Substance Abuse Among Physicians- A Survey of Academic Anesthesiology Programs

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Transcript of Substance Abuse Among Physicians- A Survey of Academic Anesthesiology Programs

  • Substance Abuse Among Physicians: A Survey of AcademicAnesthesiology ProgramsJohn V. Booth, MB, ChB, FRCA*, Davida Grossman, MD, Jill Moore, BS,Catherine Lineberger, MD*, James D. Reynolds, PhD*, J. G. Reves, MD*, andDavid Sheffield, PhD*Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; West Jersey AnesthesiaAssociates, Marlton, New Jersey; School of Medicine, East Tennessee State University, Johnson City, Tennessee; andDivision of Cardiology, Department of Psychology, Staffordshire University, Stoke, United Kingdom

    Efforts to reduce controlled-substance abuse by anes-thesiologists have focused on education and tighterregulation of controlled substances. However, the effi-cacy of these approaches remains to be determined.Our hypotheses were that the reported incidence ofcontrolled-substance abuse is unchanged from previ-ous reports and that the control and accounting processinvolved in distribution of operating room drugs hastightened. We focused our survey on anesthesiologyprograms at American academic medical centers. Sur-veys were sent to the department chairs of the 133 USanesthesiology training programs accredited at the endof 1997. There was a response rate of 93%. The incidenceof known drug abuse was 1.0% among faculty members

    and 1.6% among residents. Fentanyl was the controlledsubstance most often abused. The number of hours offormal education regarding drug abuse had increasedin 47% of programs. Sixty-three percent of programssurveyed had tightened their methods for dispensing,disposing of, or accounting for controlled substances.The majority of programs (80%) compared the amountof controlled substances dispensed against individualprovider usage, whereas only 8% used random urinetesting. Sixty-one percent of departmental chairs indi-cated that they would approve of random urine screensof anesthesia providers.

    (Anesth Analg 2002;95:102430)

    P hysician substance abuse is a significant societalproblem that affects all aspects of medical care.Previous studies of addiction, which have in-cluded alcohol abuse, have projected that 10%14% ofphysicians may become chemically dependent atsome point in their careers (14). When alcohol isexcluded from such assessments, the incidence ofdrug dependency is estimated to be between 1% and2% (1,58). However, the incidence of physician sub-stance abuse is not equally distributed across all med-ical subspecialties. Specifically, reports suggest thatthe incidence of chemical dependence may be mostfrequent among anesthesiologists (7,9). For instance,although anesthesiologists represented only 3% of

    physicians in 1983, 13% of physicians treated for sub-stance abuse at one center during this period wereanesthesiologists (9). Because published data aresparse and rely on potentially inaccurate or limitedreporting methods, it is difficult to determine whetherthe published incidence in fact reflects the true inci-dence in our population.

    Further concerns about controlled substance (CS)abuse derive from the fact that the largest rate ofcomplications resulting from addiction occur earlyin a career. A recent study by Alexander et al. (10)reported that the most frequent rate of drug-relateddeaths for anesthesiologists occurred during thefirst 5 yr after medical school graduation. Factoredanother way, drug-related causes of death producemore than 2000 yr of life lost before age 65 foranesthesiologists (10). Occupational exposure andaccess to opioids and other psychotropic medicationhave been implicated as causes of the apparentoverrepresentation of anesthesiologists with thisdisease (11,12). Thus, substance abuse among anes-thesiologists is a vitally important issue with severecomplications.

    John V. Booth and Davida Grossman contributed equally to thisarticle.

    Presented in part at the annual meeting of the American Societyof Anesthesiologists, San Francisco, CA, October, 2000.

    Accepted for publication May 29, 2002.Address correspondence and reprint requests to John V. Booth,

    MB, ChB, FRCA, Box 3094, Department of Anesthesiology, DukeUniversity Medical Center, Durham, NC 27710. Address e-mail [email protected]

    DOI: 10.1213/01.ANE.0000026379.66419.DB

    2002 by the International Anesthesia Research Society1024 Anesth Analg 2002;95:102430 0003-2999/02

  • Efforts to reduce CS abuse by anesthesiologists havefocused on education and tighter regulation of CSs.However, the efficacy of these approaches remains tobe determined. With respect to the first approach, a1991 survey of former anesthesiology residents foundthat more than 85% did not recall receiving any sub-stance abuse education during their training (13). Forthe second approach, a study of anesthesiology pro-grams found widely varying methods of CS dispens-ing and accounting, although at the time many insti-tutions were implementing or planning to implementimprovements (14). In this study, we sought to exam-ine whether there have been changes in the incidenceof CS abuse since 1990 and whether education andregulation policies designed to reduce CS abuse havebeen adopted on a widespread scale. Thus, our pri-mary hypothesis was that the reported incidence of CSabuse was unchanged from previous reports, and oursecondary hypothesis was that the control and ac-counting process involved in the distribution of oper-ating room (OR) drugs has tightened. We focused oursurvey on anesthesiology programs at American aca-demic medical centers.

    MethodsOur substance abuse survey, along with a cover letterassuring anonymity, was sent to the departmentchairs of 133 US anesthesiology training programs atthe end of 1997 (Appendix 1). A follow-up letter and asecond identical copy of the survey were sent to allresidency program chiefs, to increase the responserate. Surveys were completed and returned by June1998.

    The initial questions in the survey focused on meth-ods of dispensing, disposing, and accounting for CS atthe principal anesthetizing site in their primary teach-ing hospital. The second series of questions askedabout resident/fellow or faculty members who hadabused drugs. The residents/fellows were workingbetween July 1990 and July 1996, and faculty weredefined as attending physicians present between July1990 and June 1997. All residents were accounted foronly once between 1990 and 1996, whether they com-pleted residency or not. Subsequent questions askedabout the degree of formalized departmental educa-tion on drug abuse. The final part of the survey askedfor the chairs opinion on issues relating to drugabuse.

    The surveys were hand-scored, and the data werecompiled and analyzed with Systat. Continuous vari-ables were described with means ! sd, and categoricalvariables were described with frequencies and per-centages. Comparisons between actual practice andopinions about practice were made by using Studentst-tests in the case of continuous variables and by using

    Fishers exact tests in the case of categorical variables.For all analyses, the criterion for statistical significancewas two-sided P " 0.05.

    ResultsOf the 133 programs surveyed, 123 surveys were re-ceived, for a response rate of 93%. Some question-naires were incomplete, resulting in varying responserates for individual questions. The minimum responserate for any individual question was 118 (96%) of thesurveys received.

    A total of 167 anesthesiologists (both residents andfaculty) were listed by the 123 respondents as havingCS drug abuse issues. There were 133 of 8111 residentsand 34 of 3555 faculty members with reported CSabuse issues. Thus, the incidence of known drug abusewas 1.0% among faculty members and 1.6% amongresidents over the period of the study. Fentanyl wasthe CS most often abused. Other drugs included ket-amine and thiopental. Table 1 lists the OR drugs re-ported as being abused. Thirty individuals (18%) diedor nearly died (required resuscitation) before any sub-stance abuse was suspected. When department chairswere asked to compare the current incidence of drugabuse in academic programs with that existing in 1990,62% believed that no changed had occurred, 12% be-lieved that the incidence had increased, and 26% be-lieved that the incidence had decreased.

    The number of hours of formal education regardingdrug abuse had increased in 47% of programs. For69% of programs, this education was mandatory; part-ners of residents or faculty were invited in 61% ofcases. There were no differences in the level of educa-tion (and regulation) between programs who reportedno CS abuse cases and those who reported at least one(all P # 0.10). Despite two-thirds of the programsoffering drug abuse training for faculty and residents,little more than half (55%) of the department chairsthought that increasing the number of hours of formaleducation would decrease the incidence. As one mightexpect, programs whose chairs believed that educa-tion was effective had more hours of drug abuse train-ing for faculty (2.0 ! 1.6 h versus 1.4 ! 1.6 h; P " 0.05).

    Sixty-three percent of programs surveyed had madechanges in their methods for dispensing, disposing of,and/or accounting for CS over the past 7 yr. The mostcommon method of drug dispensing was on a per-casebasis, either by satellite pharmacy (42%) or via a dis-pensing machine (31%) (Table 2). The method for dis-posal of opened but unused portions of drugs waseither return to the pharmacy (52%) or waste of resid-ual with (41%) or without (7%) a witness. Regardingthe methods of accountability, the majority of pro-grams (80%) compared the amount of drugs dis-pensed against usage. Only 8% used random urine

    ANESTH ANALG ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH BOOTH ET AL. 10252002;95:102430 CONTROLLED, EDUCATION, SUBSTANCE ABUSE IN ANESTHESIOLOGY

  • testing of anesthesia providers (Table 3). On this topic,60% of chairs thought that tightening regulation