Special articleOne approach to the return to residency for anesthesia residents recovering from opioid addiction
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)
- et al.
Evidence of addiction by anesthesiologists as documented by hair analysis
Forensic Sci Int
(2005) - et al.
Occupational exposure and addictions for physicians: case studies and theoretical implications
Psychiatr Clin North Am
(2004) The impaired surgical resident
Surg Clin North Am
(2004)- et al.
Chemical dependency treatment outcomes of residents in anesthesiology: results of a survey
Anesth Analg
(2005) - et al.
Perspectives of treatment efficacy with the substance dependent physician: a national survey
J Addict Dis
(1997) Prevalence of alcohol and other drug problems among physicians
JAMA
(1986)
Cited by (20)
Anesthetic Drug Abuse by Anesthesiologists
2012, Revista Brasileira de AnestesiologiaBuprenorphine maintenance therapy in opioid-addicted health care professionals returning to clinical practice: A hidden controversy
2012, Mayo Clinic ProceedingsCitation Excerpt :Most nursing programs require a period away from clinical practice, ranging from a few months to a year or more, but this practice is not standardized and varies from state to state. Physician programs are equally varied, and although recommendations suggesting a minimum of 1 year have been made,25 there is still no consensus.26 When a formerly opioid-dependent HCP who is maintained with a full μ-opioid antagonist (naltrexone) returns to clinical practice, it undeniably strengthens the safety net.
Simulation-based Maintenance of Certification in Anesthesiology (MOCA) course optimization: Use of multi-modality educational activities
2012, Journal of Clinical AnesthesiaCitation Excerpt :Given the fact that attending a simulation-based course is expensive [the average course costs between $1,250.00 and $1,500.00 (USD), not including travel and lodging] and conducting such a course with the anticipated high throughput needs is a relatively new prospect for most simulation centers, it is important that members of SEN report their experience and attempt to maximize the efficiency and quality of their courses. We drew on our faculty's experience in simulation-based education and competency assessment and retraining of anesthesiologists [6-8] to create a MOCA course that was well received, required minimal facility and faculty resources, and fulfilled ABA requirements. This course was designed to optimize diplomate participation, education, and satisfaction while economizing faculty utilization and minimizing participant down time.
Drug Diversion, Chemical Dependence, and Anesthesiology
2011, Advances in AnesthesiaCitation Excerpt :Reentry for student nurse anesthetists is equally unsuccessful and risky [10]. Bryson and Levine [55] reported an innovative program for reentry in an academic center. The individual undergoes inpatient treatment, and on release to work they become faculty for an anesthesia simulation center.
Environmental cues and relapse: An old idea that is new for reentry of recovering anesthesia care professionals
2009, Mayo Clinic ProceedingsReentry of anesthesiology residents after treatment of chemical dependency-is it rational?
2008, Journal of Clinical Anesthesia