May 2001
Volume 65 |
Number 5
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| Anesthesiologists:
Addicted to the Drugs They Administer |
Eric
B. Hedberg, M.D.
Many anesthesiology departments have experienced the trauma of
a member of its staff becoming addicted to an anesthetic drug.
Anesthesiology reportedly has a higher incidence of addiction
than any other medical specialty (Healing the Healer: The Addicted
Physician Angres DH, Talbott DG, Bettinardi-Angres K; 1998). This
most likely is due to the fact that anesthesiologists administer
highly addictive drugs, have greater access to controlled substances
and seem to have a greater curiosity about drug effects than other
physicians. Due to the increasing awareness of addiction symptoms,
anesthesiology departments are becoming leaders in identifying
impaired professionals and referring them to treatment. It would
be rare for a department to have a member of the anesthesia staff
who at some point will not need treatment for chemical dependency.
Anesthesiologists addicted to anesthetic drugs face different
challenges than other medical specialists. There are few medical
specialties that require physicians to personally administer intravenous
controlled substances. Additionally, few physicians handle drugs
with the addiction potential of fentanyl or sufentanil. Also,
opiate-addicted anesthesiologists face greater temptations than
most other specialists when they return to clinical anesthesiology.
For most physicians it is not difficult to create an aftercare
plan that eliminates the necessity of administering controlled
substances. In anesthesiology, however, it is impractical to attempt
to limit the use of regularly administered, controlled anesthetic
substances. Even if an anesthesiologist removes fentanyl from
his or her anesthesia technique, that person will continue to
be exposed to fentanyl while supervising or administering anesthesia.
Opiate-addicted anesthesiologists need more from their recovery
program than other recovering addicts.
In order to consider whether opiate-addicted anesthesiologists
should return to anesthesiology practice, it is imperative that
those anesthesiologists obtain adequate treatment. For opiate-addicted
anesthesiologists, I strongly recommend treatment at a facility
that specializes in health care professional addiction. During
treatment, the addicted anesthesiologist should be evaluated carefully
for the appropriateness of his or her return to clinical anesthesia.
At the Talbott Recovery Campus, Atlanta, Georgia, all anesthesia
personnel are admitted to my service due to my training in anesthesiology,
psychiatry and addiction medicine. From the beginning, I address
with the anesthesiologist the issue of returning to practice.
Patients are given a series of questions designed to allow them
to carefully examine their choice of medicine as a career and
anesthesia as a specialty. The assignment questions are as follows:
1. If you were a freshman in college and could choose any profession,
with the wisdom you now have, what profession(s) would you consider
pursuing?
2. If you could not re-enter the field of anesthesia, what
are the possibilities you would consider in clinical or nonclinical
medicine?
3. What are the positives and negatives for you in the practice
of anesthesia?
4. What is stressful to you in the practice of anesthesia?
5. The risk of relapse for opiate-addicted anesthesiologists
returning to the operating room is potentially high. There is
a high incidence of death among anesthesiologists who relapse.
Why would you want to put yourself and your patients at such
a risk?
6. By returning to anesthesia, you are going to put your family
and yourself through a lot of pain if you relapse. How does
your significant other feel about your return to anesthesia
and the risk you are taking?
7. What safeguards would you put in place to help prevent relapse?
While the patient is working on this assignment, the treatment
team is also carefully evaluating the anesthesiologist’s progress,
response to treatment, social support at home, professional support
at work and relative safety for returning to clinical anesthesia.
In the book Healing the Healer: The Addicted Physician, the authors
outlined guidelines to help evaluate anesthesiologists who may
desire to continue their career in anesthesia. In my work with
anesthesia personnel, I have modified their criteria slightly
to include some additional considerations. The categories based
on Healing the Healer are as follows:
I. Return after appropriate treatment (for health care professionals)
1. Accepts and understands disease of addiction
2. Bonding with AA/NA with active sponsorship
3. Good relapse prevention skills
4. Other psychiatric disorders in remission
5. Healthy family relationships
6. Balanced lifestyle
7. Anesthesia department supportive
8. Committed to five-year monitoring program
9. Confident to be in operating room, administer anesthetic
drugs and not relapse
10. All of the above required for immediate return to anesthesia
II. Possible return, with reassessment after one or two years
1. Incomplete bonding to AA/NA but improving
2. Some denial / minimizing
3. Lacks complete confidence to be in operating room and not
relapse to chemical use
4. Recovery skills improving
5. Brief relapse may have occurred
6. Other psychiatric disorders improving
7. Dysfunctional family members improving (may require therapy)
8. Healthy attraction to anesthesia
III. Never return to clinical anesthesiology (any of these
conditions)
1. Prolonged addiction history
2. Significant relapse despite adequate treatment
3. Lacks confidence to return to operating room and not self-administer
anesthetic drugs
4. Significant Axis I or II psychopathology
5. Inability to follow treatment and monitoring contract
6. Poor bonding to AA/NA and recovery skills
7. Significant family pathology
One of the most important factors to consider when assessing
the appropriateness for return to anesthesia is the physician’s
confidence to remain in recovery while working in the operating
room. There are many triggers and stressors present in the operating
room that make it impossible for some anesthesiologists with a
history of addiction to function in that setting. For some anesthesia
personnel, the external drug addiction cues present in the operating
room are overwhelming. Many anesthesiologists have severe autonomic
responses to the sights, smells and environment of the operating
room. Fentanyl ampules and the sight of other drugs can cause
debilitating cravings and obsessions that distract some anesthesiologists
from being able to concentrate on their jobs. Toward the end of
treatment at the Talbott Recovery Campus, we arrange for anesthesiologists
to visit an operating room to get a sense of how they may react
if they were to return to clinical anesthesia.
Some anesthesiologists have an intuitive sense that they cannot
be constantly exposed to their drug of choice and not eventually
relapse. Like other psychiatric or physical illnesses, there is
great variation among patients’ responses to their illness. Other
anesthesia personnel seem to have the ability to return to the
operating room and not experience disabling cravings and distractions.
These individuals are not only able to remain safe in their own
recovery but also provide anesthetics to their patients in a safe
and competent manner. In the experience of this author, about
half of the opiate-addicted anesthesiologists who have successfully
completed an extended treatment designed for health care professionals
meet the criteria for return to anesthesia.
Those who do meet these criteria and have returned to clinical
anesthesia have done well. Most of the anesthesiologists who were
not able to return to clinical anesthesia have returned to other
clinical or nonclinical medical careers. Many retrain in other
specialties that allow them to work with patients recovering from
addiction. A few anesthesiologists realize that they were not
well-suited for medicine at all and have pursued nonmedical careers
that they have found to be rewarding.
It is important to note that some anesthesiologists become addicted
to nonopiate anesthetic drugs such as propofol, midazolam, ketamine,
barbiturates and inhalation agents. Propofol is of particular
concern because it is not a scheduled drug. Although fentanyl
and sufentanil seem to have greater addictive properties, these
other addictions should follow the same type of evaluation process
to ensure the safety of the recovering addict and his or her patients.
It is my experience that a substantially high percentage of anesthesiologists
addicted to nonopiates are able to return to clinical anesthesia.
Addiction among anesthesiologists is a serious and, unfortunately,
common problem. ASA has become a leader in the education of its
members about the problem of addiction. Most anesthesia training
programs have a high level of commitment to educating residents
about addiction and consequently are better prepared to identify
impaired physicians than are many other fields of medicine. Most
state medical societies have excellent physician health programs
that refer addicted physicians to approved treatment facilities.
Physician health programs can be a wonderful help in obtaining
appropriate treatment and even more helpful with monitoring recovering
physicians after treatment. With appropriate treatment, careful
assessments and adequate post-treatment monitoring, many addicted
anesthesiologists can return to clinical anesthesia and practice
in a safe and competent manner.
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Curriculum on Substance Abuse Now
Available
Susan L. Polk, M.D.
Task Force on Chemical Dependence
of the Committee on Occupational Health
The Task Force on Chemical Dependence of the Committee
on Occupational Health has completed a model curriculum
on substance abuse meant for education of residents in anesthesiology.
The Model Curriculum on Drug Abuse and Addiction for Residents
in Anesthesiology is posted on the ASA Web site at www.ASAhq.org/ProfInfo/
curriculum.htm and will be made available to all residency
program directors through the Association of Anesthesiology
Program Directors/Society of Academic Anesthesiology Chairs.
The curriculum consists of objectives, an outline for subject
matter to be covered, an extensive reference list, suggestions
for three videotapes to supplement the program and several
questions to stimulate discussion among the learners.
The Committee on Occupational Health developed this model
curriculum in an effort to aid residency programs in meeting
the Residency Review Committee requirement for education
in substance abuse. Both the ASA-funded study in the early
1990s by William P. Arnold III, M.D., and the ASA-funded
mortality study by Karen B. Domino, M.D., published last
year in Anesthesiology, pointed out that the disease usually
occurs very early in the anesthesiologist’s career. Educating
residents may be an effective method for prevention of the
disease and, through heightened awareness, will hasten identification
and treatment of the victims of the disease.
Therefore, all ASA members are urged to review the document.
The curriculum covers etiology, identification, treatment,
return to work and briefly discusses stress management.
As new information and statistics become available, the
curriculum will be updated.
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Eric
B. Hedberg, M.D., is Associate Medical Director, Talbott Recovery
Campus, Atlanta, Georgia. |
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