Drug and Alcohol Abuse Among Physicians: How Concerned Should We Be?

By John Banja 



John Banja, PhD is a medical ethicist at Emory University’s Center for Ethics, a professor in the Department of Rehabilitation Medicine, and the editor of AJOB Neuroscience.




In next month’s (December, 2014) issue of the American Journal of Bioethics, I’ll have an article appear on drug and alcohol use among health professionals. My paper is a counter-argument to one that appeared in JAMA in 2013,¹ which recommended that physicians who are involved in serious, harm-causing medical errors should be drug and alcohol tested on the spot. Now, I’ve studied the occurrence of medical errors for over a decade, and the more I thought about that proposal, the more I thought it was a bad idea. So I wrote the article, sent it to AJOB, and eventually it was accepted.²



The point of this blog post is to discuss something that stems from what I learned from the literature on drug and alcohol abusing physicians: most of them can go years, even decades, without the drug or alcohol abuse seriously affecting their work life or technical skills. Physicians who abuse alcohol—which is the most commonly abused substance—can go decades without anyone noticing performance deterioration.³ And when I asked an anesthesiologist recently about the second most popularly abused drugs, oxy- or hydrocodone based narcotics, and how long she thought a physician can be on them without anyone noticing, she pursed her lips and quietly said, “years” (although this doesn’t include intravenous injection of narcotics, where the impact on performance will probably become noticeable in months.)^3-5




The hit Cinemax series “The Knick” loosely based its central character, Dr. John Thackery, on William Halsted, arguably America’s greatest surgeon at the beginning of the 20^th century. Like Freud, Halsted became addicted to cocaine in the 1880s, but whereas Freud kicked his habit around the time of his writing The Interpretation of Dreams, Halsted never did. He suffered from a cocaine-morphine addiction for 30 years, consuming up to 195 milligrams of morphine a day at the height of his use. Yet, only his Hopkins colleague William Osler claimed to have ever seen him the worse for it (and only once) although we know Halsted’s health and general psychological equilibrium were not in good shape during those decades.⁶

William Halsted

(From the Medical Archives of the Johns Hopkins Medical Institutions)

So, while I continue to believe that drug testing physicians in the wake of their involvement in a medical error is a poor use of a health care organization’s resources—random drug testing among clinical personnel is a much better approach for a variety of reasons ^2,4,5—I remain befuddled about the effect of a health professional’s drug or alcohol use on his or her performance levels. How many are using illicit drugs just to maintain their levels of competence? How widespread is such a phenomenon and for how long do professionals do it? Would some users experience a serious decline in their performance levels if they stopped using? Do many, like Halsted, titrate their drug use so that they don’t succumb (or they delay succumbing) to the substance’s negative effects while gaining the maximum performance effect from their habit? How many start and stop at will, or use for extended periods when the going gets rough and then abstain for extended periods when life gets better? Would some who’ve never used benefit from drug use?—which perhaps isn’t as preposterous as it sounds. In neuroethics, we joke about a surgeon in the not-too-far-off future saying to a family, “The operation I’m about to perform on your loved one will take many hours and be very complex. Even though I’ve performed it numerous times, I find that when I take the drug modafinil—which ramps up wakefulness and alertness—I feel more confident and experience no fatigue whatsoever. Nevertheless, I don’t want to abuse the stuff. So, if you’d like me to take a dose before I begin your loved one’s operation, I will, but I’ll have to charge you an additional $500. What would you like me to do?”




I’ve also come across data suggesting that 80 percent of persons who abuse narcotics, especially street folk, don’t develop a habit.⁷ They can quit if they want to but like most physicians who abuse drugs or alcohol, they use to self-medicate. I wonder, therefore, about whether we’re developed an exaggerated and unreasonable fear of these substances, at least for the majority of people. But just saying that sounds reckless and stupid, given the way serious addiction wrecks communities and people’s lives. Still, the rate of drug and alcohol abuse among physicians is around 10 to 12 percent, mirroring the general population’s, implying that about 80,000 doctors are abusing drugs or alcohol right now.^3-5




While the last thing I’d want is for my physician or dentist’s performance to be affected by drugs or alcohol, the purely curious and inquisitive side of me wonders how often it’s already happened and what difference it made. And if we aspire to a rational policy about drug use and abuse, it seems to me these questions deserve a look, especially as we ramp up our physician health programs all around the country.





References



1.  Pham, J. G., P. J. Pronovost, and G. E. Skipper. 2013. Identification of physician impairment. JAMA 309: 2101-2102.

2.  Banja, J. 2014. Alcohol and Drug Testing of Health Professionals Following Preventable
Adverse Events: A Bad Idea. The American Journal of Bioethics, 14(12): 25-36, 2014.

3.  Cicala, R.S. 2003. Substance abuse among physicians: What you need to know. Hospital Physician, July 2003: 39-45.

4.  Berge, K. H., M. D. Seppala, and A. Schipper. 2009. Chemical dependency and the physician. Mayo Clinic Proceedings 84: 625-631.

5.  Merlo, L.J. and M.S. Gold. 2009. Successful treatment of physicians with addictions. Psychiatric Times. Available at http://www.psychiatrictimes.com/addiction/successful-treatment-physicians-addictions.

6.  Markel H. 2011. An Anatomy of Addiction. New York, NY: Pantheon Books.

7.  Hart C. Sept. 16, 2013. The rational choices of crack addicts. New York Times. Available at http://www.nytimes.com/2013/09/17/science/the-rational-choices-of-crack-addicts.html?pagewanted=all&_r=0.






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Banja, J. (2014). Drug and Alcohol Abuse Among Physicians: How Concerned Should We Be? The Neuroethics Blog. Retrieved on

, from http://www.theneuroethicsblog.com/2014/11/drug-and-alcohol-abuse-among-physicians.html

Can Neuroscience Validate the Excuse “Not Tonight, Dear, I have a Headache?"

Men
and women experience fluctuations in sexual motivation over a lifetime. Whether
sexual desire is enhanced or diminished at any particular time can depend on a
number of factors and circumstances, but researchers from McGill University
recently set out to determine specifically how pain impacts sexual behavior.¹ Results from this study, published in The Journal of Neuroscience earlier this
year, were the topic of the most recent “Neuroethics and Neuroscience in the
News” discussion facilitated by Emory Women’s
Gender and Sexuality graduate student Natalie Turrin and Neuroscience
graduate student Mallory Bowers.




To study how pain impacts sexual
motivation, researchers used a partitioned Plexiglas chamber where the
partition contained small, semi-circular openings only large enough for the
female mice to pass through (this study required that male mice be greater than
45 g and female mice smaller than 25 g). In this set-up, the females were free
to either cross the partition and engage in sexual activity with the male mice
or “escape” to the side where the males were unable to follow. Sexual
motivation in this study was measured by how many total mounts occurred, and since
mounting involves male participation, time spent on the male side of the
chamber was also a measure of female sexual motivation. When researchers
injected female mice with inflammatory agents in the vulva, hind paw, tail, or
cheek to induce pain, female mice consistently participated in less mounting
behavior and spent less time on the male side of the cage compared to no
injections. Males, on the other hand, when injected with the same inflammatory
agents in either the penis, hind paw, tail, or cheek, experienced unimpeded
sexual activity (total number of mounts did not decrease compared to controls) in
an open field paradigm where the males had unrestricted access to the females. Although
it has been observed that female mice can have a higher sensitivity to pain
than male mice,² researchers observed that male and female
mice exhibited the same level of sensitivity towards inflammation to the hind
leg according to the mouse grimace scale (MGS), a visual observation of a mouse’s facial
features to determine pain levels.




The final experiments to study sexual
activity involved rescuing the lack of sexual motivation from female mice using
either an antinflammatory agent or two different prosexual drugs. The analgesic
pregabalin reversed the reduction of total mounts that resulted from inducing
pain in females, and according to the MGS, also reduced the level of pain. “Prosexual”
drugs, apomorphine (APO) and melanotan-II (MT-II), had the same rescuing effect,
but based on the MGS, did not have the ability to relieve pain from the
inflammatory injections. It should be noted though that APO increases
locomotion³ in mice, which may partially account for
the females moving towards the male side of the cage more often.




From these experiments, researchers
concluded that female mice have lower levels of sexual motivation when in pain,
but even in penile pain, male mice maintain a desire to participate in sexual
activity. However, the decrease in sexual motivation can be rescued in females
by either pain reduction or aphrodisiacs,
in this case a dopamine agonist (APO) or an α-melanocyte-stimulating hormone
analog (MT-II). Perhaps these claims made regarding mice are reasonable, but it
is even more problematic that the authors confidently extrapolate the results
to humans. The final line of the abstract reads “These findings suggest that the well known context sensitivity of the
human female libido can be explained by evolutionary rather than sociocultural
factors, as female mice can be similarly affected.”




Of course, media outlets ran with this
conclusion and multiple articles were published with definitive titles like “Women ARE more likely to go off sex when
they are in pain” and “That headache excuse is real: For females,
pain kills sexual desire.”
The authors of this paper perpetrated the idea that a woman’s lack of sexual
motivation at any given moment is
either a biological or
a sociocultural one. In the press release and the paper, the authors refer to the
apparently common aphorism “Not tonight, dear, I have a headache,” and mention
that this would be evidence that sometimes wives are in too much pain to have
sex that has been initiated by their husbands. But sexual relations are so much
more complicated than just a simple relationship such as a pain from a headache
equals lack of sexual motivation. What if the woman (or man, for that matter)
doesn’t really have a headache, but there is another underlying reason that a
partner is too embarrassed to share? Or, what if pain from a headache makes you
feel less sexy, and that feeling is the sexual deterrent, not the pain alone? Pain,
either directly or indirectly, would most likely make a person feel less
sexual, but why does is take a study with mice (who aren’t insecure about love
handles or annoyed with a spouse due to an insensitive comment) to validate
this thought? It is reminiscent of neuro-realism, the
idea that attaching a brain scan to any study or correlation suddenly qualifies
the findings as real or more true.⁴ While this study only involved mice,
researchers did use fMRI to study the difference between the brains of women
with and without acquired hypoactive sexual desire disorder (HSDD) in this paper.⁵ But no one - including females, their sexual
partners, researchers, or doctors - really wins when it is being advertised
that the female libido is something that can be can characterized as either
biologically or socioculturally driven. 

Via The Telegraph

One reason for ascribing a biological reason
to the lack of sexual motivation could involve drug development; if a
biological target can be found that is responsible for diminishing sex drive,
then perhaps there is a pill to fix that. The work in the paper was supported
by a Pfizer Pain Research Award from Pfizer Canada, and Pfizer Canada did
kindly provide the pregabalin that was used in the sexual recovery research. There
have been a number of pharmaceutical companies that have sought FDA approval
for low female sexual desire,⁶ even when the diagnosis of disorders such as
HSDD and female sexual dysfunction (FSD) are controversial. One example though
is Lybrido, a drug meant to treat HSDD. (Mallory actually gave a journal club talk last year about the implications of pharmaceutical
companies targeting the female sex drive with a focus on Lybrido). Lybrido
is interesting because it was ineffective in a cohort of women who “suffer from
HSDD as a result of inhibitory mechanisms,” resulting from negative
associations with sex and for that reason Lybridos was developed.⁷ Lybidos has an additional
component that targets the prefrontal cortex areas of the brain and is meant to
alleviate these inhibitory mechanisms.⁸ A discussion of drug
development for women that have negative associations with sex is beyond the
scope of this post, but the mentality that this could be relieved with only a
pill is grossly overly simplifying the complexities of the female libido and
how this affects relationships women have with their sexual partners. If
researchers in academia though are willing to commit to the idea that female
sexuality can be classified as solely biologically determined, then can we
really expect that pharmaceutical companies, marketing campaigns, and sensationalized
news articles won’t try to capitalize on that idea?

Via The Neurocritic

References 

(1)  Farmer, M. A.; Leja, A.; Foxen-Craft,
E.; Chan, L.; MacIntyre, L. C.; Niaki, T.; Chen, M.; Mapplebeck, J. C. S.;
Tabry, V.; Topham, L.; Sukosd, M.; Binik, Y. M.; Pfaus, J. G.; Mogil, J. S.
Pain Reduces Sexual Motivation in Female But Not Male Mice. J. Neurosci.
2014, 34, 5747–5753.

(2)  Mogil, J. S. Sex
Differences in Pain and Pain Inhibition: Multiple Explanations of a
Controversial Phenomenon. Nat. Rev. Neurosci. 2012, 13,
859–866.

(3)  Horn, C. C.;
Kimball, B. A.; Wang, H.; Kaus, J.; Dienel, S.; Nagy, A.; Gathright, G. R.;
Yates, B. J.; Andrews, P. L. R. Why Can’t Rodents Vomit? A Comparative
Behavioral, Anatomical, and Physiological Study. PLoS ONE 2013, 8,
e60537.

(4)  Racine, E.; Bar-Ilan,
O.; Illes, J. fMRI in the Public Eye. Nat. Rev. Neurosci. 2005, 6,
159–164.

(5)  Woodard, T. L.;
Nowak, N. T.; Balon, R.; Tancer, M.; Diamond, M. P. Brain Activation Patterns
in Women with Acquired Hypoactive Sexual Desire Disorder and Women with Normal
Sexual Function: A Cross-Sectional Pilot Study. Fertil. Steril. 2013,
100, 1068–1076.e5.

(6)  Shames, D.; Monroe,
S. E.; Davis, D.; Soule, L. Regulatory Perspective on Clinical Trials and End
Points for Female Sexual Dysfunction, in Particular, Hypoactive Sexual Desire
Disorder: Formulating Recommendations in an Environment of Evolving Clinical
Science. Int. J. Impot. Res. 2006, 19, 30–36.

(7)  Lybrido
http://www.emotionalbrain.nl/lybrido (accessed Oct 30, 2014).

(8)  Lybridos
http://www.emotionalbrain.nl/lybridos (accessed Oct 30, 2014).

Want to cite this post?




Strong, K. (2014). Can Neuroscience Validate the Excuse “Not Tonight, Dear, I have a Headache?" The Neuroethics Blog. Retrieved on

, from http://www.theneuroethicsblog.com/2014/11/can-neuroscience-validate-excuse-not.html

Neural Prosthetics, Behavior Control and Criminal Responsibility

By Walter Glannon, PhD



Walter Glannon is a professor of philosophy at the University of Calgary where he holds the Canada Research Chair in Biomedical Ethics and Ethical Theory. He is also a member of the AJOB Neuroscience editorial board.



Philosophers have argued that moral and criminal responsibility presuppose that actions cannot result from sequences that bypass agents’ control of their mental states as the causes of their actions (A. Mele, Autonomous Agents, 1995). Agents must act from their own mechanisms, which cannot be influenced by drugs, electrical stimulation of the brain, brainwashing or other interventions (J. M. Fischer and M. Ravizza, Responsibility and Control, 1998). Moral and criminal responsibility excludes all forms of brain manipulation.

Via thejuryexpert.com

With deep-brain stimulation (DBS) and brain-computer interfaces (BCIs), neuroscientists can alter the brain and the mental capacities it mediates. The first device modulates dysfunctional neural circuits causing neurological and psychiatric disorders through electrical stimulation of targeted sites in the brain. The second allows people with extensive paralysis to bypass the site of injury and translate intentions into actions by transmitting signals from the motor cortex to a computer. Because these devices and the practitioners who implant and activate them manipulate the brain and mind, the philosophical argument noted above suggests that they undermine the mental control necessary for criminal responsibility. Yet by modulating, bypassing or replacing damaged or dysfunctional regions of the brain, they can restore the mental capacities necessary to form and execute action plans. By enabling rather than disabling these capacities, neural prosthetics allow people to regain enough control of their thought and behavior to act autonomously and be responsible for their actions. Moral and criminal responsibility does not depend on brain function or dysfunction as such but on whether or to what extent the brain enables or impairs the mental capacities necessary for behavior control. In cases of brain injury or disease impairing these capacities, brain implants may restore some of this control. Theoretically, it does not matter whether mental states and events are generated and sustained by a natural or artificial system, provided that agents identify these states and events as their own and is what moves them to action. Artificial devices implanted to regulate thought and behavior are not necessarily alien to the agent but can be considered as a type of expanded embodiment. They can ensure that the agent is the source of her actions. Brain- and mind-altering devices should make us reconsider the meaning of ‘autonomy,’ ‘ownership’ and ‘control’ in discussions of moral and criminal responsibility.



To be criminally responsible for an action, an agent must have the requisite mens rea (“guilty mind”) and perform the requisite actus reus (“bad act”). According to the first criterion, the agent acts with the appropriate mental states corresponding to the definition of the criminal offense. These include intention, knowledge, negligence or recklessness. According to the second criterion, the agent voluntarily performs an intentional bodily movement in committing the offense. The agent’s mental states explain the action insofar as they cause it, and thus the mental basis of responsibility is distinct from the physical content of responsibility, what one is responsible for. Some neural prosthetics should also make us reconsider the relationship between mens rea and actus reus and the distinction between the mental basis and the physical content of responsibility. With these devices, what an agent is criminally responsible for might not be a bodily movement but a mental act. For example, a severely paralyzed subject using a BCI cannot perform any bodily movement and has to plan how he will move a robotic arm or computer cursor in translating his intention from electrodes placed on his scalp or implanted in his motor cortex to a computer. His execution of the intention is a mental act and is something for which he could be criminally responsible. Suppose that the subject is frustrated with the slow pace at which he is learning how to operate the robotic arm but is adept enough in operating it to assault the practitioner training him. In this case, there is no bodily movement but a mental act of executing an intention to move the robotic arm in a certain way. The execution of the intention is not the cause of the guilty act but is the guilty act itself. While the agent is also responsible for moving the robotic arm, this is not the only event for which he is responsible. The assault with the robotic arm could even be described as the consequence of his mental act that is the actus reus.

Via Buchen 2012

Neural prosthetics may also generate obligations that do not apply to people with normal brain function. Suppose that a person with a DBS system implanted in his brain is able to turn off the stimulator. This could cause a return of motor symptoms in a neurological disorder or affective and cognitive symptoms in a psychiatric disorder. In both cases, the decision to turn off the stimulator could cause the person to lose control of her thought and behavior. If she committed a criminal act while incapacitated, then she could be criminally responsible for the action on grounds of negligence or recklessness in foreseeing but ignoring the risks of deactivating the device. The agent failed to discharge her obligation to keep the stimulator on. In some respects, this is similar to being criminally responsible for injuring a pedestrian while driving under the influence of alcohol. But what is different in this case is that having the device in one’s brain seems to generate an obligation to keep it on at all times, an obligation generated by a disease over which the individual had no control.




In sum, there are at least three respects in which neural prosthetics should make us reassess how we think of responsibility and obligation. They challenge the view that manipulation of the brain and mind always undermines the control necessary for responsibility and recommend a broader interpretation of autonomous agency. By including mental acts in the content of responsibility, they also raise questions about the distinction between mens rea and actus reus as a mental-physical distinction and the identification of a guilty act as a bodily movement. And they may generate obligations regarding behavior control that people with devices implanted in their brains would not have had but for a neurological or psychiatric disorder.






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Glannon, W. (2014). Neural Prosthetics, Behavior Control and Criminal Responsibility. The Neuroethics Blog. Retrieved on

, from http://www.theneuroethicsblog.com/2014/11/neural-prosthetics-behavior-control-and.html

Gearing up for the International Neuroethics Society Conference!

2014 INS Annual Meeting

November 13 & 14 in Washington, D.C.

There is still time to register for the annual International Neuroethics Society Conference.



The schedule can be found here.



Learn the latest on the United States National Institutes of Health BRAIN Initiative and the European Commission Human Brain Project. Hear about international case studies of neuroscience in the courtroom, discuss human rights in the neuroethics dialogue AND engage in networking opportunities during breakfast, lunch and two receptions.



Speakers include NIH Directors, representatives from Congress, co-director of the Human Brain Project and a representative from the US Presidential Commission for the Study of Bioethical Issues.



Public Event on November 13: "Neuroscience Knowledge & the Robotic Mind."

We kick off our meeting with a thought-provoking public event on November 13 from 5 - 7 p.m.



All-day Annual Meeting on November 14: Speakers include

• Paul Catley, Open University, UK; 


• Jennifer Chandler, University of Ottawa; 


• Lisa Clayton, University of Manchester; 


• Katy deKogel, Dutch Ministry of Justice; 


• Nita Farahany, Duke University; 


• Chaka Fattah, US House of Representatives; 


• Stephen Hauser, President's Commission for the Study of Bioethical Issues; 


• Tom Insel, National Institute of Mental Health; 


• George Koob, National Institute on Alcohol Abuse & Alcoholism; 


• Story Landis, National Institute of Neurological Disease & Stroke; 


• Alan Leshner, American Association for the Advancement of Science; 


• Geoff Ling, Defense Advanced Research Projects Agency; 


• Henry Markram, Human Brain Project; 


• Steven Marks, Harvard University of Public Health; 


• Barbara Sahakian, Cambridge University & INS President; 


• John Williams, Wellcome Trust 

Check the website for updates www.neuroethicssociety.org 



Both events take place at the award-winning American Association for the Advancement of Science (AAAS) Building, 12th & H Streets, NW. Washington, D.C. Space is limited!