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Substance Use Disorder Among Anesthesia Providers
Last updated: 02/15/2023
Key Points
- As of 2009, the overall incidence of substance use disorder (SUD) in anesthesia residents is 2.87 (95%CI, 2.42-3.39) per 1000 resident years.1
- Over the past 40 years, the incidence of SUD in anesthesia care providers (ACPs) has been increasing.1
- Opioids remain the most commonly misused medication by ACPs, but propofol misuse is also common and increasing in incidence.2,3
- Anesthesia residents who develop SUD have a mortality rate of 7.9% (95% CI, 3.1 to 20.5).5
- ACP who successfully complete a structured recovery program may be allowed to return to the clinical practice of anesthesiology.6
- Current estimates for ACPs in recovery experiencing at least one relapse is over 40%.5
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.
References
- Warner DO, Berge K, Sun H, et al. Substance use disorder among anesthesiology residents, 1975-2009. JAMA. 2013;310(21):2289-96. Link
- Bryson EO. The opioid epidemic and the current prevalence of substance use disorder in anesthesiologists. Curr Opin Anaesthesiol. 2018;31(3):388-92. Link
- Taree A, Barnet G, Bryson EO, Barnet G. Poster Presentation. Propofol Misuse in Healthcare Professionals: A Scoping Review. New York Society of Anesthesiologists 75th annual Postgraduate Assembly, December 2021, New York, NY.
- Burnett G, Fry RA, Bryson EO. Emerging worldwide trends in substances diverted for personal non-medical use by anaesthetists. BJA Educ. 2020;20(4):114-19. Link
- Warner DO, Berge K, Sun H, et al. Risk and Outcomes of Substance Use Disorder among Anesthesiology Residents: A Matched Cohort Analysis. Anesthesiology. 2015;123(4):929-36. Link
- Bryson EO, Silverstein JH. Addiction and substance abuse in anesthesiology. Anesthesiology. 2008;109(5): 905-17. Link
- Samuelson ST, Bryson EO. The impaired anesthesiologist: what you should know about substance abuse. Can J Anaesth. 2017;64(2):219-35. Link
- Skipper GE. Anesthesiologists with substance use disorders: a 5-year outcome study from 16 state physician health programs. Anesth Analg 2009;109(3): 891-6. Link
Other References
- 1. American Society of Anesthesiologists. Resources From ASA Committees. Occupational Health and Wellness. SUD Resource Materials & Model Curriculum. Accessed February 21, 2023. Link
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