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When Doctors Are Addicts

For physicians, getting drugs is easy. Getting help is not.

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Dr. Russ Reed, now in his 60s, was the eighth generation of doctors in his family. "My father was the kind of physician who believed that doctors should try each drug before giving any to a patient," he said. The senior Reed was also the kind of doctor who took three Nembutals--heavy sedatives--to get to sleep at night. "At that time no one thought of that as addiction," said the son. "The word was hardly used in polite society, and it was certainly never applied to a respected physician."

After his father's death, Reed* found a bequest: "bottles with little pills of scopolamine and morphine in them. They were the old kind that you put in a spoon with some water and heat them up until they melt and then inject the liquid."

So, having a reason to medicate himself (grief over his father's death), the modern-day Dr. Reed tried his father's 19th-century medicine. "And I really liked that. I liked the feeling I got from those," he told me, as we sat in his north suburban office surrounded by artifacts from the world's great religions--Buddhist prayer wheels, Christian rosaries, prayer beads from Islam. Reed used the little pills, melting and dissolving and injecting them, until his dead father's supply was all gone. Sometimes a son can try so hard to avoid being like his father that he becomes just like him.

Reed did as his father bade him and tried every new drug that came on the market--at least the psychoactive ones. "Then I discovered Talwin," synthetic morphine. "It didn't exactly get me high. It had all the bad side effects of the more powerful narcotics with none of the benefits. It was just the drug for me."

His general surgery practice was becoming rather frantic. Drug addiction can take up a lot of time, he discovered, especially if one wishes to keep it a secret. "Mondays and Tuesdays I'd work my ass off," he said. "Wednesday and Thursday I'd have rounds. I was injecting myself at work, often right through my pants so that I didn't have to slow down to take my pants off." Reed would sit in his office chair and stab the needle right into his thigh muscle. "It's a miracle I didn't get some kind of infection. Sometimes the needle would go right through the money in my pocket, and money is one of the dirtiest things there is," he said with a smirk.

The more frantic Reed's schedule became, the more drugs he seemed to need. The more drugs he took, the less efficiently he performed his work, leading to more anxiety, panic, desperation. To make matters worse, he was also drinking.

Incidents began to occur in surgery that made him realize that he was teetering on the brink of something--if only he could see over the edge, perhaps he could tell what it was. But like a man in a boat paddling madly down the Niagara River, he could not see until he was already on his way over the falls. One of the most profound characteristics of addiction is the inability of the afflicted to diagnose it. That effect, called denial, is the most formidable obstacle to treatment--when a drug becomes everything to a person, he hardly has a desire to give it up, no matter how painful his life has become. The surprising fact is that denial seems to be stronger for doctors with addictions, and addicted doctors are more difficult to treat than many other types of patients. Some of the pioneering work in that field is now being done in the Chicago area.

"Many health-care professionals know little or nothing about the early recognition of alcoholism, and as treaters themselves they may be unusually slow to seek help or to assume the patient role," wrote a former president of the American Medical Society on Alcoholism. "When the search for help does begin, it often leads to a friend or colleague no better prepared to deal with the problem." And certainty the addicted physician isn't likely to understand or admit to himself the nature of his own problem, sometimes not even after the first round of detoxification and treatment. "One of our physicians at [the] follow-up [interview] was using Librium, Quaalude, LSD, hashish, marijuana, and cocaine. He did not feel he had a drug problem."

The world has undergone an enlightenment about addiction in the past 15 years. With that have come two new concepts: first, that drug addiction (including addiction to alcohol) is a disease; and second, that whether the patient happens to use heroin, gin, or some other mood-altering chemical, such as Talwin or marijuana, the disease is one and the same. With the spread of those concepts, drug-abuse treatment centers have proliferated in hospital settings. We now see them advertised in the newspaper and on television. Most insurance companies now cover lengthy (and expensive) hospital stays for patients with "addictive disease" (up to four weeks). Similarly, groups such as Alcoholics Anonymous that help patients care for themselves after formal treatment is completed have multiplied across the nation. The pointed irony in this enlightenment has been the difficulty doctors themselves have in getting help when they are afflicted with what is now called primary addictive disease (PAD).

In her landmark research, LeClair Bissell studied not only doctors but other professionals, such as lawyers. She wrote in Alcoholism in the Professions, "As treaters of others, professionals may be unusually slow to seek help for alcoholism. Inappropriate treatment and long delays in intervention have been the rule. We cannot know how much harm is actually done to patients or clients by the alcoholic or drug-using professional, but it must be significant." One doctor described doing surgery in a blackout. That is, he performed an operation from beginning to end and the next day he could not remember a thing about it. "Generally, professional intervention still takes place quite late in a drinking career and usually even then only when some other agency has first become involved." The head of one treatment center for doctors and other health care professionals said that 70 percent of the doctors he saw came for help only when they were finally in danger of losing their licenses. Yet more than 40 percent of the doctors surveyed by Bissell had never had a colleague or superior mention the problem--even when they were drinking on the job--indicating a high degree of denial among doctors and those working with them. Many of those doctors sought professional help for their problems, but they misperceived their problems as depression, mid-life crisis, or something other than addiction. The people they went to for help were no better at diagnosing the illness. Forty percent of the doctors surveyed were told by psychiatrists that they were not alcoholics--not addicted--even after the doctor-patients described their drinking and drug-use habits. Some of the psychiatrists even offered the addicted doctors other mood-altering drugs as substitutes.

There appear to be good reasons for that denial, at least on the surface, as well as good reasons that doctors helping doctors fail to diagnose PAD. As its victims, doctors fear that admitting to addiction would end their careers: patients would flee, colleagues would shun them, hospital privileges would be cut off. On the other hand, doctors who are faced with attempting to diagnose a fellow doctor who has PAD may be unable to recognize it because it is not taught in medical school and because PAD often carries symptoms of other diseases that are taught in medical school. (This leads, for example, to the not-uncommon diagnosis of epilepsy for alcoholics who suffer from convulsions.) Moreover, doctors are taught that they are infallible. One doctor may be unconsciously disinclined to diagnose PAD in another doctor as long as it is still stigmatized as a disease of moral depravity.

Russ Reed recalled how his large and lucrative family practice finally came to an end because of his failure to seek help. "In 1956 I went to Europe and contracted hepatitis," he told me. "When I landed in New York, I was yellow. Being a doctor, Of course, I knew that if you have hepatitis, you don't drink. But I drank anyway. That was the first real indication I had that something was definitely wrong with me. Naturally, I ignored the warning and went ahead with my life." All the addicted doctors I spoke to could recall a moment in their lives when they asked: if I'm so smart, why am I doing this? Through the miracle of denial, they simply pushed the question aside and went ahead. Reed went plunging ahead into his personal hell, which involved 17 more years of drugs and drinking before he was finally burned out.

"In 1973 I knew there was something dreadfully wrong," Reed said. "I told my wife there was something wrong. I was depressed. I was sick." And so he did something that addicts have been doing for centuries, something that has been elevated to a thematic genre in literature: he took what's known as the "geographical cure in which the afflicted person simply moves, hoping that everything will be different in the new location. Reed moved to South America and worked in a mission. And everything, indeed, was different. Well, almost everything. Like the dying hero of Under the Volcano, he lurched through his year in the wilderness, giving one pill to the patient and one to himself--one for you, one for me--until he was on the verge of death. He fed his addiction "mostly with drugs, but occasionally I'd get a fifth of Smirnoff's and really go at it."

Looking back now, he can see that he was in the final throes of an advanced and potentially lethal case of primary addictive disease. He was quite far gone, and should have been in a hospital. When he returned after a year in South America, his partners had eased him out. There was a new general surgeon in place at his prominent North Shore practice, and Reed's services were no longer required. He was free to destroy himself. Looking back, Reed expressed his amazement that no one told him, and no one offered help.

Today, Reed is grateful that he was not allowed to perform surgery any longer. "I didn't kill anybody," he said. "But I know somebody who had an extra operation he could have done without . . ." And he trailed off into a wistful introspection. In fact, his surgical privileges were suspended at the hospital and never regained. But by that time he had already decided that he no longer wanted to practice surgery. He wanted to work treating doctors with PAD.

The problem then and now has been getting doctors to admit that they have a problem and must seek treatment. As G. Douglas Talbott, MD, a pioneer in the treatment of addicted doctors, put it, "Ignorance about alcoholism and drug addiction abounds even among health professionals."

Dr. Herbert Trace is a recovering drug addict himself, and his medical practice consists of treating other doctors who are also drug addicts. I went to visit him at his spacious Evanston home one evening. He sat in a cushioned chair, the wall behind him decorated with an array of Indonesian and African masks, souvenirs of his travels around the world.

He looked distraught as he sighed and folded his hands across his stomach. He said, "Today was a hell of a day. People were going crazy left and right. We found one of our doctors dead tonight at Saint Francis Hospital." What did he die of, I asked. "Why, alcoholism, of course!" Trace said.

Doctors today can trace physical addiction to a location in the hypothalamic instinctual center in the brain and even explain that it results from a chemical imbalance within the body's own pain-mediating system--"a biochemical defect in the hypothalamic instinctual control center in the endorphin and enkephalin systems," wrote Talbott. Yet few doctors (other than the fairly small number of specialists in addictionology who have recently arrived on the scene) are able to recognize primary addictive disease either in themselves or in their colleagues. (One of the best-known psychiatrists in the country, Mark Gold, director of research at Fair Oaks Hospital in Summit, New Jersey, told me that one of his closest friends was addicted to cocaine and Gold didn't detect it.) Addiction is a remarkable disease that tells the patient he has no disease. Then it gives him the tools with which to conceal the disease not only from himself but from others. At least for a time.

While there are no reliable data to hint at its prevalence among physicians, it is clear that doctors enjoy no special protection from PAD. Many addiction specialists such as Herbert Trace believe that professionals, including doctors and lawyers, are more susceptible than the general public. Researcher LeClair Bissell says that doctors are not much different from others in their susceptibility to PAD. They are different, however, in that they have better access to (and therefore more frequently become addicted to) narcotics. Although the Doc Holliday image of the physician-tippler is one that has been readily assimilated into literature and movies, there is no evidence to show that doctors are any more likely to become addicted than anyone else in a stressful profession.

Whether or not doctors are more susceptible to PAD than other professionals, they may risk more danger once addicted. PAD and suicide go hand in hand. "Overt suicide attempts before the first interview were reported by 17 percent of the men and 30 percent of the women," Bissell writes of one of her surveys of addicted doctors. She describes one of her subjects "who was discovered dissecting out her femoral artery." (Physicians have better skills, tools, and methods for doing themselves in: one doctor told of putting exactly the lethal dose, according to body weight, of cyanide in his bottle of scotch, and then calmly sitting down to drink himself to death. Luckily, he was discovered before the end.) The overuse of various drugs, including alcohol, can promote profound depression as a side effect.

"Typical stories," Bissell writes, "described long-delayed diagnosis and useless encounters with would-be helpers who lacked the training or expertise needed to recognize or manage the addictions. Repeatedly, we heard accounts of years of inept management before admission or referral was made to a specialized treatment facility and effective help was found."

Bissell goes on to add that only 3 of her 100 respondents in a survey "had been taught about AA in medical school. . . . Most were unaware that AA's cofounder had been a physician."

Primary addictive disease has a psychosocial component as well as a biogenetic one. Most researchers today believe that the genetic disposition to PAD is not in itself sufficient to bring on the symptoms of compulsive drug or alcohol use. Social and psychological factors must be present to trigger the disease. For example, high rates of PAD correlate with "relative affluence, exposure to the sophisticated environment of urban areas, distancing from the more abstinence-oriented fundamentalist religions, social settings in which drinking is accepted, very high (as well as very low) educational level . . ."

Today there are strong movements afoot in the medical community to address the dual problem of doctors who are ignorant of PAD and of doctors who have PAD (or have an addicted colleague) and are in turn ignorant of that crucial fact. Sometimes both problems are attacked simultaneously, as in Georgia's Impaired Health Professionals Program, upon which the Parkside Recovery Center in Lombard, Illinois, was modeled.

Talbott's program was the first of its kind, but nearly every state medical society now has or is affiliated with a program that can provide treatment for addicted doctors (who are described variously as impaired physicians, disabled doctors, and simply people with addictive disease). Curiously, although the decades of the 70s and 80s saw the elevation of PAD to the status of full-fledged medical problem, the treatment is for the most part nonmedical in nature. Not even the diagnosis follows traditional lines. "It is the only disease that cannot be diagnosed by smelling, hearing, seeing, or feeling," Talbott wrote. "Biopsy, blood test, radioactive flow studies, and CAT scans are worthless as detectors of the cause or often even the presence of substance abuse."

The fact that doctors, just like the rest of the population, suffer from PAD has been known since at least 1869, when Sir James Paget reported on some of his medical students at Saint Bartholomew's Hospital and their "habits of intemperance or dissipation." But no medical treatment was ever found, and psychiatry has done no better in treating what its practitioners perceived as the root causes, the underlying psychopathology, of excessive drug and alcohol use. The label primary addictive disease is now used to emphasize that compulsive drug-taking is not a symptom of some other disorder; it is itself a primary disease. In other words, addicts don't drink or take drugs for a reason--the drug itself is the reason. And taking it is the major symptom of the disease.

Yet even today, many psychiatrists approach such patients with this strategy: let's just see what underlying psychopathology is making you take all those pills (or drink all that booze or smoke all that weed or shoot all that morphine). Such wasted (if well-meaning) efforts can make it even more difficult for addicted doctors and other professionals to get help.

Not until Alcoholics Anonymous was formed in 1935 did a workable treatment for PAD evolve, and that program remains today the only known method of maintaining addicts in a drug-free condition for long periods of time. All treatment programs, whether for doctors or for the general public, are aimed at one ultimate goal: getting the patient into Alcoholics Anonymous (or a related program) and keeping him involved with the program of recovery to avoid relapse. There is the subtle, underlying, undeniable fact that AA accomplished what the medical arts throughout history had failed to do and what psychiatry over the last 150 years had been trying and failing to do: stop the addict from taking drugs. Prior to AA, addicts were locked up in mental wards, or else they simply died of their disease. An unintended side effect of AA's success was a turf battle. Was AA threatening to take over something that rightfully belonged to the world of medicine? Making this tension worse, AA achieves its results (i.e., mitigating a medical condition) without medical intervention.

Some people recoil at such an "unscientific" approach when they first hear how this medical problem is treated. As Dr. Talbott has said, "The substance abuser has a biogenetic disease. He or she is not responsible for being an alcoholic but is responsible for recovery or for not ever using mood-altering drugs again. Taking drugs away from a drug addict or alcohol from an alcoholic is easy, but that does not prompt recovery. Recovery is the development of nonchemical coping skills so he or she can achieve sobriety. Sobriety is not just a state beyond abstinence from drugs but is freedom from the drugs with peace and serenity." Alcoholics Anonymous provides what its proponents refer to as a spiritual program that leads to serenity and teaches those coping skills. The medical community, especially psychiatry, has been slow to catch on: this works; it may be the best answer until something else comes along. But today attitudes are changing, and a new generation of doctors and psychiatrists is coming of age.

Dr. Daniel H. Angres is medical director of the Parkside Recovery Center in Lombard, where some of the pioneering work in treating physicians is taking place. About 40 percent of the patients are physicians. The rest are from other professions. Angres is young and dresses stylishly. His modern office looks out onto a small man-made pond that gives the suburban setting the feel of a country retreat. Angres is also a psychiatrist. Or perhaps we should designate him, along with Mark Gold and their whole generation, as new psychiatrists.

"Treatment is a preliminary process to facilitate entry into AA," Angres told me. "Some need it, some don't"--meaning that some doctors, if they get to AA in an early enough stage of the disease, can successfully begin recovery and never relapse (i.e., go back to drug use).

"I don't have a problem understanding a medical condition that requires nonmedical treatment," he assured me. As well as recovering from PAD himself, Angres is also a heart patient with coronary artery disease. He thinks the comparison between the two diseases is a useful one. "In both cases we have real medical problems that may be treated in holistic, nonmedical ways. For example, for heart disease, we may prescribe life-style changes, such as diet, exercise, reduction of stress--all nonmedical methods of controlling a medical condition. The same is true of alcoholism and drug addiction. The spiritual approach is what works." He cited the necessity for patients to undergo a radical change of mind and heart, leading to self-examination, acceptance, and personal accountability, in order to achieve the serenity Talbott referred to.

According to Angres, an addict is a person who has learned that pain, discomfort, anxiety, or conflict can be eliminated instantaneously by the simple act of taking a potion, powder, pill, elixir, injection. It is a tough act to follow. To do that without drugs requires a kind of spiritual enlightenment that in previous centuries only full-time mystics were able to get. Tibetan lamas sought nirvana. Monks brought enlightenment through prayer and meditation and conscious contact with God. And today people out in the Chicago suburbs, working together at centers such as Parkside, Evanston Hospital, Glenbrook Hospital, Lutheran General, Martha Washington, and Skokie Valley are all seeking that same state, which is the only mental and emotional condition in which they can live without their previous omnipotence--the ability to kill the pain of life instantly, on demand.

Some doctors, blessed with a logical, scientific turn of mind, think that this prescription sounds awfully fishy. "But it's no more peculiar than telling a patient to jog and eat broccoli," Dr. Angres says.

In high school, Dr. Nick Walcoff wrapped his father's red-and-white Ford around a tree after a drinking spree with some of the older guys. His father, also a doctor, paid off the cops to smooth things over. During premed Walcoff struggled with hangovers to get to class, but he was young and resilient and made it through. In medical school it was not uncommon for him to lose part of an evening to a blackout, but he managed to get the work done.

I met Dr. Walcoff in his office in the North Shore hospital where he now runs a program treating people--many of them Chicago professionals--with PAD. This was a real doctor with real status in the community and a unit full of patients just outside the door behind which we were talking. As a consequence, I could hardly believe that the person he described to me was the same one now sitting before me. "It was at that time," he recalled of his premed years, "that I met the girl who was to become my wife. I remember once she was coming to town, and I stopped to have a few drinks with the guys on my way to pick her up. I ended up drinking so much that I passed out and never got to the train. Here was this beautiful, wonderful girl, and I was completely, helplessly in love with her. And yet it was more important for me to drink than to meet her at the train." Most such incidents are viewed at the time as youthful folly. Walcoff can now see it as a clear indication at something was dreadfully wrong.

Once he entered his residency, Walcoff recalled, drug companies sent samples, "and some of us would eat our mail and some of us would read it." Soon he was on a regular course of self-medication with amphetamines. "I believe now that in part I was suffering from self-esteem problems and depression, and by mixing alcohol and amphetamines I found I could get relief." Of course, the rebound effect from amphetamine is depression, which requires more amphetamine, which causes more depression . . .

The drugs and alcohol affected Walcoff's performance even before his residency was over. "Showing up late for surgery is not the way to get ahead," he said. In 1970, after four rocky years of surgical residency, he was drafted and went to Vietnam as a major. "When I realized I was going, I ran around all over town stockpiling amphetamines to see if I could get enough to last me my whole tour of duty there. I was clearly behaving in an addicted way then. Of course, it was impossible to get enough to last me. I ran out about halfway through." Another important signal that he ignored: he experienced withdrawal symptoms when the amphetamines ran out. "At that point I started smoking grass." All the while he kept on drinking.

With respect to his functioning in Vietnam, he said, "I was a good surgeon. There is no question that I was operating under the influence, but I don't think anyone got hurt. I do recall one night when I wasn't on call--I was free--and I was smoking a lot of grass. Then we had one of those mass casualty situations, and we were all called in. I operated all night long, and I really don't remember what I did." Doctors tell me that performing surgery in a blackout is a clear (and not uncommon) signal by which a physician can self-diagnose PAD.

Returning to the U.S., Walcoff stopped taking drugs and alcohol and gave up surgery in favor of a psychiatric residency. "I felt terrific because I was making a major change in my life. But midway through this course my younger brother committed suicide, and there was clear indication that he was alcohol and drug addicted." Rather than swinging Walcoff away from further use of drugs, the tragedy had the opposite effect. "It gave me a reason to start using again." Such paradoxical twists of logic are the staple fare of people suffering from PAD. Soon he was back to the old pattern of use in dealing with stress, and it quickly began to affect his home life. By that time he was married and had children, though he had little time for them.

At the age of 35 he had a heart attack, followed by quadruple bypass surgery. "I was scared for a couple of years and tried to minimize my amphetamine use," he said. But one day a patient brought in a bottle of Ritalin and left it, and Walcoff tried one, once again "to cope with feelings of isolation and depression." This brain stimulant, normally prescribed for children with attention deficit disorder (hyperactivity), was the key that fit Walcoff's lock perfectly. "I rapidly went from using a normal amount, say 20 milligrams, to using incredibly high doses. I was up around 2,000 milligrams a day." And this despite his awareness that even a normal dose of Ritalin, a cousin of the amphetamines, could be deadly for a coronary heart disease patient. "This is where the insanity really comes in," he said, recalling a state of compulsion like Reed's continued drinking in spite of hepatitis. "I just kept on taking it.

"Like most doctors, I maximized my efforts to conceal my addiction and was pretty successful at it." He was filling prescriptions all over town, and sometimes a pharmacy would call and get one of his partners on the phone by chance. Once or twice his colleagues asked him, "Are you taking this stuff?."

"Once in a while," he would say. "Nothing I can't handle." And the incident would be forgotten.

"I never had trouble filling prescriptions," Walcoff told me. "Sometimes a pharmacist would even ask me if I wanted more. But ordering 10,000 amphetamines at a time was not consistent with my denial system," he added with a wan smile.

By 1980 he was not functioning. "I was triple-scheduling patients and forgetting. I had a beard, I had lost a lot of weight, and I looked haggard and very sick. I have photographs to substantiate that." Yet still no one said anything to him.

Walcoff's crash came in 1981 when he went off to Maui for vacation. He had decided to remain drug free, but he couldn't stick with the plan. "At the last minute I went into a panic and went around filling prescriptions for Ritalin all over town." In his haste, he went to the same drugstore twice in a period of three hours without realizing it. He was reported by the pharmacist. When he returned from Hawaii, his lawyer said, "You are very sick. You ought to be in a hospital."

"It was the first time anyone had said that to me, and it wasn't a doctor; it was my lawyer," Walcoff said sadly. It was a common refrain I heard from doctors, and whenever they said that, they looked a little baffled: why didn't someone tell me how sick I was? Addicts start out believing that they are sailing away in a luxury liner, but they are already in the lifeboat, drifting out to sea. When they finally fall overboard, they can't understand why no one even throws them a ring.

Walcoff, like Reed, went away for four months to a special treatment center for doctors, such as the one Angres runs at Parkside. Special treatment facilities for doctors with PAD, and even special AA groups whose members are all doctors, are becoming common today. It is in part in recognition of special needs and issues peculiar to addicted doctors. But it is also to put them at ease about seeking help and to make it easier for them to reenter the normal world.

Just as there has been an anti-AA bias in the psychiatric and medical communities, so there is sometimes an antimedical, antiscience tendency within AA. First, medicine and psychiatry failed where AA succeeded. Second, many people get to AA and successfully begin recovery only after spending many years and a lot of money on psychiatrists who have led them astray, misinformed them, and even made their addictions worse by giving them more drugs. And third, doctors by their own admission often become egocentric, setting up an easy target for a group of people attempting to practice humility, modesty, and patience. As a consequence, some have had bad experiences in attempting to be open in talking about themselves at AA meetings.

Dr. Reed warns the doctor who has been newly inducted into AA that even in that brotherly love fellowship of sharing there are limits to what one can reveal and still remain in good odor. "I once went to a regular AA meeting--not a doctors' meeting--and I talked about an incident in surgery," Reed recalled, "and did I catch hell! There was some serious doctor bashing going on after that meeting, and I realized that all was not sweet understanding, not even in AA." People in AA may be seeking spiritual enlightenment, but they are still people. Since then, Dr. Reed has kept his more serious professional blunders to himself, sharing them only with one or two carefully selected confidants. This need for an understanding forum of one's peers is one of the reasons that AA groups for doctors have proliferated. But the idea is not a new one.

The first recovery group designed strictly for doctors began in 1949. Known as International Doctors in Alcoholics Anonymous (IDAA), it is still in existence today and meets once a year. Herb Trace says that for doctors recovering from PAD, "it's our spiritual bond." It has approximately 2,500 members. At last year's IDAA dinner in Lexington, Kentucky, there were 700 doctors. (IDAA includes both MDs and PhDs in the health care field.)

At the time of its inception in 1975, the Georgia Disabled Doctors Program, founded and run by Talbott, was established in part because "traditional one-month treatment programs are inadequate for disabled doctors." Doctors need special treatment for a variety of reasons, not the least of which is what Talbott calls "incredibly high denial." Angres lists what he calls the "four MDs" to explain why doctors need custom-tailored programs and don't necessarily benefit most from recovery programs aimed at the general public.

"M-Deity is the first," Angres says with a slight smile. "Doctors are trained to think they're God." Massive Denial, Militant Defensiveness, and More Drugs are the other three. "In addition, the physician is licensed for the care of others. His accountability is essential to his recovery if he is to continue to practice"--meaning that there has to be some way to determine with a high degree of certainty that he is no longer taking drugs.

Because of the issue of accountability, doctors who treat doctors are careful to distinguish between treatment and self-help. Treatment is medical intervention--or, at the very least, intervention by medically trained people. The object of treatment is to get the patient-doctor to the point that he can make use of AA, the self-help program for people suffering from PAD. Treatment is something that can be documented and proven--to show the public and the authorities that the doctor is getting better. Self-help cannot be documented.

Most physicians agree that AA has no role in this process of accounting for a doctor's sobriety. The entire program of AA is based upon self-reliance and personal responsibility. No record of attendance is taken at meetings. No one is looking over the shoulders of the members. People can go to meetings and then go out and drink and then go to more meetings, without ever telling anyone. Some people do. And while that does not lead to very effective recovery, neither does it result in any sanctions. Nor does it guarantee that a doctor is staying sober.

Today most states have medical societies that will act as advocates for doctors with PAD in their relationships with state licensing bodies--especially when the physician has already gotten himself into trouble, perhaps by having his hospital privileges suspended. But those societies need verification that recovery is proceeding properly. There needs to be some hard evidence that a doctor is successfully following his program--that he is staying sober, getting better. That's where the special treatment programs come in.

"We take urine drops," Herb Trace said of his Evanston program, "and we take attendance." All reliable treatment programs for doctors place emphasis on clean urine samples, taken at random, perhaps twice a month. Urinalysis is a method of detecting the residue of drugs that may have been taken.

The physician entering Angres's program in Lombard signs up for an initial stay, lasting from four weeks to four months, with a mandatory 20 months of what is called aftercare. This is different from the way nonphysician addicts get help. Many go into AA on their own and chart their own course to sobriety. Others may go through a two- to four-week hospital stay, after which they are on their own, able to go to AA or avoid it as they please. Doctors in Angres's program don't just promise to be involved in the intensive, closely monitored two-year sequence, they sign contracts.

During that time a number of goals are accomplished: detoxification and stabilization, if necessary; education about PAD; introduction to group therapy and AA groups, including a weekly peer group (other doctors) as well as a nonpeer group. It is essential that the doctor with PAD get the benefit of AA groups composed of other doctors. The reasons are obvious: to have a layperson telling a doctor about a medical condition would simply not carry the weight necessary to break through denial. But it is equally essential that the doctor with PAD meet with "ordinary people," so he doesn't get the idea that his special position in society gives him special rights where this disease is concerned. Addicts come to think they're God, because they have a kind of omnipotence, the power to alter the world at the drop of a pill (drink, injection, etc). Doctors think they're God because they have power over life and death, the power to heal by laying on hands. Addicted doctors really have a problem with the question of who is God (or perhaps more relevant, who is not God).

Many doctors are worried before seeking treatment--worried that someone will find out, worried that they'll lose their practice, worried that patients will flee in fear if they learn that their physician is an addict, worried that they'll lose their license to practice or prescribe. "All those worries are true," says Angres, "if they don't get help." And if they do get help, all those worries disappear.

Doctors don't need to worry that someone will find out about their addiction. Anonymity is fanatically guarded in AA groups for doctors as well as in treatment programs. Most doctors, by the time they need treatment, are on the point of risking their privileges to practice anyway, though they might not realize it. With treatment, the doctor with PAD can have a long and fruitful continuation of his career--with the blessing of the state and the medical community.

It is rare for a doctor in AA to find that his practice goes badly, says Trace. In fact, many believe that AA helped them professionally. "I believe we make better doctors. At least you know that we weren't out drinking last night."

Two things are changing the way physicians look at PAD--and at each other. The Chicago-based American Medical Society on Alcoholism and Other Drug Dependencies (AMSA-ODD) provides certification for doctors in treating PAD. At one time the medical arm of the National Council on Alcoholism, this organization conducts a daylong exam for doctors who wish to treat PAD. There are no residencies or fellowships yet, but AMSA-ODD is working toward fellowships and looks forward to a time when addictionology, as some call it, will be at least a recognized subspecialty. "It's difficult to change a medical school's curriculum," says executive director Emanuel Steindler. AMSA-ODD conducts its own review courses for doctors who wish to prepare for its exam or would like to learn more about recognizing and treating PAD. So far, AMSA-ODD, with 3,000 members, has certified 1,300 physicians, with an additional 600 expected to take the exam in December 1988.

One of the aims at AMSA-ODD, equally important in their view as certifying those who wish to treat PAD specifically, is to educate other doctors so that they can recognize it in their patients. "It's so prevalent in the general population," says Steindler, "and it's so commonly misdiagnosed." PAD is routinely diagnosed as essential hypertension, epilepsy, depression, borderline personality disorder, adult onset diabetes, and a wide variety of other disorders--the symptoms of which disappear when the drug causing them is removed.

Steindler credits state medical societies with a big role in getting help for physicians. "Until the state medical societies made it all right for a physician to come forward, the doc had nowhere to turn," except perhaps to face the punitive measures of the licensing body. That situation served in many cases to discourage doctors from seeking treatment in the past. Even today, with programs of advocacy and self-help in every state, most doctor-therapists believe that physicians with PAD are tough customers for treatment. Intervention still seems to be the rule rather than the exception.

Here's how intervention works: One day a physician who has been overusing drugs or alcohol will get a call. "We are from the state medical society," the caller will say. "We need to talk to you immediately about a very important personal matter of professional business. It is too personal to discuss on the phone. We'll meet you at our office or your office or your home."

As soon as the meeting can be arranged, preferably that day, "impaired physicians are told the intervenors cannot hurt them but can help them by protecting the professional status, the hospital staff privileges, and integrity within the medical society and professional community," wrote G. Douglas Talbott, who helped pioneer the use of this method to get physicians into treatment. "Additionally, an advocacy position with the licensing board and Drug Enforcement Agency is also provided. On the other hand, the dangers of malpractice, investigation by the DEA and the licensing board as well as revelation of poor medical practice within the local and national media are carefully explained to him or her. This is done by two intervenors who are peers of the impaired physician." (Often one or both of them is a recovering addict himself, since part of AA's program calls for its members to help others who are still suffering from PAD.)

In one study done by Talbott, 70 percent of 800 physicians had come to treatment with real or threatened license problems. Only 30 percent had come prior to reaching that degree of impairment from drug use. "It requires a crisis to get most physicians to treatment," Angres agreed. "Absolutely," he added.

One thing everyone in the field of addictionology agreed on: a lot more education is needed, not only because people are suffering from PAD, but because the people treating those people are also suffering from it. And no one seems able to tell, even when it comes up and slaps them in the face. Talbott wrote:

Alcohol is the base of both iodine and mercurochrome as an antiseptic. As a sedative hypnotic, it is an excellent sleep inducer--in the garage, out on the lawn, on the beach--it will induce sleep almost any place. As a tranquilizer, alcohol works almost every time on everybody far better than does Librium or Valium. Suppose someone announced the discovery of a drug--C2H5OH, ethyl alcohol--that could serve as an anesthetic agent, antiseptic, sedative hypnotic, and tranquilizer. That would be the greatest drug ever discovered. However, under every scientific and pharmacological constraint existing today for the protection of society, alcohol most certainly would be a class 2 narcotic and would be available only with a Government Narcotic Registry Number. After all, C2H5OH minus water is equal to ether. The brain has no idea whether the body is in an operating room inhaling ether or in a bar having a six-pack of beer. The brain is getting the same ether message.

Yet we use so much of this drug that tax from the sale of alcohol provides the second largest source of revenue to the United States government.

Herb Trace hung up the phone after barking orders at an addicted doctor on the other end of the line who was resisting treatment. He sighed and smiled. "When we have our doctors' AA meeting, we joke about it. We call it the "meeting of the gods." We secretly think we're better, that's why we need to meet with other doctors. But we're just as vulnerable. And we have to pay for our mistakes. We also have terrible guilt about it. 'How could we have gotten this disease--we of all people!'" He smiled knowingly.

He described his own "crash," as he called it, which brought him to treatment. "In 1974 I had a blackout and ran around the house nude and scared my wife half to death. I was a burnout," he said.

Russ Reed sought help from Jim West, who is now head of the Betty Ford Center. West sent Reed away to a recovery center for doctors in New Jersey, where he spent four months, and Reed brought what he learned there back to Evanston to begin his own practice. Most doctors in AA feel that they were always looking for something. Being in AA, they say, marks the end of that quest; they find what they were looking for. Enlightenment, serenity--whatever one chooses to call it, the way of life promoted by their activities in Alcoholics Anonymous reduces anxiety and helps them to function more efficiently--not only because they're drug free but because they take things as they come, with equanimity. Because they are no longer trying to change the world, the world is no longer such a burden to them. That does not mean it's easy.

One of the biggest obstacles a doctor in AA faces is guilt, Trace said. "The guilt was terrible. What right do I, a doctor, have to get sick, especially a self-induced sickness? The first thing that helped begin to alleviate that guilt was the fact that there were other doctors there at the treatment center." Trace and other doctors believe that is another important reason for having special AA groups for doctors. "Subsequently I was introduced to the disease concept of addiction, which relieved some of the guilt as well." But, he admits, it is an ongoing process and one that takes a very long time. Regaining self-esteem can take the rest of a doctor's lifetime. "I felt dirty for a long time," he said.

Before getting to AA, Nick Walcoff said, "I felt hopeless. I was so ashamed, so guilty. I thought addicts and alcoholics were terminally ill and didn't get well." And this from someone who was quite successful on the surface. His practice never completely fell apart. His surgical privileges weren't suspended. "Almost everything I've done I've been successful at, but I never believed it or saw it that way," he said. Now, being in AA, he says he has become able for the first time in his life to appreciate his own accomplishments and to see them for what they are. As a psychiatrist--or as any sort of physician--that ability to have a realistic perspective helps his work tremendously.

Walcoff, like every other doctor I interviewed, believes that his AA experience has made him a better practitioner. When he was in the throes of PAD, he experienced "an almost paralytic lack of emotion, which in psychiatry is not very helpful to the doctor-patient relationship." The spiritual element of AA deepened his empathic response, took him out of himself, and allowed him to help others. Moreover, he is no longer depressed, and so he has no need to medicate himself for depression.

"I had a very profound experience the first time I went to an AA meeting," Walcoff recalled. He was in Georgia at Talbott's treatment center, where he learned the skills he brought to Chicago to begin his own treatment center. He was very sick at the time. He felt his life, his practice, were over. And then he entered his first AA meeting. "What it felt like was an enormous sense of relief. I had found a group of other doctors who had gotten there the same way I had. I was overjoyed. I was no longer alone, no longer isolated. But it was only much later that I recognized that as a spiritual experience."

Trace agrees that the AA experience teaches a way of life that helps him be a better doctor. "We become more compassionate," he said. "We are taught tolerance, taught how to be calm, how to accept."

Trace also believes that "going through the experience of drug addiction actually makes us better doctors. After an experience like this, you understand people better." It is like the classic hero cycle in literature. "Anyone in life who goes through a major catastrophe and recovers from it will come out with more compassion. We are good doctors. When we get abstinent, we are very good doctors. Our motto is: We clean up awful nice."

*This name and some others have been changed.

Art accompanying story in printed newspaper (not available in this archive): illustration/John Figler; photo/Carolyn Lorence.

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