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Drug-Impaired Professionals.

Drug-Impaired Professionals, by Robert Holman Coombs (Cambridge, MA, and London, England: Harvard University Press, 1997), 351 pp., $39.95 (cloth only).


In America the issue of occupational vulnerability to alcohol- and other drug-related problems has been a subject of observation and study for more than 200 years. Dr. Benjamin Rush raised this question in 1777, when he expressed concerns about increased consumption of distilled spirits by soldiers and called into question the use of daily "grog rations" in the United States Army.(1) Literature from the inebriates' asylum era was filled with observations that particular occupational groups seemed to be prone to alcoholism and other drug addictions. For example, Dr. R. P. Harris suggested that shoemakers were "especially difficult to reform, as they incite each other to drink, and club together and send out for beer and whiskey."(2) There was particular concern about addicted physicians during the 19th century and early 20th century. In 1883, Dr. J. B. Mattison attributed the high incidence of morphine addiction among physicians to their access to narcotics, their intimate knowledge of the hypodermic, and the weary days and sleepless nights that so typified their lives.(3) Nineteenth-century autobiographical accounts of morphine dependency also underscored how easy it was for physicians to become addicted.(4) Dr. T. D. Crothers suggested that the professional classes were particularly vulnerable to addiction and estimated that 10% of American physicians were addicted to narcotics.(5) In 1911 Dr. Benjamin Burley set forth a theory of occupational vulnerability to alcoholism. In explaining the particular susceptibility of horse-keepers to inebriety, he noted: "I believe here we are dealing with a peculiar animal-loving but unstable temperament which is naturally susceptible to intoxication." Burley also believed merchants and salespeople were vulnerable to inebriety due to the custom of drinking at business meetings and dinners.(6)

Most of this concern and this literature faded from history with the collapse of inebriates' homes and asylums. While some attention to exploring alcoholism as an "occupational disease" was sparked in the 1940s in tandem with the rise of what has been called the modern alcoholism movement,(7) this was only a warm-up for the intense focus on addicted professionals that grew out of the addiction treatment industry's more recent interest in "special populations." That interest generated a large body of literature, to which Robert Holman Coombs has added a new and significant contribution in Drug-Impaired Professionals.


The growing array of literature on impaired professionals has emerged as a genre within the larger body of addiction literature. Subjects that have become mandatory in articles and texts addressing this issue include: literature reviews of problem prevalence; overviews of the sips, symptoms and stages of addiction; overviews of treatment modalities and mutual aid societies; and discussions of the specialty groups that exist specifically to aid addicted professionals. Even though Coombs's text covers these required discussions with greater depth and insight than many earlier texts, its strengths lie in another area.

Coombs's first contribution is his recognition that addicted and recovering professionals are not a homogeneous group to be easily depicted in sweeping generalizations. The addiction of "pedestal professionals" is portrayed as springing from multiple etiological pathways that unfold in diverse drug choices and patterns of use and consequence and that follow different pathways of recovery. Typical of this subtlety is Coombs's classification of professionals across a continuum of drug-involvement intensity: abstention (Type 1), those who use socially (Type 2), those who abuse drugs but are not chemically dependent (Type 3), those who are physically but not psychologically dependent (Type 4), and those who are physically and psychologically dependent (Type 5). Coombs makes particular note of how Type 4 and Type 5 differ in their response to treatment and styles of recovery; for example, Type 4 individuals share a greater capacity for self-initiated "solo recovery" (recovery without benefit of formal treatment or affiliation with a mutual aid society).

Any text on drug-impaired professionals should answer at least four questions: (1) What is the relative prevalence of alcohol- and other drug-related problems among professionals? (2) What unique factors influence the vulnerability of professionals to alcohol- and other drug-related problems? (3) How do the patterns of use and addiction differ for professionals? (4) How is the process of treatment and recovery different for professionals? Coombs addresses all of these questions, but the book's unique contribution lies in its answers to questions 3 and 4.

Coombs uses an extensive review of the professional literature and the findings of interviews with 91 addicted professionals (physicians and medical students, dentists, pharmacists, nurses, attorneys, and pilots) to answer these questions. The professional literature portrays medical professionals, lawyers and pilots to be at higher risk for alcohol- and other drug-related problems than members of the general population. This same literature notes the overrepresentation of addiction-related problems within the disciplinary actions taken against these professionals. In spite of such documentation, Coombs suggests that chemical dependency among professionals exists as a "secret sickness" masked by cultural misconceptions of who is and who is not vulnerable to addiction.

Coombs's insights into the question of the conditions that make professionals vulnerable to alcohol- and other drug-related problems include discussions of the pedestal pressure placed on such professionals and the temptation to use psychoactive drugs to bridge the gap between this idealized image and one's real self. The neglect of emotional needs within the rigorous training of professionals, the endemic overwork, the resulting social isolation and erosion of self-care, the easy availability of drugs (for medical professionals), and lack of knowledge about addiction am all explored as factors contributing to professionals' vulnerability to addiction. It is little wonder within such a context that drugs pose as magical elixirs promising improved performance, relaxation, social ease, relief from physical and emotional pain, and, not insignificantly, sleep.


What Coombs offers that others have not is an ethnography of the addicted professional. This is a well-written book, but its most unique quality is that it lets the words of addicted and recovered professionals pass directly to the reader with a minimum of adulteration and interpretation. If you would like to listen to nearly 100 professionals tell you what they have learned from their own addictions and recoveries, this book provides just such an opportunity. It takes you inside the surgery suite with the fentanyl-addicted anesthesiologist whose perfect attendance is due to the workplace's role as the source of fentanyl. You go inside the cockpit of an airplane with the hangover-plagued alcoholic pilot, and inside the hospital room with the addicted nurse. You discover how physicians and nurses "eat the mail" (use drug company samples) and use "pad power" (false prescriptions) as well as deception and theft to sustain their addictions. You learn the quite remarkable story of an addicted Samaritan pharmacist who filled patients' prescriptions out of his own drug supplies when the pharmacy ran out of particular drugs. Coombs's book opens a window into the culture of the impaired professionals--their rituals of drug procurement and of drug use, and their strategies to avoid detection. With 30 years in the addiction field, I have encountered many ingenious methods used by addicts to conceal their drug use, but the Coombs-detailed descriptions of schemes used by physicians, nurses, and pharmacists to beat drug-testing procedures were by themselves worth the price of the book. From pharmacists who concoct fake urine to physicians and nurses who devise elaborate methods of urine substitution, one learns how impaired professionals use their intelligence and creativity to sustain their addictions. We also learn how for most professionals addiction was not a plunge but a slow, insidious slide from self-willed control to loss of control. Most of all, the reader gets an inside look at the incredible isolation and secrecy that dominate the life of the addicted professional.

Coombs's book is also a cartography of the addicted professional's mind, expressed in a raw, unfiltered manner. We learn the patterns of thinking that postpone the professional's self-confrontation with his or her status as an addict. Many professionals, by viewing addicts with considerable contempt and disdain, cherish an exaggerated caricature of addiction to deny the reality of their own loss of control over their drug intake. Although Coombs's medical informants knew surprisingly little about addiction before they experienced it, their knowledge of drugs and their professionally groomed sense of omnipotence often provided a false security against addiction. Many believed they would recognize when they were getting in trouble and could switch drugs to avoid addiction. We learn in this book the turning points that marked the transition from addiction to recovery, and we learn something about the developmental stages of recovery shared by the professionals in Coombs's study. Particularly striking are the varied paths that led to recovery for those interviewed: overdoses and medical problems, self-recognition of a problem, despair, legal troubles, or pressure from family or colleagues. The reader also encounters variations in sobriety-based support structures used by those Coombs interviewed. These ranged from traditional treatment and Twelve Steps affiliation to "solo recovery." If professionals are more vulnerable to addiction, the good news is the remarkably high (75%-90%) recovery race reported in the addiction treatment literature that Coombs reviews.

Coombs does not spend much time describing the special addiction treatment programs for the impaired professional that were implemented and heavily marketed during the past 15 years. However, there is a quite complete overview of mainstream recovery support structures, ranging from AA to Women for Sobriety, Rational Recovery, Secular Organizations for Sobriety, and Moderation Management. Also included are listings and brief discussions of programs for impaired professionals organized by national and state professional associations, as well as information about other specialty support groups for professionals.

Given my disappointment with recent contributions on the subject of impaired professionals, particularly the lack of any fundamentally new data or insights, I approached this book with low expectations. To my delight, I found a source of richness drawn from Coombs's interview material that has been missing in recent literature. Drug-Impaired Professionals offers an opportunity for the researcher and the clinician alike to meet the people who exist within that category. I particularly recommend this book to those persons, such as EAP professionals and addiction counselors, whose duties include direct work with addicted and recovering professionals.


(1.) Cherrington, Ernest (1920). The Evolution of Prohibition in the United States. Westerville, Ohio: The American Issue Press, pp. 41-42.

(2.) Arthur, Timothy S. (1877). Strong Drink The Curse and the Cure. Philadelphia: Hubbard Brothers, p. 560.

(3.) Mattison, J. B. (1883). Opium Addicts Among Medical Men, Medical Record, 23:621-623.

(4.) Mattison, J. B. (1883). A Personal Narrative of Opium Addiction, Medical Gazette, 10:315-317.

(5.) Crothers, Thomas D. (1893). The Disease of Inebriety from Alcohol, Opium and Other Narcotic Drugs: Its Etiology, Pathology, Treatment and Medico-legal Relations. New York: E. B. Treat, p. 127; Crothers, Thomas D. (1899). Morphinism Among Physicians, Medical Record, 55:784-786.

(6.) Burley, Benjamin T. (1911). The Importance of Determining the Causes of Inebriety, Boston Medical and Surgical Journal, Vol. CLXV, No. 8, pp. 275-279. (Reprinted, Boston: W. M. Leonard, p. 5.)

(7.) Typical of the 1940s literature is J.I.F. (1947), Alcoholism: An Occupational Disease of Seamen, Quarterly Journal of Studies on Alcohol, 8:498-505.
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Author:White, William L.
Publication:Contemporary Drug Problems
Article Type:Book Review
Date:Dec 22, 1997
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