The public consistently ranks pharmacists as being among the most honest and ethical of all professional groups.¹ Therefore, it might be surprising to learn that one in nine, or about 11% of pharmacists, suffers from addictive disease (AD) at some point in their career.² The combination of easy access, job stress, and a host of other factors conspire to make nonmedical prescription substance abuse a problem in the pharmacy setting.

However, it is promising to note that pharmacists are generally more successful at recovery than the population at large and than other groups of health care professionals. Fortunately, numerous opportunities exist for confidential, successful treatment, including facilities that specialize in treating health care professionals. Greater awareness of treatment programs and education about AD that begins in pharmacy school are the keys to illuminating the problem, treating addicted pharmacists, and protecting the public at large.  

Risk Factors Unique to Pharmacists
Sheer access and exposure to prescription addicting substances may explain why substance abuse is more common among pharmacists than among the general public. In fact, pharmacists may have the highest risk work setting of any professional group when it comes to AD. 

It is not uncommon for pharmacists to be responsible for filling enormous numbers of prescriptions daily, often without adequate help. The high number of opportunities to make mistakes can lead to high levels of stress and, ultimately, job dissatisfaction.³

Job stress, added to ready access to highly addictive substances in an environment that often tolerates self-medication, can make diverting medications seem innocuous. If a layperson develops diarrhea, a coworker might suggest purchasing an over-the-counter remedy or seeing a doctor; however, if a pharmacist complains of diarrhea, a colleague might suggest taking a few Lomotil. Mention of a splitting headache may result in a recommendation for Fiorinal. Muscle or back pain from weekend activities might lead to Monday morning Vicodin. Pharmacists may begin rationalizing the drug-taking behavior by thinking, At least I was able to stay at work and not go home sick.  

Other factors that can place health care professionals at high risk for abuse include⁴: 

• A genetic predisposition to addiction (ie, a family history of dependence)
• Long work hours and shift work
• Feelings of invincibility, or believing that being knowledgeable about the pharmacodynamics of potentially addictive medications protects against addiction
• Social factors, including a lack of peer, academic, or occupational discouragement for prescription diversion
• Comorbid mental disorders or medical conditions, particularly those involving chronic pain 

Inadequate training and education about addiction adds to the risk of pharmacists developing AD. Most pharmacy schools teach little about the subject. They may touch on the pharmacology of an addicting agent, but seldom delve deeper. Pharmacy schools should teach students about the psychological and biological aspects of addiction, the criteria for the condition (see TABLE 1), and the options available for recovery and treatment. Students should learn that confidential treatment programs exist, and they should know how to get help if required.

Click here to view a larger version of this Table

In addition, pharmacy workplaces should have pamphlets readily available that discuss AD and detail where employees can go for a confidential chemical dependency assessment (usually free of charge). One way to find a treatment center is to visit the site of the Pharmacists Recovery Network (PRN; www.usaprn.org), a unique network dedicated to helping addicted pharmacists and pharmacy students. Moreover, information is available at www.drug-rehab.org, a non-profit group that provides referrals to treatment programs in all 50 states. (For additional treatment options, see SIDEBAR 1: Treatment Facilities that Specialize in Treating Health Care Professionals.)

Conscientiousness Leads to Reticence
Pharmacists tend to be extremely conscientious about their jobs and the responsibility they have to the health of their patients. This feeling, combined with the fear and shame of losing their license and/or livelihood, may make them more reticent than other health care professionals to seek help. Additionally, the problem may be easier for them to cover up, as it is uncommon for pharmacists to use IV or illegal drugs, and they seldom obtain drugs from anywhere other than their workplace. In fact, hydrocodone is most commonly the pharmacist’s drug of choice. 

Many pharmacists are unaware that they can get help for AD confidentially. Allowing pharmacists to come forward confidentially helps minimize risk to the public. Most pharmacists believe that coming forward and requesting assistance will mean the end of their career, but pharmacists should be aware that HIPAA guidelines strictly prohibit private treatment programs from discussing any patient with anyone. PRN programs can potentially report a pharmacist who refuses to comply with treatment or after-care protocols to the pharmacy board, but pharmacists should be assured that PRN programs give pharmacists every opportunity to succeed at recovery.

If You Suspect a Colleague Has Addictive Disease
If a coworker is exhibiting a number of the signs listed in TABLE 2, and you suspect AD, a first step might be to contact PRN or any pharmacist recovery program. Once you have done so, you can approach the addict with the information that you contacted a confidential treatment program and that they are now aware of the situation. Explain that the only way to avoid repercussions is for the addict to contact the program for help voluntarily. If the coworker does not, he or she will be reported to the pharmacy board. 



Most recovery programs are based on the 12 steps made famous by Alcoholics Anonymous (AA). In fact, most programs require a minimum of three AA or Narcotics Anonymous (NA) meetings per week. Most also require working with a sponsor and participating in a health professional’s after-care or Caduceus group. Some require individual therapy.

Treatment programs commonly begin with an active treatment phase lasting approximately 6 to 10 weeks. Although some are designed as complete inpatient programs, many are termed boarded partial hospitalization programs. For example, in the program at Presence Behavioral Health, patients live in apartments across the street from the treatment facility. This allows them to maintain some independence when they are not in treatment sessions and attend AA or NA meetings in the evenings. 

Most after-care programs last about two years and involve weekly group therapy sessions, as well as ongoing AA or NA meetings. Following participation in after-care, participants often have certain practice restrictions and should expect to be monitored in the workplace for five years. Because almost three-quarters of pharmacists who have ADs are addicted to opioids,4 one of the conditions for returning to work may be that the pharmacist takes the opioid blocker Vivitrol. Other restrictions might be that the pharmacist is not allowed to work alone or do shift work.

Participation in a pharmacy assistance program is an extremely strong predictor of successful recovery. One study reported that those pharmacists who were not engaged in a pharmacy assistance program were 10 times more likely to relapse than those who participated.4 Interestingly, workplace setting may play a role in job retention. Pharmacists working in community settings—most notably for large pharmacy chains—were far more likely to be terminated than pharmacists working in hospitals or other settings. After identifying their addiction, 75% of community pharmacists, 29% of hospital pharmacists, 17% of students, and 50% of pharmacists from other settings were terminated from their positions.4   

Pharmacists are Successful at Recovery
Pharmacists are generally more successful at recovery than the population at large and than other groups of health care professionals, such as physicians and nurses (see SIDEBAR 2). In fact, in the previously discussed study involving 116 addicted pharmacists, 87% remained abstinent at the end of a two-year follow-up period, as confirmed by random urine screens, clinician observation, and participant self-reports.⁴ The study found that being single, as opposed to married, was associated with a higher risk of relapse, as was having a personality disorder, having a prior treatment history, having alcohol as their drug of choice, and not being fully invested in the 12-step recovery program throughout the follow-up period. Notably, although alcohol is not the drug of choice for most pharmacists, it is associated with a three-time greater risk of relapse for those who abuse it compared with those who do not abuse it.⁴

Part of the reason for the high success rate among pharmacists seeking treatment is the tendency to abuse opioids rather than other agents, which makes the use of naltrexone possible. Naltrexone seems to help protect against relapse. The risk of relapse was eight times greater in pharmacists not prescribed naltrexone than among those using the agent.⁴ In addition, pharmacists tend to be more compliant with treatment than other health care groups. 

Light at the End of the Tunnel
Although certain aspects of the pharmacy profession place pharmacists at high risk for AD, confidential, effective treatment is available. Treatment programs tailored specifically to pharmacists offer promising results and the best hope of a return to work. 

It is important to remember that even after recovering pharmacists return to the workplace, the high-risk environment mandates attention to return-to-work issues and to ongoing support. Education that begins in pharmacy school and building awareness about the problem remain the best lines of defense.

References

1. Gallup. Honesty/Ethics in Professions. http://www.gallup.com/poll/1654/honesty-ethics-professions.aspx. Accessed June 10, 2014.
2. Baldwin JN. The addicts among us. Am J Pharm Educ. 2009;73(7):124.
3. Munger MA, Gordon E, Hartman J, Vincent K, Feehan M. Community pharmacists’ occupational satisfaction and stress: a profession in jeopardy? J Am Pharm Assoc. 2013;53(3):282-296.
4. Cross W, Bologeorges S, Angres D. Issues and data associated with addictive disease in pharmacists. US Pharm. http://www.uspharmacist.com/continuing_education/ceviewtest/lessonid/109516/. Accessed June 10, 2014.

Wallace Cross, BS Pharm, MHS, CADC, has recently retired, but was senior case manager and pharmacy program coordinator of the Professionals Addiction Treatment Program at Presence Behavioral Health in Chicago, Illinois, for 22 years. He continues to work as an independent consultant. 

SIDEBAR 1
Treatment Facilities that Specialize in Treating Health Care Professionals 

Betty Ford Center 
Rancho Mirage, CA
www.bettyfordcenter.org

Farley Center 
Williamsburg, VA
www.farleycenter.com

Hazelden 
(multiple locations) 
www.hazelden.org

Pine Grove Behavioral Health and Addiction Services 
Hattiesburg, MS 
www.pinegrovetreatment.com

Presence Behavioral Health (formerly Resurrection) 
Chicago, IL 
www.presencehealth.org

Professional Renewal Center 
Lawrence, KS 
www.prckansas.org

Rogers Memorial 
Milwaukee and Oconomowoc, WI
www.rogershospital.org

Talbott Recovery Campus 
Atlanta, GA 
www.talbottcampus.com

SIDEBAR 2
Portrait of a TypicalPharmacist Addict

Mary is a 28-year-old, divorced single mother with a four-year-old daughter. She works the day shift as a pharmacist on the inpatient unit in a large suburban hospital. The hospital provides a day care center where she can leave her daughter while she works. 

Mary suffers from chronic lower back pain and has a prescription for Vicodin, which she has progressively taken in larger and larger doses. She begins suffering fairly serious withdrawal symptoms whenever she tries to cut back. 

Feeling afraid, overwhelmed, and unable to manage her job and care for her daughter, Mary began diverting Vicodin from her workplace. She was successful for six months, but Mary’s diversion was eventually discovered. Her hospital offered her a last chance contract, which stipulated that if Mary sought professional help and followed through with all of the treatment recommendations, she could retain her job.

Mary was referred to her state’s PRN Program, which referred her to a recovery facility specializing in treating health care professionals. Mary successfully completed an eight-week treatment stay and began the facility’s two-year aftercare group therapy program (once per week). Mary also complied with frequent, random urine screens, three AA/NA meetings per week, and a regimen of monthly Vivitrol. Because Mary remained fully compliant with all of the recommendations made by the treatment facility and the PRN Program, she was not reported to the pharmacy board in her state. 

Today, Mary has been successful in her recovery for over five years and has completed all of her monitoring obligations, but continues to invest in her AA/NA program by attending her regular weekly AA/NA meetings and meeting regularly with her AA/NA sponsor.