Volume 6, No. 1 • Spring 1991

Substance Abuse in Anesthesia: Patient Safety Among Issues

Susan L. Polk, M.D.

The impaired anesthesia practitioner was the difficult topic addressed by a thoughtful, comprehensive workshop at the ASA Annual Meeting in October. The potentially very sensitive issue of patient safety implications of impaired anesthesia providers has been rarely addressed in the past.

This workshop, moderated by Dr. Philip Hanlon, Associate Professor of Anesthesiology at the University of South Alabama, began with a viewing of the newest ASA patient safety videotape, ” The Impaired Practitioner: What Do We Do Now?” This videotape was produced by the U.S. Food and Drug Administration under the auspices of the ASA Committee on Patient Safety and Risk Management and the ASA Committee on Occupational Health. Distribution is being funded by the Burroughs Wellcome Co. it will soon be distributed to all departments of anesthesia in hospitals with more than 100 beds.

The video is introduced by Dr. Jim Arens, and consists of dialog with Drs. Clarence Ward and John Lecky punctuated by vignettes illustrating the identification of, intervention with, and successful reentry of an anesthesiologist (who is not a resident). Dr. Arens states at the outset that the tape is designed to prepare us for a problem that might crop up in the future, since when confronted with the problem of a colleague suspected of drug abuse, we often are not able to discover and learn the proper procedure in time to intervene effectively. The fact that chemical dependency is a disease is stressed throughout the tape. The endpoint of successful intervention and treatment should always be the safety and well-being of both the colleague and his patients.

Vignettes demonstrate common signals that a colleague is impaired by his substance abuse, such as change in personality, in personal habits and demeanor, and in family and community life. Work habits may become sloppy, but usually the actual performance of the impaired physician’s job is the List aspect of his fife to deteriorate. The common ability to consume large doses of drugs and still perform his job lends the impaired anesthesiologist the feeling of being in control of his addiction.

Illustrations of a poorly executed and a property executed intervention were provided, with commentary indicating that intervention should never be attempted without planning, and never without the help of experts and family members. Intervention should stress concern for the well being of the anesthesiologist, his family, and his patients. Finally, intervention should be attempted only when solid arrangements have been finalized for the immediate entry of the anesthesiologist into an inpatient treatment program.

The components of a successful inpatient treatment program, generally taking at least 28 days, must include detoxification, a period of education to overcome the denial which is a hallmark symptom of addiction, and then behavior modification therapy to treat the disease, always including the physician’s family in the process.

Reentry into anesthesia practice must be planned to provide for monitoring to assure the continued abstinence from all mood-altering drugs as well as the continued safety and well being of the recovering anesthesiologist and his patients. The video presentation emphasized the question of whether reentry is appropriate for anesthesiologists, quoting a successful recovery rate of 60-80’/o for the total population of all physicians but admitting that good data are not available for anesthesiologists returning to the proverbial “candy store”. Questions cited at the end of the tape provided the grist for the rest of the workshop: What do you do when the recovered anesthesiologist suffers a relapse? When is a change of specialty in order? Who pays for treatment, recovery, and continued monitoring Is the recovering anesthesiologist able to obtain malpractice insurance? What is the liability of those who identify and intervene, as well as of the hospital and group, when the recovering anesthesiologist returns to practice?

What If You Are Mistaken?

Dr. Clarence E Ward addressed the risk of your liability should you attempt to intervene on a collegue when, in fact, he is not suffering from the disease of chemical dependency. It is not likely that you would come to this conclusion without irrefutable evidence, since it is the last diagnosis you would like to be making in your own colleague. It may be in some circumstances, though, that a secondary diagnosis such as a personality disorder might cloud your thinking about your colleague and allow you to operate with a feeling of malice. If you are certain that you have your colleagues and your patient’s safety paramount in your mind, and if the intervention is carried out in a closed forum, it is quite unlikely that a defamation case could be supported. It is also quite unlikely that your collegue would risk publicizing the case by suing you. Your liability is much more likely to be due to not taking action when your collegue and his patients are in jeopardy because of his disease.

Is Reentry Appropriate For Residents?

Two department chairmen, Drs. Ronald Miller (UCSF) and Thomas Hornbein (University of Washington) were to have supported opposite sides of this issue, but neither was comfortable doing so because of the lack of data. Both cited the findings of Dr. Emil Menk, which in a survey of program directors discovered a successful re-entry rate of only 34% of residents who abused narcotics, contrasted with a 70% success rate when the drugs of choice were not narcotics. A “slip” is not a minor event to be forgiven in this population. Dr. Miller reported that of the four residents in his own program who were treated for narcotic dependency in the years 1970-82, only one is still living and practicing anesthesiology. Since iw, three more residents were identified, one of whom died before treatment and two of whom were treated in inpatient programs, such as the one described in the videotape. Of those, one leftanesthesiology after two relapses and one finished residency but was lost to follow-up. Citing his dismal success rate, Dr. Miller opined that perhaps residents who abuse opioids should be counseled into another specialty since they have not yet made a large investment in their careers, and since there is a growing body of evidence that many of these chose anesthesiology specifically because of drug aside Furthermore, the apparent fatality raw of a “slip,” a relapse of opioid abuse, in the anesthesiology resident is 10-30%. Finally, residents who abuse opioids often do so while on call, and the impact on patient safety is too formidable to allow leniency about “slips.” It may be possible to restrict practice to exclude availability of narcotics for a while after reentry, but graduation from residency cannot be allowed when practice has been restricted for long.

Dr. Hornbein agreed with Dr. Miller, citing the responsibility of program directors to certify their graduates as competent and of department heads to ensure the safety of all patients under the care of members of their departments. His personal experience includes 12 residents, and his policy in the past was that everyone ” one chance to reenter but was not allowed to return if they had one relapse. More recently, Dr. Hornbein has used the continuation of denial on the part of the resident to indicate a high likelihood that reentry would meet with failure Admitting that there are no data as to whether outcome improves when recovering anesthesiologists return to another type of practice or when the anesthesiologist reports himself before his life and practice have seriously deteriorated, rather than requiring an external intervention, Dr. Hornbein leaned toward supporting the feeling that anesthesiology residents abusing opioids should not be allowed to resume their training in most cases. The Medical Society of New Jersey will no advocate for anesthesia residents in recovery to return to their programs, and will give practicing anesthesiologists only one chance at reentry into the specialty.

What Is Appropriate Treatment?

Dr. Neal Gray, an anesthesiologist practicing at the University of Tom at San Antonio and a certified Addictionologist, supported the opposite side of the question, citing his nine years experience with 600-700 chemically dependent physicians. He believes that anesthesiologists, even residents, can successfully reenter their field if & treatment and institutional policies covering reentry are appropriate for the disease. Over half of the physicians he has been involved with haw been in the top one-third of their classes and exceptional performers in their fields, and losing them from anesthesiology would unnecessarily shunt their talents, as well as, their problems off to another field.

Dr. Gray contrasted typical outpatient treatment by a psychiatrist to appropriate inpatient therapy. Outpatient psychiatric treatment might include replacement therapy rather than detoxification, psychotherapy to discover why the physician has become an addict rather than behavior modification, and aiming therapy to reduce the “causes” of addiction rather than treating the disease. Many psychiatrists do not require complete abstinence from all mood altering substances, but try to return the patient to “normal drinking.” Appropriate inpatient therapy requires a full complement of physicians from many specialties to handle the detoxification stage which often includes several days of convulsions and ARDS. Other important characteristics were listed in the ASA videotape. Dr. Gray pointed out that Addictionologists generally agree that early alcoholics with a stable family and work environment and no other psychiatric diagnosis should be able to benefit from an outpatient program, as long as they are able to remain abstinent (but not one whose goal is to return the patient to “normal drinking”).

All of the anesthesiologists that Dr. Gray has treated have returned to their work successfully, and he credits his reentry contract for this unprecedented success. It includes the following: Agreement to use no mood altering substances, participation in aftercare with regular (every evening and Saturday)AA or NA attendance, ordering of all medications (even for colds or headaches) by his personal physician, strict agreement on working hours, random observed urine or blood screening, naltrexone therapy for opioid abusers, and dismissal from employment for relapse. The drug screening must be random, and sample collection observed immediately after it is announced. The sample collector should be the same person at all times, and he should document the time and circumstances of collection, any other medications which the recovering physician has taken recently, and should hold all samples for a month in case any questions come up in the future. Reports of screens should be received by a designated supervising person. The recovering anesthesiologist must pay for the tests (around $150 for fentanyl currently) in this program.

Dr. Jim Arens, Chairman of the Department of Anesthesia at the Univenity of Texas at Galveston and Past President of the ASA, reported that the ASA will fund a prospective study, based at the University of Virginia. The study will track all anesthesia residents who enter substance abuse programs in order to determine whether their outcome depends on the type of treatment and rehabilitation program and the reentry contract. The ASA has also provided money for the development of an inexpensive, accurate, and sensitive screening test for fentanyl and its relatives, since these substances are currently not tested for in existing random drug screening program. The test, costing in the range of $12-$15, should be ready in two years, and members of the Society of Academic Anesthesia Chairmen (SAAC) will have it available for use then.

No one is willing to say that random testing will abolish this epidemic. The data cited by Dr. Arens suggest that random drug screening in the workplace might deter those who are entering anesthesia because of drug availability, might make drug users go to another institution for employment (as demonstrated in the few hospitals that have instituted such programs for all employees), and might be a deterrent for first time drug users (as has apparently occurred in NCAA athletic programs).

Who Flays For All Of This Treatment And Testing

Dr. Ward returned to provide depressing figures demonstrating the high cost and low level of support for the re-covering anesthesiologist. Treatment for the disease of chemical dependency is the fastest growing segment of health insurance currently. Inpatient programs with aftercare follow-up coast from $20,000 to $26,000, and most health insurance will cover only one 28-day inpatient course per lifetime. Many will not insure the recovering patient at all after that one inpatient course and treatment for a relapse is almost always paid out of the patient’s own pocket. Disability coverage is notoriously poor after this diagnosis, and lost salaries for the treatment and rehabilitation periods are not insignificant. Most of the tine, the recovering physician has to pay for his own random screening tests. On the bright side, malpractice insurance seems not to have been affected at all by this diagnosis, perhaps reflecting that no publicly proven patient injury has ever been attributed directly to drug use by an anesthesiologist.

Dr. Polk, University of Chicago, is well known for educational efforts within anesthesiology.