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One approach to the return to residency for anesthesia residents recovering from opioid addiction

https://doi.org/10.1016/j.jclinane.2007.10.011Get rights and content

Abstract

Study Objective

There is a high rate of relapse among anesthesia residents attempting to re-enter clinical anesthesia training programs after completing treatment for opioid addiction. Individuals may return to clinical practice after a short period of treatment only to relapse into active addiction, and for the opioid addicted anesthesia resident, this often results in death. The objective of this study was to determine weather or not a period of time away from clinical practice after treatment would reduce the rate of relapse by allowing the individual to concentrate on recovery in the critical first year after treatment, during which the majority of relapses occur.

Design

5 residents identified as being addicted to a controlled substance were removed from residency training and offered treatment. Prior to returning to residency training they were required to complete a post-treatment program involving no less than 12 months of work in the anesthesia simulator, followed by a graded re-introduction into the clinical practice of anesthesia.

Setting

Academic anesthesia practice in a large teaching hospital.

Results

Of the 5 residents who participated in the program, 3 (60%) successfully completed their residency program and their 5 year monitoring contract, and entered the anesthesia workforce as attending anesthesiologists.

Conclusions

The treatment of addicted physicians can be successful, and return of the highly motivated individual to the clinical practice of Anesthesiology is a realistic goal, but this reintroduction must be undertaken in a careful, stepwise fashion. A full understanding of the disease process, the potential for relapse, and the implications of too rapid a return to practice must be taken into careful consideration.

Introduction

There is a high rate of relapse among anesthesia residents attempting to reenter clinical anesthesia training programs after completing treatment of opioid addiction [1]. Individuals may return to clinical practice after a short period of treatment only to relapse into active addiction [1]. For the opioid-addicted anesthesia resident, relapse often results in death [2]. A period away from clinical practice after treatment may reduce the rate of relapse by allowing the individual to concentrate on recovery in the critical first year after treatment, during which most of the relapses occur.

Between 1991 and 2001, 80% of US anesthesiology residency programs reported experience with impaired residents, and 19% reported at least one pretreatment fatality [1]. As recently as 2005, the drugs of choice for anesthesia residents entering treatment were opioids, with fentanyl and sufentanil topping the list [3]. Other sedative-hypnotics such as propofol, ketamine, thiopental sodium, lidocaine, nitrous oxide, and the potent volatile anesthetics are less frequently abused but have documented abuse potential. Factors proposed to explain the high incidence of drug abuse among anesthesia residents include proximity to potent drugs, easy diversion of these agents for personal use, and exposure in the workplace that sensitizes the reward pathways in the brain and promotes substance use [4].

Only limited data are available to determine the current prevalence of drug use by anesthesia personnel. Records of disciplinary actions, mortality statistics, and registries for known addicts provide some information, but it is difficult to interpret these types of data. In the past, it was concluded that the true prevalence of addiction in physicians was unknown [5], though it had been suggested that drug abuse is at least as prevalent as it was among the general population [6].

Relapse is considered part of the disease of addiction, and it is expected that a significant number of individuals in recovery will experience one or more relapses during the course of their treatment [7]. The idea that anesthesia residents who return to the clinical practice of anesthesia after successful treatment are at greater risk for relapse has not been shown to be true, but such individuals are, however, at increased risk of death in the event of relapse. Because the initial presentation of relapse in this population is often the death of the individual, it has been suggested that susceptible individuals identified as having a substance abuse disorder be encouraged to leave the specialty and retrain in another field [1]. Others have theorized that continuing with training in anesthesia may be no more dangerous for these individuals than attempting to retrain in another field in which there is less heightened awareness of addiction issues.

The Mount Sinai Hospital's Department of Anesthesiology (New York, NY) has taken an active role in the reintroduction into clinical practice of residents who are addicted to opioids. At our institution, we developed a program whereby anesthesia residents who complete inpatient treatment of addiction and are in recovery are allowed to work in the anesthesia simulator center in a nonclinical teaching capacity for a period of at least one year before returning to clinical practice of anesthesia. This program affords individuals a flexible schedule so that they may attend to the matters of early recovery such as attending daily mutual assistance meetings and building a sober network. The resident is paid a salary equivalent to that of an anesthesia resident, allowing the individual in recovery to attend to the financial obligations they have incurred and continue to incur as a result of their treatment. In addition, medical benefits cover some of the cost of ongoing treatment. Together with providing the anesthesiology resident in early recovery with a flexible schedule and the financial means to continue recovery, a stable nonclinical work environment is created in which the individual can be monitored.

Section snippets

Materials and methods

After successful discharge from inpatient treatment, residents are allowed to return to work at our anesthesia simulator center in a nonclinical teaching capacity for a period of at least one year. These residents must agree to the terms of a reentry contract that includes regular contact with their caseworker at the New York State Medical Society's Committee for Physician Health, worksite observation by a specified member of the anesthesia faculty, and random urine drug and alcohol screens.

Results

For the 12-year period from July 1, 1995, through June 30, 2006, our residency program trained 180 resident physicians. Of these physicians, 5 individuals (2.7%) were identified as being addicted to a controlled substance and were offered treatment. Each of the 5 individuals had become addicted to fentanyl while training in anesthesia, though concurrent use of other substances, including alcohol, was suspected. All 5 residents agreed to enter a treatment program consisting of inpatient

Discussion

Historically, it was thought that anesthesia, as a medical subspecialty, had one of the highest rates of addiction to alcohol or other drugs [9]. Data suggesting that addiction is common among anesthesiologists were reported in a review of 1,000 treated physicians conducted by Talbott et al [10]. Anesthesia residents represented 33.7% of all residents presenting for treatment, but comprised only 4.6% of all US resident physicians at the time of the study. Five years later, a study by Hughes et

References (12)

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