Drug Addiction in Anesthesia

[supahfresh]

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Anybody scared about this, either for themselves or their friends? How can you tell who is likely to develop a problem? I think the percentages are pretty high and quite often it is the brightest among us.

 

[Dr JPH]

I'm an MSII and we recently had a physician come speak to our class regarding addiction in medicine. He told his personal story and how he was eventually caught. Apparently over the course of his addiction he had ingested over 77,000 percocet. I found it hard to believe myself, but it was a true story.

I know there are confidential help groups out there for docs with issues. There are a few here in the Philadelphia area.

As far as pinpointing who is going to have a problem. I don't think you can really do that very easily. Unfortunately knowledge + access can be a dangerous thing.

 

[UTSouthwestern]

fresh, the percentages are not super high for our specialty, just a little higher and probably due to access. It is a challenging problem to determine if someone is addicted versus depressed or just simply an ecclectic personality.

One thing is for sure: You should err on the side of caution. Last fall, a resident at an anesthesiology program became addicted to fentanyl, wasn't identified quickly, was given some psychiatric counseling when it was discovered, was allowed to go back to work, and promptly killed himself with an inadvertent or purposeful injection of propofol.

 

[Tenesma]

bottom line, the most commonly abused drug among physicians (including anesthesiologists) is ALCOHOL!!!! addiction is a disease and while we may have access to cooler drugs than alcohol, alcohol is still the medical profession's biggest problem!

 

[Krafty]

According to Dr.Lees of Georgetown anesthesia

(who by the way makes it a point to emphasize that they are a program that has appropriate support structure - you screw up, you do the rehab but you are GUARANTEED a spot back the the program, which I thought was cool)

said that one usually has 18 months from when a person starts abusing a substance in clinical anethesia setting until one of two outcomes occurs:
1) Intervention and rehab
2) Death

Sobering prospect. 🙁

 

[gaslady]

That's a very bold statement of that doc to say that they guarantee a spot back to residents who have abused drugs and go through rehab. If it's true I doubt that it is always in the best interested of that resident and the patients they take care of, especially if the other part is true about 18 months. Doctors do have a high rate of success with rehab, but putting someone who has an addiction in a situation where they carry around narcotics and benzos all the time seems to be careless. There may be some who can handle it, but there's definitely many who can't. To make a blanket statement like that seems irresponsible. Even with a lot of supervision, people are clever and those who can't control themselves will find a way. Some places may be okay with attendings who just supervise either CRNA's or residents and don't ever handle the narcotics and benzos.

Also, any program will help an impaired resident to find the help they need, that's not unique to Georgetown. Even if a program wasn't going to offer you a spot back, they wouldn't just boot you out without the appropriate referrals. There are some inpatient rehab programs specifically for docs and health care providers around the country. I think in a lot of cases, after the residents successfully go through rehab they are placed in other fields that don't have the access that anesthesia does.

 

[UTSouthwestern]

Unfortunately, that very situation happened at a south Texas anesthesia program. The resident became addicted to fentanyl, wasn't "caught" for some time, was finally detected, sent to see a psychologist, was deemed to be suffering from social, academic, and personal stress and allowed to return to work.

Said resident then took a bottle of propofol with him to the bathroom, placed an IV in himself, started the propofol, and died.

 

[nap$ter]

can't resist resurrecting this thread. anyone hear any SUCCESS stories of residents re-entering and completing residency after IV dope addiction? i've heard a lot of sobering (pun intended) stories of death and mayhem, but nothing positive. is this the reality? or are there residents who have made it there and back again? stories/states/programs?

a good friend of mine recently was intervened on for "diversion" in his R4 year. thankfully he's safe, but is trying to figure out whether he can or should come back to finish the last months of residency...

 

[Planktonmd]

can't resist resurrecting this thread. anyone hear any SUCCESS stories of residents re-entering and completing residency after IV dope addiction? i've heard a lot of sobering (pun intended) stories of death and mayhem, but nothing positive. is this the reality? or are there residents who have made it there and back again? stories/states/programs?

a good friend of mine recently was intervened on for "diversion" in his R4 year. thankfully he's safe, but is trying to figure out whether he can or should come back to finish the last months of residency...

Any one who becomes addicted to IV drugs should not come back an Anesthesia residency for sure, but other specialties might be OK.

 

[nap$ter]

is there any evidence that redirecting a resident to another specialty reduces the risk of relapse? I can only find empiric suggestion on pubmed.. no longterm followup; only negative data..

 

[jwk]

None of the cases I know of with fentanyl addiction have stayed clean. They go to rehab, perhaps stay out 6-12 months, are closely monitored when they come back, and still end up relapsing and permanently barred. Sadly, I've had at least two friends that I'm aware of die from fentanyl OD's.

I know one guy with a demerol addiction secondary to legitimate chronic pain issues that succesfully went through rehab and has stayed clean.

 

[Noyac]

I have more than a few tragic stories but thats not the point of this. I know of a couple anesthesiologist practicing who went through rehab and are doing fine. One of them I am very confident that those days are past him.

With that being said. I know of many more that are dead or out of this business b/c they couldn't stay away. I was on the committee for reinstatement of these individuals and we found that nobody had a chance if they returned to the OR in less than 12 months. The relapse rate was greater than 80% if less than 12 months and 60% if after 12 months. Not good odds either way.

I highly recommend another career for these individuals, as I have stated here before. This is not the kind of thing you want to take a chance on. And if we are held to discriminatory charges for firing or not rehiring someone who uses these substances then the courts do not understand the consequences and are doing a grave injustice to these individuals.

 

[Consigliere]

What does the initial "M" in LMFAO mean? Masters?

 

[Laurel123]

With addiction, I also have known many tragic stories, and few true rehabilitations, at least regarding narcotic addiction. I am unsure about alcohol addiction however.

There were two residents in my program that developed a narcotic addiction and survived. One left as a second year and never returned to medicine at all after rehab. He went to culinary school instead. The other left for a year for rehab as a third year and did come back with intense supervision. He finished residency, stayed as an attending and passed his boards. He then worked for another couple months. He was an MD/PHD so while he was working as an attending, he was busy trying to secure a spot as a researcher. He eventually did, and left clinical practice and hasn't seen a patient since then. He is 100% at the bench doing basic science research and has no exposure to narcotics. That has been 5 years now, and he is still clean.

So those are my only two stories of people that I know that have survived the addiction. It must be hard to come back to practice. Probably like a gastric bypass patient getting a job at an ice cream shop.

 

[Noyac]

What does the initial "M" in LMFAO mean? Masters?

Yep

 

[CambieMD]

I do not think that substance abuse is greater in anesthesia. The drugs that anesthesiologist have access to are unforgiving. All of us know alcoholics who function for years. Narcotics result in erratic behavior. Most of the physician addicts that I know have not been anesthesia providers.

I do not think that an anesthesia provider with a narcotic addiction should come back to anesthesia. It doesn't make sense. How can you justify the risk to the provider or his/her patients.


Cambie

 

[Consigliere]

Yep

Well, in that case........

(Got it online)

 

[ReefTiger]

I was reading this thread, & a similar one in the past, but I've decided to respond to this one.

I am a resident who went to rehab and was allowed to return. I've been sober for 17 months, and have zero desire for narcotics. I did not use fent/sufent.

The decision to return was based on many factors. I was given access to the scientific data while in treatment, and there are several factors to a successful reintegration. I am typing this on my iPhone, which is a pain, so I'll type more later on a desktop. I'll have an open discussion with this forum telling my perspective. I do agree that it takes special circumstances to return to this field successfully.

 

[Planktonmd]

I was reading this thread, & a similar one in the past, but I've decided to respond to this one.

I am a resident who went to rehab and was allowed to return. I've been sober for 17 months, and have zero desire for narcotics. I did not use fent/sufent.

The decision to return was based on many factors. I was given access to the scientific data while in treatment, and there are several factors to a successful reintegration. I am typing this on my iPhone, which is a pain, so I'll type more later on a desktop. I'll have an open discussion with this forum telling my perspective. I do agree that it takes special circumstances to return to this field successfully.

Great, looking forward to hear the rest of the story.
👍

 

[Jeff05]

most anesthesia programs, even those that were liberal in the past, are now not allowing those with a history of abuse to return. this is due to exceptionally high relapse rates and mounting medico-legal liability.

i, for one, think that in anesthesia it should be one strike and you're out. anything else poses an unacceptable burden on staff and risk to patients.

I was reading this thread, & a similar one in the past, but I've decided to respond to this one.

I am a resident who went to rehab and was allowed to return. I've been sober for 17 months, and have zero desire for narcotics. I did not use fent/sufent.

The decision to return was based on many factors. I was given access to the scientific data while in treatment, and there are several factors to a successful reintegration. I am typing this on my iPhone, which is a pain, so I'll type more later on a desktop. I'll have an open discussion with this forum telling my perspective. I do agree that it takes special circumstances to return to this field successfully.

 

[jetproppilot]

I was reading this thread, & a similar one in the past, but I've decided to respond to this one.

I am a resident who went to rehab and was allowed to return. I've been sober for 17 months, and have zero desire for narcotics. I did not use fent/sufent.

The decision to return was based on many factors. I was given access to the scientific data while in treatment, and there are several factors to a successful reintegration. I am typing this on my iPhone, which is a pain, so I'll type more later on a desktop. I'll have an open discussion with this forum telling my perspective. I do agree that it takes special circumstances to return to this field successfully.

Hey Dude, I'm most appreciative of you here.

Thanks for sharing.

We can all learn from you.

Its posts like this that make this forum invaluable.

Like Plank said I too am looking forward to reading more from you.👍

 

[jetproppilot]

I have more than a few tragic stories but thats not the point of this. .

I feel ya, bro.

I was thinking of how many I've been exposed to in the 16 years (4 residency + 12 PP) I've been around....

I wish it was justa few.

Sadly its been many.

Four of the many are dead.:cry:

 

[Arch Guillotti]

I was reading this thread, & a similar one in the past, but I've decided to respond to this one.

I am a resident who went to rehab and was allowed to return. I've been sober for 17 months, and have zero desire for narcotics. I did not use fent/sufent.

The decision to return was based on many factors. I was given access to the scientific data while in treatment, and there are several factors to a successful reintegration. I am typing this on my iPhone, which is a pain, so I'll type more later on a desktop. I'll have an open discussion with this forum telling my perspective. I do agree that it takes special circumstances to return to this field successfully.

I am interested to hear more as well.

 

[ReefTiger]

well, I had typed a super long post and I guess it took me too long and I got logged out or it didn't submit and I lost it.

Oh well. Anyway, I respect people's opinion that one strike and you're out in anesthesia, but I disagree. For me to agree I would have to believe that people are incapable of making significant changes that change the course of their lives. I simply cannot agree based on evidence/experience from my own life not including addiction. But to each his/her own.

There are many factors to a successful treatment and recovery. First and foremost is an honest WANT to be clean/sober. Proper treatment is, in my opinion, necessary. Unfortunately for many they will never have a chance to revieve the treatment I got.

I was given the data while in treatment, and the paper most everyone bases their decisions about denying residents reentry was written in the early to mid 90's. Upon first glance it was concerning. I am writing this based on my memory, so don't expect exact numbers. But, these numbers are VERY close to the study numbers.

Of those residents allowed back, approx 50-60% relapsed. Of those 10-20% died. 😱 This study included those who abused etoh and narcotics. Now, here are some of the arguments with the study. Firstly, it was a survey sent to program directors asking about residents over the past 10 yrs. So all data was gathered from memory. Secondly, >66% of the patients had 6 weeks or less of inpatient treatment, a number that any licensed addiction medicine doctor will admit is woefully inadequate. Of those who were abusing narcotics less than 20% took naltrexone, a drug that aids against relapse. There was no mention about length of time before returning to OR setting, and nothing specific about monitoring programs/aftercare requirements.

Now, this does not discount the outcomes of death, but for me specifically I felt that returning was worth the risk based on many factors.

I'll post those next, as I don't want this post erased.

 

[maceo]

i, for one, think that in anesthesia it should be one strike and you're out. anything else poses an unacceptable burden on staff and risk to patients.

I dont think there should be a one strike youre out in anything in life. the older I get the less sure i am about anything. But im glad you are so sure....

 

[urge]

I believe everyone should be offered a second chance. However I believe all of them will fail(ok, not all but most). Hence the second chance is to make the person know that the reason they are not allowed to practice is themselves, not the system.

 

[ReefTiger]

Factors that led to me pushing to return to anesthesia

I was treated at arguably the best treatment facility for physicians in the US
-90% of physicians are sober 5 years out of initial treatment

Physicians have the highest recovery rate behind only airline pilots

I do not have a psychiatric co-morbidity

I have an excellent physician aftercare program including weekly urine screens

I would have a hair test three months after discharge

Anesthesia is the only field of medicine I enjoy, if not for it I'd be out of medicine altogether

I have ZERO good memories about using

I didn't use fent/sufent

I used demerol, and I can successfully navigate a career without ever coming into contact with it-some hospitals don't even have it on formulary

My addiction stemmed from original need for pain control rather than experimentation- I had a ligamentous shoulder injury

I would be on naltrexone

Everyone in my entire department knew what was going on with me

I had full support from all residents

I would not have to be in the OR for my first three months of anesthesia except on call, and I had one month away from residency after discharge from treatment.

I also had three faculty members in recovery

Now, I understand fully that none of this matters and I could go out and get drugs and piss it all away. But I could do that anywhere. I cannot convey the sheer misery that was my life during the addiction. I self reported and I do not have any licensure issues.

I will have to train for an extended time per the ABA, not my program. So in all I will have completed 41 months of anesthesia training when finished. It is a minor detail to have a career I enjoy. I am now job searching, and expect to run into bumps. I have the advocacy of my faculty, and I know I'll be a great asset to whatever practice "takes the risk".

I am not overconfident. For me this is a way of life, an ongoing treatment if you will. People in residency used to talk about substance abuse and treatment as "expensive" and something you want to "avoid". Also "you have to call in for random urines daily" and "go to meetings". I agreed with this mindset but it is incorrect.

See, treatment is akin to surgery to remove cancer. It is not a bad thing, it is necessary. Every urine is a chance to prove I'm clean. Meetings are like a diabetic controlling their glucose. This is the mindset I live with.

People are going to judge me, and that's ok. That is human nature. It's a good thing that I don't base my value on other people's thoughts.👍

 

[ReefTiger]

Urge,

I agree with your assesment. If I relapsed, I would quit.

 

[periopdoc]

My addiction stemmed from original need for pain control rather than experimentation- I had a ligamentous shoulder injury

Of all of the things you mentioned, this is the only one that gives me hope that an individual could stay clean and might make me think it may be reasonable to give an individual a second chance.

I hope all the best for you. If you do relapse, please let someone know sooner rather than later. You already know that that **** isn't worth dying for.

-pod

 

[Jeff05]

everyone deserves a second chance? rape and murder a kid - give the dude one more chance, parole him in 10 and lets see what happens? there are many things in life for which there should be no second chances.



DIVERTING pain relieving drugs from patients (i.e. inflicting post-surgical pain) and being intoxicated while providing CRITICAL care is absolutely unexcusable. period. more than 50% relapse during a lifetime.

it's easy to say to give these individuals one more chance - because you wager nothing personal. i doubt you would want your mom or child waking up after a procedure with nothing but labetalol onboard. or not waking up at all because there was a disconnect and the anesthesiologist was too f'd up to recognize it. or having to be a collegue and being put in a position to pull up a friend's sleeve to see track marks...or confront them without much obvious evidence.

I dont think there should be a one strike youre out in anything in life. the older I get the less sure i am about anything. But im glad you are so sure....

 

[Jeff05]

to OP.

just curious what, exactly you were thinking, when you put a needle filled with an opioid (not sure why you make the distinction vs. fent/sufent) into your arm.

as a physician who had some shoulder pain, would it not have been obvious to go to a pain medicine guy and get a prescription for percocet?

these are real questions. i'm really interested in the thought process.


i'm am glad that you're doing well and wish you luck in your job search.

however, as an aside, i would never hire anyone who has a history of abuse.

any of the other posters who think that everyone deserves a second chance hire someone with a history (you're a senior partner working for a private hospital)???????????

 

[Noyac]

I also lead towards finding another career choice maybe still in medicine for anesthesia providers who use. I am not saying this to be a hard a** but strictly for the safety of the provider. I have seen too many unfortunate outcomes. It ain't worth it.

Reeftiger, I admire your approach and your willingness to talk about this subject. I disagree with you when you say that anesthesia is the only field for you. If you finished med sch and there were no spots in anesthesia then you wouldn't just say thanks but I'll have to do something else outside of medicine. I have said this b/4, it's your life you are dealing with. You wouldn't take this kind of risk in any other arena. Why take it here?
I am open to discussion if you have evidence to the contrary.

 

[pgg]

DIVERTING pain relieving drugs from patients (i.e. inflicting post-surgical pain)

Diversion doesn't imply inflicting post-surgical pain. Presumably the addict could give an appropriate dose to the patient, document he gave more, and pocket that extra bit.

I really haven't decided whether I agree that 2nd chances should be given in any field of medicine. I tend to think not, though I acknowledge I'm in a minority opinion there, and that reasonable people can make good arguments for allowing future practice. (Eg, the plausible argument that it may improve patient safety and the addict's survival by encouraging self-reporting.)

I think there are enough reasons to prohibit re-entry without tacking on the "deliberate infliction of pain on patients" crime.

 

[nap$ter]

everyone deserves a second chance? rape and murder a kid - give the dude one more chance, parole him in 10 and lets see what happens? there are many things in life for which there should be no second chances.



DIVERTING pain relieving drugs from patients (i.e. inflicting post-surgical pain) and being intoxicated while providing CRITICAL care is absolutely unexcusable. period. more than 50% relapse during a lifetime.

it's easy to say to give these individuals one more chance - because you wager nothing personal. i doubt you would want your mom or child waking up after a procedure with nothing but labetalol onboard. or not waking up at all because there was a disconnect and the anesthesiologist was too f'd up to recognize it. or having to be a collegue and being put in a position to pull up a friend's sleeve to see track marks...or confront them without much obvious evidence.

i would have no problem letting an anesthesiologist in recovery put me or my family to sleep; the guys i know with that history are the best in the biz.

your first statement deserves no response - that's silly. i agree with your second statement - that's clear.

and clearly no one wants someone who is actively using (ie track marks) to be working in the OR or to have to confront a colleague, maybe this was rhetorical on your part. (but it happens) also, if you look at the data, work is almost always the last thing to go. medical mistakes secondary to addiction are always jumped on by the media, but anecdotes are not data sufficient for me. i don't know where you get your 50% lifetime relapse data (show me the reference) - the re-entry process has changed (ie naloxone, delayed re-entry, longer rehab stays).

so the pertinent question would be- how do you differentiate between the using addict and the recovered addict in the OR? i don't think there is a perfect way.

monitoring random UA's and other tissue samples have their limitations, granted. add naloxone and other safety nets, and i'm comfortable with the margin of error.

everyone has an opinion

 

[Jeff05]

F. Overall relapse rate appears to be about 14 percent per year for residents and practitioners and about 19 percent per year for those with a history of addiction to opioids
H. Medical Society of New Jersey's Physician Health Program compared 32 anesthesiologists to 36 other recovering physicians for an average of 7.5 years over a 12-year period. Relapse rate for anesthesiologists was 40 percent versus 44 percent for controls.

Arnold, WP. 1995 substance abuse survey in anesthesiology training programs: A brief summary. ASA Newsl. 1995; 59(10):12-13,18.

Pelton C, Ikeda RM. The California Physicians Diversion Program's experience with recovering anesthesiologists. Journal of Psychoactive
Drugs. 1991; 23:427-431.

THE LATEST ISSUE OF ANESTHESIOLOGY HAS A GOOD REVIEW ON ADDICTION:

Risk Factors for Relapse
Because of the nature of the disease of addiction,
individuals who have successfully undergone treatment
are still at risk for relapse. In a retrospective cohort
study, Domino et al.67 examined the rate of relapse
among 292 physicians involved in the Washington Physicians
Health Program between 1991 and 2001. Of the
2,922 individuals studied, 74 (25%) had at least one
relapse. Factors that were associated with an increased
risk of relapse included a family history of substance use
disorder, the use of a major opioid, and the presence of
a coexisting psychiatric disorder. Interestingly, the use
of a major opioid increased the risk of relapse only in
patients with a coexisting psychiatric disorder.

Anesthesiology 2008; 109:905–17


the above study is over 10 years. the one above that cites about 40 percent in several years. i think that it's safe to say that lifetime relapse rate can be extrapolated to over 50%.

 

[ReefTiger]

It is a bit disturbing to read some of the inflammatory remarks above. To think I, as a physician, wasn't smart enough to get percocet. I did. Guess what happens when you take it chronically and then don't get refills? For some it isn't a big deal, for addicts it is a different story.

I don't expect you to understand something you can't comprehend. As I said it was surreal. Specifics don't matter because it is in the past. But to assume addicted physicians don't adequately treat pain is a poor conclusion to make. None of my patients ever woke up in pain.

I have been back in anesthesia for 13 months and not had any issues. I wanted to finish residency and get boarded. Once that happens I can do a year and get boarded in addiction medicine-which is something I'm considering. Fact is though, anesthesia makes $$ and I owe $$. Plus I enjoy my work, have the evaluations that I'm good at it, and feel comfortable in the setting despite my history.

I operate under the premise that I would submit to any and all testing including hair samples which detect any drug for the past 90 days and any postive test/relapse equals termination.

Treatment centers do NOT push for people to return to anesthesia, it takes a special circumstance. They told me it's a roll of the dice. Some can succeed, others fail-it is difficult to tell who falls into which category. Furthermore, there really aren't much data to determine adequacy for successful return.

I think anyone who works with me can attest I will do well.

 

[ReefTiger]

You must also consider a few things when you speak of relapse. If an opiod dependent person has a single drink of alcohol it is technically considered a relapse. Furthermore, of the 292 studied the treatments were not the same, nor were return to work conditions. There are a lot of variables to take into account.

 

[QofQuimica]

Reeftiger, you mentioned going to meetings. Are you talking about NA? And if so, do you plan to keep going for the rest of your career? Can you tell us more about what you view as being the role of groups like NA?

My personal belief is that addicts can stay clean if they really have the desire to do so and if they put safeguards in place to help prevent themselves from relapsing (such as what you described with being voluntarily screened). However, the danger of relapse will always be there for the rest of your life, and you will always need to be on guard against it. I guess what I'm really trying to ask is what long-term safeguards you have to protect yourself after you complete residency. As others have already said, I wish you the best with your recovery.

 

[nap$ter]

F. Overall relapse rate appears to be about 14 percent per year for residents and practitioners and about 19 percent per year for those with a history of addiction to opioids
H. Medical Society of New Jersey's Physician Health Program compared 32 anesthesiologists to 36 other recovering physicians for an average of 7.5 years over a 12-year period. Relapse rate for anesthesiologists was 40 percent versus 44 percent for controls. -

-if this were true, why re-direct to another specialty?

Arnold, WP. 1995 substance abuse survey in anesthesiology training programs: A brief summary. ASA Newsl. 1995; 59(10):12-13,18.

Pelton C, Ikeda RM. The California Physicians Diversion Program's experience with recovering anesthesiologists. Journal of Psychoactive
Drugs. 1991; 23:427-431.

THE LATEST ISSUE OF ANESTHESIOLOGY HAS A GOOD REVIEW ON ADDICTION:

Risk Factors for Relapse
Because of the nature of the disease of addiction,
individuals who have successfully undergone treatment
are still at risk for relapse. In a retrospective cohort
study, Domino et al.67 examined the rate of relapse
among 292 physicians involved in the Washington Physicians
Health Program between 1991 and 2001. Of the
2,922 individuals studied, 74 (25%) had at least one
relapse. Factors that were associated with an increased
risk of relapse included a family history of substance use
disorder, the use of a major opioid, and the presence of
a coexisting psychiatric disorder. Interestingly, the use
of a major opioid increased the risk of relapse only in
patients with a coexisting psychiatric disorder.

Anesthesiology 2008; 109:905–17


the above study is over 10 years. the one above that cites about 40 percent in several years. i think that it's safe to say that lifetime relapse rate can be extrapolated to over 50%.

thanks for the references. compelling, but there are many problems with that data (everything you quote is from the 90's) or a review of data from the 90's. maybe the relapse rate was close to 50% in the 90's. treatment and re-entry and monitoring are different now. drug testing is different now (ETG for example). surveys are only as reliable as memory, which is variable, subjective, and biased. numbers (n's) were low in some studies, etc...

"You must also consider a few things when you speak of relapse. If an opiod dependent person has a single drink of alcohol it is technically considered a relapse. Furthermore, of the 292 studied the treatments were not the same, nor were return to work conditions. There are a lot of variables to take into account." reeftiger - agreed

i don't think there's enough to data to definitively support any objective conclusion regarding anesthesia provider re-entry - that's why it's a controversial topic. i'm in favor of re-entry for select individuals, based on risk stratification and strictest monitoring.

 

[Noyac]

Reefer ( just a joke and probably a bad one) I don't think anyone is questioning your ability as anesthesiologist. If they are then that is not right and they have nothing to support it. But what people like myself are saying is that it is dangerous for you to return IMO. I know your pts are safe but are you safe, really? I can't answer that and I don't believe you or anyone else can truely answer it. I'm not bustin your balls honestly. I have had friends die in this very situation. They thought they could return and believed they were out of the woods. I don't really know what goes thru anyones mind but I know denial is strong. And I know that people can repress their thoughts for a long time. I don't have the answers but until someone does I believe it is not safe for you to return. Sorry for the honesty. But why not just switch to addiction medicine now? Screw the anesthesia boards.

 

[ReefTiger]

Noy, I respect your opinion. Did you know that airline pilots are allowed to put MANY more people's lives at risk each day than we do over the course of months? You have probably flown on a plane by a pilot in recovery. Bus drivers are another example. People do recover, some do not.

What is the fear? That I will die? That I would kill a patient? That I would commit malpractice and be sued thus causing a group higher liability? A group should never be setup to take the fall for an individual's malpractice situation. You should be as worried about those you work with who drink. There is a MUCH higher percentage of people in this world who would technically qualify as alcoholics/addicts than people realize.

There is no DENIAL on my part. There is no way to be sober when living in denial. I am an addict, and I must not take any mind-altering drugs. How difficult is that? It is not because I am not tempted. This is hard to convey to those who are not in recovery. My life is so good right now that I cannot imagine a scenario that I would want to attempt to recreate the living hell that was in my past.

I will finish residency in March, so I'm at the end. Furthermore, you need to be boarded in something in order to get an addiction medicine certificate in one year. No way I'm gonna switch into a different residency now, especially since I can see the end of the tunnel.

The risk of me relapsing and dying is one I'm willing to take given my circumstances.

 

[Noyac]

Reef, you misunderstood me. I am not saying that you are dangerous to others like an airline pilot is. I don't care about the groups liability. I care about anesthesiologists dying from overdoses. You may not know but I posted here last year after my buddy was found dead in his house of an overdose by his new wife of 6 months.
What bothers me is that you may feel wonderful now and life is great but life changes. God forbid something tragic happens to you or your family. The stress is hard to predict. It changes things. You have access to things nobody else has. You see what I'm getting at?
As far as finishing residency, I didn't understand that you were so close. I guess I would do the same. But I would like to think that I would never practice anesthesia. I would go directly into addiction medicine or what ever I chose.

And denial may be the wrong term for your circumstance. But what I'm getting at there is the thoughts of usage that are always there, right? And you may be strong enough now to fight it but what if you are at a moment of weakness b/c of something like tragedy, like I mentioned above. I don't think we can predict our responses in the future without knowing the circumstances. So removing yourself from the temptation is, IMO, a better choice. The people you talk about who may be alcoholics/addicts are not my concern. They are not pushing the drugs we push everyday. They do not have the access we have. And even if they do have access I don't care about that. It is you I am talking about right now. You are not a threat to your pts, your group, hospital,etc. You are a threat to yourself.

I hope you know my comments are genuine. I am not attacking you at all. I'm trying to discuss this in a manner that makes you think. And if you receive this wrong, my apologies. I sort of decided last year after my buddy's death, that if I came across anyone using in anesthesia I would do everything I could to talk them into leaving anesthesia.
Good Luck

 

[Gern Blansten]

if this were true, why re-direct to another specialty?

Because the stakes are higher for patients and physicians in our specialty. Relapse with other drugs may just mean a drunken stupor for a few days and not showing up to work. Unfortunately, the relapsing anesthesiologist MUST show up to work and care for patients in order to acquire the drugs. Do you know the first sign of relapse 25% of the time? It is being found dead in a call room. That's right, we as providers are so poor at recognizing people that are using that we are not able to intervene on them until they have killed themselves 25% of the time. Too often, they injure patients on their way down.
Physicians are smart people and know how to hide their abuse too well. Having been educated about the dangers, they also know what people will be looking for. They are crafty people who will deny a problem when asked directly by their best friend. They will convince their spouse that they have the problem under control despite the fact that their wife has caught them using at home. They will sit on ASA committees with other peers discussing how to combat fentanyl abuse among their colleagues while they are actively abusing fentanyl themselves. They will sit in on hospital staff meetings hooked up to a fentanyl drip disguised as an antibiotic infusion to treat an "infection" and since they are so well liked, everyone will believe them. Then one day, they are dead or they have seriously injured a patient. This completely ignores the impact on the hospital, colleagues, spouses, and children. This problem affects EVERYONE around them, but they have no ability to see that because they are addicted.
The lucky ones end up back in treatment and redirected to another specialty. The unlucky ones end up dead. Both groups that relapse leave a trail of destruction, heartache, and despair in their wake. People mistakenly think that the abusers are the only ones affected. I assure you, they are not.
Reef, I admire your sense of confidence, but please pardon me if I am very wary of it at the same time.

 

[nap$ter]

the 25% you speak of came from a study in the 90's with a low n. inpatient treatment was short - only 6 weeks for most (as opposed to 12 weeks for most now with delayed re-entry), monitoring was spotty and variable, and almost none of the participants were on naloxone (which i know does not prevent volatile or propofol OD...)

a 25% death rate is a gross overestimation, and likely represents worst case scenario - comes from one survey-based study (which is the best data out there). to continue devil's advocacy; to suggest that docs in other specialties don't show up for work and stay home because of a hangover and never show up for work when altered (making them safe?) seems a bit naive and contrary to many malpractice claims in other specialties - work is always the last thing to go. i agree we anesthesiologists deal with critical stakes all day. but gern, what you say about addicted docs applies to all addicts. in all specialties. denial and crafty lying are universal amongst using addicts, regardless of specialty. data from diversionary boards shows fewer medical mistakes and LESS malpractice for rehabbed, monitored docs. I'd rather get put to sleep by a doc who has been treated and is monitored and on naloxone rather than one who has not been caught yet..

so again, common sense seems to support redirecting to another specialty, but empiricism is sometimes wrong. i would continue to advocate risk stratification, strictest monitoring, and return for SOME, but NOT ALL anesthesia providers. I'm not an addiction doc, but it seems to me that if an addiction specialist experienced with healthcare providers and addiction in anesthesia endorsed reeftigers return, i would have to agree.

 

[Gern Blansten]

to continue devil's advocacy; to suggest that docs in other specialties don't show up for work and stay home because of a hangover and never show up for work when altered (making them safe?) seems a bit naive and contrary to many malpractice claims in other specialties - work is always the last thing to go.

My point was that our actions have more of a life or death impact than the actions of, for instance a primary care doc or a psychiatrist. They may leave the office with bad advice or as an unhappy customer. I would think it rare that a patient in most other settings would die from their encounter. In surgery or anesthesia, that might be a real possibility and as a search of lawsuits will tell you, it has happened...way too many times.

As for the 25% number, another study out of New Zealand came up with the same numbers. But then, even if the numbers aren't quite 25%, what would be your cut off? Is 20% acceptable? Is 5%? I don't know the answer for you, but I know the answer for a lot of very smart people who are leaders in the field. If you diverted opioids (yes, skimming off the top, falsifying medical records, or diluting is diversion) and injected them intravenously, a return to the practice of anesthesiology is a high risk business. Proceed with caution despite what "the addictionology experts" will tell you. If you inhale volatile anesthetics to get high, you are on the slippery slope and, if you continue, you will probably be dead soon. Like I said, doctors are smart. All of the ones I knew were. They die just as easy.

If you use opioids intravenously, there will be consequences. Sometimes sooner. Sometimes later. Don't be another statistic.

I am curious slavin. How many drug addicted physicians have you known? How many colleagues have you lost? Have you ever intervened on a colleague? If so, did they tell you the truth?

 

[nap$ter]

gern, my experience is sparse. i am a resident - you are an attending as are many others on this board. the reason i resurrected this post was to obtain the experience and advice of people like you.

i have lost two friends to addiction; neither was in medicine. being a resident i have never been in a position to intervene on a colleague but from what I have heard and read they all lie - that's part of being an addict. Whether they lie or not while using seems irrelevant; that's why they are required to be on naloxone and monitored with lab tests during re-entry. my friends who died both lied to me about their use. i do know peripherally of two anesthesia providers that went back to practice within my hospital system - they have both been doing well for years. personally i know one physician in another specialty with a drug history.

i don't have much experience with drug addicted anesthesia providers; that's why i posted to elicit yours, gern - thanks. that's also why i've read some of the data posted by others and on pubmed - to examine the experience of others - history. in communicating my opinion i did not intend arrogance. i don't know if you intended condenscension, gern, but that is how i found your string of questions.

i have insinuated that i would not be comfortable deciding who goes back and who doesn't - obviously i am not qualified to make that determination. i don't have a percentage cutoff. does not appear from the data to be a black and white standard of care. thus my suggestion that addiction medicine physicians experienced with health care professionals make the determination based on, again, risk stratification and strictest monitoring, to allow some, but not all anesthesia providers re-enter. this is suggested in the ASA's model curriculum for addicted residents from 2001. search the website to bring it up.

 

[ReefTiger]

"Reeftiger, you mentioned going to meetings. Are you talking about NA? And if so, do you plan to keep going for the rest of your career? Can you tell us more about what you view as being the role of groups like NA?

My personal belief is that addicts can stay clean if they really have the desire to do so and if they put safeguards in place to help prevent themselves from relapsing (such as what you described with being voluntarily screened). However, the danger of relapse will always be there for the rest of your life, and you will always need to be on guard against it. I guess what I'm really trying to ask is what long-term safeguards you have to protect yourself after you complete residency. As others have already said, I wish you the best with your recovery. "

I personally go to AA meetings for various reasons. I will not go to them for the rest of my career, but for the rest of my life. There are many roles for the meetings. First, it is a place where people are able to speak about anything they want and are not judged for past mistakes or what they say. Sure individuals may judge, but if so they should work on their own sobriety.

One of the most important reasons is to help people who are new to AA/NA and are trying to get sober. The best way to stay sober is to help other alcoholics/addicts. It also serves as a reminder of who you are, and what things used to be like for you. You are also able to see monumental turnarounds and changes in people as their sober time increases. The good things always, always, always come to those who follow the 12 step program to the best of their ability.

Another reason to go is to document that you are doing what needs to be done to maintain sobriety. These documents can be stored in a file for insurance companies, program directors, medical directors of physician health programs, and/or medical boards.

The funny thing about meetings is that the 12 step program can actually help anyone alive with problems they have. It is a spiritual based program that is hard to explain. If there is one thing I could recommend to anyone with any problem, not just etoh/drugs, would be to follow a 12 step program.

Glen, I understand what you're saying. Noy, same to you. I have never lied to anyone about my use. I wanted to be sober and was willing to do whatever it took before I went to rehab. I did everything in my own power to stop, but once the cycle is going you can't get off. A lot of people go to treatment after intervention/getting caught. There is a large majority of time spent trying to accept/admit to themselves they have a problem. This was not the case for me.

Nothing in life is absolute. If this were the case then the ASA, and ACGME would have a policy stating that residents would not be allowed to return to residency. Although it is easy for me to say because I am back, I still feel the LARGE majority of providers should not return to anesthesia.

How to decide who is not something I'm qualified to do. There are those who are, and I put my trust in them. I stick with my earlier post when I say that not all treatment centers are the same.

As for people worried about me being safe from myself or me dying-don't. The life I was living was worse than death. Not trying to sound overconfident although I probably do, but I am well aware what lies in store for me if I were to completely change my personality and use again. Life is good, no reason to end it now when it's only just begun.

 

[Gern Blansten]

i don't have much experience with drug addicted anesthesia providers; that's why i posted to elicit yours, gern - thanks. that's also why i've read some of the data posted by others and on pubmed - to examine the experience of others - history. in communicating my opinion i did not intend arrogance. i don't know if you intended condenscension, gern, but that is how i found your string of questions.

Not trying to be condescending at all. I respect your opinion. I was relaying opinions that I have heard from wise people that I respect. It sounds as though Reef's experience is atypical, and if anyone deserves a second chance, that is probably a good example. Very few go to rehab voluntarily, so that is probably a pretty good prognostic indicator in that he is not like the typical opioid abuser.

This is a potentially volatile topic that many will have very different opinions on, so no hard feelings here. Most who have lost colleagues to this problem seem to lean towards the no second chance side. The rest seem to lean towards the give'em a second chance side. Even Reef seems to recognize that most should not return. I agree with Reef that not all treatment centers are the same. Talbott in Georgia is widely regarded as one of, if not, the best.

 

[G0S2]

In today's Boston Globe:

http://www.boston.com/news/local/articles/2008/11/09/something_anything_to_stop_the_pain/

 

[militarymd]

Our approach to this (and many other problems) is that, for whatever reason, we've gotten into the "zero tolerance for error" mindset in making decisions about these folks.

ie. We will only kick out people who have NO chance of recovery....even though we know that the rate of recidivism is extremely high.

The reality is this. It doesn't matter what decision we make...whether it is one foul up and your're out or we're going to give everyone a second chance.

There are going to be folks who will get screwed.

That one guy who really was just experiementing for the first time and will never do it again but got busted....will be out even though he could have had a long illustrious career.

Or that guy who we let back in...and kills someone because he was high.

Either way, we're not going to be 100% about making the right decision for everyone...but for some reason we feel like we have to.??????


I say we make a rule...either zero tolerance or not....and live with it.

I'm personally in favor of zero tolerance.....knowing that some people who could otherwise be rehabilited will never get a second chance.