Physician Drug Abuse - where is the grey line?

We had a great lecture yesterday about impaired physicians that abuse recreational drugs like alcohol, prescription painkillers, cocaine, etc. It was a pretty black and white conversation - doctors shouldn't be under the influence while practicing medicine. But the gray area grows when we get to other forms of drug abuse - what about people who use drugs as a supplement? Is it wrong for a med student to Adderall to study late into the night?

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Let me go on a 3 part sports sidenote - 

1) Lance Armstrong recently came out on Oprah to admit his doping status. What he did might have been cheating, but was it wrong?  Everyone else in the Tour was doing it. (New Yorker article about what Lance did wrong)

guilty until proven innocent

2) Baseball Hall of Fame voting came out this past week and ZERO people were enshrined this year because of steroid accusations.  This included players like Mike Piazza who were great home run hitters during the steroid era, but never tested positive for steroids.  First of all, is it fair to assume these guys are guilty by association? Second of all, is it our place to stop these guys from their pursuit of greatness?  If they understand the consequences of steroids, should we stop them from bulking up, getting big time contracts, and trying to become the best baseball player that they can be?

3) Take endurance running.  One form of training is running in the mountains where there's less oxygen.  By training at altitude you train your body to produce more red blood cells, which carry more oxygen, and make your running more efficient. You have to work harder at altitude - but you get more result out of it.  Nobody would call this extra advantage cheating.

Technology has figured out how to mimic this effect with altitude tents where you can sleep in a low oxygen environment.  Whether you sleep in a low oxygen tent or you train up in Wyoming, the way your body makes more red blood cells is by producing more of a molecule called EPO.  Should sleeping in these tents be allowed?

Endurance athletes have also learned that you can inject yourself with a synthetic EPO solution to induce this RBC producing effect. Injecting EPO isn't allowed, but altitude tents are, even though neither of them require any extra work.

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Anyways, back to medicine: On an average day I have green tea in the morning. In the afternoon I have coffee around 12 or 1 PM to avoid the post-lunch coma. If I go past 2 PM without that delicious coffee, I'm hitting a wall and getting pissed off. Once I get that caffeine influx, I'm in a great mood and it's easily the most productive hour of my day.  

So if I can drink coffee to help me study, is it wrong to use ADD medication as a studying crutch?  Nobody has ever offered me Ritalin or Adderall, but if someone offered it to me.. what would I say?  Honestly.. I might consider it.  I could study more in less time. I could have more time and energy left to be a good husband. Not to mention I would be learning medicine better, and I would become a better doctor, so I would be saving lives, right?  

What if I thought I could get diagnosed with ADD and pick up some prescription fully legal Adderall?  

What if a surgeon decided to self-medicate to be especially focused for a tough case at the end of a long night?  What if he was doing heart surgery on your kid? 

..where do we draw the grey line?

See you on the other side,

from ken

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