Chemical dependency in anesthesia personnel

Published on 07/02/2015 by admin

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Last modified 22/04/2025

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Chemical dependency in anesthesia personnel

Keith H. Berge, MD

Chemical dependence is a devastating disease that must be recognized before it can be treated. In most cases, the addict is the last to acknowledge the problem. Thus, it is imperative that we—the friends, colleagues, and relatives of the addict—gain a clear understanding of the disease before we are confronted with it.

Chemical dependency, especially opioid addiction, is an occupational hazard for anesthesia providers. We have access to highly potent synthetic opiates in anesthesia practice and work in a stressful environment. Opioid abuse in anesthesia personnel typically occurs in the workplace; independent of the geographic location in which the abuse takes place, there are many tragic reports of anesthesia providers suffering severe illness (e.g., anoxic encephalopathy) or even fatality from an overdose of self-administered opioids.

Although anesthesia providers are at risk of becoming addicted to the same licit (e.g., ethanol) and illicit drugs (e.g., cocaine) as society at large, the “drug of choice” for anesthesia providers undergoing rehabilitation for chemical abuse is typically fentanyl or sufentanil, although ethanol, propofol, marijuana, and cocaine remain common drugs of abuse. Of 45,581 residents entering the American Board of Anesthesiologists certification process in the years 1975-2009, 384 were confirmed to have developed a substance use disorder (SUD) while in residency, for an overall rate of 2.16 per 1000 resident years. Of those, 26 died in training and 2 died shortly after completing residency, all of SUD-related causes. Despite efforts to educate residents on the dangers posed by SUD, the incidence is increasing.

Fentanyl, available as a street drug, is considered by addiction medicine specialists to have an addictive potential similar to that of “crack” cocaine. It carries the risk of extremely rapid addiction (Figure 254-1). This rapid effect is in contrast with that of ethanol or even other opioids, such as morphine or meperidine, for which a longer period of abuse is typically required before psychological and physical addiction occur.

Figure 254-1 Time course of addiction. Dependence on alcohol develops over years, whereas sufentanil or fentanyl addiction develops quickly after a very short period of abuse. (From Arnold WP III. Environmental safety including chemical dependency. In: Miller RD, ed. Anesthesia. 5th ed. Philadelphia, Churchill Livingstone, 2000:2701-2717.)

Recognizing impairment in a colleague

Chemical dependency threatens the career and, possibly, the life of an impaired colleague and the lives of patients under his or her care. Therefore, it is imperative that telltale signs of addiction be recognized and treated, not ignored (Box 254-1). These signs, typically subtle, may not be apparent in the workplace until the addictive illness is relatively far advanced. Instead, the afflicted individual may appear to function well in the workplace while his or her family life and social functioning may be in a state of chaos. In the case of opioid addiction, this behavior may be an attempt to preserve both career and access to the needed drug. It is interesting to note that, although the incidence of opioid abuse by anesthesia providers, even while on duty, is known to occur with distressing frequency, documented harm to patients by impaired caregivers is rare.

Intervention

Confronting an impaired colleague is extremely stressful and unpleasant. The intervention process is greatly facilitated if a departmental policy is in place outlining procedures to follow regarding intervention, evaluation, and the option of reentry into the workplace after treatment. If sufficient evidence exists to suggest that a colleague is indeed chemically impaired or addicted, it is imperative that a qualified addiction medicine specialist evaluate this physician. Because denial is a hallmark of addiction, those responsible for the intervention should not attempt to judge the presence or absence of addiction by the response of the colleague suspected of having the addiction. Rather, the purpose of the session should simply be to notify the colleague that she or he must submit to an evaluation by a qualified specialist. Prior arrangements should be made to facilitate immediate evaluation, and the colleague should be physically escorted to the evaluation, with the escort recognizing the potential for the colleague to harm herself or himself. If reasonable suspicion exists that a person is chemically dependent, then an evaluation can be demanded. It is not necessary to achieve the higher legal standard of clear and convincing evidence.

Risk of relapse

Although the potential for long-term recovery from addiction to ethanol or benzodiazepines has been reported to be good, the risk of relapse into abuse is high for the opioid-addicted physician in recovery. The rate of relapse into opioid abuse has been reported to be between 14% and 70%. In the most recent study, there was an estimated 43% relapse rate predicted over the span of a 30-year career. Relapse rates remain high despite improved treatment, aftercare, and monitoring. Of those who relapsed, death was their initial manifestation of relapse in 13%. Unfortunately, no similar published data exist defining the incidence of SUD or the relapse rate in nurse anesthesia personnel. Due to the high risk of relapse, and the severe consequences that may result, reentry of an anesthesiologist in recovery from opioid abuse into the clinical practice of anesthesiology is controversial. If reentry is undertaken, it is typically associated with an intensive aftercare program mandated by each state. Components of this program usually include random drug screening; active participation in support groups, such as Alcoholics Anonymous or NarcAnon; and prolonged witnessed use of antagonists, such as naltrexone, for those with a history of opioid abuse, or disulfiram, for those with a history of ethanol abuse.

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