Author: Michael Vlessides
A new survey of anesthesiologists has found a rate of controlled substance abuse disorder of 3.7% among residents and 1.16% among faculty. Interestingly, the survey found that although IV opioids are the most commonly abused drug among residents, the rate of propofol abuse has skyrocketed over the past two decades.
“Substance use disorders have a quoted incidence between 10% and 14% in all physicians,” said Elizabeth O’Brien, MD, the chief resident at Dartmouth-Hitchcock Medical Center, in Lebanon, N.H. “Classically, anesthesiologists have been disproportionately represented in that number. Several studies have sought to find the true incidence of substance use disorders among anesthesiologists, including Booth’s excellent 2002 survey, which looked specifically at the years 1990 through 1997 [Anesth Analg 2002;95:1024-1030].
“That group found an incidence of 1.6% among anesthesia residents and 1.0% in anesthesia staff,” Dr. O’Brien said. “We sought to update this survey, specifically looking at 2007 to 2017, to determine the incidence and look at the trend of treatment options available.”
As Dr. O’Brien reported at the 2018 annual meeting of the American Society of Anesthesiologists (abstract A3093), 52 program directors responded to the survey (response rate, 35%), and 53 program chairs participated (response rate, 36.7%).
The represented programs had an annual census of approximately 2,100 residents. Of these, 80 residents were identified as impaired in the 2007-2017 period (3.7%). By comparison, responding program chairs represented a census of 3,786 faculty. The incidence of substance use disorders among faculty members was reported at 1.16%.
If Discovered, Then What?
With respect to training and re-entry, the survey found that 100% of responding programs reported mandated substance use disorder education. Furthermore, 72% of residents with substance use disorders were guaranteed treatment through their respective program.
“In addition, 52% of programs paid for an initial evaluation; 19% felt it was the residents’ responsibility but something that could potentially be reimbursable based on circumstances; and 13% of programs felt it was the residents’ responsibility and not otherwise reimbursable,” Dr. O’Brien explained. In addition, 43.6% of programs offered no re-entry following treatment.
For faculty, the picture was slightly different. “Close to 70% of faculty were guaranteed treatment through their program,” Dr. O’Brien said. The survey found that 39.6% of programs paid for initial substance use evaluation whereas 30.2% required that faculty pay the fee, which they considered nonreimbursable.
The survey also revealed that 45.3% of programs continue to pay the faculty salary during substance use treatment and 62.3% continue faculty benefits during that time. Only 27.4% did not offer re-entry to faculty following treatment. “Only about half of these programs had mandated formal education for faculty on substance use disorders, and 22% had increased the amount of education over the 10-year period,” Dr. O’Brien added.
Annual Survey Proposed
As Dr. O’Brien discussed, drawing parallels between the current survey and Booth’s previous effort is difficult given their vastly different response rates. “Booth had a 93% response rate, compared to our 35% and 37% response rate,” she said. “However, taking these results for what they are, it appears that the incidence of substance use disorders among residents has nearly doubled.
“Equally concerning is the increase in IV propofol abuse,” Dr. O’Brien added. “In Booth’s survey, only one out of 133 identified residents using substances was using propofol, compared with our rate of 17% among both residents and faculty.”
The researchers suggested that ongoing annual surveys may help clarify the burden of controlled substance use disorders among trainees.
“We suggest an annual survey or some form of anonymous reporting platform because we believe it would be useful to track changing patterns of substance use disorders over time,” commented senior author Ying Hui Low, MD, an assistant professor of anesthesiology also at Dartmouth-Hitchcock Medical Center. “Furthermore, an annual survey is easier to carry out than asking program chairs and directors to recall 10 years of data.
“Finally,” Dr. Low added, “an annual survey will provide some means of comparison of the available rehabilitation opportunities to various anesthesia providers, including CRNAs. This information may help to direct the future development of support for all anesthesia providers who suffer from substance use disorder.”
As Franklyn P. Cladis, MD, an associate professor of anesthesiology and perioperative medicine, and the director of the Pediatric Anesthesiology Fellowship Program at the University of Pittsburgh, noted, one of the primary challenges presented by anesthesiologists with substance use disorder is identifying these individuals. “Do you have any sense of how easy it was to discover their drug use or how they were discovered? Were they found unconscious in a call room or did someone suspect something? As a program director, I always think about how people with substance use disorders are discovered.”
“We had a question relevant to that in the survey, but it wasn’t included in our results because it didn’t meet our minimum response rate,” Dr. O’Brien replied. “But yes, a lot of them were actually admissions or suspicious behavior.“
Session moderator William C. Paganelli, MD, PhD, postulated why the previous survey did not find much propofol abuse. “That survey collected information from the 1990s, when propofol really wasn’t in such common use, at least for the first four or five years of that decade,” said Dr. Paganelli, a professor of anesthesia at the University of Vermont Medical Center in Burlington. “Now it’s ubiquitous.”
Dr. Paganelli asked, “Do you have a sense of why there was a low response rate given that this is such a topical issue, especially for program directors?”
“In retrospect, I think 52 questions was a little on the long side,” Dr. O’Brien replied. “We probably should have shortened it given the potential for survey fatigue and the time commitment it took to complete it.”