May 2001
Volume 65 |
Number 5
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| Chemical
Dependence in Anesthesiologists: What Is Being Done About
It? |
William
P. Arnold III, M.D., Chair
Task Force on Chemical Dependence of the Committee on Occupational
Health
On a rather fateful day in 1983, an extremely bright resident
came to me saying, Bill, I'm in trouble I'm addicted to fentanyl.
In an attempt to hide my astonishment, I responded, So what are
you going to do about it? He had already arranged for admission
to a fine treatment program, where he remained for four months
before beginning his life of aftercare, in addition to continuing
his career as an anesthesiologist. Although he has abstained from
drug use for nearly two decades, relapse remains a constant threat
for him as it does for all individuals in recovery.
That single experience served as a stimulus for me to gain insight
into his misfortune. Over time, I have learned that while an understanding
of the disease of addiction makes it possible for one to deal
positively with an ill colleague, it is extremely difficult to
prevent the disease from becoming manifest should an individual
possess the roots that foster its development. Today, as it has
for centuries, addiction parallels diseases such as malignancies,
diabetes and a host of other sicknesses that are treatable but
incurable.
In spite of fairly aggressive attempts by ASA and many other
organizations to deal with the disease, it continues to plague
anesthesiologists, primarily those in the early portions of their
careers. Death as a result of drug overdose remains a tragic outcome
in a disproportionate number of cases involving anesthesiologists.
1 It is my purpose in this article to summarize
a variety of approaches being used to combat the disease.
Society of Academic Anesthesiology Chairs (SAAC) and Association
of Anesthesiology Program Directors (AAPD):
In 1988, SAAC/AAPD devoted a major portion of a meeting to a
series of presentations concerning chemical dependence in anesthesiologists.
Since then, the disease has been a topic for discussion at nearly
all its meetings. A major contribution was the funding of a videotape
titled Wearing Masks, a moving presentation by the widow and friends
of a resident in anesthesiology who died of an overdose of sufentanil.
This tape, produced in 1992, is shown regularly to residents in
anesthesiology as well as to their significant others. It can
be obtained by contacting the ASA Executive Office.
Accreditation Council for Graduate Medical Education (ACGME)
Since 1992, ACGME has mandated that all residency programs in
anesthesiology have a written policy for the management of chemical
dependence in trainees. In addition, each program’s educational
efforts must include presentations that address the disease as
it relates to practitioners of the specialty.
American Board of Anesthesiology (ABA)
ABA will permit persons with a history of chemical dependence,
who are satisfactorily recovering, to take both the written and
oral examinations. After a candidate with this history has satisfied
the requirements for certification, ABA will determine whether
it should defer awarding its certification for a period of time
in order to avoid certification of a candidate who poses a direct
threat to the health and safety of others. If it deems such deferral
appropriate, ABA will determine the length of time the candidate's
certification is deferred following an individual assessment of
the specific circumstances of the candidate’s history of alcohol
abuse or illegal use of drugs. This is in keeping with the intent
of the Americans with Disabilities Act.
Chief Residents’ Meetings
For several years (but ending in the mid-1990s), a pharmaceutical
manufacturer hosted an annual meeting for chief residents in anesthesiology.
Each meeting included presentations that focused on both the subjective
and objective aspects of chemical dependence. This educational
effort resulted in an awareness of the disease that has persisted
in many of the attendees. It fostered an understanding in these
persons that has facilitated assistance for addicted anesthesiologists
in the United States and several other countries. It also served
as groundwork for the formation of policies in many groups and
departments.
American Society of Anesthesiologists (ASA)
1. Since 1983, the Annual Meetings of ASA have included panels
and discussions on chemical dependence. Speakers have included
not only members of the Society who have an interest in the disease
but also experts in its treatment, persons in recovery, educators,
an advisor to the President of the United States and the father
of a resident who died of an overdose of fentanyl.
2. In a totally confidential manner, ASA has amassed 10 years
of data on incidence and outcomes of chemical dependence in residency
programs in the United States. Reviews of preliminary data have
appeared in the ASA NEWSLETTER. Until recently, the strict
confidentiality in which the data were collected and the departure
of a key individual in that confidentiality process had made detailed
analysis of the aggregate data difficult. Fortunately, that hurdle
has been overcome, and anonymity for departments and individuals
has been preserved. Publication of recent data will be forthcoming.
3. Since 1986, the ASA Committee on Occupational Health has published
three brochures on chemical dependence. The most recent edition,
published in 1998 and titled Chemical Dependence in Anesthesiologists:
What you need to know when you need to know it, has appeared both
in printed form and on the ASA Web Site at www.ASAhq.org/ProfInfo/chemical.html.
With appearance of the latter, the material covered in the brochure
has become available to a far greater audience than just the membership
of the Society. As a result, calls for information and assistance
are coming directly to the authors of the document from family
members and friends of anesthesiologists. This is particularly
heartening because were it not for the Web, most likely these
persons would have remained unaware of the Society's interest
in assisting its membership.
4. Since 1990, ASA has maintained a confidential hotline for
persons who have questions or concerns regarding chemical dependence
in themselves or others. Nearly 100 calls come annually either
through the hotline or directly to members of the Committee on
Occupational Health and its Task Force on Chemical Dependence.
Questions have addressed such aspects of the disease as assistance
with identification, intervention, referral for treatment, return
to the workplace, disability and many others. With the appearance
of the 1998 brochure on the Web, calls via the hotline have decreased
somewhat.
5. The Task Force on Chemical Dependence and the Committee on
Occupational Health are developing a curriculum on chemical dependence.
This effort, which so far has taken several years, is nearly finished.
When completed, the curriculum will be made available to SAAC/AAPD.
We anticipate that it will serve as a model for residency programs
to use in their training mandated by the Accreditation Council
for Graduate Medical Education.
In spite of these various efforts, the incidence of the disease
in anesthesiologists does not appear to have diminished significantly.
At first glance, that would seem to imply that the efforts are
ineffectual and perhaps should be abandoned. From a purely objective
viewpoint, this may be true. But from the perspective of the individual
or family member who has benefited from these services, those
previous efforts may have been life-saving. For that reason alone,
any diminution of these efforts would be a mistake.
Although education will not prevent the development of chemical
dependence, it will certainly increase awareness and thus promote
early identification and treatment. That conviction serves as
the basis for recommending that this work be continued.
Reference:
1. Alexander BH, Checkoway H, Nagahama SI, Domino
KB. Cause-specific mortality risks of anesthesiologists. Anesthesiology.
2000; 93:922-930.
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William P. Arnold
III, M.D., is Associate Professor of Anesthesiology, University
of Virginia Health System, Charlottesville, Virginia. |
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