Joseph Szokol, MD, ASA’s Chief Health Policy Officer, would love nothing more than to say that he has not been directly affected by substance use disorders (SUDs), but that is sadly not the case.
“Unfortunately, I have had to do interventions on several residents and attendings who were diverting opiates and other substances,” said Dr. Szokol, who served as Chief of Staff at a large hospital in Illinois, and Vice Chair and Chair of the Department of Anesthesiology there for 20 years. Dr. Szokol also served as Chair of the Illinois Medical Disciplinary Board.
“It was especially heartbreaking when two of the attendings were high performers and very well regarded in the department.”
But he also learned from tragedy that intervention is necessary. “During residency, a former Chief Resident at another program, who was accepted for continuation of residency, was found dead over a bowl of an inhalational anesthetic,” he recalled. “It was devastating for all of us. This is one of the most difficult issues that an anesthesia chair or department leader will face.”
Jodi Kuhlman, MD, opened up about her addiction recently in an Anesthesiology News podcast, which followed a 2018 story in Marie Claire. She talked about graduating high school and medical school at an early age, but at the expense of her emotional growth. She came from a high-achieving Tennessee family of seven siblings and had never previously drank much or smoked what are perceived as gateway drugs. Dr. Kuhlman shared her experience, including her recovery as well as what her career looks like now, underscoring the importance of awareness and support (asamonitor.pub/3HUfwYX).
Incidence of SUDs
A recognized expert in the field, Harvard Professor Michael G. Fitzsimons, MD, an Assistant Professor at Harvard Medical School, helmed a program 15 years ago and notes valuable lessons learned, even if they are painful. He cited multiple studies showing the incidence of SUDs in trainees and staff is between 1%-2%. The presenting factor is death in 7%-16% of the cases.
In 2008, Ethan O. Bryson, MD, and Jeffrey H. Silverstein, MD, released the exhaustive results of their research on addiction and substance abuse in the specialty (Anesthesiology 2008;109:905-17). They reached the following conclusion:
“Addiction is still considered by many to be an occupational hazard for those involved in the practice of Anesthesiology. It has been suggested in this review that the presence of readily available highly addictive agents in our work environment contributes to the potential for abuse in a subset of the population at risk. Since it is not possible to identify these people before they become addicted, it is essential that each of us learn to recognize the signs and symptoms of addiction when they become manifest, such that we may preserve the safety of both our colleagues and the patients they care for.
While some highly motivated individuals have been able to successfully re-enter the clinical practice of anesthesia and avoid relapse, this is not always the case. Successful completion of a treatment program does not guarantee freedom from future relapse, even several years into recovery. As such, each case must be carefully evaluated before the decision is made to allow an addicted physician to attempt a return to the practice of anesthesiology.”
Meanwhile, OpenAnesthesia.org revealed the following characteristics of addicted anesthesiologists:
- 76%-90% abuse opioids as their drug of choice
- 33%-50% are polydrug abusers
- 50% are younger than 35 years
- 33% have a family history of addictive disease
- 65% are associated with academic departments.
Arguments for and against drug testing
Workplace drug testing has been suggested as a way to screen for SUDs; however, there are many concerns regarding employer drug testing, including possible privacy violations and false positive results. Contracts may or may not address random drug testing, and unionized employees may have protection against it.
“Arguments have been made against testing only anesthesiologists while not testing other physicians. Physicians other than anesthesiologists are not immune to the diseases of substance use disorders,” says Dr. Szokol. However, he notes that “anesthesiologists are unique in that they practice within a specialty which directly handles highly potent substances that can kill. Handling occurs in high-stress environments over long, unpredictable hours – factors which may lead to substance use.”
Dr. Szokol indicates that legitimate concern among individuals tested is fair management of positive results. It is critical that institutions that implement random drug testing have a formal written policy for management of positive results, including professional intervention, repeat testing if requested by the individual, and emotional support during the period of investigation. Positive drug tests do not prove abuse, misuse, or diversion – only the presence of a substance.
There are also concerns over logistics of implementing drug testing programs as well as overall costs. Dr. Fitzsimons’ research showed that cost components of drug screening recovery programs include initial assessment, detoxification, inpatient treatment (often up to 90 days), outpatient treatment upon discharge, legal fees, arrangement for other coverage during the leave of absence, and additional post-treatment drug testing.
Although these concerns are valid, Dr. Szokol notes that “patients have a right to expect their anesthesiologist to be unimpaired and fully able mentally and physically to care for them. The patient’s interest should be foremost.”
Alternatives to drug testing
Recognizing and preventing SUDs does not necessarily require workplace drug testing. Dr. Fitzsimons notes that policing by other health care providers would seem like a natural solution; however, he cited a 2010 study by DesRoches et al. that said approximately one-third of physicians would not report an impaired colleague to a higher authority (JAMA 2010;304:187-93). Reasons cited included fear of retribution, uncertainty about how to report, fear of excessive punishment for the individual, or the notion that others will report them.
Dr. Szokol pointed to other options, such as use of automated drug dispensing carts in the OR to track medication. Controlled substances are logged into the computer system and can then be matched with the anesthesia record. Waste of controlled substances is verified by a second individual. Unused controlled substances can be returned to a locked box.
“Other things that may be considered in addition to random drug testing and automated drug carts are returning unused controlled substances to a centralized location, random testing of drug waste, auditing anesthesia records to identify outliers in administration, witnessing waste of controlled substances, and creation of a safe environment for immediate reporting of drug diversion. Hospitals should consider development of drug diversion prevention task forces to investigate any suspicions of diversion,” he added.
Arguments have also been made for increased education to help identify signs of substance abuse. Additionally, an increased focus on physician well-being may also help minimize the incidence of drug diversion and SUDs. Dr. Szokol is uncertain, however, that there is solid evidence of this being the case. It is also too early to tell whether there has been an increase in substance abuse during the COVID-19 pandemic and whether pandemic burnout has affected the incidence among anesthesia professionals.
SUDs are a clear threat to physician and patient safety. While employer drug testing is one possible way to identify and mitigate issues, there are alternatives. In any case, enrollment in a treatment program after SUDs are identified should be considered.
Indeed, Dr. Fitzsimons notes a major positive to treatment programs: nearly three quarters of individuals treated through physicians’ health services and in good compliance with the conditions of the recovery contract will remain free of drugs for at least five years (Anesth Analg 2009;109:891-6).
“There is hope if we discover these individuals,” he said.