revention and treatment of chemical dependence among anesthesiologists continues to be a focus of concern and activity for ASA. For more than 40 years, ASA has been aggressively attacking this problem through research efforts, educational programs and political advocacy. ASA was instrumental in the development and implementation of the efficient gas scavenging and air recirculation systems that are now required at all anesthetizing locations. ASA advocated for educational reform that resulted in the current Accreditation Council for Graduate Medical Education requirement for annual education of residents in matters related to chemical dependency. Our Task Force on Chemical Dependence, composed of practicing anesthesiologists who also are experts in addiction medicine, is arguably the most visible and active such group among its peers from other specialty societies.

In spite of these and many other efforts by ASA as well as work by others in the field, chemical addiction remains a concern for members of our specialty. This concern was highlighted by a recent article in a popular magazine.¹ The article cited preliminary work that has appeared in a number of venues and has been used to make unsupported generalizations about the prevalence and etiology of addiction among anesthesiologists.

The work that was featured in the Men’s Health article was published in a series of abstracts^2,3 and journal articles.^4-6 Each of these publications contains the same two independent observations: 1) anesthesiologists are over-represented in the Florida Recovery Program (anesthesiologists are 25 percent of patients in the treatment program despite comprising only 5.6 percent of Florida physicians) and are frequently unable to return to clinical anesthesiology, and 2) very low concentrations of fentanyl are measurable in samples of patients’ exhaled breath, in the air around anesthesiologists’ work stations (specifically cardiac surgery rooms) and in the “effluvia” (sic) from the cardiopulmonary bypass machine.

Neither of these two findings is unique or surprising. Using data collected from treatment programs, many authors have reported an excess of chemical dependence in certain medical specialties, including anesthesiology. Whether this truly represents an increased incidence of the disease or simply an increase in reporting of the disease among anesthesiologists remains in question. Similarly there is extensive literature on the exposure of health care personnel to trace anesthetic gases. To date, there is no evidence of adverse health effects resulting from the low levels of exposure found in a modern adequately scavenged and ventilated operating room.

What is surprising is the attempt to link these two independent observations with the claim that exposure to the trace amount of ambient fentanyl in the workplace environment is the source of the excess prevalence of addiction among anesthesiologists. The authors’ hypothesis states that fentanyl given for surgical anesthesia enters the atmosphere as a result of leakage from intravenous injection sites, open ampules and from the patient’s exhaled breath. They then posit that anesthesiologists are more susceptible to opiate addiction because they become sensitized from chronic exposure to this ambient fentanyl in the operating room air. They conclude that fentanyl in the operating room air “can be expected… to change the brain, motivation and behavior” of an anesthesiologist⁵ and could result in “place preference, abstinence-like withdrawal dysphoria, and even an acquired drive for the drug.”³

In our opinion, there are several problems with the data used to draw these conclusions:

1. There is an incomplete description of the methodology by which air samples are collected in the operating room as well as the assay techniques used to detect the ambient fentanyl.

2. The concentration of ambient fentanyl is poorly quantitated. The only quantitative information is the comment in one article that fentanyl was found “in excess of 1 nanomole per liter.”⁴

3. There is no accounting for waste gas scavenging and air recirculation in the operating rooms, which would be expected to remove any trace narcotic vapors from the air.

4. The authors have not demonstrated that fentanyl in the air actually enters the bloodstream or brain of anesthesiologists.

5. There is no evidence presented that the exposure suggested by these studies changes the brain or learned behavior of anesthesiologists.

6. The data presented in the publications do not prove causality or even an association between this possible source of exposure to fentanyl and the disease of chemical dependence in anesthesiologists.

The hypothesis presented in the referenced articles is intriguing, but the conclusions are premature and not supported by data. Much more work remains to be done, and independent confirmation of the data is necessary to confirm or reject the hypothesis. We look forward to peer-reviewed publication of results to answer questions such as ours and those posted by other experts in the field.^7-9 Until more is known, the theory must be viewed with caution.

References:
1. McDougall CM. The junkie in the O.R. Men’s Health. 2006; 11:186-193.
2. Gold MS, Melker RJ, Pomm R, et al. Anesthesiologists are exposed to fentanyl in the operating room: Addiction may be due to sensitization. XXIVth CINP Congress. Paris, France, 2004.
3. Gold MS, Dennis DM, Morey TE, et al. Addiction: An occupational hazard for anesthesiologists. Anesthesiology. 2004; 101:A1323.
4. Gold MS, Dennis DM, Morey TE, Melker RJ. Exposure to narcotics in the operating room poses occupational hazard for anesthesiologists. Psychiatric Annals. 2004; 34:794-797.
5. Gold MS, Melker RJ, Dennis DM, et al. Fentanyl abuse and dependence: Further evidence for second-hand exposure hypothesis. J Addict Dis. 2006; 25:15-21.
6. McAuliffe PF, Gold MS, Bajpai L, et al. Second-hand exposure to aerosolized intravenous anesthetics propofol and fentanyl may cause sensitization and subsequent opiate addiction among anesthesiologists and surgeons. Med Hypotheses. 2006; 66:874-882.
7. Cohen PJ. Fentanyl abuse and dependence: Further evidence for second-hand exposure hypothesis. Comments by Peter J. Cohen. J Addict Dis. 2006; 25:135-136: discussion 41-44.
8. Denisco RA. Fentanyl abuse and dependence: Further evidence for second-hand exposure hypothesis. Comments by Richard A. Denisco. J Addict Dis. 2006; 25:137; discussion 41-44.
9. Gorman E. Fentanyl abuse and dependence: Further evidence for second-hand exposure hypothesis. Comments by Eugene Gorman. J Addict Dis. 2006; 25:139-140; discussion 41-44.

Susan L. Polk, M.D., M.S.Ed., is former Professor of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois. She is now retired.

Jonathan D. Katz, M.D., is Clinical Professor of Anesthesiology, Yale University School of Medicine and Attending Anesthesiologist, St. Vincent Medical Center, Bridgeport, Connecticut.

Arnold J. Berry, M.D., M.P.H., is Professor of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia.

Diana G. McGregor, M.B.B.S., F.R.C.A. is Clinical Associate Professor of Anesthesia, Stanford University, Stanford, California.

William P. Arnold III, M.D., is Associate Professor of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia.