Anesthesia and Drug Abuse
Alex Roher
4/20/08
Dr. Charleton

Physicians, like the general public, are believed to have a 10 to 15% addiction rate. Amongst physicians, however, anesthesiologist have a disproportionately high drug addiction prevalence. Despite constituting less than 4% of the United States physician population, anesthesiologist make up 13% of physicians treated for chemical dependency, three times higher than any other medical field. So is substance abuse an occupational hazard and if so why?

The reason seems intuitive: anesthesiologist have often poorly regulated access to the most highly addictive prescription drugs, like opiates, benzodiazepines, barbiturates, and other hypnotic/sedative agents.

There is more to the explanation than just access, however. There are three leading models which attempt to explain the factors leading to addiction. The addictive disease model says addiction is a chronic, progressive, relapsing, incurable and potentially fatal condition that is mostly a consequence of genetic irregularities. The academic model says that it is the use of drugs that causes the body to adapt through physiological mechanisms such as tolerance, tissue dependence, withdrawal and psychic dependence. Finally, the behavioral and environmental model says that certain influences of one’s environment, including stress, abuse, anger and peer pressure can induce addiction. As Dr. David R. Gastfriend of Massachusetts General Hospital, Department of Psychiatry, Addiction Research Program explains:

Addiction is a disorder of the brain's reward system. Functional imaging shows the vulnerable circuitry for addiction originating in the paleocortex. Paradoxically, human kind's greatest adaptive advantage, the neocortex, responsible for the phenomenon of consciousness, is at best only minimally protected from addictive disease and may pose a hurdle for recovery. Unlike most medical disorders, additionally, a net effect of supraphysiologic reward, impaired inhibition, or both paradoxically leads the limbic drive system to reinforce exposure to the disease vector. This is in direct violation of the principle of survival of the species. In individuals with underlying vulnerabilities, limbic drive progressively recruits neocortical function to protect continued access to abused substances, the polar opposite of self-preservation. Thus, when physicians, who society selects for high-level cortical functioning, become addicted, they often manifest exceptionally rationalized denial and sophisticated resistance" (Talbott, 2929).

Thus, the combined effects of easy access, a stressful work environment, and intelligently-crafted rationalization in addition to curiosity about patient’s experiences with these substances, seems to account for the very high rate of addiction observed in the field.

The same trends are seen amongst anesthesia residents. One University of Georgia study, which followed residents for five years post-medical school graduation, found anesthesiology residents to suffer from the highest rate of substance abuse morbidity and mortality. Despite represented only 4.6% of the US resident physician population, anesthesiologists made up 33.7% of all residents presenting to the Medical Association of Georgia's Impaired Physician Program.

A recent study conducted by the American Society of Anesthesiology’s Committee of Occupational Health revealed the following characteristics associated with addiction within the field.

• 50% are less than 35 years old
• Residents are over-represented
• 67-88% are male
• 75-96% are white
• 33% have a known family history of addictive disease (most frequently alcohol)
• 65% of anesthesiologists (combined resident and attending physicians) with a documented history of addiction are associated with academic departments

Traditionally, opioids are the drugs of choice with fentanyl and sufentanil being the most common followed by merperidine then morphine. This choice is particularly evident
in anesthesiologists less than 35 years of age. Alcohol is seen as the abused substance of choice primarily in older anesthesiologists, as time to produce impairment is believed to be after a significantly longer period of time with alcohol than with opiate addiction (fentanyl, 6-12 months; sufentanil, 1-6 months; morphine > 1 year; merperidine > 1 year; and alcohol > 20 years, usually).

Other agents which have been abused include: cocaine, benzodiazepines (midazolam), and more recently propofol. Over the past five years, there has been a major switch to needle-less approaches for delivery of commonly abused agents. These approaches provide a cleaner alternative to the more traditional intravenous or intramuscular routes. Every possible route of administration has been tried and reported including unusual IV sites (hidden veins in feet, groin, thighs, penis), oral/nasal administration (particularly benzodiazepines), rectal and sublingual. The inhalation agents are now entering the abuse arena as well. Sevoflurane (most likely due to its physical characteristics) has been reported as the drug of choice among the inhalational agents. Regardless of the primary agent, after six months, there is an increasing incidence of poly-drug abuse among users.

Addicted anesthesiologists have developed numerous ways of obtaining his or her drug of choice. These methods include false recording of drug delivery, improper recording on the anesthesia record or keeping wastage. It is important to be weary/concerned of the faculty or resident who is too anxious to give breaks or volunteers to do every late case. One of the most frequently reported retrospective markers of addictive behavior is a desire to work overtime, particularly during periods when supervision may be reduced such as evening and weekends.

Other behaviors/trends to look out for include wide mood swings with periods of depression and periods of euphoria, anger and irritability and denial. symptoms at work are usually last to appear, following symptoms picked up at home and in the community, but physicians should keep a look out for the following often overlooked characteristics:

• Desire to work alone
• Refuse lunch relieve or breaks
• Frequently relieves others
• Volunteers for extra cases/call
• Frequent bathroom breaks
• Patients pain needs in the PACU are out of proportion to narcotic record
• Weight loss

Studies indicate highly structured monitoring and long term follow up were the most important determining factors of sustained abstinence. For this reason, in the 1970s Physician Health Programs or PHPs were created. These programs include a full continuum of care: longitudinal (1-5 year) management, contracting for treatment, mutual help group (i.e. Alcoholics Anonymous) participation, frequent assessment, random urine testing with observed micturition, hair testing for abused substances, and workplace surveillance. Referral is non-punitive and can be life saving. Additionally, most states have laws requiring that hospital medical staff members report any suspected addictive behavior. Failure to report may have significant consequences depending upon individual state statutes. Information on regional PHPs can be found at http://www.fsphp.org.

One source gave the following evidence-based advice when confronting a suspected drug abuser. Do not intervene on an individual basis. Instead, utilize the expertise of your hospital committee, or county/state medical society. Additionally, when the individual has been confronted and you are awaiting final dispensation, do not leave him/her alone as new identified addicted physicians are at an increased risk of suicide following the initial confrontation.

Admission to any alcohol or drug addiction treatment program is not itself a reportable event to state or national agencies. This issue can be dealt with as a medical leave of absence, so early detection will not only protect patients, but physicians as well.

Unfortunately, the relapse rate for anesthesiologists with a history of narcotic addiction is the highest amongst all physicians . This risk of relapse is greater in the first five years (14% per year) and decreases as time in recovery continues. The positive news is that 81% of anesthesiologists who complete treatment and commit to "aftercare" remain abstinent for >2 years. However death remains the primary presenting symptom of relapse in opiate addicted anesthesiologists.

The Talbott Recovery Program in Atlanta, Georgia has developed the following re-entry recommendations following completion of an inpatient treatment program:

• Abstain from all mood-altering substances
• Select primary care physician who prescribes all medications
• Three to five-year monitoring period
• Attend a minimum of four self-help (AA/NA) group meetings per week
• Not handle narcotics for three months
• Supervised administration of naltrexone three times a week for at least six months
• Random, monitored urine drug screens
• Random testing of returned syringes for drug content

Residency programs have also reacted to this ongoing problem. The analysis of 183 responses to a survey of former anesthesiology residents of the Medical College of Wisconsin found that 29 had been self-administered problematic substance abusers during their residencies, 23 had been alcohol dependent, and 6 had been drug dependent. More than 85 percent of respondents considered the drug policy information available during their residencies inadequate As a result of this study and others like it, the number of hours set aside in residencies for formal education regarding drug addiction has increased in 47% of programs in the last three years. Within the same time period, 63% of surveyed programs had tightened their methods for dispensing, disposing of, or accounting for controlled substances. 80% of programs now compare controlled substances dispensed against individual provider usage. Thus, if one resident is using more anesthetic agents per patient than an institution’s accepted values, a formal investigation/confrontation may follow. Additionally, 8% of residencies now use random urine screening. If addiction during residency is detected, a 1989 study of residency program directors found that only 34% of intravenous opiate-abusers and 70% of non-opiate abusers were able to reenter and complete their training. A majority of those unable to finish their residency in anesthesia, successfully completing a residency in another field of medicine. Twenty-six deaths amongst drug addicted anesthesiology residence had been reported at the time of the study.

Anesthesia can be a very rewarding field, but a career in anesthesiology comes with a great deal of responsibility. Anesthesiologist have access to the most potent and highly addictive substances in modern medicine. Because of their high potency, even small volumes of unaccounted drugs are enough to give an individual a sense of euphoria and because of their highly addictive nature, very few exposures are needed to form a dependence. As someone who is about to embark on a career in anesthesia, I chose to write this paper on the effects of substance abuse on the field. As a result, I personally classify drug abuse as an occupational hazard, one with extremely serious consequences. Completing medical school during a period of time in which strong emphasis is placed on evidence-based medicine, I need only look at what the studies show:

• Despite constituting less than 4% of the US doctors, anesthesiologist make up 13% of physicians treated for chemical dependency
• Average length of time between use and discovery of use- fentanyl: 6-12 months; sufentanil: 1-6 months; morphine > 1 year; merperidine > 1 year; and alcohol > 20 years
• 50% of addicted anesthesiologists are less than 35 years old with resident over-representation
• The Medical College of Wisconsin resident survey
• 66% of intravenous opiate-abusers and 30% of non-opiate abusers were unable to reenter and complete their training in anesthesia
• Relapse rate of 14% per year

An understanding of why anesthesiologists become addicted, as well as the prevalence and consequences of addiction will prove to be a valuable resource in my career.

9. WORK CITED


1. Talbott GD, Gallegos KV, Wilson PO, Porter TL. The Medical Association of Georgia's impaired physicians program review of the first 1,000 physicians: Analysis of specialty. JAMA. 1987; 257:2927-2930.

2. Arnold, WP. 1995 substance abuse survey in anesthesiology training programs: A brief summary. ASA Newsl. 1995; 59(10):12-13,18. (Full report in preparation)

3. Alexander BH, Checkoway H, Nagahama SI, Domino KB. Cause-specific mortality risks of anesthesiologists. Anesthesiology. 2000; 93:922-930.

4. Menk EJ, Baumgarten RK, Kingsley CP, et al. Success of re-entry into anesthesiology training programs by residents with a history of substance abuse. JAMA. 1990; 263:3060-3062.