May 2001
Volume 65 |
Number 5
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| Chemical
Dependency in Anesthesiologists |
Daniel
H. Angres, M.D.
Chemical dependency is a disease process that can affect all
professions. Although a great deal of progress has been made in
terms of understanding chemical dependency as a disease, there
remains considerable misinformation and bias both in the general
population and among health care professionals. This article will
outline factors in physician impairment, intervention, assessment
and treatment modalities. Also, outcome data will be reviewed
from our experience at Rush Behavioral Health Center in Downers
Grove, Illinois, as well as some comments specifically regarding
prevention and detection of chemically dependent anesthesiologists.
Factors in Physician Impairment
A. Physicians as a group lean toward compulsivity and perfectionism.1
Physicians often see themselves as healers and authority figures
and can have some limitation for introspection and often use
their profession to defend against feeling. Anesthesiologists
in particular occupy a position that places them in control
of the multiple life functions of their patients. Being in this
role on a day-by-day basis can make it more difficult for anesthesiologists
to look at their own vulnerabilities.
B. Physicians attempt to diagnose themselves – but too
often incorrectly. Traditionally, physicians have been known
to attempt to save time and money by self-diagnosing and self-treating
various illnesses. 2 This can be as innocent
as attempting to diagnose and treat a minor illness such as
an upper respiratory infection, but also can extend to even
more significant illnesses. The mindset of attempting to diagnose
and treat oneself or get curbside help from professional peers
can lead to more serious issues; it can lead to self-prescribing
or obtaining mood-altering, addictive substances such as narcotics
to self-medicate. As stated before, this may start out innocently
to conserve time and energy, for instance. If someone is predisposed
to the disease of addiction, however, such behavior often leads
to an accelerated process of dependency.
C. Physicians can be extremely defensive about interventions
that may pose a threat to their license or ability to practice
medicine. Physicians have put in many years of hard work and
have made multiple sacrifices in order to become licensed practitioners.
Chemically dependent physicians are typically fearful of the
repercussions on their practice and even licensure status if
their chemical dependency becomes known. Peers often protect
the chemically dependent physician for the same reasons. Today,
we have a lesser stigma in regard to chemical dependency and
greater acceptance on the part of hospital administrations,
medical staff and licensing boards recognizing chemical dependency
as a disease and subsequently supporting intervention, treatment
and re-entry.
D. Physicians have greater access to controlled substances.
Although there is an enormous availability of mood-altering
substances available to the general public, physicians have
additional access to samples and medications used in clinical
practice. This is of particular concern for anesthesiologists
who have a unique accessibility to extremely powerful and reinforcing
narcotics such as fentanyl and sufentanil. Such access to these
narcotics poses great risks to anesthesiologists.
E. Accountability is a major factor in physician chemical dependence
and impairment. The previously mentioned risk factors are of
critical importance, but accountability in regard to patient
care makes this a particularly sensitive issue. For the safety
of the chemically dependent physician, his or her family and
most certainly his or her patients, there needs to exist an
aggressive posture for prevention, detection, intervention,
treatment and re-entry.
Increased Need for Intensive, Specialized Treatment
Most physicians will benefit from specialized treatment involving
a program for chemical dependency that has expertise in treating
health care professionals. 3 Most specialized
programs recognize the need to remove the dependent physician
from work, particularly when the disease has shown itself in the
workplace. If there are comorbidity issues such as depression
or severe character disorder in addition to the chemical dependency,
there is an added risk and need for expertise in the treatment
program. If there exist high-risk situations such as in anesthesiology
or emergency medicine, the course and re-entry process is further
complicated. Length of stay and type of treatment also will be
determined by the dependent physician’s support systems. The presence
of significant family dysfunction might also determine type of
treatment and length of stay. Re-entry issues are paramount in
providing appropriate treatment to this population. Prognostic
indicators are important in determining the treatment of the health
care professional. Regarding re-entry, it is important to evaluate
the duration of the disease, type of drug used and the nature
of the practice setting.
Specialized Treatment
A. Phase I:
Specialized programs for physicians generally include a primary
treatment experience that lasts four to eight weeks. It includes
breaking through the denial process, expressing feelings and bonding
with peers in the therapeutic setting. Working toward recognition
of one’s consequences of chemical use and establishing a 12-step
(e.g., Alcoholics Anonymous) support foundation are also critical
during this phase. Exploration of one’s spirituality and intensive
family work need to occur during this primary phase.
B. Phase II:
This phase, also known as placement, can last anywhere from two
to six weeks. It is a phase where a patient who successfully has
completed Phase I is considered in a more senior role in the treatment
process. While continuing to work on his or her own issues, he
or she also provides a role model for new patients in treatment.
During this phase, the physician-patient can also undergo a mirroring
process that includes a recognition of personal dynamics through
interaction with new patients. During this phase, the physician-patient
also works with the staff in examining work-related stresses and
triggers and develops a relapse prevention plan. Re-entry plans
begin to formulate during this time, and the physician-patient
receives a clear-cut written aftercare plan (the Caduceus Contract,
for instance).
C. Phase III:
This phase consists of the aftercare monitoring, which in most
specialized programs is a minimum of 20 months following treatment.
This phase includes weekly Caduceus support groups and individual
follow-up visits with one’s primary physician. It also includes
urine monitoring and 12-step participation. At this stage, there
is an emphasis on coordination with state physician assistance
programs as well as hospital wellness committees. Pharmaceutical
adjuncts in aftercare, such as the use of naltrexone, are often
part of the plan, particularly when dealing with anesthesiologists.
Although the average contract for specialized programs involves
a 20-month minimum in aftercare, state physician assistance programs
average a five-year duration. This time period includes the continuation
of behavioral and urine monitoring.
A physician's involvement with the peer group and other physicians
is critical at this time. Having enough time in treatment to go
through the necessary phases, including acceptance of the disease,
are all critical in this specialized process. Emphasis on a 12-step
recovery has been noted as a critical aspect of recovery from
chemical dependency, for health care professionals and all members
of society.
Outcome Measures
Several outcome studies have been noted regarding chemically
dependent physicians.6 The following trends have
been noted in Rush Behavioral Health studies, including a seven-year
outcomes study completed between 1985-92. 7
A. Eighty percent of the 100 physicians in the study who completed
treatment and committed to aftercare stayed abstinent for a
period of two or more years.
B. Risk of relapse was greatest in the first year and decreased
as time in recovery increased.
C. Fifty percent of the relapse group had limited slips and
went on to have two or more years of total abstinence.
Relapse Risk Factors
The Rush Behavioral Health study also noted some specific relapse
risk factors among health care professionals in general.
A. Anesthesiologists addicted to fentanyl were at higher risk
if they stayed in anesthesiology.
B. A dual-diagnosis patient is at the greatest overall risk.
Comorbidity of either an Axis I or Axis II type (such as a major
depressive disorder and/or significant character pathology)
were over-represented in the relapse group.
C. Narcissistic personality disorder was a major risk factor
as were personality disorders overall.
Detection
Anesthesiologists have some additional risk factors compared
with physicians in general. There needs to be particular emphasis
on detection of the use of substances among anesthesiologists.
A. Urine and body fluid screening: It has been an area of debate
as to whether all health care professionals should undergo random
urine and/or body fluid screening for mood-altering, addictive
substances. Considering the risks inherent in anesthesiology,
a case could be made for random urine and/or body fluid screening
for all anesthesiologists in training and post-training. Although
controversial, this would certainly lead to an earlier detection
of chemical use problems and make for a safer work environment.
B. Surveillance: Most operating rooms already have some surveillance
capacity. It would be conceivable to implement even greater
surveillance of anesthesiologists during procedures. Again,
also controversial, appropriate surveillance could minimize
the ability of diverting narcotics and provide a visual tracking
method. This could be protective for anesthesiologists who are
not diverting substances and provide detection for those who
are.
C. Analyzing wastage: This is a standard procedure in most
operating rooms. One of the most frequent means of diverting
narcotics in the operating room by anesthesiologists and other
health care staff is taking wasted narcotics for one’s own use.
The appropriate measuring and analyzing of all wastage certainly
reduces diversion of substances and can increase detection capacity.
Ideally, the wasting of narcotics should be a formally observed
process.
Risk Reduction
Currently, there are a number of strategies used to reduce the
risk of diverting substances by anesthesiologists.
A. Chain of custody: Having a solid chain of custody is critical
in risk reduction. Many operating rooms have an internal pharmacy
that checks out narcotics. It is difficult, however, for many
reasons to have a foolproof chain of custody in regard to an
analysis of wastage and narcotic use. Typically, a certain amount
of narcotic is dispensed to anesthesiologists in the beginning
of the day, with some room for variation for the various cases
with which they will be involved. To have a strict and exact
determination of what is needed, what is used and what is returned
will only reduce the risk of diversion of controlled substances.
This involves extra work and cooperation between pharmacists,
anesthesiologists and operating room personnel.
B. Electronic dispensing: As technology improves, the possibility
of electronic narcotic dispensing may become more feasible.
Such a device might prevent intraoperative diversion of narcotics
by using a portable system that could include the ability to
record timing and dose of narcotic delivery and perhaps double
as an infusion pump. This device might also function as a locked
electronic syringe.
C. Locked narcotics: One of the greatest risks to anesthesiologists
in the operating room involves unsupervised narcotics in the
workspace. It is not uncommon for these narcotics to be laying
around an anesthesiologist’s workspace between cases. This makes
for easy access to narcotics for anesthesiologists and anyone
else working in an operating room setting. There has been and
needs to be continued emphasis on making sure narcotics are
appropriately stored and locked, and used only by appropriate
personnel.
Despite increased risks, there are still outstanding outcomes
when the chemically dependent physician is appropriately intervened
upon, treated and re-entered into his or her profession. Efforts
to enhance detection and reduce risk need to continue on a consistent
basis.
References:
1. Gabbard GO. The role of compulsiveness in
the normal physician. JAMA. 1985; 254(20):2926-2929.
2. Robinowitz CB. The physician as a patient.
In: Scheiber SC, Doyle BB, eds. The Impaired Physician. New York:
Plenum Medical Book Co.; 1983.
3. Talbott G. Elements of the impaired physician
program. J Med Assoc Ga. 1984; 73(11):749-751.
4. Smith PC, Smith JD. Treatment outcomes of
impaired physicians in Oklahoma. J Okla State Med Assoc. 1991;
84(12):599-603.
5. Porter T, Talbott GD, Irons R. Addiction treatment
outcomes: A seven-year follow-up study; 1994 (Unpublished manuscript).
6. Reading EG. Nine years’ experience with chemically
dependent physicians: The New Jersey experience. Md Med J. 1992;
41(4):325-329.
7. Angres DH, Talbott GD, Bettinardi-Angres K.
Healing the Healer: The Addicted Physician. Madison, CT: Psychosocial
Press. 1998:34-42.
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Daniel
H. Angres, M.D., is Director, Rush Behavioral Health Center,
Downers Grove, Illinois. He is also Chair, Section on Addiction
Medicine and Assistant Professor of Psychiatry, Rush-Presbyterian-St.
Luke's Medical Center, Chicago, Illinois. |
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