Substance Abuse: A Culture Of Denial
When substance abuse and mental health issues are higher in medical professionals, why are veterinarians excluded from a national monitoring program?
Veterinary Practice News Managing Editor Somyr McLean contributed to this report.
Veterinary medicine is the only U.S. medical profession that does not have a national monitoring program for substance abuse and mental health issues. Considering that medical professionals in general have a statistically higher incidence of suicide, drug and alcohol abuse, many who are passionate about veterinary wellness are asking why DVMs are excluded.
Authorities say they’re concerned not only for the health of those in the veterinary profession, but for the animals they treat as well. Even basic questions on the issue go unanswered, as no comprehensive, large-scale study of veterinarians and substance abuse has ever been conducted in the U.S.
“Veterinarians in need of assistance fear losing their license and the stigma attached to suffering from an addiction or mental issue,” said Jeff Hall, DVM, a self-described recovering addict who formerly chaired the American Veterinary Medical Assn. Wellness Committee.
“There isn’t an updated national support database of veterinarians, there isn’t a hotline. There isn’t a catalog of animals harmed by a compromised veterinarian or technician, there’s no statistic that shows veterinarians or staff who succumb to addictions or depression,” Dr. Hall said.
“No one is expressing an interest in gathering this information for the profession. Veterinarians have to fight for the same programs that have been automatically granted to other professions for years.”
Hall is a consultant at St. Jude Medical, a cardiovascular medical technology company in St. Paul, Minn., where he creates medical devices used in human medicine. He said that although addictions can make a person feel ostracized regardless of profession, veterinarians should have support from colleagues.
“AVMA dropped the ball in creating a program to address addiction issues,” he charged, citing “lack of acknowledgement of a significant problem within the profession.”
“In 2007, addictions cost the economy $185 billion,” said Herbert Munden, M.D., director and founder of Austin Addiction Medicine Services in Austin, Texas. “Chemical dependency is an equal-opportunity disease, affecting the dependent individual and all who surround him or her, and the veterinary profession hasn’t escaped this.”
The lack of acknowledgement that veterinarians suffer substance abuse is only part of the problem.
Veterinarians also seem to be more difficult to reach for preventive education, said Gregory E. Skipper, M.D., a fellow of the American Society of Addiction Medicine. Skipper is the medical director for the Alabama Physician Health Program and the Alabama Veterinary Professional Wellness Program. This state program seeks to aid in the early detection and treatment for veterinarians with drug or alcohol abuse, depression or other mental wellness problems without risk of disciplinary action.
Every two years, Skipper’s group visits hospitals and clinics in Alabama in an outreach effort to educate physicians on mental wellness and substance abuse awareness. They have not been able to reach veterinarians in the same way.
“We think the reason they are more difficult to reach is that unlike physicians, who frequent hospitals where they obtain much of their continuing education daily, and where we can give talks, veterinarians are more isolated in their private clinics, especially veterinarians with mental health problems,” Dr. Skipper said.
“Troubled vets especially seem to become reclusive, and their employees are reluctant to report them. Therefore they are more seriously ill by the time they come to our attention. We have empirically found that veterinarians are much more troubled and advanced in addictions or mental illness before they are finally reported,” Skipper said.
Hall received his DVM in 1977 from Cornell University and practiced veterinary medicine for nine years before entering a program for alcohol and drug abuse.
Twenty-two years later he still labels himself a recovering addict, saying that mentally and financially, he couldn’t continue practicing during or after he completed a six-month program. He said he decided to take control of his life and career by entering corporate America and forming Veterinarians in Recovery, a national support network for veterinarians in recovery from alcohol and drug addiction, providing support and referrals.
“In 1986, I went through a brutal divorce and had a relapse,” Hall said. “The experience gave me incentive to initiate Veterinarians in Recover in 1990.
“Society hasn’t yet grasped that addiction is not compromised morals, it’s a disease. As part of my recovery plan, I went to Minnesota to first flip burgers, sell ice cream and stay sober. After six weeks with direction from the treatment center, I began teaching at the Medical Institute of Minnesota in Minneapolis.”
Hall has stopped updating his network of veterinarians for now. He said the time and cost involved in keeping information current makes the job impossible for one person to handle. But he continues to thrive professionally, holding more than 20 patents dealing with cardiac defibrillation.
In February at the Western Veterinary Conference in Las Vegas, Denise Tumblin, CPA, president of Wutchiett Tumblin and Associates in Columbus, Ohio, a veterinary practice management company, lectured on why practice managers fail at their jobs.
She quoted from a survey conducted by her company and Veterinary Economics in which 100 veterinary practices across the country were surveyed. Among those practices, 14 percent of veterinary practice managers left practice because of substance abuse issues.
“The veterinary profession is way behind all other medical professionals’ comprehension of the need for a standardized veterinary wellness program,” said Jerome Williams, DVM, chairman of the Alabama Wellness Committee and owner of Red Mountain Animal Clinic in Birmingham.
The Wellness Committee supervises the Alabama Veterinary Professionals Wellness Program. Its members are nominated by the Alabama VMA and appointed by the Alabama Board of Veterinary Medical Examiners.
“Nothing will be done until there is an overt crisis over a compromised veterinarian committing an egregious crime,” Dr. Williams said. “There’s ignorance and a lack of commitment at the leadership level when it comes to veterinary wellness.”
Without a national program to guide them, individual state veterinary medical associations and state veterinary medical boards are left to cope with veterinarians needing help. But only a few states have coordinated wellness programs.
Skipper suspects that many associations want and value life balance for their members but the average veterinarian doesn’t believe drug and alcohol abuse is common in the profession. Because of this, he said, the associations aren’t sure they want to spend the money.
“If doctors can come forward without being stigmatized or criminalized, they tend to want to stay away from the boards,” Skipper said. “But the boards [should] want [a wellness program] from an early prevention stand point.”
In states without rehabilitation and monitoring programs, a veterinarian or veterinary technician would be able to enroll in a treatment facility without reporting it to the board. In this case, the board could not regulate its licensees or impose sanctions if necessary for possible licensing violations based on the impairment, according to the Indiana Board of Veterinary Medical Examiners.
Part of why Alabama’s veterinary wellness program is successful may be the collaboration between the ALVME and the state VMA, which allows impaired veterinarians to come forward without risk of losing their practice or their license.
“What gets success is monitoring,” Skipper said.
“Vets sign a contract when they get out of recovery that holds them accountable for their recovery process. Also, we can advocate on their behalf if we need to, to licensing boards, etc., for example if they want to relocate to another state for a job. We encourage them never to lie on an application about a mental illness or substance abuse problem.”
“Not reporting to the board poses a problem as far as animal welfare is concerned,” Hall said. “I improperly sutured a Doberman puppy’s Achilles tendon when I was drunk. I had already gone through a rehabilitation facility in Minnesota when the veterinary board approached me about possible malpractice. I was honest about my actions, but I decided to leave general practice.”
Society tends to view any addiction as a defect, Hall said.
“Once you cross the line with an alcohol addiction, there’s no such thing as social drinking,” he noted. “After more than a decade of sobriety, I crashed and burned. Addictive disease characteristics are eloquent, and require support and that should be available through AVMA no matter where you live. I know if I relapse again, I will die.”
Hall said he found working around controlled substances to be very difficult as an addict.
“As an equine practitioner, I found myself filling prescriptions for an equine patient that didn’t need medicating,” Hall said. “Instead, I used the drugs myself. I knew I needed help after the Doberman incident. I knew I couldn’t keep it up in practice much longer.”
Existing state-based veterinary programs are handled differently in each state. Some programs are run through the state VMA, others through the board of veterinary medical examiners or through a combined program that includes other medical professionals. Hall said this complicates an already difficult situation.
“In 2005, AVMA sunset the Wellness Committee and their charge was transferred to the Member Services Committee,” said Sharon Granskog, assistant director of media relations for AVMA. “MSC has a goal of positioning the association as a resource for state and local veterinary leaders to provide wellness programs that best serve veterinarians and their communities.”
This past August, the member services committee developed a survey designed for state VMAs to determine which resources and types of programs would most benefit their members.
“Results of the survey indicated that 66.7 percent of those who responded said Employee Assistance Programs should be handled through the state,” Granskog said. “While 33.33 percent believe AVMA should handle the programs, 28.57 percent believe programs should be handled through the employer and 4.76 percent believe a program is unnecessary.”
Granskog did not detail how many responses were received.
Some contend that a national monitoring program would still be beneficial.
“This doesn’t address whether the VMAs would use a program designed and implemented by the AVMA,” Williams said. “The problem is, no one thinks about the need for a program until there is an immediate need. Only ignorance allows a person to say there isn’t a problem. They just don’t know who has the problem.”
Granskog said the member services subcommittee believes that wellness and peer assistance are issues crucial to the well being of the veterinary profession and would be best addressed by associations closest to the veterinarians who need assistance. But the AVMA’s website implies a more proactive approach than what has been delivered.
Barbara Baldwin, assistant director of the AVMA’s membership and field services division, said the association has no statistical information on these issues.
“AVMA does not have statistics on veterinary substance abuse or mental health,” she said, “We do not have a person assigned to keep the data updated, but it could eventually be part of a staffer’s job.”
AVMA reviews councils and committees every year, Baldwin said, noting that the Wellness Committee was discontinued because it no longer served members’ best interests.
“Since Employee Assistance Programs are out there as a benefit employers can offer employees, AVMA believes making a substance abuse program available to the 76,000 practicing veterinarians would be cost prohibitive,” she said.
“The MSC has a lot on its plate. We still have to look at what would best serve our members in this area. Any time you have a medical professional with access to medications, this is an issue. We haven’t had time to look at U.S. info for this to see what AVMA should do to best serve its members. We have a list of contacts on the AVMA website, but it is outdated and we don’t have contacts for some states.”
In 2003, AVMA’s Wellness Committee created a model wellness program that addresses addiction for states to consider. Those guidelines will be reviewed in 2009, according to AVMA, and currently appear online and annually in AVMA directories.
“We do not know what form AVMA will assist members with this topic, but we are investigating what resources we can provide,” Baldwin said. “Right now there is no plan for AVMA to implement a substance abuse/mental health plan for veterinarians. We see the AVMA as a clearinghouse of information in this instance. I hope to update the information on this topic on AVMA’s website over the next year.”
UK vs. US
“It’s staggering to find that there is no plan in the United States to deal with these issues,” said David Bartram, BvetMed, when contacted for this report. Bartram is one of two British veterinarians who found the suicide rate for veterinarians in the United Kingdom to be four times that of the general population.
Bartram and David Baldwin FRPCPsych (no relation to Barbara Baldwin), University of Southampton School of Medicine in Hampshire, U.K., recently released a study of veterinary suicide rates and substance abuse issues. It was published in the U.K. journal Veterinary Record.
Bartram and Baldwin’s research pulled from several other studies that surveyed different facets of the medical profession. Once the statistics were compiled, Bartram said he knew he wanted to conduct a more comprehensive study on U.K. veterinarians’ mental health.
“Although compassion fatigue is not a term we use in the U.K., we do look at veterinary job-related stress and find that plays a role in mental distress,” Bartram said.
Job stress, lethal drug access and euthanasia acceptance are among the potential driving forces behind U.K. veterinarians’ heightened risk for substance abuse and suicide, Bartram and Baldwin said.
“The study, which encompasses UK veterinarians’ depression, suicide, alcoholism and working conditions, is expected to be complete at the end of this summer,” Bartram said. “I received a 56 percent response rate out of 3,200 questionnaires sent out.”
Of the lack of a wellness plan for U.S. veterinarians, Bartram said, “Considering many of these issues are concealed, there is no way to conclude what the importance of the issue is in the States without answers to specialized questions in a comprehensive survey.
This will give a starting point for action.”
Since 1999, the United Kingdom has had a well-developed program sponsored through the British Veterinary Association (BVA), and the Veterinary Benevolent Fund (VBF), among other sponsors.
The website, run by VBF, reports in the Veterinary Surgeons Health Support Program’s 2006 annual report that 39 new veterinary practitioners were treated in the program. Nineteen of the participants were female and 20 were male. The report also shows that 48 percent of veterinarians in the program were referred by colleagues and 41 percent were under the age of 30.
The Veterinary Benevolent Fund assists veterinary surgeons unable to work as a result of ill health. It also helps dependents of deceased veterinary surgeons, retired veterinary surgeons and veterinary surgeons and their dependents needing short-term assistance. The program provides a help hotline, which can be called for support or direction.
The Veterinary Surgeons Health Support Program was created to combat problems of alcohol, drugs, eating disorders and other addictive and mental health issues among its members. The program is based on similar options available to members of the U.K. dental and pharmaceutical professions.
The U.K.’s proactive approach to spark awareness is what is necessary in the U.S., according to Hall and Williams.
“Those working within the profession overlook signs that indicate a problem exists, either because they’re not educated in what the signs are, they do not want to seem like a tattle-tale or they simply do not want to get involved,” Hall said. “The person calling an agency to help another suffering from an addiction is saving their life.”
The difference between veterinarians and MDs is that vets are more isolated, Hall said.
“There are many more outlets for MDs, whereas in a small-animal practice, no one sees the problem and it persists,” Hall says. “It’s especially easy for equine practitioners to acquire an ample supply of codeine, considering horses take ten times the dose of a human. I could write off the medication as an equine cough syrup.”
The U.S. Substance Abuse and Mental Health Services Administration estimated the general population’s substance abuse rate at 8.8 percent in a 2002-2004 survey, while the Centers for Disease Control rated the general population’s rate at 8.1 percent in 2005.
In a 1992 report about alcohol and substance abuse and impairment among physicians, the National Institute of Health’s National Center for Biotechnology Information said that high substance abuse in the medical profession is an ”occupational hazard.” Although societal concerns surrounding substance abuse and mental health issues persist, the issue has been acknowledged as an area where MDs need assistance, but veterinarians wait for that national recognition.
Williams has been in practice since 1969 and said his recovery from an opiate addiction has been extremely difficult and remains an ongoing process. Williams said he hasn’t used opiates since 1992 and added that while support isn’t available within the profession, it is essential for recovery and mental success.
“I do not feel the profession’s attitude reflects a ‘Let-me-help-you persona,’” he said. “It’s more of an overwhelming impression that ‘I am an isolated case,’ and that’s not the case. This is apparent by the lack of U.S. data, the lack of discussion, the lack of assistance.”
“Most veterinarians don’t remain vigilant over narcotics records,” Williams noted. “It is a difficult thing to police. Veterinarians trust their staff and vice versa. No one goes into a position expecting someone to be stealing animal drugs. However, most of the time when drugs are reported missing from a veterinary practice, it was an inside job.”
“If we don’t begin making an effort at the university level, generation after generation will be introduced to the profession, unprepared to deal with this,” Williams said. “The issue goes beyond addictions. It is also mental issues and compassion fatigue.”
Williams said the Alabama Veterinary Professional Wellness Program will ask the Alabama Board of Examiners to include the organization’s wellness survey with the annual veterinary license renewal done in December. The organization also plans to survey the school this fall if the schools agree to implement it.
“We’ve been trying to get more involved with the veterinary schools on these issues, but we’re having a really hard time getting them to accept that there is a problem to be addressed,” Skipper said. “We were recently invited to speak at the annual SCAVMA meeting at Auburn and only one person showed up for the lecture. This denial is a cultural phenomenon [among veterinarians].”
State VMAs’ Programs
Veterinary Practice News asked state veterinary medical associations about their programs through the American Society of Veterinary Medical Association Executives Among responses:
“The IVMA proposed changes to the Indiana Veterinary Practice Act during the 2008 Indiana General Assembly,” says Lisa Perius, executive director, Indian Veterinary Medical Assn. “In that, we have added provisions for the IVMA and the Indiana Board of Veterinary Medical Examiners to provide a monitoring program for substance abuse. The new law went into effect July 1. We plan to move forward with making this happen.”
- “South Carolina’s Recovery Professionals Program is administered through one of the state drug and alcohol treatment centers,” says Marie Queen, executive director. “To my knowledge, SCVMA has never discussed having its own program.”
- “Neither the VMA or Board has a veterinary substance abuse program,” says Tracy Thomas, administrative assistant for the North Dakota VMA. “Significantly limited financial resources means our state cannot support a substance abuse program.”
- The Kentucky Veterinary Medical Assn.’s program has been in existence for about 20 years, but was a discrete volunteer program that assisted veterinarians, family and staff when they contacted the committee,” says Louise Cook, executive director, KVMA. “The Kentucky Board of Veterinary Examiners handles a program now.”
- “We have a Wellness Program with three veterinarians who work confidentially with members of the association,” says Mollie Rasor, executive director, North Carolina Veterinary Medical Assn. “The North Carolina Veterinary Medical Board has a program called NC Physicians Health Plan that has been in place for four years. It’s [open to] all veterinarians and registered vet techs.”
- “The Michigan Veterinary Medical Assn. does not have our own program,” says Karlene Belyea, executive director of the organization. “The State of Michigan has a program called the Health Professional Recovery Program that serves all health professions. We refer cases to them.”
- “The Wisconsin Veterinary Examining Board has a great program,” says Leslie Grendahl, executive director, Wisconsin Veterinary Medical Assn. “Veterinarians in the program are monitored for several years, are allowed to practice and the program is not public record. The program is extremely expensive, considering the ongoing testing and monitoring.”
- “Nevada veterinarians piggy-backed with a medical professional program,” says Michelle Wagner, executive director, Nevada Veterinary Medical Assn. “I don’t know if the problem is getting worse, or people are just becoming more aware.”