Rev. Bras. Anestesiol. vol.67 número3

RevBrasAnestesiol.2017;67(3):227---230

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

www.sba.com.br

SPECIAL

ARTICLE

Chemical

dependence

in

anesthesiologists:

the

actuality

Dependência

química

em

anestesiologistas:

atualidade

Stuart

Brooker

,

Michael

Fitzsimons

,

Roger

Moore

,

Gastão

Duval

Neto

a_{EmoryUniversitySchoolofMedicine,Atlanta,USA} b_{ProfessionalWellbeingCommitteeWFSA,USA}

c_{HarvardUniversity,DepartmentofAnesthesia,Boston,USA}

d_{CommitteeofChemicalDependenceMassachusettsGeneralHospital,HarvardUniversity,Boston,USA} e_{PennMedicineUniversity,DepartmentofAnesthesia,Philadelphia,USA}

f_{OccupationalHealthCommitteeofBrazilianSocietyofAnesthesiology,USA}

Availableonline5April2017

Definition

of

chemical

dependence

Braindiseasecharacterized byneurobiological and behav-ioral disorders thatresult in compulsive use of drugs and intensedesiretoobtainthem.

Thesedisordersreflectneuro-adaptivechangesin trans-ductionandgeneticcodingafterthechronicuseofthedrug (alcohol,opioids,etc.).

Causes

of

chemical

dependence

The occurrenceofchemicaldependency,burnout and sui-cide are tragic late stage symptoms for an increasing numbers of physicians across the globe in every country evaluated. Though not alone in the medical community, anesthesiologists seem to be at increased risk for these problems comparedtoother physicians,especially chemi-caldependency.Thecauseforanesthesiologists’increased

∗_{Correspondingauthor.}

E-mail:gduval@terra.com.br(G.DuvalNeto).

riskdoesnothaveasinglesimpleanswerduetothe

combi-nationofmanyfactorsplayingimportantroles.However,the

tollthatchemicaldependencytakesprofessionallyand

eco-nomicallyontheanesthesiologist,aswellastheemotional

upheavalthatoccursforthephysiciansandtheirfamilies,

mandates thatour professionalsocieties look seriously at

allcausesofthisscourgeandwaysthatwecaneffectively

intervenetopreventand, when necessary,to treatthose

thatareaffected.TheProfessionalWellbeingCommitteeof

theWorldFederationofSocietiesofAnesthesiologistsisin

theforefront of this effort and has a free e-book that is

downloadableonitswebsiteinEnglish.Portuguese,Spanish

andChineselanguages.1

Animportant predisposingandnon-modifiable causeof

substance abuse is the individualgenetic make-up of the

anesthesiologist. Genetic variation may account for the

pre-selection of over 50% of anesthesiologists developing

substance abuse and dependency. A single exposure to

addictivesubstancesbyan anesthesiologistwithagenetic

predispositioncanlead todependency onthe drug.

How-ever,itmustbestressedthatgeneticpredispositionalone

is not the sole causative factor for developing addiction,

nor is it certain that those with a genetic predisposition

http://dx.doi.org/10.1016/j.bjane.2017.01.001

228 S.Brookeretal.

willbecomeaddicted.Manyenvironmentalfactorsalsoplay

a crucialrole, and that limits ourability tomake

defini-tive statements about the relative importance of genes

comparedtothepersonal experiencesinthe physicaland

psychosocial environment. A prime example of this

com-plexityis shown by an evaluation ofpsychological factors

thatcontributetothedevelopmentofsubstanceabuseand

addiction.Some50%ofphysiciansdependentondrugshave

personality disorders with the majority being depressed.

This observationhas ledtothe hypothesis that substance

abuseisnothingmorethanaformofself-medication.The

rolethatgenetics,asopposedtoenvironmentalfactors,play

inthedevelopmentofthesepersonalitydisordershasyetto

bedefined.2,3

Equallyimportant tothe genetics areprofessionaland

personal stress factors. There is a vicious cycle

encoun-teredinroutineanesthesiapracticethattendstoteardown

copingmechanismsandincreasethechancesthatan

anes-thesiologistmightturntomisuseofasubstanceinorderto

copewiththestresses.Thecycletypicallystartswith

emo-tionalandphysicalfatigue.The fatigueisaugmentedbya

disruptionofthenormalcircadianrhythm,whichseemsto

havebecome an integralpart of modernanesthesia

prac-tice.Fatigueleadstomedicalerrors,whichinturn,through

self-recriminationand/oramalpracticesuit,leadstostress,

emotional fatigue and burnout. Any one of these factors

canleadtoananesthesiologistlookingforawaytorelieve

stress. With the availability of drugs, one avenue that is

unfortunatelyselectedisdrugabuse,whichinturnleadstoa

spiralofaddiction.Theavailabilityofdrugsinroutine

anes-thesiapracticeandtheeaseindivertingthemforpersonal

usefacilitatesthisaddiction cycle. Therefore,the

combi-nation of geneticand environmental factors conspires to

increasetheriskforanesthesiologistsbecomingchemically

dependent.

Recognition

and

prevention

Manyassumethat healthcareproviderssee theeffects of

substanceusedisorders(SUD)onindividualsaswellas

soci-ety.Itis believedthat suchexposure servestodiscourage

theuseofsuchdrugs. Healthcareprovidersareinnoway

protectedfromsuchdiseases.Infacthealthcareproviders

haveaboutthesameincidenceasthegeneralpopulationbut

unlikethoseoutsideofmedicine,havethelivesofmembers

ofsocietyintheirhands.Traditionaleffortstocontainthese

diseasesinhealthcarepersonnelhavefocusedprimarilyon

self-reportingandeducation.Controlofsubstancesand

pro-grams designed for surveillance of transactions has been

enhancedorsowefeel.Manyprogramsarenowresorting

todrugscreeningpriortoemploymentfollowedbyrandom

testing.

Medicine is considereda self-selectednoble profession

whereindividualspolicenotonlytheircolleaguesbut

them-selves for incompetence or impairment.DesRoches etal.

providedastatementtophysiciansthat:‘‘Physiciansshould

report all instances of significantly impaired or

incompe-tentcolleaguestotheirprofessionalsociety,hospital,clinic

and/orrelevantauthority’’.4_{Althoughmorethanhalf(64%)}

agreed, one-third did not for reasons like the impression

thatotherswilltakecareoftheproblem,noactionwillbe

taken,fearofretribution,lackofknowledgeaboutonhow

toreport, and simplythat it is not ourresponsibility. We

cannotrelyuponself-regulation.

Education has traditionally relied upon presentations

to trainees early in their residency. Cautionary tales of

careersandliveslostisbelievedtobeastrongdeterrent.

Often these talks are‘‘one-and-done’’ with little

follow-up.Spousesthatmaybethefirsttoseechangesarerarely

invited. Booth et al. reported that despite increases in

educationaboutSUDoverthecourseoftheirstudy,the

inci-denceofSUDdidnotdecrease.5_{Moreandmoreregulatory}

trainingisimposedonphysicianseveryyear.Educationabout

SUD is likely relegatedtothe same dry importanceasan

annualupdateoftheelectronichealthrecord(EHR).

Surveillance of drug transactions via automated

dis-pensingmachines hasshown somepromise.Epstein etal.

performedaretrospectivereviewofdrugtransactionsfrom

individualsthathadbeenpreviouslydiscoveredtobe

divert-ingsubstances.6_{Factorsconsistentwithdiversionincluded}

transactionsafterdutyhoursaswellaswhenanindividual

obtainscontrolledsubstancesfromanautomateddispensing

systemawayfromtheirusualsiteofwork.Highwastageuse

orwastageofsubstancesdidnotcorrelate,nordid

transac-tionsoncanceledcases.Thepositiveaspectsofsurveillance

arethatonecanfollowtrendswithoutalertingthesubject

ofconcern.Surveillancethoughislaborintensiveandmayin

factresultinfalseaccusationsifoneindividualisdiverting

underanother’sname.Automateddispensingthoughisoften

accompaniedbythepracticeof‘‘witnessedwasting’’where

acontrolledsubstanceiswastedinalocationandtwo

indi-vidualsattestthatthesubstancehasbeen disposed.Many

feelthat thispracticemay facilitate diversion sincemost

narcoticsaswellassalineareclearliquidsand

indistinguish-able.

Diversionforpersonaluseisaconstantriskinmedicine.

Controlledreturnofsubstancewithsubsequent

concentra-tiontestingispracticedbymanyinstitutionstoassurethat

areturneddrugis notmerelyadilutesample of apotent

agent.1_{Thismethodmaydetecttheclinicianthatattempts}

tomaintaintheappearancetheirclinicaluseofsubstances

iswithinthesamerangeastheircolleagues.Itissomewhat

laborintensiveandchainofcustodymaynotbeassured.

Urinedrugscreeningisgrowingasameanstodeterand

detectthoseindividualsthatenterthepracticeofmedicine

with a SUD (pre-placement), prevent those that may be

contemplatinguse(random),anddeterminewhetherthose

whose behavior or performance does not meet

expecta-tionsareimpairedbydruguse.7_{Thepracticeisestablished}

and accepted in industries responsible for the safety

of the general public such as aviation and commercial

groundtransportation.Protocolsareestablishedunderthe

United StatesDepartment of Transportation (DOT).Costs,

fear of false positive results, and challenging logistics

have prevented many institutions from moving beyond

pre-placementtesting.Thosethathavecomprehensive

pro-gramsareforwardthinking.

Thelastbutmostconcerningpreventionmeasurethough

is the institution of policies that serve toostracize even

establishedclinicianswhodeveloponeofthespectrumsof

conditionsthatmakethefamilyofdiseasesofsubstanceuse

disorders.Thepracticeof‘‘one-strikeandyouareout’’may

Chemicaldependenceinanesthesiologists:theactuality 229

anesthesiaor select institutionsthat have more lax

prac-ticeswherecontrolisnotstrong.The majorriskthoughis

tocareforprovidersthathavecontributedtoourspecialty

yetdevelopaSUDduringpractice.Theseindividualmaybe

reluctanttoseekcareor supportfortheir owncondition.

Suchpolicies arecontrarytothepracticeof medicine. In

our zealto protectour patients we must avoid measures

thatarecontrarytoouroverallmission.

No single toll is or will ever be 100% effective in our

effortstodetectorpreventSUDamongourranks.Our

pro-grams must be multi-armed and include strong recurrent

education,vigoroussubstancecontrolandfrequent

transac-tionsurveillanceataminimumandprogramsareadvisedto

institutepre-placementurinedrugscreeningatleast.Lastly,

hospitalsareencouragedtodevelopculturesthatare

sym-pathetic totheplightof allindividuals inhealthcare that

sufferfromSUD.8,9

Treatment

and

re-entrance

AddictionhasbeenrecognizedasadiseasebytheAMAsince

1956,andsincethattimemedicaltreatmentprotocolshave

become increasingly sophisticated. Accordingly, effective

managementof theaddictedanesthesiaprovider depends

upontimelyrecognitionofimpairment/diversion,aplanned

intervention,andreferraltoafacilitywithspecificexpertise

in the treatment of impaired healthcareproviders. Initial

therapyconsistsofweekstomonthsofintensiveinpatient

treatmentandmustbefollowedbyabstinenceand

demon-stratedrecovery.Onlyafterthisprogramoccurscantherebe

anydiscussionofre-entrytothepracticeofanesthesiology.

Sinceself-reportingofdrugdiversionandabuseisrare,

it willfall tothe addictedprovider’speers and/or family

memberstoconsiderthepossibilityofimpairment.Obvious

signsmaynotbeinitiallyapparent.However,asthedisease

progressesandtheaddictionintensifies,behavioralchanges

willalmostcertainlybepresent. Thesemayormaynotbe

accompanied by irregularities in the controlledsubstance

records. Once a high index of suspicion exists, an

inter-ventionshouldbeconsideredwiththegoalofdirectingthe

impairedprovidertoaprearrangedtreatmentfacility.Plans

shouldbeinplacepriortoanyinterventiontoensurethat

thereisspaceavailableandthatthefacilityhasexperience

withthecareofaddictedanesthesiaproviders.

Thefirstphaseoftreatmentbeginswithanassessmentof

thescopeofthepatients’druguse.Inaddition,afull

psychi-atricexaminationshouldoccurtoassessforthepresenceof

anyaccompanyingmentalhealthdiagnosessuchas

depres-sion, anxiety, or personality disorder. Care should occur

underthedirectionofapsychiatristandshouldbeholistic,

aimingtoprovideacomprehensiveapproachtoallaspectsof

thepatient’shealth.Followingtheseinitialphasesof

treat-ment, intensiveinpatient care willcommence.Treatment

amongst a peer group of impaired health care providers

is an effective method of facilitating the breakdown of

the sophisticated denial mechanisms frequently

encoun-tered in this population. The goals of this treatment are

totalabstinencefromallmindormoodalteringsubstances

concurrentwiththedevelopmentofcopingmechanismsthat

willallowtheindividualtofunctioninsociety.Thisisa

signif-icantendeavor,andexplainsthelengthystayintreatment

typicalof recoveringhealth care professionals. After

dis-charge, long term follow-up is the norm, with weekly

professional’sgroupmeetings,regularattendanceat12step

meetingsorothersupportgroups,andfrequentmonitoring

viarandomurinedrugorhairscreening.

Theconceptofre-entrytoanesthesiologyishighly

con-troversial as earlier studies suggest a high relapse rate

accompaniedbysignificantmortality.Morerecentwork

indi-catesthatwithappropriatetreatment andfollow-up,five

years sobriety rates of 80% are attainable.8 _{This is the}

samerate asnon-anesthesiologist physicians andsuggests

that the current model of treatment for substance

abus-inghealthcareprovidersconsistingofspecializedlongterm

care,intensivefollow-up,andlengthymonitoringishighly

effective.9_{Consequently,individualsconsideringre-entryto}

the practice of anesthesiology will need to demonstrate

establishment of a robustand healthy recovery,and

doc-umentedsobrietyfora minimumof12 months.Anyother

psychiatric or medical diagnoses should be addressed as

well.Thedecisiontoallowanindividualtoreturnto

prac-tice must be made by the treating physician working in

concertwiththelocalphysician’shealthprogram(PHP)or

equivalent.10_{Dependingonthejurisdiction,theappropriate}

licensingboardsmayalsoneed tobeaware.The

prospec-tiveworkplacemustbesupportiveandwillingtodealwith

any restrictions on work hours and/or drug handling that

may accompany the return to work contract. These

con-tractstypicallystipulatea periodofat least fiveyearsof

randomurinedrugscreenmonitoringandwitnessed

admin-istrationoforalorinjectablenaloxone.Recentstudieshave

documentedtheefficacy of witnessednaltrexone therapy

forrecoveringopiateabusers.11 _{Itisnowcommonpractice}

toinsiston100%compliancewithinjectabledepot

naltrex-oneforopiateabusingAnesthesiologistspriortotheirreturn

toahighaccessenvironment.12,13

Withmoderntreatmentandfollow-upthereisreasonto

believethatsignificant proportionof Anesthesiaproviders

afflictedwithsubstanceusedisordersmaybeableto

reen-terthepracticeofAnesthesiology.Asthepreviousdiscussion

highlights,appropriatecandidates forreentry shouldhave

received adequate treatment, be enrolled in a Physician

Health Program with an aftercare contract, and will be

subjected to long term monitoring. If the individual is

notpreparedto abide bythese conditions,redirection to

anotherfieldshouldbeconsidered.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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