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Robert Holman Coombs
351 pp Price £13.50 ISBN 0-674-00174 (p/b)
Cambridge, Mass: Harvard University Press, 2000 .
Between 1992 and 1995 Professor Coombs and his assistants interviewed 91 addicted professionals—doctors, medical students, dentists, pharmacists, nurses, lawyers and pilots. With numerous anonymized extracts from these his book makes clear the extreme price that professionals (and those who rely on them) have to pay for dependence on drugs and alcohol. One doctor was nearly killed before he realized he might be in trouble. Addicted to cocaine, he found that his social life was now taking place on the street, where one night he was stabbed. With a punctured abdomen but afraid to go to hospital and have his secret revealed to colleagues, he went to his own surgery, sutured the laceration and put himself on high doses of antibiotics. He had previously taken so much cocaine and heroin that he felt no pain throughout. A medical intern performed a successful tracheotomy on a child in casualty despite having drunk so much alcohol that he had no recollection of the procedure: ‘I found myself thinking that because the procedure had turned out so well, maybe being in a blackout was a good way to do surgery and I should experiment with the effects of alcohol on surgical performance’.
Sometimes the interviewees had displayed impressive ingenuity. A doctor kept himself and his cocaine-dependent colleagues supplied for several years. They took it in turns to steal vials of sheep's blood used for hospital research. One of them would squirt blood up his nose and walk into casualty where he would obtain 10% cocaine solution, the standard treatment for nose-bleeds. It had to be signed out by two people but the other person was in the know. This was the cocaine source for weekend parties for nearly four years—at which point somebody noticed that the hospitals in the area were using excessive amounts of cocaine. A lawyer who was arrested for possessing large quantities of drugs was acquitted: the jury accepted his plea of temporary insanity and his argument that a ‘proficient trial attorney would never participate in such a crime unless he was crazy’.
Coombs uses a five-point continuum to rate severity, type 5 being physically and psychologically dependent. Why do some professionals become type 5 addicts? Those interviewed mention several factors. A pharmacist said, ‘I was at low risk because I was intelligent and knew about drugs’. This perception of low vulnerability is not helped by the fact that even medical professionals hear little during their training about the progressive stages of addiction and what can be done to help. One doctor said ‘I never considered that I was an addict. I was a doctor... I saw it as my right to relax and release pressure because I was under such an incredible amount of pressure’. A dentist, after being handcuffed and put in jail for the night, walked away the next morning telling himself, ‘I'm a dentist, I'm above all this stuff’. Pilots, says Coombs, tend to see themselves as invincible. Professional training can actually reinforce denial by inculcating ‘ideals’ of superhuman performance. Independent professionals are accustomed to helping others but keeping personal problems to themselves. Many fear that if their secret becomes known they will lose professional reputation and with it their careers—though sometimes it turns out that everyone at work already knows the secret.
What can be done? Although he acknowledges the importance of insight, Coombs challenges the view that nothing can be done unless the addict asks for help. He suggests the possibility of ‘planned confrontations’, carefully prepared and documented. A rehabilitation place for the addict is prearranged and s/he is urged to start treatment at once. There is some evidence that, in general, individual psychotherapy works less well than group therapy. Behavioural contracts, drug screening, coping skills training, ‘lifestyle planning and monitoring’, family education, the use of prescribed drugs to assist withdrawal and maintain abstinence, acupuncture, meditation, dietary advice, psychological techniques to reduce the risk of relapse—all these can be helpful. When treatment works the results can be remarkable. Professionals often experience a radical shift of attitudes and come to regard inner peace more highly than possessions and achievements.
The force and authority of the book derive from its concentration on type 5 dependence, with a detailed description of the most severely affected professionals. This has the disadvantage that earlier stages in the progression receive less attention. Admittedly, much less research has been done on type 3 (social abusers) and type 4 (solitary abusers). The book will be of greatest value to researchers and to people often involved in the treatment of addicted professionals. Unfortunately, the people who might above all benefit from these insights are often blinkered by their own denial.