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May 2001
Volume 65 |
Number 5
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| Primary
Prevention for Anesthesiologists |
Richard
L. Brown, M.D.
Organized medicine has long appreciated the importance and impact
of physician impairment, including substance abuse and addiction.
The American Medical Association (AMA) advanced a definition of
physician impairment in 1972. 1 State licensure
boards discipline and withdraw licenses from impaired physicians
who threaten patient safety. Many state medical societies have
established physician health programs. These programs promote
early identification of impaired physicians, engage such physicians
in effective treatment and monitoring programs, protect patients
and help to preserve the careers of physicians who are engaged
in recovery.
Because of its traditional emphasis on diagnosis and treatment,
it is not surprising that organized medicine has not focused more
heavily on preventing physician substance abuse. Substance abuse
prevention is particularly relevant for anesthesiologists since
they suffer disproportionately from drug-related deaths and are
over-represented in substance abuse treatment programs for physicians.
2
Although detection, intervention and treatment programs are important,
programs that help anesthesiologists avert substance use disorders
would be a valuable contribution. Designing such programs will
be challenging, in part because there is little experience or
research on such programs for physicians. Rather than designing
such programs from scratch, it might be useful to consider the
growing research literature on the prevention of substance use
and related disorders for youth. Although some of the challenges
of substance abuse prevention would differ between these two populations,
lessons learned from youth prevention efforts may be useful to
consider in designing prevention efforts for anesthesiologists.
This article discusses classifications of prevention efforts,
possible systems levels to target, a framework for designing substance
abuse prevention programs and other suggestions.
A useful historical classification of prevention consists of
primary, secondary and tertiary preventions. Tertiary prevention
aims to ameliorate the effects of established disorders. Secondary
prevention involves early detection and treatment of disorders.
Primary prevention consists of efforts to prevent the onset of
disorders and substance use itself. Primary prevention is the
chief focus of this article.
Another way of classifying prevention efforts is by universal,
selective and indicated preventions. 3
Indicated prevention is aimed at individuals who have already
manifested signs and symptoms of an early disorder (e.g., the
aforementioned physician health programs). Universal preventions
are designed to reach the entire population; they may be useful
when entire populations are at risk, as anesthesiologists seem
to be. Selective prevention efforts are aimed at subpopulations
at special risk. Research is needed to identify whether certain
groups of anesthesiologists are at higher risk than others such
as: academic versus community-based, urban versus rural, male
versus female, and among various cultural groups.
Another useful distinction in substance abuse prevention has
been supply reduction versus demand reduction. Supply reduction
has included efforts to keep illicit drugs from being produced,
imported and distributed through such acts as interdiction and
strong criminal penalties. For health care professionals, especially
anesthesiologists who have access to addictive medications, analogous
efforts would include systems for preventing diversion and actions
on licensure. In general, supply reduction efforts have perhaps
increased the price of drugs but have not been sufficient to prevent
substance use and abuse in the face of continuing demand. We can
expect, similarly, that supply reduction efforts alone would not
curtail diversion and substance use by all anesthesiologists.
However, systems that make diversion more detectable and difficult
might help discourage potential first-time diverters.
Even if diversion could be curtailed, anesthesiologists would
continue to be at risk for use of, abuse of and addiction to alcohol
and street drugs. Demand reduction must therefore be an important
component of any substance abuse prevention plan for anesthesiologists.
Demand reduction efforts are the focus of the remainder of this
article.
One scheme for considering methods of primary, universal or selective
prevention is the risk-resiliency model. 4,5
In this model, risk factors are identified, and interventions
are aimed at ameliorating such risk factors. A risk factor is
a characteristic that occurs more frequently among individuals
who will develop a disorder. In the risk-resiliency model, protective
factors are also identified and bolstered. A protective factor
is a characteristic that occurs more frequently among individuals
with risk factors who do not develop the disorder. Thus, a protective
factor is not simply a negative risk factor; it is an attribute
that mitigates risk. Protective factors promote resilience, i.e.,
a resistance to using substances and developing related disorders
despite the presence of risk factors.
Six systems levels have been identified as potential targets
for preventive interventions: 1) individuals, 2) families, 3)
peer groups, 4) work/school environments, 5) community environments
and 6) society at large. Risk and protective factors are present
at each of these systems levels. Research has begun to identify
some risk and protective factors for youth. Many of these research
results are controversial, as few long-term prospective studies
have been done, and randomized controlled trials on risk and protective
factors are nearly impossible to perform. Nevertheless, it is
worthwhile to consider some of the tentative conclusions about
risk and protective factors for youth, as there may be some analogous
factors for anesthesiologists. Such factors are shown in Table
1.
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Table 1:
Risk and Protective Factors for Substance Use Disorders
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| Level |
Risk Factors |
Protective Factors |
| Individuals |
Genetic predisposition (positive family
history), psychiatric disorders, low perception of risk
of substance use, impulsiveness, hostility, rebelliousness,
deficits in social skills, aggression, alienation |
Strong social skills, caring and cooperative
nature, positive sense of self, problem-solving skills,
sense of humor, autonomy, sense of purpose, religiosity
or spirituality, skills to resist negative influences
by peers |
| Family |
Families with abuse or excessive conflict,
families with interpersonal distance or low support,
poor cooperative problem-solving, positive attitudes
toward substance use |
Positive bonding, lack of severe criticism,
trust, mutual and reasonably high expectations, clear
rules, mutual involvement in activities, involvement
in religious or spiritual groups |
| Peer Group |
Involvement with other individuals who
use alcohol and drugs or engage in other risky behaviors |
Involvement in activities not involving
substance use, good communication and support among
peers |
| Work/School |
A negative climate, low or overly high
expectations of employees/students |
A caring and supportive climate, appropriately
high and attainable expectations, clear standards and
rules, participation in important tasks and decisions |
| Communities |
Norms, customs and policies that permit
or promote substance use, extreme economic deprivation,
disorganization, alienation of individuals from their
cultures, pro-use messages in the media and advertising |
Caring and supportive climate, high expectations
for citizenship, opportunities for participation |
| Society |
Availability of substances, poor economic
conditions, unemployment, discrimination and marginalization |
Counter-advertising messages, enforcement
of relevent laws, restricted availability of and access
to substances |
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Prevention programs are designed to ameliorate risk factors and
bolster protective factors for the targeted individuals, groups
and institutions. In designing such programs, it is important
to consider cultural factors of the target group. Culture is defined
as the framework or filters through which groups of individuals
interpret all experience. Anesthesiologists are most familiar
with the culture of their profession and should therefore be integrally
involved in the design and implementation of prevention programs.
Strategies for prevention include information dissemination,
development of coping skills, provision of alternatives to substance
use, community development, advocacy for a healthy environment
and implementation of programs for early detection and intervention.
Experience with youth prevention has shown that information on
the risks and consequences of such use is insufficient as a single
prevention strategy. The most effective programs have employed
a combination of strategies and have targeted several levels.
A lack of resources for an ideal program, however, should not
deter initial efforts that can be built upon over time.
Steps for effective primary prevention programs include identifying
a target population (universal or selective), establishing a team
for design and implementation, identifying desired outcomes, designing
strategies and then implementing and evaluating the program. Evaluation
is essential to determine whether the program is achieving its
desired effect and how to improve programs over time. Thus, evaluation
planning should occur hand-in-hand with program design.
Possible targeted outcomes could relate directly to substance
use, abuse and addiction. Alternatively, programs could target
risk-factor reduction or protective-factor enhancement that, presumably,
will have desirable effects on substance use, abuse and addiction.
Outcomes can be related to any of the prevention levels. Although
it is difficult to prove that a program has had impact on changes
in policy or laws, such changes are among the most effective measures
in preventing substance use and abuse.
In summary, anesthesiologists are at a special risk for substance
use disorders. Anesthesiologists are challenged to protect themselves
and their patients with not only early detection and intervention
programs but with primary prevention efforts. Anesthesiologists
themselves are the key to designing effective prevention because
they are intimately knowledgeable about the culture of their profession.
Although research on youth prevention has many gaps, the framework
and results of such research can help to guide initial efforts
to prevent substance abuse and addiction among anesthesiologists.
Such efforts would not only help fellow anesthesiologists but
would also serve as a model for other physician and health professional
groups, all of whom are affected by substance abuse and addiction.
References:
1. The sick physician: Impairment by psychiatric
disorders, including alcoholism and drug dependence. JAMA. 1973;
223(6):684-687.
2. Alexander BH, Checkoway H, Nagahama SI, Domino
KB. Cause-specific mortality risks of anesthesiologists. Anesthesiology.
2000; 93(4):922-930.
3. Mrazek PJ, Haggerty RJ, eds. Reducing Risks
for Mental Disorders: Frontiers for Preventive Intervention Research.
Committee on Prevention of Mental Disorders, Division of Biobehavioral
Sciences and Mental Disorders, Institute of Medicine. Washington,
DC: National Academy Press; 1994.
4. Hawkins JD, Catalano RF, Miller JY. Risk and
protective factors for alcohol and other drug problems in adolescence
and early adulthood: Implications for substance abuse prevention.
Psychol Bull. 1992; 112(1):64-105.
5. Marcus M. HRSA-AMERSA-SAMHSA/CSAT Interdisciplinary
Program to Improve Health Professional Education, Syllabus, Module
5. Providence, RI: Association for Medical Education and Research
in Substance Abuse; 2001.
Richard L. Brown, M.D., is Associate Professor, Department
of Family Medicine, University of Wisconsin-Madison Medical School,
Madison, Wisconsin.
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