A sociological examination of illicit prescription drug use among pharmacists

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A sociological examination of illicit prescription drug use among pharmacists
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Dabney, Dean A., 1968-
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Thesis (Ph.D.)--University of Florida, 1997.
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Includes bibliographical references (leaves 266-277).
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by Dean A Dabney.
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Vita.

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A SOCIOLOGICAL EXAMINATION OF ILLICIT PRESCRIPTION
DRUG USE AMONG PHARMACISTS















By

DEAN A. DABNEY


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


1997














ACKNOWLEDGMENTS


The foundation beneath all of my accomplishments can be traced to my parents.

The memory of my father has long served as the basis for my self-confidence and

motivated my pursuit of excellence. My mother has instilled in me a sense of strength,

hard work, and individuality that is reflected in my every endeavor. Words cannot capture

the sense of love and gratitude that I feel for both of them.

I have been granted the good fortune of having two outstanding academic

supervisors during my graduate education. My masters' supervisor, Bruce Berg, is directly

responsible for my choice to pursue an academic career. He taught me the skills of

technical writing and showed me the ropes of academia.

My doctoral supervisor, Richard C. Hollinger, has provided me unending respect

and interpersonal support for the past five years. He has showed unwavering confidence in

me and inspired so much of my personal and professional growth. He is both a good friend

and a mentor, I cherish all that he has given to me. This dissertation most certainly would

not have been possible without his patience, direction, and complete funding support.

I would like to thank the members of my supervisory committee, Ronald L. Akers,

Donna E. Berardo, Jaber F. Gubrium, John C. Henretta, and Sally A. Hutchinson, for their

direction and comments regarding the various drafts of this dissertation. Moreover, the

rest of the University of Florida Department of Sociology, in particular the members of the









office staff, deserve thanks for their assistance and support throughout over the course of

my stay.

There are a number of individuals outside of the university community that deserve

thanks. The supporting partners of the Security Research Project have been directly

responsible for the funding of this project and I say thank you to all of them. Several

pharmacy advocates, in particular, Ken Dickinson and Jean Sheffield, were instrumental in

the success of my data collection efforts Officials within the American Pharmaceutical

Association, namely, Ron Williams and Susan Winkler, are owed thanks for their

assistance and support throughout the project Also, I thank M. J. Schaer for her efforts

in formatting this document and Marcus Harvey for his copy editing assistance.

Finally, I would like to acknowledge the emotional support and comical release

that were offered to me by my many friends in Gainesville. The list of contributors is too

long to mention by name, but I thank them all and am grateful for the fact that each made

this writing process livable


















TABLE OF CONTENTS


ACKNOWLEDGMENTS .....

LIST OF TABLES .. .....

ABSTRACT .....

CHAPTERS

I INTRODUCTION .......


Notes .....

II PROBLEM STATEMENT

Framing the Research Problem .......... ..
The Extent of Illicit Prescription Drug Use among Pharmacists ...
Sociological Significance of the Problem .. ... ...
Practical Significance of the Problem ....
Specific Research Foci .... ..
N o tes . . . .

III LITERATURE REVIEW .. .. .........

Literature on Pharmacists' Use of Controlled Substances .......
Employee Deviance Literature .......
Literature on Educational Socialization .. ... .........
Literature on Pharmacy Work Culture ..................
Literature on Professional Socialization ....
Sum m ary .... ... ............
N o tes .. ... .. .

IV RESEARCH METHODOLOGY .. ..... .......

The R research Plan ... .........................
In-depth Interviews with Recovering Drug Using Pharmacists ....
Analysis of Loss Prevention Incident Reports ..... .
Survey of Practicing Pharmacists .. .
Summary of the Multi-method Analysis Plan .. ...............


. v ii


. 1


7
. 7

.... 12
14

18
. 2 1

.... 23

.. 23
..... 39
46
50
53
. .. .... 56
57

. 59
59

. ... .. 59
63
... 69
74
.. .. 8 1










V FINDINGS OF THE PERSONAL INTERVIEW COMPONENT


Participant Demographics ....
Drug Use Behaviors .... ....... ...
Onset and Progression of Drug Use Behavior...
Consequences of Drug Use .... ...
Educational Influences ........ .... .. .......
Occupational Influences .. ....
Professional Influences .........
Summary .. .... ....
N otes .. .... .....


... 84
. 8 8
. .. 10 7
... .. 127
... 129
.. 140
. .. 15 2
. 16 4
167


VI FINDINGS OF THE ARCHIVAL EXAMINATION OF CORPORATE
LOSS PREVENTION APPREHENSION RECORDS ....


Demographic Profile of Apprehended Offenders .
Typical Incident Description ..... ...........
Response of the Accused Pharmacist ...........
Corporate Response to Drug Apprehension Incidents
Summary .. ... .
Notes ....


. 169
. 173
. 179
... 181
. 183
186


VII FINDINGS FROM THE SURVEY OF PRACTICING PHARMACISTS ... 187

Sample Demographics ...... ............ ... ... 187
Drug Use Behaviors ...... ....... ........... 190
Minimal Drug Abuse Education ............. ................. 195
Occupational Trends .. ....... .......... .. .. 196
Professional Socialization Trends ........... ........ ....... 198
Ordinary Least Squares Regression ........................... .... 200
Logistic Regression Analysis ..... ...... ............ 214
Summary ....... ............................... 221
Notes .................... .......... ....... ... .. .... 223

VIII SUMMARY AND IMPLICATIONS .. .................... 226

Limitations of the Research .............. ... ... ... 226
Drug User Demographics .... .. ............................. 230
Pharmacists' Drug Use Trends and Patterns ....................... 234
Theoretical Implications .. ................. ............ 245
Policy Im plications .............. ............ ..... ........... 249
Future Research Directions .. ............ .............. 252
Notes... ... ............. 253









APPENDICES

A RECOVERING PHARMACIST INTERVIEW GUIDE ............... 254

B CORPORATE LOSS PREVENTION INCIDENT REPORT DATA
TEMPLATE ............... ............... ........ 258

C PRACTICING PHARMACIST SURVEY INSTRUMENT .. .......... 261

D PRACTICING PHARMACIST SURVEY INSTRUMENT .......... ... 262

REFERENCES .................................... .. ...... .. .266

BIOGRAPHICAL SKETCH .... ....... ..... ............... 278















LIST OF TABLES


1. Demographic Characteristics (as %) of the Interview Participants and the
Population of Practicing U.S. Pharmacists ....... ..................... 85

2. Relationship Between the Respondent's Preferred Job Role and Their Drug
Use Classification (N = 50) .......................... .......... 151

3. Demographic Characteristics of the 89 Pharmacists from the Loss Prevention
Apprehension Report Analysis ..... ...... ..... ................ 170

4. Comparison of the Demographic Characteristics (as %) of the Pharmacists
from the Loss Prevention Apprehension Report Analysis and the Interview
Participants ....... .............. ....... .. ..... 172

5. The Types of Drugs and Number of Dosage Units Stolen by the 89
Apprehended Pharmacists .. ................. ........... 178

6. The Intent Behind the Pharmacists' Drug Thefts ......... ..... 180

7. Corporate Response to Drug Theft Incidents (N = 89) ...... .... 182

8. Demographic Characteristics of the 1,016 Practicing Pharmacists Who
Responded to the Mailed Survey ........... ... ... 188

9. Employment Characteristics of the Survey Respondents (N = 1,016) ......... 190

10. Reported Number of Lifetime Illicit prescription drug use Episode Percentages
(N = 1,016) .... ....... .. 192

11. When Drug Users Began Their Unauthorized Prescription Drug Use (%) ..... 194

12. Pharmacists' Illicit Use of Any Potentially Addictive Prescription Drug (N =
959) .. .. ... .... ..... ......... 195

13. Zero-order Correlations, Means, and Standard Deviations (N 927) ......... 207









14. Multiple Regression Results (N = 883) ............. ............... 211

15. Multiple Regression Results-Reduced Model (N = 937) ............... 215

16. Continuation Ratio Logistic Regression Results ................... ..... 217

17. Relationship Between Attitudes Toward Self-medication and Self-reported
Illicit Prescription Drug Use Behaviors ( N = 958) ..... ............... 222

18. Demographic Characteristics (as %) of the Drug Using Pharmacists from the
Three Data Sources Interview and the Population of Practicing U.S.
Pharmacists ................... .. ............... .231














Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

A SOCIOLOGICAL EXAMINATION OF ILLICIT PRESCRIPTION
DRUG USE AMONG PHARMACISTS

By

Dean A. Dabney

December 1997

Chair: Richard C. Hollinger
Major Department: Sociology

This research investigates pharmacists' illicit use of prescription drugs. In particular,

it considers the ways that various educational, occupational, and professional socialization

processes affect the onset and progression of such behaviors.

Data were gathered using three data separate collection efforts. First, fifty personal

interviews were conducted with pharmacists recovering from drug abuse. Second, the

apprehension reports for all drug-related investigations (N = 89) conducted by the security

departments of two major retail pharmacy chains between 1991 and 1996 are analyzed. A

mailed, anonymous, self-report survey was used to query a random sample of 1,016 U.S.

practicing pharmacists. The personal interview and apprehension report data were

analyzed using a standard form of content analysis. The survey data were analyzed using

descriptive statistics, ordinary least squares regression, and logistic regression.









The results suggest that substantial numbers of pharmacists engage in illicit

prescription drug use. Over one-half (58.4%) of the practicing pharmacists from the

survey inquiry reported at least one lifetime illicit prescription drug use episode, 30.7%

reported five or more lifetime episodes, and 5.6% identified themselves as drug abusers.

Collectively, the results suggest that some drug using pharmacists tend to develop

surprisingly extensive drug use habits that involve the theft and use of multiple controlled

substances. The analysis shows that being and becoming a pharmacist is central to the

onset and progression of the individual's drug use. In pharmacy school, students receive

limited substance abuse education and the college culture exposes them to social

acceptance toward the recreational use of prescription drugs. In the workplace, coworkers

expose pharmacists to relaxed attitudes and behaviors regarding the therapeutic use of

prescription drugs. The professional socialization process contains conflicting messages

about drugs. Unrestricted access and constant social reinforcement about the positive

potentials of prescription drugs fosters a benign overconfidence toward drugs.

I conclude that pharmacists knowledge and familiarity with drugs contributes to a

mind-set wherein individuals come to believe that they are immune to drug abuse and thus

capable of monitoring their own therapeutic usage. The theoretical discussion calls for an

expansion of the medical model approach to substance abuse wherein social factors are

included. Numerous preventative policy implications also are presented.














CHAPTER I
INTRODUCTION


More than 1.6 billion drug prescriptions are filled in the United States each year

(Wivell & Wilson, 1994). Every day, hundreds of thousands of Americans walk into their

local drug stores and rely on pharmacists to accurately dispense their medications. What

the public does not realize, however, is that some of the pharmacists filling their

prescriptions are themselves using the drugs that they are entrusted to dispense.

Lay persons tend to be surprised to learn that the pharmacy profession is

confronted with problems of illicit prescription drug use among its ranks. After all, the

pharmacy profession is highly regarded by the general public. For a decade, annual public

opinion polls ranked pharmacy as the most honest and ethical occupation, above even the

clergy (McAneny & Moore, 1994). Beyond the high ethical ratings, there is a more

fundamental basis for our dismissing suggestions that significant numbers of pharmacists

engage in illicit prescription drug use--we assume that pharmacists, perhaps more than any

other members of society, are above such behaviors. We perceive pharmacists as highly

educated "drug experts." We point to the fact that they have achieved a highly prestigious

status as a medical professional. Both their employers and patients entrust them with the

important responsibility of dispensing controlled medical substances. It is difficult to

accept that pharmacists sometimes put aside what they have learned about the harmful

nature of controlled substances, that they breach the very trust that we grant them, and

that they commit what most would see as a serious professional violation of which they









are capable. Yet, the National Association of Retail Druggists (NARD, 1988) estimates

that, profession-wide, one in seven pharmacists suffers from chemical dependency at some

point in their careers.

The present study draws upon multiple sources of data to consider the nature and

dynamics of pharmacists' illicit drug use Ironically, much of this illicit drug use can be

attributed to the very educational, occupational, and professional factors that are crucial to

the process of becoming a pharmacist. My discussion frames pharmacists' use of illicit

drugs as incidents of "trust violations" (Cressey, 1953) in which individuals use their

professional position to perpetrate, perpetuate, and justify their deviant behaviors. In

particular, I will argue that social factors such as a lack of training on the psychological

aspects of drug abuse, exposure to peers or mentors who engage in or condone

self-medication practices, and a benign belief system in their ability to self-medicate are

consistently related to pharmacist's drug use behaviors.

This study is not confined to illicit prescription drug use among pharmacists It

also focuses on how we conceive of, manage, and react to the broader phenomenon of

drug abuse,2 both within the pharmacy profession and through society as a whole. At

present, the majority of the research, literature, and policies treating drug abuse among

pharmacists (and drug abuse in general) draws heavily on a medical model explanation

(Jellinek, 1960): one's drug abuse condition is conceived of as a bio-psycho-social disease.

The onset, progression, and maintenance of an individual's drug use behaviors are said to

be symptomatic of a personal pathological condition. The source of the pathological

condition is principally attributed to predisposing biological--genetics--or psychological--

early childhood development--factors.









A medical model orientation focuses little attention on the ways in which social or

environmental conditions influence an individual's drug use and abuse situations. There is

little interest in the effect of social factors on the onset, progression, or maintenance of an

individual's drug use behavior. Instead, social factors receive only secondary attention and

are usually described as facilitators, catalysts, or enabling mechanisms to an individual's

drug use behaviors.

The educational, occupational, and professional experiences of pharmacists are

wholly social in nature. These experiences have no biological origins and occur during the

adult stages of individuals' lives. Thus, they are of little concern to medical model scholars

who explain the problem of drug use among pharmacists. The present study presents

evidence that links the educational, occupational, and professional experiences of

pharmacists to the onset, progression, and maintenance of their illicit prescription drug

use. I show that social factors not only affect pharmacists' drug use behaviors, but they

also contribute to the progressive and problematic psychological, emotional, and physical

conditions that have come to be associated with the broader phenomenon of drug abuse.

We need to critically examine and expand upon the dominant medical model orientations

to drug use and abuse. Namely, scholars need to become more sensitive to the role that

social factors play in all facets of individuals' drug use and abuse.

This dissertation has seven chapters, namely, problem statement, literature review,

research methodology, three findings chapters, and a summary and implications chapter.

The problem statement chapter justifies more research on the topic of pharmacists'

illicit prescription drug use This chapter begins by conceptually positioning the topic of

pharmacists' illicit prescription drug use within the sociological discipline, and then it

defines the behaviors, concepts, and issues that will be considered in the present study.









This definitional exercise is necessary because ongoing discussions of drug related topics

have produced diverse conceptualizations, vocabularies, and assumptions.

The problem statement chapter also discusses the significance of the present

research project. First, I demonstrate that significant numbers of pharmacists illegally use

prescription medicines. This unique form of drug use requires further investigation. Next, I

establish that the present research topic lies at the nexus of several sub-disciplines within

sociology. This conceptual position offers an opportunity theoretically to inform numerous

scholarly audiences. Finally, I present the many practical consequences associated with

pharmacists' illicit prescription drug use. Namely, discussion centers on the ways in which

pharmacists' illicit prescription drug use harms the general public, pharmacy employers,

the profession at large, and the individual pharmacist

The problem statement chapter concludes with a precise listing of the project's

principal questions. Here, the specific educational, occupational, and professional

influences that can be linked to pharmacists' illicit prescription drug use are outlined.

The literature review chapter surveys the existing literature on pharmacists' use of

controlled substances,' employee deviance, the use of controlled substances in other

occupational settings, educational socialization among pharmacists, the pharmacy work

culture, and pharmacy professionalization The purpose here is twofold. First, the

discussion offers the reader insight into the contemporary empirical and theoretical

understandings of the present research topic. Second, it introduces and reviews literature

from the substantive areas of drug abuse, workplace deviance, medical sociology, and

occupations and professions. These studies help substantiate the theoretical framework of

the present study.









The research methodology chapter explains the sampling, data collection

procedures, measurement, and data organization and analysis plans associated with each

of the three data sources used in this study. These data sources include 1) in-depth

interviews with a snowball sample of 50 pharmacists with extensive drug use histories; 2)

incident reports detailing 89 officially discovered cases of pharmacists' drug related

wrongdoings in the retail pharmacy environment; and 3) a self-administered questionnaire

survey of a random sample of 1016 practicing pharmacists. The chapter concludes with a

discussion of how this multi-method inquiry process is synthesized.

Next, the study's research findings are presented in three separate chapters. The

first findings chapter outlines the results of the interview component. The second findings

chapter presents data from the archival incident report component. The third findings

chapter reviews the data from the survey component

The summary and implications chapter addresses several issues. It begins by

drawing together the evidence from the three findings chapters. Specifically, I outline the

educational, occupational, and professional factors that have previously been shown to

influence pharmacists' illicit prescription drug use. Next, I suggest ways in which these

findings can be used to inform us about the broader phenomenon of drug abuse. This

chapter will also consider the limitations of the present research project The dissertation

concludes with a discussion of the study's policy and theory implications.


Notes


1. In the context of the present study, the term illicit prescription drug use/user represents
a legal distinction This concept is meant to refer only to the illegal use of prescription
medications as outlined in the Controlled Substance Act of 1970. It includes the use of
mind altering, prescription medications when such use is done without a legitimate
prescription order that has been signed or authorized by a licensed, FDA approved,









physician. The use of prescription medications without an authorizing prescription order
constitutes illicit prescription drug use regardless of whether such medications were
procured from pharmacy stock, from a street level drug dealer, or any other illicit market
source. My use of the term illicit prescription drug use does not refer to the use of those
mind altering controlled substances that are deemed to have no medicinal purposes and
thus are classified as "Schedule I" substances under the Controlled Substance Act of 1970
(e.g., marijuana, hashish, heroin, industrial inhalants, hallucinogens such as LSD). Moreo-
ver, the term illicit prescription drug use does not include the use of prescription
medications when such use is done in accordance with the instructions on a physician
authorized prescription order, regardless of how substantial or prolonged the use may be.
The term illicit prescription drug use does not include the use or abuse of alcohol. Also,
note that this concept carries no functional distinction. That is, it is not intended to speak
directly to any physical, emotional, or mental consequences or resulting states of be-
havior/consciousness associated with an individual's use of any prescription medicine.
Issues related to an individual's drug related behavioral or mental functionality will be
referred to under the heading of "drug abuse", "impairment" or "problematic drug use."

2. The term "drug abuse" focuses on the consequences of drug use, not the use itself To
this end, it is concerned with appraisals of functional or acceptable drug use. Any drug
use, regardless of whether it is deemed illicit or not, that results in negative physical,
social, and/or professional consequences is said to be indicative of a drug abuse condition.
What constitutes a negative consequence can be determined by the individual user, or, as
is more often the case, by some external appraisal. This type of functional appraisal of
drug use outcomes is closely related to the concepts of "drug impairment" and
"problematic drug use."

3. Given the paucity of literature focused explicitly on what I refer to as "pharmacists'
illicit prescription drug use" (see note 1 above) this section includes the existing literature
on the etiology, occurrence, prevention, and management of pharmacists' use of many
controlled substances.














CHAPTER I1
PROBLEM STATEMENT


Framing the Research Problem


Scholarly discussions on drug related topics are often hindered by fundamental

definitional issues: Misunderstandings arise when discussants use terms or concepts with

multiple meanings or interpretations. To avoid this problem, it is necessary to clarify the

terms, concepts, and issues that appear in the present project.

This study is principally concerned with pharmacists' illicit prescription drug use.

Illicit prescription drug use refers only to drug use that violates the provisions of the

Controlled Substance Act of 1970. The Controlled Substance Act of 1970 stipulates how

prescription pharmaceuticals are to be legally defined, handled, dispensed, and utilized in

our society. From the start of their pharmacy training, pharmacists are made keenly aware

of the interpretations, applications, and guidelines from this important piece of legislation.

This piece of legislation is a cornerstone of pharmacy practice and shapes the pharmacist's

daily prescribing practices. When a pharmacist knowingly uses a drug without first

obtaining a prescription, he/she is knowingly violating the Controlled Substance Act of

1970. Such a violation represents a breach of the core governing principles of the

pharmacy profession and falls under the rubric of employee deviance.

Donald Cressey (1953) was one of the first sociologists to systematically

investigate the nature and dynamics of employee deviance. In his classic analysis of

embezzlement, Cressey asked convicted embezzlers to recount the behaviors and









motivations associated with their financial wrongdoings. He described their acts of

embezzlement as a form of "trust violation." His data link these acts of embezzlement to

the individuals' insider knowledge of their work environment and their interpretations of

the organizational culture within which they are embedded. When confronted with a need

for a quick financial fix, these individuals used their heightened understanding and

familiarity with the intricacies of bookkeeping to fill it. Moreover, they used these same

organizational understandings and their position of trust to conceptualize their behaviors

as being legitimate and non-deviant. Using what Cressey called "vocabularies of

adjustment," they defined their continued and extensive thefts as instances of well-

intentioned borrowing in which they were using nonessential company funds to help

themselves out of tight financial spots. In short, his data show that embezzlers neutralize

their normative appraisals of their own theft behaviors by contextualizing them within the

framework of their employment situation.

Cressey argued that these vocabularies of adjustment were causally related to the

embezzlers' trust violating behaviors. He insisted that individuals did not simply enlist

these cognitive mechanisms as ex post facto explanations or justifications for past

behaviors. He claimed that they also served as a prior mechanisms allowing for the onset

of theft behaviors.

The phenomenon of pharmacists' illicit prescription drug use' is analogous to

Cressey's embezzlers Most of a pharmacist's contact with prescription medications occurs

under autonomous and unsupervised working conditions. Their employers and the public

must rely largely on the pharmacist's internalized professional identity and informal

professional norms to prevent pharmacists from abusing their dispensing authority This

dissertation considers the paradoxical role played by these supposed control mechanisms









in the onset and progression of pharmacists' illicit prescription drug use. In particular,

pharmacists use their professional standing and familiarity with controlled substances to

convince themselves that their own personal drug use (i.e., trust violation) is acceptable.

To this end, being and becoming a pharmacist serves as a contributing factor to the onset

and progression of trust violating drug use behaviors.

While some drug-using pharmacists engage in alcohol use and/or the use of

nonprescription drugs (defined as Schedule 1 substances under the Controlled Substance

Act of 1970), this project is not directly concerned with such use. The use of alcohol or

street drugs (e.g., marijuana) does not involve the same form of ethical violation that is

associated with prescription drug use. As such, it is unlikely that issues of professional

identity and informal social control play the same role in the onset and progression of

these behaviors.

From time to time, as with any human beings, pharmacists develop ailments and

avail themselves of doctor-prescribed medications. In some cases, a pharmacist's position

as a health care professional may lead to excessive or prolonged prescribing patterns that

are supported by a doctor's legitimate prescription. The present analysis is not directly

concerned with pharmacists' use ofbonafide prescription medications done under the

supervision of a prescribing physician. This distinction does not discount the possibility

that pharmacists can and do develop drug abuse situations due to a doctor's ignorance.

Moreover, it does not deny that it is possible for codependent drug use relationships to

arise between pharmacists and their prescribing physicians. However, when a pharmacist

develops a prolonged and progressive drug use/abuse condition while under the

supervision of a prescribing physician, he/she is not involved with the same ethical breach

of trust as a pharmacist who engages in illicit prescription drug use. In the former







10

situation, the pharmacist's use/abuse of the drugs is implicitly or explicitly sanctioned by a

doctor and is not therefore an independent trust violation.

Past research (Bissell et al., 1989) shows that a pharmacist's ability to perform

his/her daily job related functions is hindered by the physiological or mental effects of the

drugs that he/she ingests. When a pharmacist's work suffers from his/her drug use, he/she

is said to be "impaired." Pharmacists' impairment raises numerous practical and theoretical

issues. Although the present analysis speaks to the ways that a pharmacist's illicit use of

drugs affects his/her work productivity, such considerations are of secondary importance.

Job performance issues will be highlighted only when they can be linked back to breaches

of professional responsibility. That is, 1 will be concerned with the linkages between the

individual's self-definition of impairment and his/her standards of what constitutes

acceptable behavior for a practicing pharmacist.

Why should we learn more about illicit prescription drug use among pharmacists?

This question is best answered by focusing on three issues. First, one must consider the

available data on the extent of the problem. We know that significant numbers of

pharmacists engage in unauthorized prescription drug use At the least, this concentrated

prescription drug use among members of a single community of professionals represents

an intriguing research question in need of further study. Second, a study of illicit

prescription drug use among pharmacists potentially augments our understanding of

several substantive areas of sociology: This study should benefit scholars studying deviant

drug use, work place deviance, medical sociology, and occupations and professions.

Finally, additional research on illicit prescription drug use among pharmacists is needed to

illumine the practical ramifications of such behaviors: pharmacists' drug use has negative

consequences for the affected individuals, their families, their employers, the profession,









and most importantly, the public's welfare. Given that the existing theoretical and policy

approaches to the problem have done little to curb the problem, perhaps it is time that we

pursue fresh perspectives. Hopefully, the present study will provide new insight that will

assist future policy makers


The Extent of Illicit Prescription Drug Use among Pharmacists


How prevalent is the illicit prescription drug use problem in the pharmacy

profession? Simply stated, there are no accurate incidence or prevalence data, only rough

estimates. Two small-scale, regional studies provide indications of the problem's extent. A

survey conducted in New York (McAuliffe et al., 1987) found that 46% of the 312

practicing pharmacists surveyed had used some form of controlled substances at least once

and 19% had done so within the past year. However, these numbers include both the use

of street and prescription drugs and do not adhere to the more limited definition of illicit

prescription drug use in the present study. The New York data further suggest that

pharmacists tend to use drugs more often for therapeutic, self-treatment purposes than for

recreational purposes: 21% claimed that their use was "instrumental" to their work.

Measures of problematic drug use in the New York sample show that 2.3% of the

respondents admitted drug dependency,2 8.9% reported experiencing adverse effects in

their private or professional life due to their usage, and another 6% were identified as

being at risk of drug dependency.' The authors conclude that 18% of the respondents

were dependent on drugs, or at risk of drug dependency.

Another study conducted among practicing North Carolina pharmacists

(N = 1,370) revealed that 24% of the respondents had worked with a colleague who they

believed was abusing or addicted to drugs (Normack et al., 1985). This study estimated









that 21% of the respondents admitted to personal behaviors that place themselves at risk

of chemical impairment '

Extrapolating from the available estimates of drug use/abuse onto the overall

population of over 190,000 practicing pharmacists nationwide (Martin, 1993), one might

conservatively estimate that tens of thousands of pharmacists presently engage in some

form of illicit prescription drug use behavior. Moreover, the prevalence data suggest that a

considerable segment of this drug using sub-population of pharmacists engages in high

levels of usage and/or experience personal or professional problems that they themselves

define as problematic.


Sociological Significance of the Problem


Illicit prescription drug use among pharmacists represents an intriguing

sociological problem. For the sociologist who studies deviant drug use or abuse, the issue

of illicit prescription drug use among pharmacists raises numerous research questions.

Most fundamentally, this topic poses an opportunity better to understand the dynamics of

drug use and abuse within a select population of professionals. This initial research focus

spawns a host of more specific research questions, including, but not limited to, the

following: what factors are associated with the onset of an individual's illicit prescription

drug use, what are the techniques and motives associated with the individual's illicit

prescription drug use, and what are the levels and patterns of usage associated with an

individual's drug use career? Collectively, information of this kind can be used to inform

theories and policies aimed at understanding and confronting drug abuse problems.

Pharmacists' illicit prescription drug use also complements the interests of

sociologists studying deviance in the workplace. Sociologists are increasingly concerned









with such topics as the effects of drug use in the work place, employee theft, and the

social and organizational factors that affect varying rates and forms of workplace

deviance. Given that the existing literature demonstrates that the majority of drug using

pharmacists also engage in the theft and use of drugs while at work, this topic offers an

opportunity to explore how organizational culture, social controls, and socialization issues

connect with specific acts of deviance committed in the pharmacy workplace By

approaching pharmacists' illicit prescription drug use as instances of deviant trust

violation, we are better able to attribute such behaviors to professional ethics, work group

norms, and the learning processes associated with such issues.

For medical sociologists, drug use among pharmacists speaks to several

contemporary research and policy interests The medical sociology literature has long

focused attention on various aspects of the educational process within the health

professions. Pertinent issues have included the development and dissemination of ethical

standards and the role that the educational process plays in the long term attitudes and

behaviors of its members. The present study allows us the opportunity to further our

understandings of the intricacies of the formal and informal socialization and social control

processes within the pharmacy profession. In particular, it offers insight into the ways in

which socialization processes may contribute to the onset and progression of a specific

form of deviant behavior--illicit prescription drug use among pharmacists.

A study of drug use among pharmacists also benefits sociologists specializing in

the study of occupations and professions. Numerous scholars have studied alcoholism and

its manifestations within certain work groups whose occupational or professional cultures

place them in close proximity to the sale or use of alcohol (Fillmore & Caetano, 1982).

The present research offers an opportunity to consider a similar form of occupational









deviance in which pharmacists abuse the very drugs that they are entrusted to dispense.

This issue becomes significantly more intriguing when one considers that the pharmacy

profession's central occupational identity is inextricably linked to its unchallenged role as

the sole legitimate authority in charge of the dispensing and monitoring of prescription

medicines. As such, illicit prescription drug use among pharmacists is a manifestation of

the most problematic form of occupational deviance that a pharmacist can commit.


Practical Significance of the Problem


Most obviously, illicit prescription drug use among pharmacists almost always

affects their ability to fulfill their professional responsibilities. An individual's progressive

illicit prescription drug use inevitably spills over into his/her working hours and

compromises or impairs his/her abilities. This situation raises obvious concerns for the

general public: A drug impaired mental and physical state could potentially affect any one

of the crucial components of a pharmacist's daily work tasks For example, the drug

impaired pharmacist might misread the doctor's prescription form Their impairment might

lead to carelessly dispensing the wrong type of medication from a shelf A state of reduced

mental alertness might result in a failure to identify and correct potentially harmful drug

interactions. He/she might inaccurately measure out the various dosage units of potentially

lethal prescription medications. Finally, he/she might provide the patient with improper

administration instructions. Any one of these mishaps can result in injurious or fatal

consequences for the unsuspecting patient who depends upon the actions of an alert and

capable pharmacist.

A pharmacist's illicit prescription drug use can also have negative consequences for

his/her employer. Regardless of the occupational setting--retail pharmacy or hospital









pharmacy--drug use among pharmacists means financial losses for their employers.

Potential litigation is one of the most alarming financial concerns facing employers of illicit

drug using pharmacists. When the potential harms to consumers outlined above become

reality, the pharmacy employer runs the risk of being targeted for civil litigation and large

financial negligence judgments. In fact, multi-million dollar judgments against employers

have resulted (Brushwood, 1986). Granted, pharmacy malpractice suits are rare, but the

precedence of large financial awards make them a monumental concern for pharmacy

employers.

Public relations issues pose another concern for pharmacy employers. Although

drug-related malpractice suits may result in financial losses from civil judgment, the

potential dollar loss from negative public relations are a far more pressing and costly

concern. The volatile nature of this issue is heightened by the potential for adverse media

coverage. In the best-case scenario, media coverage of a pharmacist's illicit prescription

drug use results in the dissemination of facts related to the situation and implies that the

problem can be solved by specific, local actions taken against the individual pharmacist. In

the worst-case scenario, media accounts sensationalize the negative potential and place the

focus on the employer's negligence. Either way, consumers may choose to patronize other

pharmacy providers.

Moreover, drug using pharmacists almost always steal drugs to satisfy or expand

their illicit prescription drug use behaviors. These thefts represent the most direct and

immediate form of financial loss, linked to illicit prescription drug use behaviors, for their

employers. Given that the drug theft feeds illicit prescription drug use behaviors, one must

confront the use problem to address the drug theft problem.







16

The potential for this drug use/drug theft interaction to develop is amplified by the

very nature of the pharmacist's job Pharmacists have open access to a wide variety of

medications. They have low levels of supervision and are granted high levels of autonomy

in accounting for these medications. Moreover, they are familiar with and often control the

purchasing, dispensing, and accounting functions in their places of work. All of these

factors facilitate the potential for pharmacists to engage in significant and prolonged drug

theft followed by illicit prescription drug use patterns without any real accountability.

The extent of pharmacists' illicit prescription drug use may be exacerbated by the

pharmaceutical expertise possessed by the individual in question. Since pharmacists are

keenly aware of the various physiological effects of prescription medications and

understand the nature of drug interactions, they can easily self medicate themselves to

"walk a chemical tightrope." Past research on recovering impaired pharmacists (Bissell et

al., 1988) suggests that drug using pharmacists often experiment with drugs, ingesting

different dosages, combinations, and drug types in an effort to counteract the negative side

effects of one substance with another. Not only do such situations mean larger financial

losses for pharmacy employers, but also, they place the consumer at even greater risk and

increases the potential for pharmacists to develop prolonged and very intense drug

theft/use careers.

The presence of drug using pharmacists raises several problems for the pharmacy

profession as a whole. First and foremost, such behaviors represent a serious form of

professional misconduct in which a pharmacist can engage. Although, accorded respect

and social status, pharmacists' social credits are counterbalanced with expectations of

accountability and high-quality professional performance, especially when it comes to

dispensing prescription medications. When a pharmacist uses drugs without a prescription,









he/she violates the foundation of his/her professional existence, and engages in precisely

the behavior against which the pharmacy profession was intended to guard against.

Norms of professional conduct seem to allow no latitude for serious ethical

violations, especially when such violations result in the kinds of personal, organizational,

or profession-wide irresponsibility that invariably accompany pharmacists' illicit drug using

behaviors. Since the mass media views such incidents as being extremely newsworthy,

they pose the potential for widespread public relations frenzies rendering the entire

profession vulnerable to unwelcomed attention and scrutiny. Consequently, the pharmacy

profession is sensitive to the potential that individual drug-related deviations have to

endanger the trust, respect, and social status afforded the profession.

The issue of pharmacists' illicit prescription drug use indirectly causes attrition

problems for a profession already in very high demand. Faced with a growing demand for

pharmacists and a relatively stable number of practicing pharmacists, the profession has

been forced to address the fact that it cannot afford to lose significant numbers from its

ranks due to the drug abuse that results from pharmacists' prolonged illicit prescription

drug use. In recent years, the pharmacy profession has committed a great deal of energy

and resources to understanding its impairment problems and recognizes that research on

the topic can pay valuable long-term dividends. There has recently been a concerted effort

to head off the myriad of mental, physical, and emotional problems that drug abuse causes

for all involved parties.

Much of the reaction on the part of employers and the profession has humanitarian

foundations. There is a growing consensus that concerns about illicit prescription drug use

among pharmacists should be focused on the affected individual. Obviously, pharmacists

who engage in prolonged illicit prescription drug use experience considerable mental,







18

physical, and emotional problems. These individuals tend to fall into a downward spiral of

progressive drug use that has a wide variety of problems for themselves and their loved

ones.

Despite the presence of numerous negative consequences and relevant sociological

issues raised by pharmacists' illicit prescription drug use, our present understanding of the

phenomenon is relatively limited. There is a paucity of literature and research on the social

sources of pharmacists' illicit prescription drug use. These needs are particularly important

since they represent the prerequisite foundation upon which a sociologically based

understanding of the phenomenon must rest.


Specific Research Foci


The goals of this research endeavor are both descriptive and analytical. First, the

project seeks to profile the individuals and events associated with pharmacists' illicit

prescription drug use behaviors. Multiple sources of data will be utilized to detail the

following issues: the onset of pharmacists' illicit prescription drug use, the various

methods of drug procurement that they employ, the types of drugs that are commonly

used, the patterns of drug usage, the stated and perceived reasons and rationalizations for

initial and progressive drug taking, and he various personal and professional consequences

and sanctions that result from pharmacists' drug use.

Next, insight from the three data sources will be used to construct a theoretical

framework that expands upon the medical model orientation to drug abuse This analytical

task will be accomplished by first identifying various social factors that are consistently

present among three different groups of illicit prescription drug using pharmacists. In









particular, the discussion emphasizes the ways in which educational, occupational, and

professional factors affect the etiology of pharmacists' illicit prescription drug use.

The observations on the illicit prescription drug use of pharmacists are then used

as the basis for a more general theoretical discussion of drug abuse. In particular,

consistent facilitating relationships between various social factors and the onset,

maintenance, and progression of pharmacists' illicit drug use are used to argue for an

expansion of the prevailing medical model orientation to drug abuse. The importance of

educational, occupational, and professional influences in an individual's drug abuse

condition suggests shortcomings and limitations to the medical model orientation to the

drug abuse phenomenon and hence warrant a broader theoretical orientation to the

problem.

Educational foci. My theoretical framework explores the ways that the educational

experiences of pharmacists affect pharmacist's drug related behaviors. Several past

researchers (Baldwin et al., 1991; McAuliffe et al., 1987; Miederhoffet al., 1977) have

found considerable levels of recreational drug use among pharmacy students. The present

research will attempt to determine if and how levels of college drug use effect individual's

progressive post-graduation drug use, theorizing that relaxed attitudes and experience

with recreational drug use will add to the likelihood of continued use.

Several scholars (e.g., Bissell et al., 1988; Kurzman, 1972; McDuffet al., 1995)

have shown that most pharmacy students receive only cursory training on the

psychological aspects of drug abuse. I will explore the status of such training in an effort

to determine how prepared pharmacists are to recognize, counsel, and combat problematic

drug use in themselves and others. I expect that a lack of a well rounded drug abuse

education will contribute to illicit prescription drug use potentials.









My inquiry will also focus on prevailing formal and informal socialization

processes that are present within the pharmacy school environment. In particular, 1 will

argue that the pharmacy school experience instills in pharmacists a relaxed, arrogant

attitude toward prescription medicines that leaves them more vulnerable to self medication

practices.

Occupational foci. The theoretical framework of this study also draws upon a

series of occupational or workplace specific research foci in an effort to demonstrate their

relationship to the behavioral and/or perceptual aspects of pharmacists' illicit drug use. In

particular, the issue of early occupational training or mentorship will be considered in

depth. Given the long term, formative potential ofmentoring relationships, I expect that

exposure to meters with relaxed attitudes and/or behaviors toward self-medication will

facilitate neophyte pharmacists' subsequent prescription drug use.

The nature of the drug related attitudes and behaviors of other pharmacy

co-workers will also be considered as a potential contributing factor to pharmacists' illicit

prescription drug use behaviors. Based on the assumption that individuals are influenced

by their work culture, I expect that exposure to pro-drug use norms will increase the

likelihood of personal drug use.

Inquiry and analysis will focus on the availability and implementation of

organizational in-service training specific to the issue of drug use. I will examine the

nature and extent of such training, theorizing that an illicit prescription drug using

pharmacists report having been exposed to low levels of training.

Quinney (1963) found that competing business versus health care goals within

pharmacy practice (i.e., role strain) was related to prescription violation deviance among









pharmacists. The present inquiry will attempt to determine if such role strain still exists

and, if so, how it impacts upon pharmacists' illicit prescription drug use.

Professional foci. Lastly, a series of research questions specific to professional

socialization will be considered. Issues of professional identity, such as the tendency of

pharmacist to conceive of themselves as "drug experts," will be considered as contributing

factors in the onset, progression, and denial of problematic drug use. I expect that a

combination of familiarity and overconfidence in their understanding of prescription

medicines will make pharmacists' vulnerable to self-medication practices.

Inquiry will also be focused on the ways in which the pharmacy profession

characterizes and reacts to the problem of illicit drug use among its ranks. I will consider

the way that such professional norms facilitate the drug-related perceptions and behaviors

of pharmacists. Based on past research (Bissell et al., 1988; Normack et al., 1985a), I

expect that drug using pharmacists will report having been exposed to signs of

professional ignorance and tolerance.

The particulars of how each of the above specific research foci were pursued

empirically will be addressed in the Methodology chapter of this document. Next, a review

of the existing literature on the topic of illicit drug use among pharmacists, as well as other

ancillary issues, will provide the reader with a background of information on the present

research topic.


Notes


1. While pharmacists' illicit prescription drug use is often preceded by acts of drug theft,
these acts of theft are of secondary importance to the present study. For the purposes of
this research, the actual illicit use of the drugs will be considered evidence of a "trust
violation." Given that the illicit prescription drug use involves both the inappropriate
dispensing and use of the very drugs over which pharmacists are given sole authority. I







22

view this use as representing a more serious violation than an incidence of theft.

2. The researchers asked respondents to indicate why they used drugs. One possible
response category was "instrumental" use. This category was defined as use of
"amphetamines or other stimulants (besides caffeine) to study, work, or perform better in
athletics" (McAuliffe et al., 1987, 312).

3. Pharmacists in the McAuliffe et al. study were asked to offer a self-assessment of drug
dependency to any one of a number of psychoactive controlled substances. This list
included prescription as well as non-prescription medications. Individuals were classified
as being at risk of drug abuse if they reported more than 100 total drug use episodes and
experienced more than one drug-related interference with functioning (as determined by a
standard checklist of items such as calling late to work due to substance use, seeking
treatment, etc).

4. Normack et al. used a scaled usage inventory which sampled the presence and
frequency of an individual's use of a variety of substances to establish their criteria for
"impairment risk". Like the McAuliffe study, they did not limit their inquiry to prescription
drug use. Anyone scoring more than a 2 on the usage scale that ranged from 0 to 4 was
identified as being at risk.














CHAPTER 111
LITERATURE REVIEW


The study of illicit prescription drug use among pharmacists cuts across numerous

disciplinary boundaries This topic lies at the intersection of numerous sub-disciplines

within sociology (e.g., crime and deviance, occupations and professions, and medical

sociology). As such, a need for a comprehensive review of the existing literature will allow

me to build upon the various contributions of past research and to synthesize the

theoretical foundation for the present research effort. The following review will be

organized under a number of thematic areas including pharmacists' use of controlled

substances, employee deviance and the use of controlled substances in other work

settings, educational socialization among pharmacists, the work culture of pharmacy, and

professional socialization in pharmacy.


Literature on Pharmacists' Use of Controlled Substances


Pharmacists' use of controlled substances (i.e., drugs and alcohol) has long been a

problematic issue within the profession However, until a few decades ago, the profession

was able to keep the topic out of the public spotlight. This "conspiracy of silence" was

broken in 1982, when the American Pharmaceutical Association (APhA, 1982) issued a

policy statement which acknowledged substance abuse as problem among its membership.

In an effort to explore the scope of the substance abuse problem, researchers from

various medical professions reacted to the APhA policy statement by conducting studies









that focused on the extent of the problem among practicing pharmacists. Early studies

(McAuliffe et al., 1987; Normack et al., 1985a) established that there is a considerable

amount of illicit prescription drug use among practicing pharmacists. While these studies

made significant inroads into our understanding of the extent of the substance use problem

among pharmacists, their applicability to the present research is somewhat limited. First,

both the McAuliffe and Normack studies utilized imprecise measures and definitions of

drug use. Their principal goal was to assess the extent of pharmacists' substance use

behaviors and as such included the use of prescription drugs, street drugs, and in the case

of the Normack study, alcohol. Both research teams used these data to estimate levels of

problematic drug use among pharmacists. This is a very different focus than the one being

pursued in the present study. I am principally interested in the ethical dimension of

pharmacists' drug use and have chosen to focus only on pharmacists' illicit use of

prescription medications. Such a distinction temporarily moves the functional

consequences of drug use (i.e., impairment or drug abuse) into a secondary role and

focuses primarily on the ways in which being and becoming a pharmacist can contribute to

an individual's use of the very substances that they are trained to monitor and control. This

distinction is not meant to downplay the significance of the findings that the McAuliffe and

Normack studies have produced. However, the present study will address different

conceptual issues and hence should be expected to yield a different understanding of

pharmacists' drug related behaviors.

The differences between the present study and both the McAuliffe and Normack

studies are further demonstrated by the fact that these previous studies relied principally

on medical model explanatory variables and largely ignored possible social factors. For

example, the Normack study (Normack et al 1985a) includes only a cursory discussion of









how structural workplace variables such as work environment (i.e, retail pharmacy vs.

hospital pharmacy) are related to pharmacists' drug use. Moreover, the measures and the

resulting discussion are noticeably underdeveloped. As such, readers may be misled into

believing that social factors do not have an influence, when, in fact, their lack of

significance may actually be attributable to measurement issues.

More importantly, the existing inquiries into the extent of pharmacists' drug use

(McAuliffe et al., 1987; Normack et al., 1985a) are largely descriptive and offer little in

the way of causal explanation. Thus, while they help frame the nature of the present

research question, they do very little to explain the underlying etiology of the problem.

The most highly respected and most frequently cited research on the topic of

pharmacists' use of controlled substances is a study conducted by LeClair Bissell, Paul

Haberman, and Ronald Williams (Bissell et al., 1989) These researchers explicitly set out

to offer a benchmark study that would better inform the profession about the etiology of

pharmacists' substance abuse.' Specifically, they asked a snowball sample of 86 recovering

pharmacists to describe their substance abuse experiences in hopes of explaining how and

why substance abusing behaviors come about.

The Bissell study offers considerable insight on the topic of pharmacists' use of

mind altering substances. For example, these researchers asked the respondents about the

details of their substance abuse problem. Their data suggest that a near unanimous 99%

claim to be addicted to alcohol.2

While the Bissell study employs a broad definition of substance use, they do break

out data on pharmacists' use of prescription medications (i.e., the substances of interest in

the present study). They show that 24% chose to principally use nonnarcotic prescription

drugs, 22% used "mild" narcotics, and 31% focused their use on "strong" narcotics.







26

Ingestible medications such as benzodiazepines and amphetamines were among the most

popular. Conversely, the pharmacists reported very little use of injectable drugs.

It was not uncommon for respondents in the Bissell study to report using massive

amounts of prescription medications on a daily basis. Moreover, significant numbers of the

respondent pharmacists reported that they engaged in complex drug use patterns. They

discussed the practice of titratingg" in which they would systematically ingest various

combinations of medications that were aimed at counteracting the psychotropic and

physiological effects of one another.

Note that while the Bissell study did offer data on the pharmacists' use of

prescription medications, they did not inquire or theorize about the causal significance of

this prescription drug use. Thus, the focus of their research remained at a more general

level as they tried to explain why pharmacists succumb to substance abuse conditions.

The Bissell study also showed that the recovering pharmacists tended to progress

into the latter stages of the substance abuse process (i.e., exhibiting visible signs of mental,

physical, and emotional problems stemming from their substance use) before they entered

treatment. It was not at all uncommon for the respondents to attempt suicide (21%), get

arrested due to their use (51%), or drink and/or use drugs while at work (71%) prior to

entering treatment Furthermore, the respondents reported a mean length of drug using

history of 16 7 years and a mean length of alcohol using history of 21.7 years. Despite the

presence of the above mentioned warning signs, 58% of the respondents had never lost a

pharmacy position or come to the attention of their state pharmacy board due to their

substance abuse problem. The fact that these individuals were able to avoid official

sanctioning or treatment for so long suggests that the pharmacy profession, their









employers, and especially their peers did not do a very good job of identifying and/or

reporting the problem of drug use within their ranks.

A suspected lack of professional response to the problem of pharmacists' drug

related deviance has been illustrated in several survey research efforts (Chi, 1983; Epstein,

1990 & 1991; Sheffield et al., 1992). For example, Chi (1983) reports that over one-third

of the retail pharmacists she surveyed claimed that they knew a fellow pharmacist who

was working under the influence of controlled substances. Of these pharmacists who were

aware of an impaired colleague, less than one-half chose to report or act upon their

knowledge of the wrongdoing.

A similar trend is illustrated by the data from a small scale interview study of

female recovering pharmacists in Texas (Sheffield et al., 1992). These data show that the

23 interviewees had knowledge of 32 practicing pharmacists whom they claimed were

actively abusing chemicals of some type. Surprisingly, none of these women had acted

upon this knowledge. The significance of these data is amplified by the fact that all of

these female interviewees were recovering from substance abuse, a status that tends to

heighten the tendency to reach out to or intervene in the lives of those who suffer from

drug related problems. It could well be that the drug tolerant cultural ethos within the

pharmacy profession is so dominant that it overrides or nullifies the protective tendencies

that are fostered in the recovery community.

In summary, the data from the above studies are quite disturbing. They suggest

that practicing pharmacists routinely cover up or ignore the presence of pharmacists' illicit

prescription drug use. While many are aware of their peer's deviant behavior and claim to

disapprove of it, they do nothing about it. I submit that this lack of response potentially









serves to reinforce the individual's continued abusive behavior. This possibility will be

explored in the present study.

The suggestion that pharmacists experience different substance use situations than

other health care professionals is offered support by a study conducted by Gallegos et al.

(1988). These researchers surveyed all of the health care professionals that were referred

to Georgia's state-sponsored impaired professional program for assessment between 1975

and 1987 Their analysis included data on 1,352 doctors, 303 nurses, 129 dentists, and

127 pharmacists. The data show that, when compared to other health care professionals,

the pharmacists had the highest rate of poly-drug use 3 More importantly, much like the

Normack study (Normack et al., 1985a) of nonrecovering pharmacists, this recovering

pharmacist group (in the Gallegos study) consistently had the highest use rates of

prescription medications such as narcotics, stimulants, and hypnotics. While many of the

pharmacists also claimed to be using street drugs or alcohol, they engaged in

disproportionate amounts of prescription medication use when compared to the groups of

chemically dependent nurses, doctors, and dentists. These data again suggest that there is

something special about pharmacists that leads them to a higher incidence of prescription

drug use. It seems unreasonable to suggest that these disparities can be attributable to

pharmacists' increased levels of access to such drugs.

One of the reoccurring themes of the research on substance abuse among

practicing pharmacists (Bissell et al, 1989; Gallegos et al., 1988; McAuliffe et al., 1987;

Normack et al., 1985a; Sheffield et al., 1992) is the lack of a well-rounded educational

exposure of the respondents to the harms and manifestations of chemical dependency. For

example, while the respondents in the Bissell study were clearly aware of the toxic effects

of drugs and alcohol and other "physical" components of chemical dependency, the







29

authors report that their education was limited in other areas. This trend is apparent in the

following statement:

What appeared to be lacking was attention to the human side--the process
by which a person, in spite of an intellectual appreciation of the dangers, is
led to experiment, then to rationalize continued use, then deny what is
happening. Several believed that their superior store of information about
drugs and familiarity with them would somehow magically provide protec-
tion or that if any trouble began it would be recognized and promptly
handled. (Bissell et al., 1989, 22)

Taking this thought a step further, Gallegos et al. observe that

little attention has been dedicated to the occupational risk for the
development of chemical dependence during the process of formal
education in professional schools This appears to be in part related
to the limited fund of knowledge about the problem and in part to a
kind of "global denial" that exists. (Gallegos et al., 1988, 195)

The above research on controlled substance use among practicing pharmacists

offers considerable insight into pharmacists' substance use behaviors However, one must

note that all of these studies draw heavily on a medical model orientation to the problem

and largely ignore possible social or environmental influences that might have affected the

pharmacists' behaviors. Only in the case of educational experience do any of the

researchers address the issue of substance abuse using factors that are unrelated to the

individual actor. For example, when confronted with the differences in drug use that were

noted between pharmacists and other health professionals, Gallegos et al. (1988) sidestep

potential sociologically based explanations. In fact, there is no mention of the possible

association between professional or occupational socialization and pharmacists' substance

of abuse. As such, while this body of research furthers our understanding of the

phenomenon, it presents only a partial picture of the dynamics of pharmacists' drug use

behaviors.







30

There is considerable research that focuses on the use of controlled substances by

pharmacists in training (i.e., pharmacy students).4 This literature is of particular interest to

the present study since it offers insight into pharmacists' drug use behavior during their

earliest years of professional training and ethical development. Experiences during these

years would be expected to have a long lasting effect on the individual's personal and

professional outlook.

The above mentioned McAuliffe et al. (1987) study also included a sample of 278

pharmacy students. The researchers found that the pharmacy students engaged in

significant amounts of controlled substance use. They report that 62% of the pharmacy

students admitted some use of controlled substances, 18% doing so at least once a month

and 23% doing so more than once a month

McAuliffe et al. (1987) break down their drug use data into several use frequency

and motivational categories. Of particular interest to the present study are the findings that

show the students' recent and lifetime use of prescription medications.' These data show

that 33% of the students report at least one lifetime prescription drug use episode, 10%

report using once a month, and 8% report using more than once a month.

In comparing use data from the pharmacy students group to that of the practicing

pharmacist group, McAuliffe et al. (1987) found differences in the reasons why the

individuals were using drugs. Specifically, they found that the pharmacy students tended to

use more drugs than practicing pharmacists. However, students did so more often for

recreational, not self-medication reasons.6 As pharmacists move from pharmacy school

into the practice of pharmacy, it appears that recreational drug use tapers off significantly

but their self-medication practices stay the same or increase. On the surface, this shift in

the use and motivations seems encouraging. That is, the proportion of drug using









pharmacists clearly decreases. This trend might be construed as evidence of decreased

usage resulting from positive professional development or an increased respect for the

medications.

Note, however, that these data showing decreased usage and a motivational shift in

drug use (i.e., from recreational to therapeutic self-medication) can also be interpreted to

suggest that pharmacists come to rationalize the use of drugs in such a way that it

becomes defined as self-medication, not deviant drug use. This is an important distinction

and speaks directly to one of the central foci of the present project. We can expect that

individuals' drug use will taper off some as they age (i.e., the data show that pharmacy

students are younger than the practicing pharmacists and that use was negatively

associated with age). However, if they come to use their professional status and expertise

as a form of license for their continued and often progressive illicit self-medication

practices, it can be argued that their drug use/abuse is exacerbated by their positions as

pharmacists.

Intrigued by the motivational aspect of health professionals' drug use, McAuliffe et

al. (1984) conducted several case studies with recovering health care professionals who

had histories of recreational opiate addictions Three of the six case studies involved

recovering pharmacists. McAuliffe et al. found that each of these recovering health care

professionals began their recreational drug use before or during college. The onset of their

experimental recreational drug use (usually concentrated on street drugs such as marijuana

and cocaine) was closely linked to the "hippy" subculture of the 1960s and 1970s. In each

case, a fascination with drug induced euphoria led to the experimentation and then

increased usage of opiates. In most cases, the individuals obtained their drugs from work

and avoided black market sources. McAuliffe et al. attribute the emergence of recreational









drug abuse among health care professionals to changing social definitions of drug use. In

short, he sees more permissive attitudes toward drug experimentation and "controlled" use

as the chief contributing factor to this type of drug use. He concludes that

drug use by health professionals was generally an unfortunate side effect of
self-treatment, not the result of a conscious deviation from norms
concerning recreational drug use. But as a consequence of the radical
changes in middle-class attitudes toward drug abuse that occurred during
the mid-1960s, the health professionals described here did not explain their
drug use as a response to pain, fatigue, or stress, but as a result of curiosity
about how the drug's effects might make them feel. (McAuliffe et al.,
1984, 16)

McAuliffe et al. (1984) conclude that these individuals' status as health care

professionals also contributed to their recreationally based opiate abuse situations. While

their use may not have been therapeutically driven, these individuals still used their formal

training to facilitate their use behaviors and temper their inhibitions. McAuliffe et al.

observe that

they were already highly knowledgeable about the possible adverse effects
of drugs. [They] had extensive prior drug use experience, which they did
not define as harmful overall. Rather than deterring the subjects, this prior
experience and professional knowledge seemed to help them rationalize
their use by discounting the risks (they understand drugs, have been able to
handle their use, and would be too smart to let their use get out of hand),
and by focusing on physiological dependence .. Only in retrospect, it
seems, did they recognize the importance of the insidious psychological
(conditioning) dimension of addiction and the subtle symptoms of a
gradually increased addiction. (McAuliffe et al., 1984, 17-18)

These McAuliffe et al. (1984) data on recreational opiate abuse illustrate an

important point. They suggest that pharmacists' recreational drug use, much like their

therapeutic self-medication, can be tied directly to the profession-specific stock of

knowledge of the individual. This type of socially-derived drug use facilitator will be


explored in depth in the present study.









Several other scholars (Hankes & Bissell, 1992; Spencer, 1994) have suggested

that health care professionals can use their training to dupe themselves into believing that

they are above issues such as illicit prescription drug use and drug abuse. For example,

Hankes and Bissell state that

some have proposed the existence of "malignant" denial in medical
professionals. Doctors often develop an attitude of omnipotence in the face
of frustrations surrounding their true limitations. This omnipotence may
intensify the whole denial process. The "M.D-ity syndrome" follows: it says
that the possession of information is protective (omniscience), and
whatever happens, I myself have the skill and capacity to get the
information, overcome the obstacle, and solve the problem (omnipotent).
In other words, doctors declare, "It wont happen to me, and even if by
some quirk of fate it does, I'll be able to handle it!" They may also
emphasize the socioeconomic differences between themselves and other
alcoholic/addicts and the fact that their own drugs are legal. (Hankes &
Bissell, 1992, 899)

Nowhere among the health professions is the potential for drug related

"omnipotence" or "omniscience" more real than among pharmacists. Pharmacists are the

"drug gurus" who spend the bulk of their adult lives reading about, talking about,

handling, and dispensing prescription medications. This level of familiarity and expertise

can lure the individual into a mind set that excuses, or even encourages self-medication or

even recreational drug use. The presence of pharmacists' permissive self-medication

attitudes and practices lend credence to the suggestion that the onset and progression of

their illicit prescription drug use behaviors can and do have social origins. Moreover, the

McAuliffe et al. (1987) findings tie these shifting motivations for pharmacists' drug use to

the course of their pharmacy careers.

Normack et al. (1985b) conducted a study on substance use among the University

of North Carolina's pharmacy students (n=391), only to find further widespread evidence

of the same problem. These researchers found that substantial percentages of the

pharmacists-in-training claimed that drug abuse7 (37%) was a problem among their fellow







34

students. When asked if they were aware of one or more fellow students that they thought

had a drug abuse problem, sizable percentages of the third, fourth, and fifth year pharmacy

students answered affirmatively (39%, 13%, and 37% respectively). These numbers are

quite similar to the figure of 36% reported by Miller et al. (1990) and 46% reported by

Szeinbach & Benjamin (1990).

Several studies have been conducted that compare the use of controlled substances

among pharmacy student to that of other students from other health care majors (Baptista

et al., 1994; Coleman et al, 1997). Coleman et al. (1997) surveyed substance abuse

among the University of Arkansas' health care students. This study included students from

pharmacy, nursing, medical, and a generic health related professions category. Students

were surveyed when they entered school in 1989 and then again in 1991. The data show

that when broad definitions of substance use were employed (i.e including prescription

drugs, street drugs, and alcohol), pharmacists use was equal to or less than the other

groups and their general substance usage numbers did not increase markedly over the first

two years of their program of study. However, when attention was focused solely on

prescription medications, pharmacists had the highest usage rates. In particular, the

number of students involved and the frequency of the use of drugs such as amphetamines

and oral analgesics increased markedly over the two year period.

Studies such a Kriegler et al. (1994) and Miller et al. (1990) compared pharmacy

students' drug use behaviors to samples taken from the general college population. Both of

these studies found that pharmacy students report lower drug and alcohol use than college

students in general. However, the Kriegler study shows several interesting characteristics

among the pharmacy students. Specifically, members of the pharmacy student group were

found to exhibit more high-risk drug use behaviors than other college students. They









reported higher levels of perceived drug related peer pressure. They were more likely to

begin drinking and using drugs while at college. They were more likely to attribute their

substance use to stress. They reported higher levels of prescription drug use (e.g.,

sedatives and amphetamines). Each of these differences support the premise of the present

study. That is, these Kriegler et al. (1994) data suggest that there are social factors

associated with the demands and interactions of pharmacy school that foster prescription

drug use.

In the Problem Statement chapter, 1 indicated that the present inquiry would

examine the relationship between pharmacists' drug use education and their own personal

drug use behavior Namely, I suggest that, while pharmacists may be exposed to

considerable course work and instruction dealing with the pharmacological aspects of drug

use and addiction, they are exposed to very little training on the psychological aspects of

drug use and addiction. This situation can lead to an ignorance or overconfidence about

drug use that places them at higher risk of illicit prescription drug use or abuse. This

assertion is directly grounded in the findings of past research. Several studies (Baldwin et

al, 1991; Bissell et al., 1989; Kurzman, 1972; McAuliffe et al., 1987, McDuffet al., 1995;

Miederhoffet al., 1977; Rascati & Richards, 1993) have examined issues related to

pharmacy students' drug abuse education. The data suggest that pharmacy students are

exposed to very little training on the psychological aspects of drug use and addiction. For

example, pharmacy students in the McAuliffe et al. (1987) study report an average of 5.9

hours of drug abuse education. Moreover, there is evidence that this lack of education

leads to conservative attitudes toward drug abuse. Armed with a wealth of

pharmacological training and a deficiency of drug abuse training, pharmacists come to

view drug abusers as weak individuals. For example, the Miederhoffet al. (1977) study









found that pharmacy students reported considerably more conservative attitudes toward

drug abuse and drug abusers than did students in the physical sciences, biological sciences,

social sciences, humanities, and social work. Moreover, the Miederhoffstudy shows that

this conservativism increases over the course of the pharmacy student's college career.

These data suggest that pharmacists develop an overconfident attitude toward drug use

and abuse. That is, as they become more educated about the pharmacological aspects of

drug use, their belief in the healing powers of drugs appears to cloud their perception of

drug abuse. Specifically, as they become technically proficient with the drugs they become

calloused and view the abuse of such drugs as a character flaw. I submit that this is a

dangerous form of overconfidence or denial that can have profound effects on their

potential to engage in and rationalize their own illicit prescription drug use and abuse.

Rascati and Richards (1993) present insight into the pharmacy student's attitudes

toward drug and alcohol use among their peers. They attempted to assess pharmacy

students' attitudes toward drug and alcohol use by having them complete a standardized

instrument known as the Substance Abuse Attitude Survey.' They made an alteration to

one of the survey questions in an attempt to focus specifically on pharmacists' views of

prescription drug use among peers. Respondents were presented with the following

statement: "A pharmacist who has been addicted to narcotics should not be able to

practice pharmacy again" (Rascati & Richards, 1993, 57). The resulting analysis show

that, on average, the students agreed with this statement and hence held conservative

sentiments toward this statement.

In summary, several studies (Baldwin et al., 1990; Baptista et al., 1994; Giannetti

et al., 1990; Kirk et al., 1989; Krieger et al., 1994; Kurzman, 1972; McAuliffe et al., 1991;

McDuffet al., 1985, Miller et al., 1990; Miederhoffet al., 1978; Rascati & Richards,









1993, Szeinbach & Banahan, 1990; Tucker et al., 1988; White, 1985) have used varying

methodologies and measurement indices to study issues related to pharmacy students' drug

use attitudes and behaviors. There seems to be four underlying themes in these studies. 1)

students and faculty agree that there is a substance abuse problem within their schools; 2)

pharmacy students repeatedly point to a lack of formal instruction on the topic of chemical

dependency and the psychological aspects of drug use; 3) the students exhibit conservative

attitudes toward substance abuse and substance abusers; and 4) students feel unprepared

or uncertain about how to react to substance abuse among their peers.

Pharmacy journals have become very receptive to articles which focus on the topic

of substance use and abuse among pharmacists. These journal articles can be classified into

three categories: biographical sketches of recovering impaired pharmacists, policy oriented

pieces which offer managerial suggestions for dealing with and detecting substance using

pharmacists, and evaluation research which focuses on treatment alternatives.

While the biographical accounts of recovering substance abusing pharmacists are

not based on systematic research efforts, they do offer a sort of "wake up call" for the

pharmacy profession. These articles (Babbicke, 1991; Crawford, 1992; Reimenschneider,

1990; Starr, 1989a and 1989b; Tucker, 1985) recount chilling first hand accounts of how

pharmacists were able to develop, perpetuate, and disguise their substance abuse problem

from their families, coworkers, and employers. Collectively, they suggest that substance

abuse can take on a number of forms and characteristics. These articles illustrate how the

violators are able to use both the structure of their jobs and the individuals around them to

perpetuate their substance abuse problem. Moreover, they tend to illustrate how job stress

or occupational socialization issues contributed to the individual's substance abuse

situation.









Several articles (Corsino et al., 1996; Hankes & Bissell, 1992; Haynes, 1988;

Richardson, 1990; Simonsmeier & Fox, 1985; Sonnenstuhl, 1989; Smith & Starnes, 1988;

Williams, 1993) focus on the special management issues raised by drug and alcohol

impaired pharmacy practitioners. These discussions tend to summarize the existing

evaluation research and/or utilize their own personal experiences to make proactive policy

suggestions. The general consensus of these authors is that one needs to focus on early

detection and treatment of substance abusing employees in an effort to "clean-up" the

profession. Hankes and Bissell (1992) make a distinction between "primary" and

"secondary" prevention. Primary prevention focuses on strategies aimed at proactively

avoiding illicit prescription drug use and impairment situations. Secondary prevention is

concerned with the reactive strategies of early identification and therapeutic intervention.

The authors suggest that primary prevention is rarely accomplished in the case of

pharmacists' drug use. I submit that this assertion is based in their adherence to a medical

model orientation to substance abuse. By overlooking the possibility that social factors can

and do contribute to pharmacists' drug use, one is forced to settle for secondary

prevention strategies.

A third and final category of literature evaluates and describes existing treatment

alternatives (Baldwin et al., 1988, 1991; Bunting & Talbott, 1985, Giannetti et al., 1990;

McNees & Godwin, 1990; Penna & Williams, 1985; Sanchez, 1989; Sheffield, 1988;

White, 1985). These articles strongly reflect the pharmacy profession's complete

acceptance of the medical model. For example, Penna & Williams (1985) supply a

handbook that is intended to serve as a model for those trying to plan and implement a

recovery program for impaired pharmacists. This handbook clearly stresses a medical







39
model orientation. It offers a clear summary of the medical model literature and suggests

practical applications for a treatment philosophy that replicates medical model ideas.

Upon reviewing the existing literature on pharmacists' use of controlled substances

it is apparent that the literature presents a narrow view of the problem. There exists an

unmistakable tendency toward an exclusively individual level focus that relies heavily on a

individual or personal interpretation of pharmacists' substance use. This revelation should

not come as a surprise given the fact that the researchers and authors who are responsible

for this literature base were predominantly members of the medical profession.


Employee Deviance Literature


Considerable insight for the theoretical framework of the present study has been

drawn from the existing literature on the various other forms of employee deviance. This

literature can be grouped into three areas: employee theft literature on trust violations,

literature on substance use and abuse in nonmedical work settings, and literature on

substance use and abuse in the health care professions.

Literature on Trust Violations

As previously mentioned, the conceptual tenets of the present study are firmly

grounded in the ideas that Cressey (1953 & 1976) expressed in his classic study of

embezzlement. Several past research efforts have approached the issue of employee

deviance from a similar theoretical perspective. For example, in studying what he called

"blue collar theft" among workers at an electronics factory, Homing (1970) found

evidence that employees constructed their own definitions of what did and did not consti-

tute "real" theft within the organization These definitions depended on the type of

property involved The respondents classified property into three categories: company









property, co-worker's personal property, and property of uncertain ownership (e.g.,

scrap). The misappropriation of personal property or company property was clearly

defined as theft. However, a similar definition was not applied to property of uncertain

ownership. Because there was no identifiable victim, the workers felt justified in taking the

property. The origins of these definitions and techniques of trust violations were traced

back to the normative culture of the work group. The worker was taught what was

acceptable behavior and what was not by his/her peers. These behaviors often directly

contradicted company policies (i.e., trust violations) but the workers most strongly

adhered to the group norms, not company policy. There was clear evidence that these

factory workers were using their occupationally derived knowledge and expertise to

perpetrate and justify their deviant behavior

Other researchers have considered the ways in which organizational culture and

the nature of one's job can facilitate instances of trust violations. These include Geis

(1967), Benson (1985), Hollinger (1991), Tathum (1974), Sieh (1987), Dalton (1959),

Gouldner (1954), Ditton (1977), and Mars (1982). While each of these studies takes on a

slightly different theoretical twist, and focuses on a different work setting, each illustrates

how the normative definitions of the work group enable the employees to neutralize their

violations of organizational trust

The present study focuses principally on Cressey's original conceptualization of

trust violations. Namely, pharmacists' illicit use of drugs will be conceived of as an

instance of trust violation. I will emphasize how pharmacists use the definitions that they

gain through their educational, occupational, and professional experiences as a pharmacist

to facilitate their drug use behaviors. I will show that pharmacists view themselves as

immune to the pitfalls of substance abuse. The discussion will center on how the well







41

intentioned behaviors of the hard working and dedicated pharmacist can and do give rise

to their use and abuse of the very prescription medications that they are entrusted with

dispensing.

Literature on Substance Abuse in Nonmedical Work Settings

There is a great deal of research on the broad topic of substance use in the

workplace. This literature can also help inform the present project Numerous researchers

have illustrated how the culture of a given organizational environment can contribute to

workers' substance abuse behaviors. For example, Hollinger (1988) demonstrated how job

dissatisfaction and organizational culture among retail, manufacturing, and hospital em-

ployees were related to on-the-job drug and alcohol use. Plant's (1979) study of drinking

behaviors among brewery workers shows that the pro-drinking attitudes and pride in the

fruits of one's labor (i.e., the alcoholic beverages that they produce) were linked to high

incidence of alcoholism. Rix (1981) and Molloy (1988) have demonstrated how the

combination of heavily masculine occupational culture and limited social contacts among

seaman and fisherman contribute to heighten heavy drinking and drugging. Several studies

(Eichler et al., 1988; Licht, 1983; Mannello & Seaman, 1979) have linked the autonomy

and stress of railroad work to drinking and drug use. Sonnenstuhl (1996) has shown how

high stress and a pro-drinking subculture within New York tunnel workers called

"sandhogs" played an integral role in the onset and progression of abuse among neophyte

employees. Similar job-related drinking socialization processes have been identified among

construction workers (Staudenmeier, 1985; Clawson, 1989). In short, reviews of the

existing research and theory on substance use in the workplace identify a wide array of

social factors that can be linked to employee's use of controlled substances (Fillmore &







42

Caetano, 1982; Hollinger, 1988; Staudenmeier, 1989, Trice & Sonnenstuhl, 1988; Trice &

Roman, 1978).

In their classic analysis of substance abuse in the work place, Trice and Roman

(1978) suggest that there are substance use "risk factors" inherent in many occupational

environments. These risk factors will take on different forms in different work

environments but share a common theme. Namely, they refer specifically to structural

conditions associated with the nature of the work tasks or the work environment that

facilitate employees' substance use at or away from work. These risk factors are com-

monly grouped into the following categories general unstructured work environment,

heightened levels of work related stress, and an absence of social controls. Numerous

examples of each of these general categories of risk factors can be found in pharmacy

work. Given the repetitive nature of filling prescriptions, pharmacists often comment on

the structured and seemingly mindless nature of pharmacy work. Existing research (see

Wolfgang & Korek, 1986 for a general overview) identifies the high stress levels of

experienced by pharmacists. Finally, the unsupervised and limited social control

constraints experienced by pharmacists are evident in their professional status and

autonomous working conditions. These are but a few examples of the ways in which the

risk factors outlined by Trice and Roman (1979) manifest themselves in the work of

pharmacists

Literature on Substance Use and Abuse in Health Care Professions

Not surprisingly, pharmacy is not the only health care profession to have attention

focused on the incidence of substance use and abuse among its members. Over the past

several decades, scholars have inquired into the nature and extent of substance abuse in

each of the health care professions.






43

For example, there is considerable literature that focuses on the issue of substance

use and abuse among nurses. In 1984, the American Nurses Association (ANA) released a

document stating that 8-10% of the 1.7 million practicing nurses in this country are

dependent on drugs or alcohol (ANA, 1984). This study was followed by the Michigan

Nurses Association's (MNA, 1986) estimates that one in every seven nurses will abuse

drugs during his or her career.

There also have been several studies done on samples of nurses who were

recovering from substance abuse (Bissell, 1981; Bogardus, 1987; Green, 1989;

Hutchinson, 1986; Poplar and Lyle, 1969; Shaffer, 1987; Smith, 1989; Sullivan, 1987).

While these studies are principally descriptive in nature, they present evidence that links

the occupational culture of nursing to the recovering nurses' past substance use behaviors.

This collection of research illustrates that nurses tend to use drugs for self-medication

purposes, that nurses are often are aware and cover up for the substance use behaviors of

fellow nurses, and that the high stress/high drug access nature of the job feeds the progres-

sive substance use.

My own research on drug use among nurses (Dabney, 1995a, 1995b) identifies

numerous social factors associated with nurses drug use. In interviewing 25 nurses from

various critical care settings, I found that on-the-job therapeutic drug use (i.e.,

self-medication) was common and accepted within the nursing work groups. The data

show a multitude of personal, eyewitness, and hearsay accounts wherein nurses used

nonnarcotic, prescription drugs such as Valium, Darvocet (nonnarcotic analgesic), and

various Codeine-based medications. These behaviors were excused on the basis that they

were medicinal in nature (i.e., helped the nurse perform his/her work duties) and involved

what were perceived as less threatening/addictive nonnarcotic prescription medications.9 It







44

was apparent that occasional therapeutic drug use was condoned and even encouraged at

times within the nursing culture. Note that there are other studies that link organizational

norms to nurses' drug use (Hood & Duphorne, 1995; Moodley-Kunnie, 1988).

The above studies on substance use among nurses identify a number of ways in

which being a nurse contributes to an individual's drug use. While there have been no

efforts to tie nurses drug use to potential educational and professional level social factors,

there is considerable evidence that links the onset, progression, and maintenance of nurses'

substance use to the work group interactions that they encounter over the course of their

careers.

Considerable research has also addressed the issue of substance use and abuse

among doctors. The most widely cited studies include Carlson et al. (1994), Hughes et al.

(1990), and McAuliffe et al. (1986). Much like the existing studies on pharmacists and

nurses, these studies conclude that significant numbers of doctors regularly use significant

amounts of prescription medications. Again, the trend among doctors seems to be

therapeutic self-medication that leads to progressive drug abuse. Various occupational

factors are linked to doctors' drug use. These include supreme autonomy, a lack of

accountability, high access, high stress, and peer group approval Moreover, numerous

characteristics associated with the profession of medicine are attributed to doctors' drug

use. These include a socialized sense of invincibility, a proscribed faith in the healing

powers of medicines, and weak social control mechanisms within the profession.

The existing research on substance use behaviors and attitudes among medical

students (Baldwin et al., 1991; Conrad et al., 1988; Clark et al., 1987; Ewan & Whaite,

1983; Hughes et al., 1991; McAuliffe et al., 1984; Varga & Buris, 1994) identifies several

educationally-based social factors that contribute to medical students' college and post









college substance use. These include limited levels of substance abuse education, peer

pressure to drink and use drugs to self-medicate or as a study aid, the fostering of a

so-called "better living through chemistry" mind set, and the development of an elitist and

omnipotent self-concept.

Over time, researchers have come to investigate the incidence of substance use in

most of the health care professions. For example, there is research on substance use

among dentists (Balevi et al., 1996; Doherty & Bennett, 1991; Oberg, 1988; Peterson &

Avery, 1988), psychologists (Skorina et al., 1990; Thorenson et al., 1989), and

anesthesiologists (Borg, 1997; Farley & Talbott, 1983; Gallegos et al., 1986; Pelton &

Ikeda, 1991). While there is considerable variation in the form and content of these

research efforts, each offers evidence that links various educational, organizational, and

professional factors within the profession to the onset and progression of substance use

and abuse among its membership.

My review of the existing literature on substance use among pharmacists and other

health care professionals has identified numerous instances wherein evidence supports the

premise that social factors can and do facilitate profession-specific substance use. This

evidence has been gleaned from studies that invariably adopt a medical model orientation

to substance use, hence, the identification and analysis of these social influences have

never been a central concern to the researchers. In most cases, these social factors have

been treated as extraneous results. There is, however, a wealth of sociologically-based re-

search on the topic of substance use in the work place This research is explicitly dedicated

to investigating the ways in which the social factors associated with a given occupational

or professional environment influence the incidence of substance use.







46

The present study draws upon both of these literatures. I have used the literature

on substance use in the work place as a point of conceptual departure, maintaining that

organizational cultures can and do influence the substance use behaviors within a given

work environment. Next, I have reviewed the literature on substance use among

pharmacists and other health professionals in an effort to identify aspects of these

organizational cultures have been empirically linked to members' substance use. However,

since a sociologically-based focus is new to the study of substance use among pharmacists

it is necessary to review other literatures that speak to the dynamics of being and

becoming a pharmacist. This literature will be organized into three sections: educational

socialization, work culture, and professional socialization.


Literature on Educational Socialization


The past research on substance use among pharmacy students has identified

several ways in which the pharmacy school experience contributes to an individual's

substance use. For example, researchers have identified factors such as a lack of substance

abuse education (Baldwin et al., 1991; Bissell et al., 1988; Kurzman, 1972; McAuliffe et

al., 1987; McDuffet al., 1995; Miederhoffet al., 1977), the existence of permissive

student attitudes toward recreational drug and alcohol use (Baldwin et al., 1990;

McAuliffe et al., 1984; Miederhoffet al., 1977; Normack et al., 1985b), evidence of

"instrumental" drug use to facilitate studying (McAuliffe et al, 1984), and a new found

access to intriguing prescription medications (Bissell et al., 1988; Hankes & Bissell, 1992).

The above list represent but a few of the potential educationally-based social

factors that can impact upon pharmacists' illicit prescription drug use There are numerous









additional aspect of the typical pharmacy training experience that can potentially con-

tribute to permissive drug related attitudes and behaviors.

The American Council on Pharmaceutical Education (ACPE) oversees the

accreditation of all colleges and schools of pharmacy in the United States. The ACPE

attempts to develop general curricular guidelines that are intended to assure that,

regardless of their chosen educational emphases and pedagogical techniques, all pharmacy

schools will adhere to baseline standards of education and training. In a chapter outlining

the societal role of the pharmacist, Manasse (1977) states that, in pursuit of this goal, "the

ACPE stresses course content in three broad areas, general education, pre-clinical

sciences, and professional studies and training" (Manasse, 1977, 237).

There exists considerable debate over the way that pharmacy educators interpret

and implement accreditation guidelines. More specifically, scholars have questioned the

quality and utility of contemporary pharmacy education (Buerki, 1984; Buerki & Vottero,

1991; Hepler & Strand, 1989; Johnson, 1983; Reinsmith, 1987; Smith et al., 1991). These

criticisms tend to be centered on the claim that pharmacy curricula and instruction tend to

sacrifice the goal of professional training in favor of the highly technical preclinical

sciences Buerki & Vottero (1991) maintain that this has led to a situation wherein many

pharmacy students emerge from pharmacy school with a limited understanding of ethics

and their professional prerogatives. Left without formal or well coordinated training on

the human side of pharmacy practice and professional responsibility, pharmacy students

adopt these issues or glean them from a collage of inconsistent and unorganized

experience This is not to suggest that pharmacy schools could somehow program

pharmacy ethics and professional development into its students. Given their status as

impressionable, free thinking beings, we can assume that a even the most systematic and







48

structured educational experiences will produce different interpretations across pharmacy

students. However, when issues of professional development and professional

responsibility are compromised in favor of technical training in the area of preclinical

sciences, there is a potential for negative profession-wide consequences. Beginning

pharmacists are left to self-regulate and self-define their own professional responsibilities

and professional roles. When applied to issues of drug use, this definition process can

result in permissive attitudes toward self-medication, relaxed prescribing practices, or a

lack of respect for the medications Any one or more of these manifestations can lead to

illicit prescription drug use

Formal training and course work are not the only parts of the pharmacy school

experience that help shape an individual's professional identity. There is also a strong

cultural aspect associated with the pharmacy school experience. That is, individuals spend

a significant amount of their lives engaging in informal interaction with faculty and other

pharmacy students. These interactions impact upon the self-concept of the neophyte

pharmacist. Unfortunately, the nature and extent of the informal socialization process in

pharmacy school has not been the focus of empirical study. However, numerous

researchers have documented the informal socialization process that individuals encounter

in medical school (Becker et al., 1961; Bloom, 1973, Broadhead, 1983; Fox, 1989; Haas

& Shaffir, 1987; Konner, 1987; Merton et al., 1957; Shapiro & Lowenstein, 1979). While

these studies do not deal specifically with pharmacy education, they do offer the best

possible parallel for the issue of informal socialization in a health care profession

Collectively, these studies present a comprehensive picture of the multitude of ways that

informal socialization manifests itself and the ways in which such manifestations impact

upon the self-concept of aspiring physicians This body of research clearly demonstrates









that informal interactions contribute to a heightened self-esteem and pretentiousness

among medical students. Medical students gradually come to view themselves as

occupying a higher social status than the rest of society. This raised self-confidence that

Hankes & Bissell (1992) refer to as "omnipotence," can lead to a sense of overconfidence

toward the tools of one's trade. In the case of the physician, they often adopt what is

commonly referred to as a "god complex" in which they think that they can cure any

illness. This situation is often linked back to the early socialization process in medical

school.

In the case of pharmacists, it seems realistic to suggest that this type of

overconfidence might also be turned toward the use of prescription medications and hence

result in self-medication practices. Given that pharmacy students are impressionable

neophytes, these socialization functions can have a long lasting impact on their

professional identity.

The research on the medical school experience also offers important insight into

the ways that informal social control mechanisms are developed in medical school.

Namely, there is evidence that members develop and impose strict behavioral expectations

that all individuals must adhere to Like all social control functions, individual deviation

results in sanctions. Researchers such as Haas and Shaffir (1987) argue that informal

interactions between new and more advanced medical students define what are socially

desirable behaviors for medical practitioners. These informal group norms are tied to a

"cloak of competence" that has its foundation in the social status associated with being a

medical professional. In short, pretentiousness is a built in part of the group socialization

process Anyone who defies or deviates from this prescribed presentation of self is thought







50

to threaten the legitimacy of the entire group. In many cases, the individual faces ostracism

from the group.

Perceptions of this type of severe, group imposed form of social control presents a

situation in which an individual has a vested interest in disguising those behaviors that the

group has defined as most deviant. In short, if the group views a certain behavior as a

threat to the legitimacy of the group, the individual will go to great extents to keep these

behaviors from the group. In the case of pharmacy, illicit prescription drug use represents

a threat to the profession's "cloak of competence" and hence threatens its legitimacy.

Given this situation, strict group norms and the interpretation of such norms may result in

increased denial, cover-up, and deception on the part of the drug using pharmacist. As

such, the progression of a pharmacist's drug use situation may be exacerbated by the fact

that he/she fears the informal sanctions that will be imposed by the group and

understanding such a lack of tolerance becomes important.

The nature and dynamics of pharmacy education can be an important source of a

pharmacist's long term professional identity The formal and informal socialization

processes that occur during one's pharmacy education serve as the foundation for many

future attitudes and practices. It is reasonable to suggest that this premise is applicable to

the issue of illicit prescription drug use. Pharmacists are undoubtably exposed to cultural

interpretation of such behaviors that shape their perceptions and behaviors.


Literature on Pharmacy Work Culture


The normative culture of the setting in which a pharmacist practices can also have

a significant impact upon their decisions to engage in deviant behaviors. Numerous







51

scholars have focused on the ways in which various issues such as occupational role strain,

stress, and job satisfaction impact upon pharmacists' involvements in deviant behavior.

Denzin and Mettlin (1968) argue that pharmacy suffers from "incomplete

professionalization."'l The authors criticize pharmacy on two fronts. First they argue that

the pharmacy profession has been unable to achieve exclusive control over the social

object that defines their existence, namely drugs. While pharmacists are in charge of

dispensing drugs, they are dependent on physicians to prescribe the medications and their

employing organization (i.e., hospital, retail pharmacy) to supply them with the drugs and

the potential client base. Second, Denzin and Mettlin (1968) argue that pharmacy has been

unable to consistently recruit individuals into their ranks who share a commitment to the

same professional goals That is, pharmacy recruits large numbers of individuals who are

driven by economic or business ideals as opposed to purely human service motives.

According to Denzin and Mettlin, these shortcomings reduce pharmacy to a

quasi-professional status

The issues expressed by Denzin and Mettlin speak directly to the problem of role

strain. These authors were principally criticizing pharmacy for its inability to pull together

into a unified professional entity. The pharmacy profession's precarious dependence on

both the prescribing practices of the medical profession and the bureaucratic support of

the hospital or retail pharmacy store produces role confusion and role strain within its

members. In short, a successful pharmacist must come to accept both health care and

business skills and ideals in order to cope with their complex professional position.

Quinney (1963) analyzed the influence that occupational role strain has on

pharmacists' involvements in deviant behavior. He hypothesized that role strain would

produce conflict within the practicing pharmacist and increase the likelihood that the indi-









vidual would lash out against those entities that he/she saw as producing these strains.

Quinney's analysis involved an assessment of the amount of perceived role strain among

retail pharmacists. He found that occupational role confusion had a marked influence on

prescription violations among retail pharmacists. He argues that the nature of retail

pharmacy is such that it forces pharmacists to struggle between professional roles (which

stress patient care) and business roles (which stress profits). Quinney found that those

pharmacists who were more business oriented in their occupational role were more

vulnerable to prescription violation than were the more professionally oriented

pharmacists.

The late 1960s and early 1970s was marked by other inquiries into the relationship

between role strain and the incidence of professional disillusionment or job dissatisfaction

among pharmacists (Akers & Quinney, 1968; Shaw, 1971; Linn, 1973; Kronus, 1975).

Each of these studies showed that pharmacists often do experience role strain and that

heightened levels of perceived role strain can lead to problems for practicing pharmacists

Admittedly, these studies are now quite dated but these structural problems still remain in

the profession Outside of inquiries into job satisfaction issues, there has been very little

empirical inquiry in this area since the mid-1970s. And while scholars (Buerki, 1984;

Buerki & Vottero, 1993; Hepler & Strand, 1989) agree that there have been significant

changes in the direction of pharmaceutical practice over the past twenty years, most all are

quick to conclude that there remains considerable unresolved occupational role strain. The

present study will inquire into the nature and extent of occupational role strain in an effort

to ascertain if its presence has any effect on pharmacist's illicit prescription drug use.

Role strain is often targeted as a chief source of work related stress among

pharmacists. However, this is not the only source of work related stress that the









pharmacist encounters. Wolfgang and Korek (1986) have linked stress inducing factors

such as a lack of challenging work, under staffing, perceived job insecurity, pressure from

overly demanding clients, and feelings of inadequate compensation to pharmacists'

potential substance abuse. In short, these authors argue that work related stress can

produce emotional, intellectual or physical problems that lead to self-medication and then

possibly more self-destructive substance abuse.

Other scholars (Appelbaum, 1981; Numerof, 1983) have linked heightened levels

of work related stress to the incidence of substance use, psychological problems, as well

as physical problems across a number of health professions. These studies suggest that job

stress and job dissatisfaction can lead to self-destructive coping strategies. Moreover, they

point out that health professionals' increased knowledge and access to prescription

medications place them at risk of turning to the tools of their trade to relieve or treat these

stressful conditions.


Literature on Professional Socialization


Clearly, a pharmacist's professional socialization process begins in pharmacy

school. Issues related to the ways in which this early professional socialization process has

been linked to pharmacist's substance use have already been outlined in an earlier sections

of this chapter. However, there is no available research that specifically explores the

effects that the ongoing professional socialization process has on a pharmacist's drug-re-

lated rule-breakings We can, however, draw inferences about this by examining the

existing literature in the areas of professional socialization among pharmacists and other

health care providers. Of particular interest to the present study are the ways in which

perceived codes of conduct affect pharmacists' drug use behaviors. Specifically, part of the








present inquiry will attempt to assess the ways in which pharmacists internalize

professional norms and how formal and informal self-regulation are related to drug use

behaviors.

Studies of recovering substance abusing pharmacists (Bissell et al., 1989) suggest

that pharmacists go to a great lengths to cover up their drug use behaviors from detection

by others. The individuals interviewed emphasize how they feared informal sanctions from

their peers in the way of professional ostracism. However, there was also significant

emphasis placed on the fear of formal sanctions from their employers (i.e, termination) and

regulatory agencies within the profession (i.e., actions against their license by the State

Board of Pharmacy). In short, fear of perceived informal, negative sanction and formal

regulatory response encourage the abuser to hide their substance use, thereby allowing it

to intensify.

The salience of these perceived sanction threats has been questioned by some

researchers. Data has repeatedly shown that, despite their disapproval and negative value

judgments, pharmacists are very reluctant to report drug related wrongdoings among their

peers. This fact can clearly be seen in the research on pharmacy students (Miller et al.,

1990; Normack et al., 1985b; Szeinbach & Benjamin, 1990; Woodward et al., 1995) as

well as practicing pharmacists (Chi, 1983; Epstein, 1990, 1991; Sheffield et al. 1992). For

example, Woodward et al. (1995) presented pharmacists with a series of vignettes

intended to assess their reactions to peers who drink alcohol. The results show that the

pharmacists clearly disapproved of heavy drinking and viewed peers who did this as less

attractive, un-professional, and un-trustworthy. However, there was very little evidence

suggesting that the pharmacists would act upon their disapproval and formally report the

heavy drinking behavior of their peers.








This noninvolvement tendency was supported in a study on retail pharmacists'

reactions to theft and illegal substitution practices by their peers. Wertheimer & Manasse

(1976) found work group norms to be tolerant of deviant behaviors such as the theft, use,

or substitution of drugs by pharmacists. Based on their observations, these researchers

conclude that "the deviant behavior exhibited by the violator pharmacist yielded no known

rejection of those pharmacists by their peers in the population studied" (Wertheimer &

Manasse, 1976, 232).

Similarly, studies of various forms of deviance within other health care

professionals further illustrate that deviant medical professionals usually overestimate the

likelihood that their peers will come forward and report the wrongdoings to others. For

example, Rosenthal (1995) illustrates how doctors often cover up for obvious

incompetence or malpractice of their peers. She attributes doctors' tendency to cover up

or "turn the other cheek" to a combination of several factors. First, she points out that

there exists a certain fraternal obligation between doctors. Faced with perceived

misunderstandings and pressures from nonmedical regulators, the individual doctor is

more likely to protect the back of his/her troubled peer instead of sending him/her to the

proverbial "wolves." Second, she argues that doctors do not like to deal with the

pressures associated with blowing the whistle on a suspected wrongdoing of a peer. In

short, coming forward means getting involved in the investigation and inquest issues and

doctors would rather avoid these time and stress laden confrontations.

Elliot Freidson (1970, 1975), a noted authority in the area of professional

socialization, also speaks to this paradox of informal norms of conduct and fraternal

allegiance among doctors. He argues that professional socialization emphasizes group sup-

port and group protection. He points out that these ideals make for problematic situations









when medical professionals are faced with deviant peers. It seems that medical

professionals adopt an ignorance about the potential for deviant behaviors to exist among

their ranks. When peers do stray from the primrose path, the imposition of informal

sanctions become a facade--individuals are often not willing to transcend their fraternal

allegiance in favor of informal social control. In some cases, the witness assumes that the

problem will go away. Other times, the witness assumes that the deviant behaviors will

come to the attention of some external entity that is better suited to exercise their formal

position of authority.

The literature suggests that there exists a problematic paradox among pharmacists

when it comes to the issue of substance use among its members. On one hand, the

substance using pharmacist may tend to slip deeper into denial and progressively greater

usage because they fear that their peers will ostracize them or turn them over to higher

authorities if they become aware of their use. On the other hand, it appears that pharmacy

peers are often already aware of the substance use but choose to do nothing about it. This

situation results in progressive substance use that is fed from both the paranoia of the user

and the avoidance of their peers. The present inquiry will attempt to determine if such a

situation exists, and if so, how it impacts upon pharmacists' drug use behaviors.


Summary


This chapter has included scholarly literature that is focused on a broad spectrum

of topics. Moreover, this scholarship has been produced by individuals who come from

diverse substantive and theoretical backgrounds. While there has been a significant amount

of discussion and research specific to the topic of drug use among pharmacists, none of

this research has been principally focused on the sociological origins of the problem. In-









stead, the past research has approached pharmacists' drug use from a medical model

orientation, stressing the ways in which individual-level psychological or genetic factors

contribute to the etiology of drug use behaviors. The present study represents a significant

departure from medical model explanations of drug use in pharmacist and other special

populations. In particular, it will consider the role that social factors associated with the

educational, occupational, and professional experiences of the individual have on their

drug use situations. Given this conceptual focus, it has been necessary to draw upon

sociologically based literature from areas such as employee deviance, substance abuse in

the work place, pharmacy education, pharmacy work culture, and pharmacy

professionalization


Notes


1. The researchers used a broad definition of drug use, stating that they were interested in
"pharmacists recovering from alcohol and other drug addictions" (Bissell et al., 1989). As
such, much like the above studies, they have not limited their analysis to pharmacists' use
of the substances that they are responsible for dispensing

2. This disproportionate percentage of alcohol addiction can be explained by the fact that
the majority claimed to be cross-addicted to a alcohol and a number of other substances
(21% claimed to be solely addicted to alcohol) This should not be surprising since all of
the respondents were active members in some form of mutual support group (i.e.,
Alcoholics Anonymous, Narcotics Anonymous). These groups tend to socialize their
recovering members into endorsing a very liberal definition of "addiction" which subsumes
a broad range of substance use behaviors

3. Poly-drug use refers to an individual's use of multiple forms of mind altering
substances. This use may involve mixing substances during one use episode or using
different substances during separate use episodes.

4. Invariably, these studies of pharmacy students employ functional definitions of drug
use. That is, they are principally concerned with issues of impairment. This type of focus
results in substance use measures that include all types of mind altering substances, not
simply prescription medications. Nonetheless, most of the studies present their data in a
way that allows for such a distinction to be identified









5. While this definition does focus exclusively on drug use, thus excluding alcohol, most
of their discussion focuses on a definition of drug use that includes marijuana. They term
this use "recreational drug use." Moreover, the marijuana use numbers tend to account for
the majority of the student overall drug use.

6. Under the heading of "self-treatment," these researchers focus specifically on the
students' use of prescription medications. Included in this category are sedatives,
stimulants, analgesics, tranquilizers, and opiates. This definition closely parallels the
definition of prescription drug use used in the present study. The only difference is that
these researchers did not stipulate that the use be done without a prescription. The data
show that 57% of the pharmacy student group had engaged in recreational drug use and
33% had engaged in self-medication. In the practicing pharmacist group the recreational
and self-medication use numbers were both reported at 29%.

7. The researchers offered the students a definition of the substance abuse concept which
read as follows: "abuse exists when any normal function, including work, eating,
socializing, sexual relations, sleep, etc. becomes dependent on alcohol or drugs.

8. The Substance Abuse Attitude Survey is a Likert-type survey instrument that was
designed to measure an individual's views of drug and alcohol use. The instrument
contains 43 statements coded in a strongly agree/strongly disagree format. The instrument
allows for an analysis of five factors associated with substance abuse attitudes:
permissiveness, views of treatment interventions, stereotypes of users, treatment
optimism, and moralism.

9. The nurses made a clear distinction between the use of narcotic vs. nonnarcotic
medications. Narcotic medications were seen as a threat to patient care and a potential
source of addiction. Conversely, nonnarcotic prescription medications were viewed as a
source of therapeutic, nonthreatening pain relief, and hence provide work enhancement

10. Denzin & Mettlin identify numerous qualities that are necessary conditions to achieve
a complete professional status. These include developing and maintaining specialized
training, providing a skilled service with a fee attached, development of a code of ethics,
engaging in formalized recruitment, establishing formal organizations and institution to
preserve and perpetuate the occupation, self-governance, and achieving and maintaining
exclusive control over the social object which defines the profession. The authors refer to
pharmacy as a quasi-profession since it has been unable to actively recruit individuals who
are committed to the professional goals and they have been unable to achieve control over
their social object--drugs.














CHAPTER IV
RESEARCH METHODOLOGY


This study employs a multi-method research plan. Three separate data sources

have been used to achieve a comprehensive inquiry into pharmacists' illicit prescription

drug use behaviors. These data sources include 1) in-depth interviews with pharmacists

who were recovering from illicit prescription drug use behaviors; 2) incident reports

detailing officially discovered cases of pharmacist's drug related wrongdoings in the retail

pharmacy environment; and 3) a self-administered, anonymous survey of practicing

pharmacists. The following chapter outlines the details of the research plan, from data

collection to data analysis.


The Research Plan


The origins of this research project can be traced back to 1993. Long interested in

the phenomenon of drug use among health care professionals, I began to read the available

literature on the subject. My preliminary review of the literature led me to conclude that

there had yet to be any significant inquiry into the sociology of illicit prescription drug use

among pharmacists. From here, I set out to develop a methodological plan that would

allow me to produce an etiologically-based understanding of the topic.

The foundation of my research plan is built around an in-depth interview

component. The strategy was to locate pharmacists who had extensive personal

experiences with drug use and engage them in a conversation that detailed the onset and









progression of their drug use experiences The use of a personal (face-to-face)

interviewing strategy was particularly well suited for the present project. Berg (1998)

argues that face-to-face interviews are an especially effective tool for constructing a

foundational understanding about sensitive and complex research topics. The Problem

Statement and Literature Review chapters have already demonstrated that the onset and

progression of pharmacists' illicit prescription drug use behaviors is clearly a sensitive and

complex research topic.

Furthermore, Berg (1998) states that interviewing affords the researcher numerous

methodological benefits in both the collection and analysis of data. From a data collection

standpoint, personal interviews afford the researcher greater latitude to explore different

substantive avenues within a flexible conversational format, while probing for new

conceptual leads. The face-to-face format of an interview allows for a level of rapport

with one's research subjects that is unheard of in most other modes of inquiry. The

physical presence of the researcher at the time of data collection allow for points of

clarification to be made that would be missed in self-administered surveys or other data

collection techniques. The researcher can also better identify and react to the verbal and

nonverbal cues of the interviewee. Each of these issues are particularly germane to the

present project. A pharmacist's disclosure of the details associated with their illicit

prescription drug use behavior is a very private and sensitive topic. As such, I was in need

of a minimally-threatening data collection strategy.

Berg (1998) notes that the conversational format of the interview also produces

benefits for data analysis phase of research. Namely, interviews allow a researcher to

engage in a constant comparative method (Glaser & Strauss, 1963). This standard

qualitative method brings data collection and data analysis together into one ongoing









process. It allows the researcher to explore and flesh out conceptual leads across the

course of numerous interviews, thus, gradually building a more complete interpretation of

ideas. Given the nature of my conceptual framework, the ability to closely connect the

data collection and data analysis became an important criteria in my decision to begin the

data collection effort with an interview-based inquiry.

The face-to-face interview component of the research project serves as the

inductive center of this study. This component will be first used to gather descriptive data

and ideas about the nature and dynamics of pharmacists' illicit prescription drug use

behaviors. The resulting insight was then to be used to construct the two other data

collection instruments.

The first application of the interview data involved the formulation of an

archival-based data collection effort of officially discovered deviants. I successfully solici-

ted two major retail pharmacy chains for their permission to access all available loss

prevention department documentation regarding cases involving pharmacists' drug-related

wrongdoing. My goal was to use these incident report data to both support and

complement the evidence and ideas that were generated by the earlier interview inquiry.

To this end, the interview component was instrumental in the development of both the

standardized data collection template and the proposed analysis plan.

Admittedly, the interview component of this project is open to criticisms that it is

unrepresentative of the drug use attitudes and behaviors of the typical pharmacist This

initial component of the project was purposely designed to generate rich interpretive and

experiential information on how social factors affected the drug use behaviors of a small

but exclusive group of pharmacists who have substantial drug use histories. As such,







62

generalizability was compromised in favor of examining a rich data source that identifies

important relationships within a special group of deviant individuals.

The archival-based loss prevention apprehension incident report component of the

project is also open to criticisms and questions about the representativeness of the

findings. Namely, the small, nonrandom sample and the utilization of apprehension data

limit the ability to generalize from the data However, generalizability is again of

secondary importance to this archival-based data collection effort. These data are intended

to offer descriptive data on pharmacists' drug use behaviors that will be used to

supplement and support the findings from the interview component.

This is not to suggest that the present project is unappreciative of generalizable

findings. I very much wanted to produce a comprehensive sociologically-based study of

pharmacists' illicit prescription drug use behaviors that could be used to consider the

nature of the problem within the larger pharmacy profession. In an effort to achieve this

goal, 1 formulated plans for a mailed, self-administered, anonymous survey that was to be

distributed to a large sample of typical practicing pharmacists. This third and much larger

source of data queried a random sample of practicing pharmacists on the topic of illicit

prescription drug use, and hence offered considerable potential for generalizability. Here

again, the personal interview component served a critical role to every aspect of

questionnaire development. The trends uncovered in the interview inquiry were

intentionally operationalized within the questionnaire to allow for comparisons to be made

between the two data sets. In particular, 1 wanted to be able to use quantitative techniques

to expand upon and verify the findings uncovered in the interviewing component.

The use of a multi-method research plan is somewhat different from the strategies

used in other studies. My inductively based research design differs from the often









employed multi-method approach wherein qualitative interview data will be used to add

context to quantitative data. I submit that my methodology offers a more comprehensive

assessment of pharmacists' illicit prescription drug use behaviors. The combination and

coordination of both qualitative and generalizable quantitative data allow me to discussion

that offers both depth and breadth to the understanding of the topic.


In-depth Interviews with Recovering Drug Using Pharmacists


The face-to-face interview component was intended to examine personal

life-histories offered by a snowball sample (Berg, 1998) of pharmacists who were in

recovery for their past prescription drug abuse. I began by developing a loosely structured

interview guide (see Appendix A). The substance of the interviews were oriented toward

retracing the individual's pharmacy career, paying particular attention to the intertwined

dynamic of their personal drug use Conceptually, the goal of this endeavor was to

contextualize the individual's drug abuse within their complex life system. Drug use

behaviors were not separated from the individual's personal or professional life. Instead,

the pharmacist's drug use was conceived of as a form of behavior that co-exists and

interacts with a myriad of other behaviors. I hoped that this conceptual approach would

allow me to gain insight into the complex interaction patterns that contribute to,

perpetuate, and exacerbate pharmacists' drug using activities.

A copy of the interview guide is presented in Appendix A. Referring to this

appended information, one will notice that most of the interview topics are committed to

exploring possible linkages between individuals' illicit prescription drug use and various

social factors. Most notably, they inquire about the ways in which educational,

occupational, and professional experiences influenced personal drug use.









Participant Recruitment

Most every U.S. state has developed a recovery network for impaired pharmacists.

While their organizational structure, funding sources, and other administrative aspects

differ from state to state, each of these social assistance networks is committed to serving

as a liaison between drug and/or alcohol using pharmacists and the governing social

control and sanctioning bodies (e.g., state board of pharmacy, pharmacy employers, Drug

Enforcement Administration--DEA) that oversee pharmacy practice. Key figures in these

networks, as well as the recovering pharmacists that they work with, routinely congregate

at various local, regional and national conferences. These venues were used as the central

recruitment sources in the personal interview component of the present study.

The early months of 1993 were spent fostering relationships with key figures in the

pharmacist recovery network. The details of the study were explained to each of these

individuals and they were asked if they would be willing to assist in gaining access to

pharmacists with prescription drug abuse histories. Every individual approached was quite

receptive to both the study and the potential of assisting in its completion. Three of the

more influential individuals in the recovery movement were chosen as primary respondent

"recruiters."

The selection of respondents and subsequent data collection were carried out over

four separate occasions. The first occasion involved my attendance at the 1993 annual

conference of the American Pharmaceutical Association. The second involved my

attendance of the University of Utah's week long seminar known as the School on

Alcoholism and Other Drug Dependencies, held during June of 1994. The third occasion

involved a 1995 two week long trip to several cities in Texas. The final occasion involved

a 1995 two week long trip to several cities in the Pennsylvania/New Jersey/Delaware area.








Each of the above times and locations were chosen because it was known that 1) there

would be significant numbers of recovering pharmacists present; 2) one or more of the

above described recruiters would be present to assist me in locating potential interview

participants.

My methodological strategy allowed me to gain access to large numbers of

recovering pharmacists from around the country. I continued a "snowball" sampling

strategy until I had successfully contacted and interviewed 50 pharmacists who were in

recovery treatment programs for prescription drug use behaviors.

Data Collection

Prior to departing for each of the above destinations, 1 contacted my recruiters and

asked them to assist me in locating potential interview participants. They were instructed

to contact pharmacists with prescription drug use histories and offer them the opportunity

to participate in the study. The recruiters were asked to briefly describe the research

project and indicate how the pharmacists could contact me with any questions about the

project. When I was contacted by potential respondents, I answered any questions that

they had and made arrangements to meet and interview them. None of the individuals who

contacted me refused to participate in the project. Moreover, the recruiters reported that

they had little difficulty getting people to initiate contact with me.

I personally conducted all 50 of the face-to-face interviews that are included in this

analysis. These interviews were held in a variety of places. While most took place in hotel

or dormitory rooms, others were conducted in public parks, cafeterias, the respondent's

home, the respondent's place of employment, or meeting rooms. Regardless of the

location, all of the conversations involved only myself and the volunteer respondent.

Despite the odd assortment of locations use, we were always able to achieve a reasonable









level of privacy. At the start of each interview, the respondent was read an

explanation/consent statement pursuant to UF-IRB approved protocols and asked for

permission to tape record the conversation. All respondents willingly cooperated.

Measurement

The interview guide contained in Appendix A offers an outline of the interview

content. This interview guide is separated into thirteen "topical areas." These topical areas

served to remind me of the various substantive issues that 1 wanted to work into the each

interview conversation However, note that the loose organization of this interview guide

allowed for each interview to be reordered to accommodate the natural flow of the

conversation. While I consciously sought opportunities to work each of the interview

topics into the conversation, the respondent was granted considerable freedom in

determining the direction and pace of the interview conversation. This resulted in

interviews that ranged from one to three hours.

The interviews began with a query into each person's pharmacy background.

Referring to Appendix A, Topic #1 was designed to inquire into the individual's work

history. My first goal was to develop a time line documenting each individual's work

experiences that could then be used as a reference point to organize the rest of the

conversation

Topic #2 on the interview guide was designed to probe into the formal pharmacy

education of each respondent Individuals were encouraged to describe the socialization

process that they experienced while in pharmacy school. Attention was focused on the

ways in which peer interactions as well as formal institutional interactions help shape

student's lives. Again, this information is intended to serve a baseline function that was

then referenced in subsequent parts of the conversation.








The next two topics on the interview guide (Topics #3 & #4 in Appendix A)

focused on the issue of professional socialization. Details of the individual's early work

experiences and continued pharmacy work were discussed in an effort to gain insight into

the process by which a professional identity was nurtured.

Topic #5 (Appendix A) queried the individual about the concept of job

satisfaction. This section of our discussion drew attention to their experiential and

aspirational appraisals of their professional situation. Note that temporal cues were used to

ground these appraisals within the various stages of their pharmacy career.

Referring to Appendix A, Topic #6 was intended as a transitional item moving into

the individual's substance abuse history. Specifically, the individual was asked to describe

his/her attitudes toward controlled substances. Here, I was interested in determining the

individual's personal and professional views on drug use and abuse. This line of inquiry

was particularly sensitive to the ways in which these views changed over the course of the

individual's pharmacy career. Attention was focused on how pharmacy school, early work

experiences, and later work experiences shaped the individual's personal attitudes about

drugs.

Topic #7 from the interview guide (Appendix A) focused on the individual's

substance use history. This section of the discussion was centered around a pencil and

paper exercise in which the respondent was asked to draw a time line of his/her substance

use history. I found that this exercise allowed me to contextualize significant substance

related events within each individual's personal life and professional career. This technique

facilitated exploration of potential contributing factors related to the person's substance

abuse trajectory. Specifically, my probes directed the conversation to issues socially

related to the individual's educational, occupational, and professional experiences.









The discussion of the behavioral components of their substance abuse history was

supplemented by an inquiry into possible rationalization techniques that have been

employed by each respondent (see Topic #8, Appendix A) Particular attention was given

to the sources of the individual's rationalizations and the interactional patterns that

facilitated their development and internalization. Every effort was made to determine the

temporal and situational contexts in which these rationalizations were developed and

imposed by the respondent.

Topic #9 (Appendix A) solicited input from the individual regarding the etiology of

his/her substance abuse situation. The individual was asked to reference the pencil and

paper drug use history time line and theorize about the ways in which significant life

events impacted upon their substance abuse situation. Again, I directed the individual's

attention to the ways in which various social factors were related to his/her drug use

behavior.

The next three topics on the interview guide (Appendix A) addressed issues related

to the individual's ongoing recovery from substance abuse Topic #10 inquired into the

details of their substance abuse treatment and after care. Topic #11 was concerned with

the personal and social conditions associated with the individual's substance abuse

after-care. Finally, Topic #12 focused on the individual's perceptions of various personal,

professional, and societal reactions to the issue of substance abuse among pharmacists.

Upon completion of the interview conversation, each individual was asked to

complete a one page demographic checklist. This checklist is attached as Topic #13 of the

interview guide. Referring to Appendix A, the individual was asked to indicate his/her age,

gender, race, marital status, educational background, pre-and-post-treatment levels of

income, and aspects of his/her religious orientation.









Note that the above interview guide was pre-tested on several individuals. Two

recovering pharmacists for the Florida area were interviewed and asked for feedback on

the interview structure and its content. Moreover, one of the members of my Supervisory

Committee conducted a pretest interview. None of these pretest interviews was included

in the final sample of 50 interviews. Also note that two other interviews were excluded

from the analysis because the individuals had only used alcohol in the past.

Data Organization and Analysis

Once all fifty of the interviews were completed, the tape recording of each one was

transcribed verbatim. Next, a standard form of thematic content analysis was used to

analyze the data. The coding of the transcribed interview data wase done electronically

using the Qualpro computer coding program. This involved computer-assisted sorting and

resorting the data from general to more specific thematic categories. The mundane

categories included but were not limited to the various topical areas contained in the

above described interview guide. By sorting through these more general themes, I was

able to search for and identify more specific themes in the data. Several phases of this

sorting and coding process were conducted until I developed a comprehensive

classification of the interview data. At this point, patterns were reported and direct

quotations were readied for their inclusion in the forthcoming findings chapter.


Analysis of Loss Prevention Incident Reports


The second data collection effort involved an analysis of formal documents

provided by the loss prevention departments of two major retail pharmacy chains. A

standardized data collection template (Appendix B) was used to gather descriptive data









from the corporate documents associated with loss prevention investigations into the

incidents of pharmacists' drug related wrongdoings.

The data from the loss prevention apprehension reports were used to develop a

profile of pharmacists' officially documented illicit drug related behaviors within the retail

pharmacy setting. Specifically, these data allow me to identify and summarize the offense

characteristics, the offender characteristics, and the formal and informal responses

associated with officially documented cases of pharmacists' illicit drug incidents.

Sampling

Existing personal relationships with loss prevention administrators from two major

chain drug store firms were used to gain access to each company's corporate loss

prevention records. These companies were chosen principally chosen out of convenience.

That is, the corporate officials were ready and willing to cooperate with my research

efforts. However, note that convenience was not the only reason for approaching these

two particular firms. Both firms are among the largest retail drug chains in the United

States. This fact assured that each firm employed large numbers of pharmacists and would

have significant experience with the problem of pharmacists' illicit prescription drug use.

These firms were also approached because each had a comprehensive loss prevention

record keeping system. As such, each firm had the ability to isolate drug related cases

from all other nondrug investigations They were also willing to offer the necessary

staffing assistance to assist me in locating and interpreting the available documents.

Data Collection

Since all of the loss prevention records that I was interested in gaining access to

were kept on-site in the loss prevention department of each company's corporate

headquarters, it was necessary for me to travel to each location to gather the data. Once at









the corporate headquarters, 1 had to develop some way to systematically record the

documented information. A two-page data collection template (Appendix B) was

developed to achieve this goal. Construction of this data template began with my referenc-

ing the interview component of the project. First, I considered what the corporate officials

had told me and shown me about the documents that 1 would access. Next, I referenced

my interview data to determined areas of substantive overlap between the interview and

archival data sources. In constructing the data template, I intentionally included items that

could be cross-referenced with the interview data. For example, I included items such as

the individual's motivation for drug use, the types of drugs involved, the amounts of

overall and daily drug use, and the demographics of the offender. The details of this data

template will be reviewed below.

The archival loss prevention incident data collection was completed during the

Summer of 1995. Upon arriving at corporate headquarters, I found that each firm had an

indexing system which allowed administrators to readily identify and access individual case

information. These indexing systems were used to identify only those incident reports

containing cases of drug related behavior involving at least one licensed pharmacist. All

incident reports from 1990 to 1995 were included in the study. This produced a sample of

89 cases.

Measurement

Appendix B contains the standardized data collection template that was used to

gather information from each incident report. Referring to Appendix B, one notices that

this data collection template is divided into the following areas: incident information,

substance information, and perpetrator demographics. The section entitled "incident

information" focuses on the social response to the act(s) and individuals) that came under






72

investigation from loss prevention administrators. The first five items, namely the date of

report, location information, mode of detection, incident description, and length of

investigation items focus on the details surrounding the loss prevention department's

investigation of each incident. This information allowed me to determine the variety of

behavioral patterns being used by the offending pharmacists.

The next four items on the data template (Appendix B) explored the potential

involvements of various external formal social control agencies had in the case. These

items addressed the nature and extent of any involvements on the part of law enforcement,

State Board of Pharmacy, recovery network, or other external social control agencies.

This information allowed me to indirectly gauge how severely the various corporate, local,

state, and national social control agencies reacted to the social problem.

The last five items on the first page of the data template, namely, response of the

accused, resulting sanction, restitution arrangements, present status of the case, and

pending actions, focused on the various outcomes of the collective investigative actions.

In short, these items were intended to provide me with a better understanding of the

formal disposition of each case.

The first item on the second page of the data template (Appendix B) solicited an

itemized account of any and all substances that were allegedly involved in each case. Here,

the type, amount, and dollar value of each drug used was recorded. These data allow me

to compare the details of the drug thefts and subsequent usage to those described by the

interview participants.

The next several items are specific to those cases which involve some type of drug

theft. The first of these items inquired into the mental intent of the perpetrator. If the sub-

stances involved were being removed from pharmacy stock, then it is important to








understand what the individual intended to do with them. Recognizing that this type of

information is at times speculative, an effort was nonetheless be made to determine what

each individual's intentions were (i.e., personal use versus sale). Furthermore, an attempt

was made to determine the theft techniques as well as the total dollar amount of the stolen

drugs. Note that the incident reports usually contained some form of documentation on

each of these items.

The loss prevention incident reports were also utilized in an effort to determine the

nature and extent of other individuals' involvement or knowledge about the documented

drug related behavior. Group-supported deviance, as well as enabling behaviors on the

part of the co-workers, friends and family members, are particularly interesting since they

speak to the social component of these behaviors.

Most pharmacists who steal drugs from their place of employment do so for

personal consumption Over time, personal consumption patterns are known to increase

and diversify. As such, a series of items on the data template (page 2 of Appendix B)

sought to gather information about the pattern of drug use behaviors. This information

was supplemented with any information regarding possible treatment that the individual

had undergone. Anticipating the diverse details that can and do accompany a substance

abuse situation, additional space was provided in this section to account for unforeseeable

circumstances in the data. In many cases, this space came in useful as considerable

comments had to be recorded.

The final section of the incident report data template (page 2, Appendix B) was

intended to gather demographic information on each of the individuals who were

implicated in the drug related incident Of particular interest was the individual's age,









gender, race, length of tenure, job description, performance evaluation, and their

disciplinary record. These data were often not available and had to be left blank.

Analysis of Loss Prevention Incident Data

The data collection effort yielded information on 89 of pharmacists' drug related

wrongdoing. The SPSS Data Entry II computer program was used to convert the

handwritten data templates into an computer analyzable form. Next, SPSS/PC+ was used

to generate descriptive statistics for each of the response item on the data template. The

open ended items were subject to the same form of standard thematic content analysis plan

that was used for the interview data The results of these descriptive analyses will be

presented in a forthcoming Findings chapter. The goal of the analysis was to produce a

descriptive profile of the drug related behaviors that have come to the attention of, and

been investigated by, the loss prevention officials from this particular group of chain drug

stores during the 1990's. These data would then be used to supplement and support the

data from the other components of the project.


Survey of Practicing Pharmacists


As mentioned above, the research plan called for the interview data from the

recovering pharmacists to besupplemented and supported by survey data obtained from a

sample of practicing pharmacists. This third data source would included both pharmacists

with illicit drug histories and pharmacists with no previous involvements in such behaviors.

Sampling

Potential survey respondents were obtained via a random sampling strategy drawn

from the membership list of the American Pharmaceutical Association (APhA) The APhA

is a national professional society for pharmacists that offers membership to any licensed









pharmacist or pharmacy student. Note that this is the only professional society that

represents all pharmacy practice settings. Its current membership exceeds 48,000. The

APhA was asked to generate a random sample of roughly 2,000 pharmacists. I reasoned

that this sample size would allow for stable statistical analysis.

The APhA membership information was used to impose the following sampling

selection criteria. First, only members whose file showed that they were a licensed,

practicing pharmacist were included. This allowed me to exclude nonpharmacists or mem-

bers from another country. Second, the sample was restricted to individuals with one of

the following job titles: staff pharmacist, director, owner, manager, or supervisor. This

limited the sample to dispensing pharmacists and excluded technicians, educators,

researchers, clinical pharmacists, residents or fellows, and various other APhA members

whose job is not closely linked to the dispensing of medications. Finally, the APhA

information on place of employment was used to ensure that no retired or nonpracticing

members were included Only those individuals who listed their "primary place of practice"

as either a community and ambulatory or organized health care practice (i.e.,

hospital-type) setting were included. Mailing labels containing the name, title, and home

address of 2,036 pharmacists were generated and sent directly to the researcher for the

preparation of mailing materials

Data Collection

Each potential respondent was mailed a packet via first class mail that contained

four items. The first item was a four-page questionnaire. The questionnaire was

constructed using a desktop publishing program (Ventura Publisher). This assured a

professional appearance for the questionnaire. A photocopy of the questionnaire is

presented as Appendix C. Second, each mailing packet included a postage paid, business









reply envelope. Third, a cover letter, signed by myself and Dr. Richard Hollinger was

included. This one-page cover letter was reproduced on University of Florida, Department

of Sociology letterhead. It offered a brief description of the project, participation

instructions, and invited the recipient to participate in the survey. Finally, each mailing

packet included a one-page cover letter signed by the co-coordinators of the APhA's

pharmacy recovery program. This second cover letter, which was reproduced on APhA

letterhead, assured the potential respondents of the confidentiality and importance of the

project and once again encouraged them to participate.

The above mailing packet was sent out to all 2,036 practicing pharmacists in the

sample through a single wave mail out. Eleven mailing packets were returned due to

expired or bad addresses. This reduced the total number of potential respondents to 2,025.

In all, 1,016 surveys were returned, yielding a response rate of 50.2%.

Survey Instrument

Appendix C details the self-administered, anonymous, mailed survey questionnaire

that was used in this component of the data collection effort. The questions are principally

focused on the details of each respondent's pharmacy career and their attitudes,

understanding, and personal involvement related to illicit prescription drug use. The

development of these survey items involved heavy referencing of the topical areas

contained in the above described interview guide. Modeling the survey of practicing

pharmacists after the in-depth interviews with recovering impaired pharmacists allowed

me to compare the professional and personal lives of individuals who have drug histories

with those who have no previous history of drug use.

The first seven survey items (questions #1-7, Appendix C) replicate the

demographic checklist that each interview respondent was asked to complete (see Topic









#13, Appendix A). Specifically, these items gauge the respondent's age, gender, race,

marital status, and religious beliefs.

Referring to Appendix C, questions #8-13 focus on the details of the respondent's

work history. These items query the respondent on aspects of their present employment

situation, the length of their licensed pharmacy career, the types of pharmacy practice that

they have experience in, and their motivation for entering the profession.

Several survey items (questions #14, 18, and 19-24, Appendix C) focus on general

aspects of the respondent's formal pharmacy education. Respondents were asked for

information about their pharmacy credentials, the school that they attended, their year of

graduation, their grade point average (GPA), and their age at graduation. Also, they were

asked to specify their marital status, type of residence, and Greek fraternity affiliation

while in pharmacy school. These largely demographic items allowed me to gain a better

understanding of the individual's pharmacy training and provided educationally-based

measures for the subsequent analysis.

Recall that past research (Baldwin et al., 1991; Bissell et al., 1989) has shown that,

in general, pharmacists are poorly trained in the behavioral aspects of drug abuse

education This ignorance has been linked to the incidence of drug use among pharmacists.

As such, two survey items, namely numbers 15 and 16, measure the individual's exposure

to formal education on the psychological aspects of chemical dependency The nature of

this formal training/drug use relationship will be explored in the subsequent analysis.

As a follow-up to the above formal training items, question #17 (Appendix C) asks

the respondents to indicate what educational and informational resources related to the

problem of drug abuse among pharmacists have been made available to them by their









present employer. This occupationally-based training item offers further insight into the

individual's level of knowledge and resource bases specific to the problem of drug abuse.

Survey item #25 (Appendix C) addresses the issue of one's faith in the therapeutic

potentials of pharmaceutical drugs and medications. This item is intended to explore the

individual's disposition toward the therapeutic use of prescription medications and whether

these sentiments have changed over the course of their careers. In other words, this set of

items provides indirect measure of how much confidence the individual places in the tools

of his/her profession. This information can potentially offer insight into whether or not

levels of ideological commitment are related to one's potential to engage in drug related

improprieties.

Previous research has explored the effects that aspects of occupational roles and

job environment have on various forms of deviance among pharmacists. For example,

Quinney (1963) argued that the structure of pharmacy work fosters a tension between the

occupational role as a businessperson and a health care provider and that these tensions

can contribute to their subsequent involvement in job related deviance. Referring to

Appendix C, the issue of perceived occupational role conflict is the focus of questions #26

and #27.

The next series of questions focus on various ethical or professional socialization

issues that may act as contributing factors to pharmacist's problematic drug use. First,

questions #28 and #29 (Appendix C) poll the respondent on their views and exposure to

the practice of relaxed drug dispensing. It was expected that exposure to relaxed

dispensing practices would yield more self-medication.

The second professional socialization item (item #30, Appendix C) asked the

individual about their attitudes toward the recreational use of prescription medications.









This item was intended as a proxy measure of the individual's likelihood for engaging in

the recreational use of prescription drugs

The next professional socialization line of questioning (questions #31 and #32

inquires into the individual's attitudes and exposures to the practice of self-medication.

Past research (McAuliffe et al., 1987; Normack, 1985b) has linked pharmacists'

self-medication practices and attitudes to the incidence of substance abuse in the

profession. Moreover, the subsequent findings chapter will illustrate that this was

identified as an important theme among the recovering pharmacists who were interviewed

in the present study. As such, it was important to inquire further into this issue among a

sample of practicing pharmacists.

One last ethics-based item (question #33, Appendix C) asks the respondent to

estimate how well prepared they think they are to deal with a drug abusing colleague. This

is a standard item included in pharmacy ethics texts (Buerki & Vottero, 1993). In this

case, it was principally intended to offer an abstract compliment to the formal training

items listed above.

Several items attempt to determine individual's exposure to and response to other

drug using pharmacists (Questions #34 #36, Appendix C). These learning based items

can offer a proxy measure of the individual's acceptance of drug using peers. It is expected

that relaxed attitudes toward drug using peers will be related to personal drug use

behaviors.

At this point, the substance of the survey shifts to the individual's personal drug

use experiences. Question #37 (Appendix C) is a forthright attempt to determine if the

individual has ever thought that they were abusing any prescription or nonprescription

drugs.









In question #38 (Appendix C), the respondent is presented a list of twelve drug

types/classes and asked to indicate if and when they first used each. This item offers

important insight into when pharmacists began using the various substances. Moreover,

the career-based response choices (pre-college, during college, post-college) offer an

indication of where the use began in reference to their pharmacy training and practice.

The next item (Question #39) queries the individual about his/her use of the same

twelve different types/classes of prescription and nonprescription (e.g., marijuana/hashish,

cocaine) drugs. The nonprescription controlled substance items are included in an effort to

determine if there is any evidence of pharmacists making a normative distinction between

the use of prescription versus nonprescription controlled substances. The responses to the

prescription drug items serve as the foundation for the dependent variable in the pending

analysis.

The final survey item (question #40, Appendix C) focuses on how pharmacists

actually gain access to the drugs that they use. Specifically, respondents are asked to

indicate the ways in which they obtained each of the twelve drug types/classes that they

may have used in the past.

Only a small part of the survey instrument focuses directly on issues related to

personal drug use. This is done in anticipation of the fact that the majority of the

responding pharmacists will report very few illicit prescription drug use episodes in their

past. Note, however, that considerable attention is focused on the respondent's

perceptions of pharmacy ethics and drug use within the profession. This focus seeks to

explore emergent personal or structural social controls that may have contributed to their

abstinence from drug use. These survey data allow for statistical inquiry into the ways in









which various social factors influence the onset and progression of pharmacists' illicit

prescription drug use.

Data Analysis

The data from the survey component of the study were coded, cleaned, and

analyzed with the assistance of the SPSS/PC+ statistical analysis computer program.

Descriptive statistics were run for all survey items. Next, the analysis focused on the

construction of an conceptual model that could be used to predict illicit prescription drug

use among pharmacists. Here, thirteen variables were identified for bivariate and

multivariate analyses. Frequency of illicit prescription drug use was chosen as the

dependent variable The independent variables can be classified into four categories.

educational variables, occupational variables, professional variables, and control variables.

The bivariate relationships between the drug use outcome measure and each of the

independent variables were assessed by using cross-tabulations and accompanying

measures of association. The results of these procedures will be presented in table form.

The results of the bivariate analysis were used to construct a multivariate analysis

plan that would allow me to predict illicit prescription drug use among pharmacists. This

was achieved using ordinary least squares (OLS) regression (Achen, 1990) and a ratio

form of logistic regression (Fienberg, 1977) Namely, the various prescription drug use

outcome measures were regressed on a series of the independent variables described

above. The results of this analysis will be presented in a subsequent chapter.


Summary of the Multi-method Analysis Plan


The above analysis plan is intended to present a comprehensive picture of the

nature and dynamics of pharmacists' illicit prescription drug use. This will be by examining









three complimentary and coordinated data sources. Each of the data sources attempts to

supplement and support the data from the other two.

The results from the analysis of these data sources will be presented in three

separate Findings chapters. While each chapter will highlight the unique aspects of the

given data source, each will touch upon a series of related themes. For example, each

chapter will present data on the descriptive aspects of the respondents. This will be done

to substantiate comparisons across the data sets.

Next, each data source will offer a descriptive profile of the drug using pharmacists

contained therein. This will involve a discussion of the types of drugs being used, the

frequency of use, methods of use, methods of procurement, and the like.

Each data source will offer insight into the onset of drug use behaviors. The

archival and survey components will speak only to temporal issues (i e., when drug use

began) but the interview component will speak to both temporal and contextual issues.

That is, the interview data will also outline the social and motivational issues surrounding

the onset of drug use.

The interview and archival data sources will speak to issues regarding the

progression of one's drug use involvement. Where possible, the data will be used to show

how the pharmacists progressively slipped into a more intensified drug use habit

Most importantly, the interview and survey data will be used to identify the

relationship between various social factors and drug use. I will show how the educational,

occupational, and professional trends identified in the interview data are statistically

supported via the survey data. In particular, the data will show that permissive attitudes

toward self-medication, exposure to drug using peers, a lack of drug abuse training in







83

school and on the job, success in pharmacy school, and historically based attitudes toward

the dispensing of drugs are all related to the incidence of drug use among pharmacists.

The summary and conclusion chapter will attempt to tie together the predominant

themes that have been presented within the three data sources. This chapter will bring

together the conceptual contributions of the project and attempt to offer theoretical and

practical implications that are spawned by the data.














CHAPTER IV
FINDINGS OF THE PERSONAL INTERVIEW COMPONENT


Participant Demographics


In the Research Methodology chapter, I outlined the details of the snowball

sampling technique (Berg, 1998) that was used to gain access to pharmacists with drug

use histories. This recruitment strategy yielded a group of 50 pharmacists. In total, the

interviewees included pharmacists from 24 different States.

Table 1 contains a variety of demographic information about the interviewed

pharmacists. A series of demographic variables are listed down the left side of the table.

The first column of data outlines the demographic characteristics of the 50 interview

participants. The far right column presents the available demographic information for the

entire population of practicing U.S. pharmacists.

Referring to Table 1, notice that the interview participants were predominantly

male (78% male vs. 22% female). These data also illustrate that the interview sample was

made up almost exclusively of Whites (96%). There was only one African American and

one Hispanic in the interview group. Note that the interviewees ranged from 27 to 62

years of age. The average age was 41.4 years. The age distribution (see Table 1) was as

follows: 8% were under 30, 38% were in their 30s, 36% were in their 40s, 12% were in

their 50s, and 6% were over the age of 60.









Table 1. Demographic Characteristics (as %) of the Interview Participants and the
Population of Practicing U.S. Pharmacists.

Interview Practicing U.S.
Participants Pharmacists*
Variable (N = 50) (N 179,445)
Gender
Male 78 64.2
Female 22 29.2
Unknown -- 6.2
Race
White 96 81.9
African American 2 24
Hispanic 2 1 4
Asian -- 3.3
American Indian .5
Unknown -- 10.7
Age
0-29 8 6.3
30-39 38 28.6
40-49 36 25.2
50-59 12 15.2
60+ 6 16.2
Unknown -- 8.3
Degree Status
Bachelor's 84 84.1
PharmD 4 6.2
Master's 12 4.7
Other -- 1.4
Unknown -- 3.5
Practice Setting
Hospital 28 23.6
Chain Retail 26 33.1
Independent Retail 16 32.6
Home Infusion 6
Nursing Home 4 2.2
Temporary Contract 2
Other -- 8.4

*These data were obtained from the Pharmacy Manpower Project. This nationwide study
offers demographic data on 179,445 of the 194,570 licenced to practice in the U.S. on
12/31/92.









The data on degree status (Table 1) show that the vast majority (84%) of the

interview participants held Bachelors of Science degrees in pharmacy. Another 12% held

Masters degrees. The remaining 4% had obtained PharmD' degrees.

The data in the left column of Table 1 also illustrate that there was a diverse

occupational status among the interviewees. For example, 28% were working in hospital

settings, 26% were working in retail drug chains, 16% were doing independent/commun-

ity pharmacy work, 6% were in home infusion, 4% were working in nursing homes, and

2% were working as a temporary contracted pharmacist in various settings. Notice that

nine (18%) of the pharmacists were no longer in pharmacy work. Three of these

individuals were not practicing because their license had been revoked or suspended.

Note that a diverse distribution was observed in the marital status of the

respondents: 58% were presently married, 26% were divorced, and 16% were single. The

religious composition of the interview group was as follows: 38% were of Protestant

denomination, 28% were Roman Catholic, 10% were Jewish, 16% claimed to be

Nondenominational, and another 8% (N=4) claimed no formal religious affiliation

In the early 1990s, the Pharmacy Manpower Project was conducted. This

collaborative research undertaking involved the cooperation of a host of national

pharmacy organizations Its goal was to assess the demographic characteristics for the

entire population of U.S. pharmacists The findings (Martin, 1993) offer us the most

up-to-date source of demographic information on the 190,000 plus pharmacists who are

currently licensed to practice pharmacy in the U.S. An overview of these results are

presented in the far right column of Table 1. These data offer valuable baseline

demographic information that can be used to better assess the representativeness of the

composition of the pharmacists who have agreed to participate in the present study.









The gender data in the far right column of Table 1 indicate that a significant

majority of the nation's pharmacists are males (64.6%). An even greater majority are

White (82.6%). The age data suggest that U.S. pharmacists are largely middle-aged; more

than 60% are under the age of 50. Referring to the data on degree status, one sees that the

vast majority (86.2%) hold a Bachelor's of Science degree in pharmacy. Finally, note that

there is considerable diversity in the practice setting variable: almost one-third of all U.S

pharmacists are practicing in independent community pharmacies, another one-third are

practicing in chain retail settings, and just under one-quarter are practicing in hospital

settings.

On the whole, the information in Table I suggests there are significant differences

between the demographic makeup of this study's snowball sample of interviewees the

larger population of U.S. pharmacists. In particular, there are disproportionately larger

percentages of Whites and Males represented among the sample of recovering drug using

pharmacists. There are also less dramatic differences in the average age, degree status, and

job setting variables. These demographic disparities were expected. Since similar

demographic characteristics have been observed in each of the previous studies of

recovering pharmacists (Bissell et, al., 1989, Gallegos et al., 1988; Sheffield, 1992). The

details of this demographic profile is also supported by the existing apprehension and

treatment data (NARD, 1988, Penna & Williams, 1985). In short, all of the available

evidence suggests that recovering drug abusing pharmacists tend to be highly educated,

White, Males who are disproportionately in the 30- to 40-year-old range.

The reoccurrence of a similar demographic profile in different samples of

recovering pharmacists generates several sociological considerations. First, the presence of

disproportionate numbers of well educated pharmacists suggests that the educational









process may have some effect on their personal propensity to deviate. The existence of

large numbers of recovering pharmacists between the age of 30 and 40 presents yet

another consideration. In fact, 74% of the interviewees were between 30- and 50-years

old. Pharmacists in this age group would likely have attended pharmacy school during the

late 1960s and early 1970s. This era was marked by more permissive societal attitudes

toward experimentation with drugs, and more importantly, widespread recreational drug

use among young people. Numerous comments to this effect were offered by the 50

recovering pharmacists that I interviewed. Therefore, it is reasonable to suggest that these

more tolerant societal views also permeated the walls of pharmacy school and pharmacy

practice. Given what is known about the temporally progressive nature of drug abuse and

addiction, it is understandable why we are now beginning to notice the evidence of even

larger cohorts of drug abusing pharmacists


Drug Use Behaviors


Each of the 50 pharmacists that I interviewed spoke at length about the details of

their drug use histories. Their frank openness was undoubtably facilitated by the fact that

they were all members of some form of substance abuse support group. The vast majority

were actively involved in either Alcoholics Anonymous or Narcotics Anonymous. Having

experience with a support group meant that our interview conversation was not the first

time that they had recounted their problematic drug use past as it is commonplace for

substance abuse support groups to encourage individuals to "tell their story" to the other

members of the support group. Moreover, each individual indicated that their support

group involvements encouraged them to engage in a "substance use inventory" wherein

they documented the intricate details of their past drug use behaviors.







89

As expected, there were many unique aspects to each individual's drug abuse and

usage past. However, my thematic content analysis revealed several noticeable trends and

patterns. These trends will be summarized below. In particular, I will focus my discussion

on the following substantive topical areas: the nature and extent of drug use, drug

procurement, and how and where the drugs were used.

Nature and Extent of Drug Use

Each individual's past was marked by an extensive drug addiction history. All 50

individuals recounted daily drug use. They all showed clear signs of being chemically

dependent on one or more prescription drugs. The constant presence or threat of physical

withdrawal was the most obvious indicator of chemical dependency. Most individuals

described progressive drug use situations wherein even short periods of abstinence would

lead to withdrawal. For example, one 39-year-old male pharmacist said,

Two years before I sobered up I was really reaching my bottom. I would
chase these delivery trucks down in the morning, because I didn't come to
my store until mid afternoon. 1 was in withdrawal in the morning, and I was
without drugs, so I had to have it, I was just going nuts. Many mornings I
had gone to work sweating. It would be 30 degrees, it would be January,
and the clerk would say, you look sick, and I would say, it's the flu.

Almost all of the respondents spoke about a conscious or unconscious recognition

of their chemical dependency, especially the coinciding threat of physical withdrawal. To

counter this threat, most of the pharmacists maintained a near perpetual state of chemical

intoxication. That is, they generally designed a tightly structured and continuous drug use

pattern to avoid physical withdrawal. This trend is demonstrated in the following comment

made by a 38-year-old female pharmacist.

During the last 4 years of my use I used every single day. Day in and day
out, all the time to try to stay out of withdrawal and just maintain.









Many individuals described how they had progressed to dosage intervals of an hour or

less. One 45-year-old male pharmacist said,

It was just crazy.. I just kept taking more and more stuff because I
loved it .... Percosets [narcotic analgesic], you know. CIIs, it was
unbelievable. And I would be popping these things and 30 minutes later I'd
have to pop some more. It just really snowballed fast on me until I wasn't
knowing what I was doing. ... Oh gosh, I was probably doing 20 Percoset
a day at work.

Only 10 of the 50 interviewees described a drug habit that focused on a single type

or class of prescription medication Three of these individuals engaged in heavy, daily

use of cocaine (up to 5 grams per day). The other eight individuals claimed that their drug

habit was exclusively focused on narcotic analgesics.'

The remaining 40 respondents can be described as "poly-drug users."' Their daily

drug use behaviors included multiple types and classes of controlled substances.

Thirty-two of these 40 poly-drug users were regularly using at least one type of narcotic

analgesic. However, their narcotic analgesics habit usually coincided with the use of some

other class of prescription medication such as amphetamines (e.g., Dexedrine, Ritalin),

barbiturates (e.g., Seconal, Phenobarbital) or benzodiazepines (e.g., Valium, Xanax). As a

45-year-old male pharmacist explained

I was taking amphetamines, not necessarily every day but occasionally.
The opiates [narcotic analgesics] I was taking every day. And the
benzodiazepines I was taking sporadically ... daily. So, it was mainly
opiates.

Note that many of the interviewees chose to mix alcohol with prescription

medications. In fact, a considerable number of the respondents described daily or weekly

drinking habits. Most of the drinking can be described as binge drinking behavior wherein

the individual drank high volume over a short period of time.




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