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 health care 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 health care 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 health care 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%.
• Health care 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.