When investigating any serious question, it is necessary to both identify what it is, exactly, that is being investigated, as well as what other reliable, scholarly research has found. This is especially true during an era in which modern medical technology and pharmacology result in an increasing number of individuals who must put their very lives in the hands of health care professionals whom they do not know. Therefore, it is rational and reasonable to investigate substance abuse issues among those health care professionals who have ready access to drugs.
Research Questions
The following research questions have been identified as appropriate for inclusion in this study:
- Is working in a stressful hospital environment a risk factor for health care personnel to become substance abusers?
- Is working in close proximity to areas in which narcotics and anesthetics are readily available a risk factor for health care personnel to become substance abusers?
- Is there a personality profile that suggests a particular health care worker might be at greater risk than others for developing a substance abuse problem?
- If substance abuse is shown to be a problem in the health care professions most readily exposed to drugs (See Research Question #2), have health care institutions taken steps to prevent or remedy the situation?
Review of Literature
The review of relevant research includes studies whose focii are on both nurses and physicians, including those who work in specialty settings.
Nurses
Bell, McDonough, Ellison, and Fitzhugh (1999) investigated the misuse of controlled drugs by Certified Registered Nurse Anesthetists (CRNAs) in an effort to determine its prevalence. Self-administered surveys were mailed to 2,500 CRNAs who were actively practicing in the United States. The response rate was 68.4%. Findings showed that 9.8% of the sample admitted to the misuse of controlled drugs, with most admitting to the misuse of more than one controlled drugs. The strongest predictors of risk for misusing controlled drugs were found to be: between 31 and 45 years of age, male, between six and ten years in practice, currently practicing in a clinical position in an urban Midwest or Southeast location. Drugs of choice seem to be Benzodiazepines, propofol, inhalation agents, and opioids, in that order. The preference, by far, is for midazolam, and nitrous oxide. Hotlines seem to show that there is a steady increase in the misuse of midazolam. The reason for this is unknown. Recommendations are for expanded education with respect to role strain and addiction among nurses from the time they are in school, on through their professional experience. This article has value to the nursing profession, in that it provides concrete data on which to build prevention, intervention, and treatment programs.
Griffith (1999) defined an array of substance abuse disorders among nurses. With respect to epidemiology, it has been found that substance abuse among nurses is approximately equal to that among the general population. Griffith (1999) goes on to define the etiology of substance abuse disorders as clearly biopsychosocial, the result of a complex combination of biological, psychological, and social influences. The treatment of choice, for nurses, is currently a diversion program in which the nurse voluntarily withdraws from practice and does not return until safe practice can be assured. Treatment outcome is mixed. On one hand, nurses report an 85% to 90% recovery rate but, without effective treatment plans and support, also report approximately a 50% relapse rate. Education and a knowledgeable administration are seen as the most promising means of addressing the issue of controlled substance abuse among nurses, especially among those nurses who work in environments associated with anesthesiology, severe injury, and surgery. The value of this article lies in its identification of the factors influencing substance abuse among nurses, as well as the program that is, as of now, the best choice for this group.
In an earlier study, Trinkoff and Storr (1994) had already begun to investigate a possible relationship between specialty and access to substance use among registered nurses. The method used for this study was an anonymous, eight page survey mailed to 200 registered nurses in Maryland. The response rate was 55%. From this survey, it was learned that 69% reported having used illicit drugs on at least one occasion and 15% reported illicit drug use within the past year. Ninety-three percent had used alcohol on at least one occasion and 19% reported having more than 5 drinks in one day within the past year. Smoking was shown to have dropped from 40% to 16%. Overall, 2% reported a drinking problem and 8% reported a drug problem. Predictably, those who have easy access to controlled substances had the highest incidence of drug abuse. It was also found that the combination of easy access and working in any area associated with a critical care specialty was the greatest predictor or substance abuse. It is also believed that those nurses who do self-medicate are more comfortable taking the drugs they regularly administer to patients. These are the drugs with which they are most familiar and the drugs whose pharmacological properties they best understand. The value of this study lies in its identification of the drugs that are most widely abused, so that steps can be taken to develop prevention strategies.
Physicians
The use of psychoactive substances in three medical specialties was investigated by Lutsky, Hopwood, Abram, Cerletty, Hoffman, and Kampine (1994). The three specialties under consideration included anesthesia, medicine, and surgery. Results were obtained from 1,624 mailed questionnaires. Findings showed a prevalence of 14.4% impairment in surgery, 19.9% in medicine, and 16.8% in anesthesia. The greatest predictor of abuse was not which specialty a physician practiced in, but whether or not there was a family history of substance abuse. It was shown that 32.1% of the abusers has a family history of substance abuse, compared to only 11.7% of non-abusers. Neither increased stress, nor problem areas in medical life were factors in contributing to substance abuse among physicians. The value of this study lies in the fact that it disproves the commonly held, but erroneous belief that stress and accessibility are factors leading to substance abuse among health care professionals.
Cook (1998), a personnel selection research specialist, conducted his own study, after observing what he believed to be the non-valid criteria used to hire physicians at his hospital. In effect, what he did was a mini-meta analysis, to determine what, if any, kinds of testing should be done on both physicians applying for positions, and even medical students who are still in school. What Cook (1998) found was that such criteria as good grades in school and letters of recommendation are predictors only that the physician or medical student knows how to do their job and present a good image to the public. This researcher wanted to find tests that would be predictors of risk for substance abuse and discovered that only personality tests can successfully predict whether or not an individual is at risk for any type of substance abuse. Cooks (1998) findings were further validated when he looked at the testing done by such organizations as the United States Military. Ultimately, Cook (1998) compiled a 30 year historical background study showing that IQ tests, dexterity tests, behavior tests and personality tests should all be given to potential physician employees and medical students. However, only the personality test has the capability of predicting whether or not an individual is at risk for substance abuse.
According to Cook (1998), the most common warning signs of potential risk for substance abuse among physician employee applicants and medical students include:
- Scoring, overall, in what would be a normal range for the general population. Their overall score should be higher than that of the general population.
- Their highest score is not a wish for achievement via independence.
- Their lowest scores, traditionally self-control, wanting to make a good impression on others, and amicability, are in what would be a normal range for the general population or below. While these are normally low for physicians, they should still be higher than those in the general population.
- If they lack interest in others and have low levels of empathy.
Any, or all of the personality characteristics listed above should raise a question in the minds of those who are responsible for the hiring of physicians and for the education of medical students, if they wish to intervene at the beginning of the risk for substance abuse among health care professionals. The value of this study lies in the fact that it was conducted by someone who is not a health care professional. Instead, this researcher is a personnel research specialist, whose work can assist hospitals in avoiding hiring individuals who are at high risk for substance abuse.
Summary
The review of relevant scholarly research reveals that health care professionals are, overall, no more at risk for developing problems with substance abuse and addiction than any other group in the general population. In addition, the review of literature also shows that even working in a stressful work environment is not a predictor for drug abuse. Although drug abuse among nurses is slightly higher than in the general population, it is not significantly higher; and drug abuse among physicians is fairly consistent with the incidence in the general population. It is interesting to note that the greatest predictor of substance abuse and addiction, among health care professionals, is a family history of addiction. Armed with this information, suggestions for further research would necessarily include the development of prevention and intervention programs designed to meet the needs that were uncovered in the historical and epidemiological research. The review of relevant research has spoken to the research questions posed, and will serve as a foundation to support further investigation.
References
Bell, D.M., McDonough, J.P., Ellison, J.S., & Fitzhugh, E.C. (1999). Controlled drug misuse by Certified Registered Nurse Anesthetists. AANA Journal, 67(2), 133 – 140.
Cook, M. (1998). New approaches to selecting medical staff. British Journal of Medicine, 316, 7134. Retrieved: October 1, 2004, from: http://bmj.bmjjournals.com/cgi/content/full/316/7134/S2-7134
Lutsky, I., Hopwood, M., Abram, S.E., Cerletty, J.M., Hoffman, R.G., & Kampine, J.P. (1994). Use of psychoactive substances in three medical specialties: Anesthesia, medicine and surgery. Canadian Journal of Anaesthesia, 41(7), 561 – 567.
Griffith, J. (1999). Substance abuse disorders in nursing. Nursing Forum, 34(4), 19 – 28.
Trinkoff, A.M., & Storr, C.L. (1994). Relationship of specialty and access to substance use among registered nurses: An exploratory analysis. Drug and Alcohol Dependence, 36, 215 – 219.
