Substance Use Disorder Among Anesthesia Providers

Incidence and Prevalence

• Alcoholism and other forms of chemical impairment impact ACPs at rates similar to that of the general population.
• 12-16% of all healthcare professionals will misuse alcohol or drugs at some point during their career.⁴
  • 6-8% will meet the diagnostic criteria for substance use disorder.
  • Up to 14% will meet the criteria for alcohol use disorder.
  • Medical students misuse drugs and alcohol mostly for “recreational” purposes, but residents and attending physicians misuse drugs for performance enhancement and self-medication for pain, anxiety, or depression.
  • The incidence of opioid misuse in the general population and in anesthesia care providers has continued to increase since 2009.
  • Fentanyl and sufentanil are the most commonly abused opioids, followed by meperidine and morphine.
  • Opioid abuse is more commonly seen in anesthesiologists < 35 years of age, while alcohol abuse is more frequently detected in anesthesiologists who have been out of residency for more than 5 years.
• Propofol misuse is now common and increasing³
  • 5 published cases between 1990-1999
  • 32 published cases between 2000-2009
  • 51 published cases between 2010-2020
• In 88 reports of propofol diversion in the literature between 1990 and 2020:
  • Anesthesia care providers represented 68% of cases.
  • Death was the initial presentation in 51.5% of cases.

Risk Factors for Developing SUD

• Male sex: 2.68 (95%CI, 2.41-2.98) for men vs. 0.65 (95%CI, 0.44-0.93) for women per 1000 resident-years⁵
• Location of Medical School: Increased risk for residents who attended a medical school in the United States (odds ratio, 2.4; 95% CI, 1.6 to 3.7)⁵
• Age: SUD tends to present in younger residents, though some cases have presented > 5 years after completing residency.⁶
• Family history of substance misuse
• Co-existing psychiatric illnesses include:
  • Depression and bipolar disorder (with or without psychosis)
  • Attention-deficit hyperactivity disorder (ADHD)
  • Borderline personality disorder
  • Antisocial personality disorder
• Prior history of untreated substance misuse

Signs of Impairment

• Addicted anesthesia care providers may appear quite functional early in the course of the disease and often remain extraordinarily attentive at work.
• The following changes in behavior are frequently noted:⁷
  • withdrawal from family, friends, and leisure activities;
  • mood swings with periods of depression alternating with periods of euphoria;
  • increased episodes of anger, irritability, and hostility;
  • spending more time at work even when off duty;
  • volunteering for extra call;
  • refusing relief for lunch or coffee breaks;
  • requesting frequent bathroom breaks;
  • signing out increasing amounts of narcotics or quantities inappropriate for the given case, especially on a
  • Friday or before a vacation;
  • intoxication at social functions;
  • arrests for DUI or behavior while intoxicated;
  • weight loss and pale skin (late signs).
• The median time from first use to detection is 4 months for injectable opioids as tolerance develops rapidly.
  • Self-administration of a single injection of 1,000 micrograms of fentanyl may be required just to relieve the symptoms of withdrawal.

Intervention and Treatment Strategies

• If you suspect your colleague has a problem, do not confront the individual yourself.
  • Addicts have been known to commit suicide once they have been discovered.
• Immediately contact your supervisor or a member of your department’s wellness committee.
• Make sure the individual remains supervised and is in a safe place. The colleague should be physically escorted to the evaluation by a qualified individual.
• An intervention needs to take place and should be handled by trained individuals.
• Treatment begins with detoxification in an inpatient facility that specializes in the treatment of healthcare professionals. Currently, there are several specialized programs for medical personnel within the larger inpatient population.
  • Residential treatment may last anywhere from 2 months to a year or more.
  • The typical 28-day rehabilitation program does not work well for most APCs, and longer length of stay programs are recommended.
  • After inpatient treatment program, the ACP is discharged either to a halfway house or directly to the community.
• Most states allow healthcare professionals to return to work, provided ACPs in recovery remain under supervision that includes:
  • regular contact with a caseworker;
  • worksite observation;
  • random urine drug and alcohol screens.
• Monitoring contracts are usually a minimum of five years in length.
  • These contracts can increase recovery rates by 20- 30%.
• Healthcare professionals are typically highly motivated to complete the program and return to clinical practice.

Prognosis for Return to Work and Relapse Risk

• Returning to the practice of anesthesiology after treatment for SUD increases the chances that an individual will:⁵
  • fail to complete residency (odds ratio, 14.9; 95% CI, 9.0 to 24.6);
  • fail to become board certified (odds ratio, 10.4; 95% CI, 7.0 to 15.5);
  • fail to achieve subspecialty certification (odds ratio, 34.6; 95% CI,12.0 to 100.0).
• SUD is a chronic, relapsing disease. The chances that an individual in recovery will experience a relapse are high:^5,6
  • Estimate of survivors experiencing at least 1 relapse by 30 years after the initial episode is 43% (95%CI, 34%-51%).
  • Median time from initial SUD episode to the first relapse is 2.6 years (IQR, 0.8-8.3 years).
• When opioids are involved, relapse can be deadly. The first relapse may manifest as death in as many as 13-19% of cases.^5,6
• The current thought is that the decision to allow an individual to return to practice should be made on a case-by-case basis, regardless of the level of training.⁸

Testing Methodologies and Prevention

• Drug testing is performed either pre-employment, for-cause or randomly. This involves analyzing a biological sample such as urine or hair.
• Random drug screening remains a contentious issue, though it has been shown to demonstrate a positive deterrent effect in several organizations:
  • Every branch of the United States Military
  • Department of Transportation
  • Federal Transit Administration
  • Federal Aviation Administration
  • Federal Railroad Administration
• Very few nonmilitary programs use random screening. However, most require pre-employment drug screens and allow for-cause drug screening after a critical event or near-miss.
• Detection of diversion involves:
  • auditing anesthesia information management system data and automated dispenser transactions;
  • evaluation of use patterns suspicious for diversion;
  • investigating individual ACPs with high use of opiates or high wastage of controlled substances;
  • investigating transactions that occur on canceled cases, after case completion, or in a different location from the original case.
• Preventative measures can focus on:
  • early detection of afflicted colleagues;
  • educational videos that directly address the issue of substance abuse and anesthesia personnel;
  • educational programs for anesthesiology trainees.