THE IMPAIRED PROFESSIONAL, PART IV TREATING THE ADDICTED PHARMACIST: DEFINING THE ISSUES WALLACE J. CROSS, RPH, MHS, CADC, JEFFREY N. BALDWIN, PHARMD, RPH, FAPHA, FASHP, BRIAN E. FINGERSON, BS PHARM, RPH, FAPHA, & MERRILL NORTON, PHARMD, DPH, ICCDP-D

his year our nation will once again largely suggested this population is to be the case. In terms of , Tspend somewhere in the area of neither significantly less nor signifi- the work setting itself pres- $559 billion on addiction, potentially cantly more likely to experience such ents hazards on multiple levels (Merlo, making it our nation’s largest health problems (Kenna, Baldwin, Trinkoff, Cummings, & Cottler, 2012). care problem (NIDA, 2008). In studies & Lewis, 2011). However, health pro- Nevertheless, when pharmacists done in 2001–2002 using the DSM-IV fessionals are typically more likely to receive tailored treatment and effec- criteria it was estimated that about 12.5 use addictive prescription tive monitoring and aftercare recom- percent of the population would experi- rather than street . One would mendations they tend to be extremely ence and about 2.5 percent assume that pharmacists, having unique successful in recovery, with a recovery would experience addiction at some knowledge of the pharmacodynamics rate of 87 percent (Cross, Bologeorges, point in their lives (Comton, Thomas, of potentially addicting medications, & Angres, 2013). Stinson, & Grant, 2007; Hasin, Stinson, would be less vulnerable to addiction Regardless, addiction is a disease Ogburn, & Grant, 2007). than other professionals, in at least one in seven individuals, Studies on health professionals have but unfortunately this does not seem affecting many others in many ways.

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Pharmacists need to be prepared to • Recovery processes, including expertise—to significantly interface with address this common disease and its relapse prevention pharmacy colleges and schools to pro- tangential impacts. • Codependency and family mote addiction education for our future Recently, there has been a sharp in- issues and support pharmacists and a safer community. crease in the number of deaths attribut- able to abuse of prescription These areas of deficiency can often Risk Factors for (). Many pharmacists face sig- be opportunities for pharmacy colleges Addiction in Pharmacists nificant challenges in differentiating le- and schools to reach out to their stu- Substance use disorders (SUDs) pose a gitimate and appropriate prescriptions dent counseling programs and addic- significant problem that for addicting medications from scams tion counseling and treatment programs impacts individual and societal well- (e.g., early refills, altered prescriptions, in their communities for guidance and being (US Department of Health and unbelievable excuses, inappropriate assistance. According to self-reflections Human Services, 2010). Among health quantities or doses). Pharmacy robber- related to attendance of pharmacy stu- professions, pharmacy represents a ies and diversion for personal use by dents at open Twelve Step mutual-help group at high risk for experiencing pharmacists are additional concerns. groups such as SUDs. Recent studies suggest several How does the pharmacy education com- (AA), Narcotics Anonymous (NA) or risk factors that may contribute to the munity address addiction prevention, Al-Anon, such experiences have been development of SUD (see the text box education, and assistance? beneficial to their education. on page 64). The American Pharmacists Occupational hazards unique to Addressing Addiction Association Academy of Pharmacy pharmacy involve additional risk fac- Education in Pharmacy Practice and Management (APhA-APPM) tors; these include accessibility to Colleges and Schools established the Practice Interest Group controlled substances, stressful and While addiction remains a common and on Addiction (Addiction PInG) in 2000. unpleasant workplace issues, lack of significant problem, causing consider- In 2012, this was transitioned to the addiction education related to the pro- able societal harm and frequently still Pain, , and Addiction fession, and professional shame that being inadequately addressed in many Special Interest Group (PPCA SIG). develops with impaired pharmacists pharmacy colleges and schools, there Membership in the PPCA SIG currently and their family members prior to treat- exists no mandate in the pharmacy exceeds 3,500 pharmacy students and ment (Merlo et al., 2012; Norton, 2009). education accreditation system defin- pharmacists. It is probable that much of ing the scope or content of addiction the interest in membership in the PPCA Treatment and education. An additional confound- SIG has been generated from student Reentry Differentials ing factor in providing addiction edu- participation in the University of Utah Based on general population studies, cation is content expertise. Pharmacy School on Alcoholism and Other it can be estimated that about one in colleges and schools may often elect Dependencies (Utah School). Beginning seven pharmacists will become addicted not to expand their addiction educa- in 2015, the Utah School has been transi- in their professional careers (Comton et tion, including continuing education tioned to a free-standing APhA Institute al., 2007; Hasin et al., 2007). Therefore, for practicing pharmacists, because on Alcoholism and Drug Dependencies what type of treatments and reentry re- they feel their faculty is unable to ap- with a program and target audience quirements are necessary to rehabili- propriately address the issues involved. very similar to the previous program tate an addicted pharmacist? These issues include: (APhA, 2014). These addiction prevention and Differential #1: • Addiction recognition education challenges, processes, and The Shame of Addiction • Methods for addiction evaluation, resources afford numerous potential Does the pharmacist understand ad- diagnosis, and referral opportunities for counselors—particu- diction as a disease state or is addic- • Addiction treatment larly those with addiction counseling tion perceived as a moral or character issue? Do addicted pharmacists feel that they are an embarrassment to the : If I suspect drug use, should I call the pertinent licensing board? Or, profession? Do addicted pharmacists Q if it is a pharmacy student, do I notify someone in Student Affairs at recover from their and can the pharmacy school? they return to the practice of pharma- : If you are fortunate enough to live in a state that has a recovery facili- cy? These questions are connected to A tation and monitoring program for pharmacists (i.e., a PRN program), an issue that the impaired pharmacist either free-standing or through the licensing board or board of registry, must address in treatment: the profes- call them. They know pharmacists and can give direction. sional shame of addiction. Pharmacists are often able to receive help without this becoming a The professional shame of addiction matter of public record. You may also feel free to contact the Kentucky is an attitude regarding addiction de- Professionals Recovery Network at [email protected] and reference this article. veloped by a professional from person- al, environmental, and societal beliefs

www.counselormagazine.com 61 THE IMPAIRED PROFESSIONAL about addiction. Several authors have substances in a typical practice setting. and support networks (Terrie, 2006). defined professional shame as “a pain- It is possible to place that restriction Even with the success of the PRNs, ful emotion caused by consciousness on the licenses of , dentists, reentry to the profession of pharmacy of guilt, shortcoming or impropriety.” and nurses. can become a somewhat difficult and The treatment of pharmacists must ad- When pharmacists have been iden- slow process. Recovering pharmacists dress this critical issue of professional tified as having a substance use issue, are not guaranteed a job even with ad- shame. In addition, the treatment of they are often not allowed to practice vocacy of state boards and PRNs, and pharmacists must include knowledge pharmacy—due to licensure suspen- sometimes they may be terminated of the disease of addiction, open and sion or revocation—until the problem after long-term employment for past honest communication, and acceptance is resolved and advocacy is granted. substance use transgressions. Recently, of their disease (Milkenovich, 2013). This is accomplished by successfully several of the major drug chains dis- Once pharmacists have demonstrat- completing treatment and initiating in- missed recovering pharmacists for ed a commitment to recovery and a volvement in a PRN program for urine various employment reasons unrelat- substance-free lifestyle, reinstatement monitoring, advocacy, and support. ed to job performance or any evidence with a state pharmacy board to prac- Each state board of pharmacy has its of relapse. tice pharmacy may commence. In most own regulations and procedures for ad- cases, the state pharmacy board will dressing the issue of a pharmacist sus- Relapse Issues require pharmacists to maintain regu- pected of substance abuse. Impaired and Prevention lar contact with an assigned counselor, pharmacists can be reassured that, with Relapse prevention is a core purpose submit to random drug testing, and par- the assistance of PRN programs, they of addiction treatment. The pharma- ticipate in support group meetings on a can face their addictions and get the cy work setting itself presents poten- regular basis. In addition, a pharmacy necessary treatment. It is imperative tially the highest risk work setting for board will very likely place pharmacy for impaired pharmacists to adhere to any health care professional (Kenna, practice restrictions on pharmacists as treatment plans and comply with the Erickson, & Tommasello, 2006). The well as require remedial training and terms of returning to the practice of work setting likely plays a significant reporting, depending on how long they pharmacy in order to remain in good role in both the initial development of have been separated from the pharma- standing with their local boards of addiction and in increasing the poten- cy profession and professional practice pharmacy. Some requirements for re- tial for relapse. The stressors associat- (Milkenovich, 2013). turning to work include the following ed with returning to such a setting can (Kendall, 1991): be significant (Merlo et al., 2012). Many Differential #2: Treatment Aspects community pharmacists fill upwards Addressing mental health and stress- • Six months minimum in of four hundred prescriptions per day, related illnesses are important issues group/individual often with inadequate help. This affords for the rehabilitation of impaired phar- or treatment program them four hundred opportunities each macists to avoid relapse and possible • Attend ninety recovery meetings day to make a mistake which could death. There is evidence that other fac- in the first ninety days, then as cause patient harm and is responsible tors also play a role in developing an designated in the contract for significant stress. Late-night work addiction and depression problems. • Assume financial responsibility shifts can impair a pharmacist’s abil- These personal and environmental fac- for stipulations (e.g., urinalysis) ity to get adequate sleep. Pharmacists tors include personal history of trauma • Submit to random drug testing often suffer from “pharmaceutical in- (violent, emotional or environmental), • Find a recovery sponsor vincibility,” simply meaning that they high stress environments (the pharma- • Abstain from mood-altering drugs feel their knowledge of the pharmaco- cy), obsessive-compulsive traits, the • Provide monthly progress reports dynamics of addicting medications will need to be perfect, and the need to be to pharmacy board and employer somehow keep them safe from addic- in control (Norton et al., 2013). tion (Kenna et al., 2006). Given these Pharmacists who participate in these considerations, as well as free access to Differential #3: Licensure and programs are generally required to addicting medications, the pharmacy Return to Practice sign a contract—often referred to as a work setting, in many ways, is a setup The pharmacy profession has developed Caduceus contract—that obligates them for addiction. the Pharmacists’ Recovery Networks to adhere to certain rules and regula- (PRNs), which operate in nearly every tions that require them to maintain Factors that Increase state in the US. These networks have routine contact with an assigned coun- Relapse Potential multifactorial approaches to effective selor, submit to random drug testing, Pharmacists are not immune to the pit- treatments for pharmacists. The prima- and attend regularly scheduled support falls that face other recovering addicts ry reentry issue to be resolved is that group meetings. Impaired pharmacists (Merlo et al., 2012). For example, not a pharmacist’s license is “all or noth- need long-term care and follow-up to accepting that addiction is a chronic ing,” which means a license cannot be reduce the likelihood of a relapse, as disease can lead individuals to believe restricted from dispensing controlled well as assistance from family, peers, that they have “gotten better” after their

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characteristics of the individuals who relapsed. In this study, eighteen vari- ables were tracked, and seven of the eighteen variables tended to be the strongest predictors of relapse. For the pharmacists in this study group, having an Axis II dual diagnosis (personality disorder) placed them at a 6.75 times greater risk for relapse. The most im- pactful variable in the study stemmed from failure to invest in Twelve Step re- covery (AA/NA), placing them at 17.83 times greater risk for relapse. For those pharmacists in the study with a diagno- sis of either moderate or severe use disorder, the relative risk for relapse was three times greater than for those individuals without that diagnosis. In addition, of significance in this study was the disproportionate percent- age of pharmacists addicted to narcot- ics (74 percent). The use of as an adjunct to aftercare and safely returning pharmacists to their work setting was also of great significance in the study. Narcotic-addicted phar- macists returning to work who were not on a naltrexone regimen were eight times more likely to relapse than phar- Online Resources macists on the naltrexone regimen. The • APhAs Pain, Palliative Care, and Addictions naltrexone regimen lasted for only one Special Interest Group: www.aphanet.org year of the two-year outcomes study. • American Society of Addiction : www.asam.org Fifty-seven of fifty-nine pharmacists • National Institute on Drug Abuse: www.nida.nih.gov on this two-year protocol were suc- • International Doctors in Alcoholics cessful. Seemingly, their success in the Anonymous (IDAA): www.idaa.org second year (without naltrexone) was • Pharmacy-related information: www.usaprn.org due to compliance with their other af- tercare treatment recommendations. Noninvolvement in formal monitoring lives have returned to normal several with narcotics, not alcohol”). This may (PRN programs) after treatment pre- years later. Inadequate investment in lead them to drink occasionally, which dicted a 10.18 times greater risk for re- Twelve Step recovery is probably the in turn makes it very difficult for them lapse. Pharmacists with a prior history most frequent refrain heard by coun- to continue with Twelve Step meet- of relapse were 5.5 times more likely to selors after a relapse. This commonly ings and be honest. A family support relapse than individuals with no prior results from ineffectively shopping system, uneducated in the concepts of relapse history. For those pharmacists for AA or NA groups where they feel addiction and addiction recovery, can who were not married or in a long-term comfortable and connected (e.g., a unwittingly make recovery more diffi- committed relationship, the relative home group) and/or having a sponsor cult for addicts just out of treatment. risk for relapse was 2.94 times greater in name only. Minimal acceptance of Questions may be asked like, “Do you (Cross et al., 2013). addiction frequently leads individuals have to go to these meetings?” or “Why to believe that they are “not as sick as can’t you have a glass of wine with me? Relapse Prevention Strategies those other individuals at meetings” Your problem was with a narcotic” Treatment programs that effectively and is often responsible for not follow- (Angres, 2012; Cross, 2015). address the aforementioned factors— ing through with treatment recommen- In a fourteen-year outcome study factors that increase the potential for dations. Occasionally, individuals may published in the journal US Pharmacist relapse both throughout the course of not buy into the concept that they are in November 2013, 116 pharmacists were the individual’s treatment as well as ef- unable to safely use any mood-alter- followed for two years to determine both fectively adopting a comprehensive af- ing substance (e.g., “My problem was their success rate and to study specific tercare plan (e.g., Caduceus contract) to

www.counselormagazine.com 63 THE IMPAIRED PROFESSIONAL maintain focus on these same factors— include elements such as working only Information regarding addictive dis- should optimize the chances of success with another pharmacist present for six ease is not taught in any detail in many (Cross, 2015; Domino et al., 2005). months, avoiding shift work, avoiding health care professional schools such Having strong family participation responsibilities for inventory control, as medicine, pharmacy, , and in education regarding addiction and and, when possible, working in a posi- (Wood, Samet, & Volkow, their role in patients’ recovery are es- tion without direct access to controlled 2013). Consulting a primary care pro- sential features in a well-constructed substances for the first three months, vider about options can therefore be a treatment program. For those indi- and in some cases, finding a permanent risky proposition. There has been some viduals struggling with Twelve Step position with no access (Cross, 2015). recent emphasis for primary care pro- participation, directly addressing any A current and significant problem viders to become more educated about barriers that have come up for them that exists for pharmacists is difficulty risk, recognition, and finding a resolu- can be most helpful as most of them finding work. In the pharmacy profes- tion to this type of a problem. Dr. Mark have a solution. Education is recom- sion there exists a judgmental atmo- Willenbring, director of the Division of mended regarding the effective use of sphere, mostly based on inadequate Treatment and Recovery Research at such meetings, such as how to shop for knowledge of addiction and recovery the National Institute on meetings that will work for them over that may hinder pharmacist reentry and Alcoholism (NIAAA), recommends time as well as criteria they can use and recovery. The following is a direct that physicians consult the NIAAA’s re- when looking for a sponsor (Angres, quote from the American Society of cently updated “Helping Patients Who 2012; Cross, 2015). Addiction Medicine’s (ASAM’s) policy Drink Too Much: A Clinician’s Guide” Recovery contracts should be well statement number 11: (2005; Willenbring, Massey, & Gardner, thought out with the provisions in the 2009). A related Journal of the American contract discussed with pharmacists Addictive illness is a stigmatized Medical Association (JAMA) article throughout treatment. They could in- malady misunderstood and stated that the guide outlines tools clude the following recommendations encumbered by myth and for rapid screening, assessment, and (Cross, 2015): misinformation based on antiquated management of high-risk alcohol use, beliefs from the 18th, 19th, and early including use. Screening, • Participating in a PRN 20th centuries . . . Historically, many , and Referral to program for urine monitoring, regulatory agencies (RAs) and the Treatment (SBIRT) is also shown to be advocacy, and support health care community have viewed an effective way for primary care pro- • Individual therapy, addictive illness from the moral model viders to intervene with patients who marital therapy or both perspective (ASAM, 2011). may have a problem (Saitz et al., 2013). • Follow up with a psychiatrist In addition, there is a treatment lo- to monitor mental This mindset continues to make cator site available to access online at health medications it difficult for pharmacists to find https://findtreatment.samhsa.gov/. • Frequent AA/NA meetings with work. While this treatment locator may be significant sponsor involvement helpful, it is best to check with some- • A quarterly meeting with Resources Available one within your state who works with an addictionologist to Counselors treating or monitoring addicted health • A comprehensive section Being confronted with someone who professionals to get an opinion on the for specific “back to work” has a possible effectiveness of the treatment provided practice recommendations can be overwhelming—to whom does at a particular facility and whether it one turn for help? Where does one is suitable for the type of patient to be These recommendations frequently begin to look for answers and options? referred. Please refer to the text box on page 63 for further resources available to pharmacists online. c Risk Factors for SUDs • Age of first use Acknowledgements: The authors would like to thank Suzanne Albrecht, PharmD, MSLIS, • Current alcohol/drug use for her help in preparing this document. • Trauma history • Family history of SUD and psychiatric illness Wallace Cross, RPh, MHS, • Impulsivity CADC, has worked as a certi- fied addiction therapist with ad- • Protective factors dicted health care professionals • Negative proscriptions for the past twenty-six years. • Genetic use patterns Mr. Cross has lectured both na- tionally and internationally and • Perceived stress published various articles on Source: Babor, Higgins-Biddle, Saunders, & Monteiro, 2001; Brown, Stout, & Mueller, 1999; Cyders et al., 2007; DeWit, Adlaf, Offord, & Ogborne, 2000; Hawkins, Catalano, & Miller, 1992; Kellogg et al., 2003; Merikangas et al., 1998; Norton, 2009; Norton, Ford, & Al-Shatnawi, 2013; Wells, the topic of addiction in phar- 2010; Whiteside, Lynam, Miller, & Reynolds, 2005. macists. He is a faculty member at the University of Illinois College of Pharmacy and Chicago State University College of Pharmacy.

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Jeffrey N. Baldwin, PharmD, Brown, P. J., Stout, R. L., & Mueller, T. (1999). Substance Merlo, L. J., Cummings, S. M., & Cottler, L. B. (2012). RPh, FAPhA, FASHP, is vice use disorder and posttraumatic stress disorder co- Recovering substance impaired pharmacists’ views re- chair and professor of phar- morbidity: Addiction and psychiatric treatment rates. garding occupational risk for addiction. Journal of the macy practice at the College Psychology of Addictive Behaviors, 13(2), 115–22. American Pharmacists Association, 52(4), 480–91. of Pharmacy, University of Nebraska Medical Center. A Comton, W. M., Thomas, Y. F., Stinson, F. S., & Grant, Milenkovich, N. (2013). The impaired pharma- past president of the American B. F. (2007). Prevalence, correlates, disability, and co- cist: Rehabilitation, regaining dignity, and licen- Association of Colleges of morbidity of DSM-IV drug abuse and dependence sure. Mental Health Clinician, 3(6), 313–5. Pharmacy, he is recipient of in the United States: Results from the national epi- the Hugo H. Schaefer Award demiologic survey on alcohol and related condi- National Institute on Alcohol Abuse and from the American Pharmacists Association for tions. Archives of General , 64(5), 566–76. Alcoholism (NIAAA). (2005). Helping patients his professional and societal contributions to sub- who drink too much: A clinician’s guide. Retrieved stance use disorder assistance and education. Cross, W. (2015). Issues surrounding relapse in phar- from http://pubs.niaaa.nih.gov/publications/ macists. Presented at the American Pharmacist Practitioner/CliniciansGuide2005/guide.pdf Brian E. Fingerson, BS Association’s Institute on Alcoholism and Other Drug Pharm, RPh, FAPhA, is ad- Dependencies, June 7, 2015, Salt Lake City, UT. National Institute on Drug Abuse (NIDA). 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Chronic care management for dependence on al- University of Georgia College cohol and other drugs. JAMA, 310(11), 1156–67. of Pharmacy. Dr. Norton has Domino, K. B., Hornbein, T. F., Polissar, N. L., Renner, also been a faculty member G., Johnson, J., Alberti, S., & Hankes, L. (2005). Risk Terrie, Y. C. (2006). Lean on me: Help for the im- of the Fairleigh-Dickinson factors for relapse in health care professionals with paired pharmacist. Pharmacy Times. Retrieved University postdoctoral train- substance use disorders. JAMA, 293(12), 1453–60. from http://www.pharmacytimes.com/ ing program in the University of publications/issue/2006/2006-11/2006-11-6061 Georgia School of Continuing Education and Alliant Hasin, D. S., Stinson, F. S., Ogburn, E., & Grant, B. International University in the areas of psychophar- F. (2007). Prevalence, correlates, disability, and co- US Department of Health and Human Services. macology and addiction pharmacy. 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