites who took special vows of consecration [40] and the Hebrews during their desert wanderings.[41]

Over-indulgence in alcohol and drunkenness are severely discouraged. The dangers of drinking in excess are often pointed out - including woe, sorrow and strife. The writer of Proverbs describes the physical effects dramatically: staggering, confusion of the mind, blurred vision, addiction, hangover, delirium tremens and hallucinations ('eyes will see strange sights').[42] Other passages mention sexual immorality, nakedness, poverty and violence as consequences of over-indulgence.[43] Biblical characters who were tempted into drunkenness and suffered the consequences are highlighted. Lot's daughters get him drunk in order to commit incest, Jacob gave his father wine in the process of stealing his brother's blessing, and Noah is humiliated while 'under the influence'.[44]

Drinking and drug-taking were often part of the ritual behaviour of other religions and as such are expressly forbidden as idolatrous.[45] Greek converts to Christianity had been used to worshipping Bacchus by drunken revelry. In like manner, the hippie movement of the sixties was associated with Eastern mysticism. Occult practices also included drug-taking which was strongly forbidden too. The Greek term used by Paul for witchcraft, pharmakeia, literally means 'drug taking'.[46]

Jewish law, both from the Old Testament and in rabbinical tradition, prohibits harmful things on principle, and this must surely include drug-taking.

Self-control and moderation are strongly advocated in the New Testament. 'Teach the older men to be temperate, worthy of respect, self-controlled and sound in faith.'[47] Although 'temperance' has become synonymous with 'teetotalism', its original meaning was moderation rather than abstinence.

Another important principle in biblical teaching is the instruction not to cause others to sin; particularly with regard to food and drink. Paul teaches the early church that there is no real problem with eating food offered to idols. However, he urges that the 'strong in faith' abstain so as not to lead weaker brothers astray. 'All food is clean, but it is wrong for a man to eat anything that causes someone else to stumble. It is better not to eat meat or drink wine or to do anything else that will cause your brother to fall.'[48] Paul himself makes the application to drinking alcohol.

What does the Bible say about addiction?

While the Bible says little explicitly about addiction, it implies a great deal.

Firstly, it teaches that the only true and trustworthy answer to life's problems and stresses is found in Jesus Christ. Instead of looking to fill the gaps in our lives with hedonistic pleasures, we are directed to the Creator who alone can give fulfilment and peace. By comparison, experimentation with substances is self-seeking.

Secondly, addiction is linked to idolatry, the worship of anything that is not God. Habits which lead to the sacrifice of money, career, family and friends surely fall into this category. Drugs can become the most important thing in life, when this position belongs to God alone. Addiction makes slaves out of its victims. The God of the Bible is totally opposed to such slavery.

Lastly, the behaviour caused by addiction - for example, selfishness, strife, jealousy, theft and poor stewardship of resources - is uniformly condemned throughout Scripture. The Bible teaches that no one can act in isolation; what affects one person affects the whole community. Therefore each member of the community is responsible not only for themselves but for others as well. This applies to the family, to the work team and to patients.

What can be done?

There is hope for the addicted. Physicians are thought to respond better to treatment than the general population does. Rates of recovery can be between 60 and 97%, [14,16,19,50] although it should be remembered that recovery is a life-long process.

In Britain, the current systems in place for dealing with sick doctors are local ones, which should deal with most cases, and the General Medical Council's procedures, which should be used only in more serious cases or when the local machinery has failed. Locally, hospital doctors should be referred to the 'three wise men', a committee made up of senior staff. GPs are referred to the local committee of the Family Health Services Authority. These local systems can arrange treatment and interim working practices.

The GMC becomes involved if a doctor is reported by the local committee, another doctor or a member of the public. The preliminary screener for health decides whether there is sufficient evidence to suggest a problem. The doctor is then invited to be examined by two consultants, and this is arranged locally. If the examiners agree that the doctor's fitness to practise is impaired, the screener can then deal with the case by arranging treatment and setting conditions on practice.

The doctor is referred to the Health Committee if an offence has been committed or he or she has failed to comply with any stage of the proceedings. The committee is made up of 12 elected members who are assisted by one legal advisor and two medical ones. They can choose between conditions on practice, suspension or treatment.

The GMC saw approximately 400 doctors between 1980 and 1988. Of these, one third were not pursued by the screener, one third were rehabilitated and one third suspended. It is thought that this is only a small fraction of those needing help.[51]

Help and advice are also available from the National Counselling Service for Sick Doctors, the BMA members' helpline and the Medical Council on Alcoholism.

Although treatment can be arranged by local committees, the GMC or the sufferer's GP in the UK, there are no dedicated programmes here like those in the USA. Most states and local medical societies there have programmes for treatment, some of which have been running since the 1970s. Doctors may have their licence suspended under individual state laws, many of which allow supervised continuation or reinstatement if treatment programmes are completed.[14]

American medical schools are beginning to have similar programmes, both for students and residents. For example, AIMS (Aid for Impaired Medical Students) is one where a committee of faculty and students deal with students to organise treatment and to minimise the harm to their education.[6] Students can be sent by their peers or their teachers or can refer themselves. Reports are investigated, and if appropriate the student is seen by specialists in addiction for diagnosis and treatment. Those students who do not co-operate are referred to the Dean of the Medical School.

Rehabilitation for medics is carried out in much the same way as for the public, including drug treatment, counselling and involvement with agencies such as Alcoholics Anonymous. Support for families is also available. A general plan for treatment would be as follows:

• the extent of substance abuse, its current effects and the long-term consequences are reviewed;
  
• withdrawal is arranged either at home or in hospital, using drugs such as diazepam to control symptoms;
  
• any medical or psychiatric problems are addressed;
  
• goals are set for abstaining (or controlled drinking if appropriate), resolving interpersonal problems, engaging in new activities and solving any legal or financial difficulties.
  

Longer term help may include counselling, AA meetings and graduated return to work, preferably supervised.

Support and help are also available from the church and from Christian organisations, such as the Evangelical Coalition on Drugs (ECOD) which has amongst its members a range of rehabilitation organisations. Alcoholics Anonymous itself enshrines Christian ideas in its original 12 steps to personal recovery:

1. 'We admitted we were powerless over alcohol - that our lives had become unmanageable.
   
2. Came to believe that a Power greater than ourselves could restore us to sanity.
   
3. Made a decision to turn our will and our lives over to the care of God as we understood him.
   
4. Made a searching and fearless moral inventory of ourselves.
   
5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
   
6. Were entirely ready to have God remove all these defects of character.
   
7. Humbly asked him to remove our shortcomings.
   
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
   
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
   
10. Continued to take personal inventory and when we were wrong promptly admitted it.
    
11. Sought through prayer and meditation to improve our conscious contact with God as we understood him, praying only for knowledge of his will for us and the power to carry that out.
    
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practise these principles in all our affairs.'

God is willing to help those who turn to Him

'Everyone who calls on the name of the Lord will be saved.'[52]

Christians believe that the ultimate answer to addiction lies in Jesus Christ. Belief in him opens up a whole new world of possibilities. Through his death on the cross, we are forgiven for past sins and given a fresh start with a new life. This is not to say that all our character defects, our sinful behaviours or our problems instantly disappear, but they do begin to change as we are transformed into his perfect likeness. This process of change, initiated and continued by God, coupled with his help, enables us to live as his children in this life and finally to be made perfect by him in the life to come.

'If anyone is in Christ, he is a new creation; the old has gone, the new has come.'[53]
'I can do everything through him who gives me strength.'[54]

'Withdrawal from drugs involves the real agony of facing deep emotions previously submerged beneath the effects of drug abuse. Even prescribed drugs and an atmosphere of human warmth fail because they cannot deal with the agonising question - what is really different when the withdrawal is over?'[55]

Although this comment was made in relation to impoverished drug addicts in Hong Kong, it applies equally well to materially rich doctors. What is there to replace the drug? What can be done to address the problems that drove the addict to alcohol or drugs in the first place? The Good News of the Bible is not only that Jesus will give the strength to beat addiction; he will replace the drug as the focus of life. He will help addicts in a way drugs never could. Christians are not people who live a life without difficulties, they are people who have known God's forgiveness, and who have his help to face this life and his promise of the life to come.

Where do we go from here?

Significant numbers of students and doctors are misusing alcohol and drugs. In order to make any real progress the profession must accept that there is a substantial problem. This requires a concerted effort to make every doctor aware of it.

New education programmes are needed in undergraduate and postgraduate training. Currently only a small percentage of time is spent on substance abuse, despite its importance in society. Effective teaching should involve not only diagnosis, but should help dispense with stereotypes and unhelpful attitudes about sufferers.[24]

Medics should also be taught to recognise danger-signals (both in their colleagues and themselves), to understand why dependence happens (with assurances that medics are allowed to be vulnerable and become ill), and to learn how to deal with it. Despite the signs, most people who eventually receive help have had a serious addiction problem for some years before it was noticed.[16]

Better surveillance of doctors' health would allow for earlier treatment (or perhaps prevention). Self-prescribing should also be discouraged even more vigorously.

Medics must be helped to deal with personal problems as they present, and to cope with stress in more constructive ways. Where possible, stress in professional life should be reduced. Greater support should be available for students, residents and more senior doctors, especially those likely to be isolated. This is an area where churches could and should become involved.

Greater awareness is needed of where to find help and what to do with colleagues in whom difficulties are suspected. We have much to learn from the Americans about treatment programmes specifically designed for doctors and students, and about local, accessible and more informal services.