Download - 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; and§Division 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;95:1024–30)

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 (1–4). When alcohol isexcluded from such assessments, the incidence ofdrug dependency is estimated to be between 1% and2% (1,5–8). 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;95:1024–30 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 chair’s 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 Student’st-tests in the case of continuous variables and by using

Fisher’s 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;95:1024–30 CONTROLLED, EDUCATION, SUBSTANCE ABUSE IN ANESTHESIOLOGY

testing of anesthesia providers (Table 3). On this topic,60% of chairs thought that tightening regulation ofdrugs would decrease the incidence of CS abuse. Asimilar percentage (61%) indicated that they wouldapprove of random urine screens of anesthesia pro-viders. The actual practice of urine testing was unre-lated to the chair’s opinion on whether testing shouldbe implemented (P # 0.1).

DiscussionThe rate of known CS abuse in academic anesthesiol-ogy programs during the period 1990–1997 was 1.6%for residents and 1% for faculty. This rate was calcu-lated from 123 replies to 133 surveys, a response rateof 93%, sent out to the department chairs of every USanesthesiology program. From a study of anesthesiol-ogy residents between 1975 and 1989, Menk et al. (15)reported a 2% incidence rate for chemical addiction,which included alcohol and street drugs. Ward et al.(7) analyzed the 10-year period between 1970 and1980; they reported a drug abuse rate of 0.9% forresidents and 1.3% for faculty. Their data also in-cluded alcohol. Discrepancies in calculation methodsand the inclusion or exclusion of alcohol or streetdrugs in these and other previous studies make directcomparisons with our results difficult. However, itappears that the overall incidence of chemical depen-dence among anesthesiologists is unchanged.

The consequences of this incidence of CS abuse canbe inferred from other reports: one study compared

causes of mortality between anesthesia and internalmedicine physicians and reported a 2.8-fold increasedrisk from drug-related deaths in anesthesiologistscompared with internists (10). Although it is not cer-tain that anesthesiologists have use rates of psychoac-tive substances similar to those of internists (9–11,13,16), anesthesiologists do have greater access topotent opioids in the workplace. Our study indicatedthat the most commonly abused drug among anesthe-siologists was fentanyl, a drug associated with fre-quent morbidity and mortality (17,18). Furthermore,18% of CS abusers were identified by a drug overdoseproducing death or a near-death event. In contrast,Menk et al. (15), in a 1975–1989 study, found death ornear death to be the presenting symptom in 7.2% ofabusers.

Medical training has traditionally neglected drugand alcohol abuse awareness training (19–21). Per-haps in response to this, 55% of department chairsbelieved that increasing the number of hours of formaleducation would decrease the incidence of CS abuse.Furthermore, our results demonstrate that all resi-dents received at least one hour of drug abuse educa-tion. Although this is an improvement from the 1991survey of anesthesiology residents, in which 85%could not recall any substance abuse education at all(13), there are still some limitations. Our study dem-onstrated that 24% of faculty did not receive any ed-ucation, and in 31% of programs, education was elec-tive; spouses were not invited by 39% of programs.These figures illustrate the variability in the impor-tance with which education is regarded and incorpo-rated into programs. It is unclear whether this educa-tional focus is having an effect, because mostdepartment chairs (62%) believed that the incidence ofCS abuse was unchanged over the past 7 years. How-ever, it is difficult for us to ascertain whether thisopinion is accurate or whether, as 38% of chairpersonsasserted, the incidence of CS abuse has changed. Thisis because our data do not permit the calculation of theincidence of CS abuse on a year-by-year basis.

Anesthesiology drug control methods have changedsince the previous surveys were conducted. For ourstudy, 63% of department chairs reported that changeshad been made in their department’s methods for

Table 1. Operating Room Drugs Reported as Abused byResidents and Faculty (Raw Numbers)

Drug No. Residents No. Faculty

Fentanyl 73 16Sufentanil 12 4Cocaine 7 2Nitrous oxide 5 0Meperidine 3 0Midazolam 3 0Diazepam 2 1Ketamine 2 1Halothane 2 0Propofol 1 1Others 23 9

Others indicate either drugs not listed or drugs reported by class, e.g.,opioids, narcotics, or benzodiazepines.

Table 2. Dispensing Method of Controlled Substances(n $ 119)

Method n (%)

Traditional nurse dispensing 13 (11)Satellite pharmacy 50 (42)Locked box 19 (16)Dispensing machine 37 (31)

Table 3. Methods of Controlled-Substance Accountability(n $ 123)

Method n (%)

Pharmacy record 106 (85)Pharmacy summation 95 (77)Pharmacy comparison 98 (80)Analysis of residual returned controlled

substance59 (48)

Random tracking of controlled substance 48 (39)Random urine testing 19 (8)

1026 ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH BOOTH ET AL. ANESTH ANALGCONTROLLED, EDUCATION, SUBSTANCE ABUSE IN ANESTHESIOLOGY 2002;95:1024–30

dispensing, disposing of, and/or accounting for CSs.The greatest change in dispensing practice has been ashift away from nursing staff distribution of CS to theuse of dispensing machines. In our survey, only 11%of programs used traditional nurse dispensing, com-pared with 42% in a 1990 survey. In contrast, the useof dispensing machines increased from 4% in 1990 to29% in 1998 (Table 2). Accounting methods alsoshowed a move toward tighter control. In 1992, Kleinet al. (14) found that 21% of institutions used a dailyrecord of CS dispensing as their only method of ac-counting. At the time of our survey, this had de-creased to just 2% of programs using dispensingrecords as their only method of accountability. Fur-thermore, in 1990, Klein et al. found that 23% of insti-tutions conducted random chemical analysis of resid-ual CS. Our survey showed that this number has nowincreased to 48%. As noted, the survey population ofKlein et al. differed slightly from ours in that theirsincluded affiliated hospitals, whereas we specificallytargeted the primary teaching hospital. Despite thisdifference, the data indicate that there has been anincrease in the regulation of CS distribution over thelast 10 years in most institutions. Regarding the meth-ods of accountability, the majority of programs (80%)compared the amount of CS dispensed against indi-vidual provider usage, whereas only 8% used randomurine testing.

This study specifically examined the question ofabuse of CS available in the work setting of an anes-thesiologist. We did this to investigate whether tighterregulation of CS has occurred and whether tighterregulation had any effect on the incidence of abuse ofCS. Many substances can cause addiction that are notavailable in the OR setting, and these, e.g., alcohol, canhave a profound effect on individuals and families.We do not underestimate the importance of thesesubstances, and in fact these other substances mayhave a greater effect as a whole on anesthesiologists.However, investigation of these important matters isnot within the scope of this study. Indeed, it is un-likely that tighter regulation of CS in the OR will affectthese other issues.

We also chose to obtain data from the departmentalchairs’ (and their residency directors’) records. At thepresent time there is no continuing data collection at aregional or national level with regard to addictionamong anesthesiologists. Thus, our data, or any otherdata, are open to the criticism of being unverifiable.Although this may be true, we believe that if ourincidence of CS abuse is inaccurate, then it likely un-derestimates rather than overestimates the problem,because we relied on “discovered” cases only. Thus,our conclusions will not be altered. Of course, directlysurveying anesthesiologists would only bias the datatoward those still practicing (less likely to be stillabusing CSs) and would miss those who have left the

practice of anesthesiology (who are more likely to beabusing CSs). At the present time there are no “clean”data available, but we believe that our survey, evenwith this limitation, still correctly describes the prob-lem issues. We hope that our data will encourageothers to investigate these issues in more depth. Spe-cifically, there is a need for a national registry tomonitor the success or failure of efforts designed toreduce addiction.

Our survey determined that recommendations forincreased accountability and regulation of CS inacademic institutions have started to be imple-mented. Unfortunately, despite greater regulationand an increase in the education of anesthesia pro-viders with regard to chemical dependency, the in-cidence of CS abuse has not decreased (at least at thetime of the survey), and perhaps the lethality hasincreased. One possible solution to the problem israndom drug testing of providers. Urine drug test-ing is now a common practice in the US workplace,with more than 90% of companies with more than5000 employees using some form of testing program(22,23). Some authors claim that these programshave reduced the rate of drug-positive test resultsand resulted in cost savings for those companies(24). Others would argue that drug testing in theairline industry has only increased the cost of air-fare. In fact, even when the best available methodsare used, the validity of results is often questioned.Problems—such as false-positive results, chain ofcustody, reliability of assays, curtailing of individ-ual freedoms, and cost— have generally made test-ing unpopular. Nonetheless, our data suggest thatdespite these potential disadvantages, most chair-persons of academic institutions in the United Statessupport the random testing of anesthesia providers.The decision to implement a testing scheme in an-esthesiology programs should be based on balanc-ing the individuals’ rights against the potential ef-fect of a major accident attributable to the use ofdrugs in the workplace. It is important that all an-esthesiologists involve themselves in the debate onthis issue.

In conclusion, this survey indicates that the fre-quency of CS abuse has changed little in the past fewyears, whereas discovery of drug-dependent physi-cians is often a fatal or nearly fatal overdose. At thesame time, there has been an increase in the controland accounting procedures for CS, as well as in-creased mandatory education. It is unclear how effec-tive these methods have been, because the timing ofCS abuse cases may have occurred before or afteraccounting methods or education tightened. How-ever, it is clear that new, more effective means ofprevention are required if substance abuse amonganesthesiologists is to be reduced.


Appendix 1. QuestionnaireControlled Substances Accountability and Dependence in United States Academic Anesthesiology Programs

1. Choose the method of controlled substance dispensing which most closely resembles that used at theprimary anesthesia site in your primary training hospital.a. Traditional nurse dispensing-nurse dispenses controlled substances to anesthesia provider per patient

caseb. Traditional nurse dispensing-nurse dispenses controlled substances to anesthesia provider at one time

for use throughout the whole dayc. Satellite pharmacy-anesthesia provider checks out controlled substances to anesthesia provider at one

time per patient cased. Locked box-anesthesia provider checks out a box of controlled substances directly from pharmacy for

use through out the whole daye. Dispensing machines-anesthesia provider obtains controlled substance from vending machine per

patient case1a. Is this method the same as that used at the other sites/hospitals through which your residents

rotate? Yes No1b. If a second team of anesthesiologists take over an ongoing case, do they

a. Take over the pool of controlled substances already in use for that patientb. Obtain new controlled substances for their portion of the case

2. Choose the method of disposal of opened but unused (residual) portions of controlled substances whichmost closely resembles that used at the primary anesthesia site in your primary training hospital.a. Anesthesia provider wastes excess controlled substance without witnessb. Anesthesia provider wastes excess controlled substance with witnessc. Anesthesia provider return excess controlled substance to pharmacy

2a. Is this method the same as that used at the other sites/hospitals through which your residentsrotate? Yes No

3. Choose all of the methods of controlled substance accountability currently in use at the primaryanesthesia site in your primary training hospital.a. Pharmacy record of controlled substance dispensedb. Pharmacy summation of controlled substance dispensed and returnedc. Pharmacy comparison of controlled substance dispensed and returned, with amount used according to

anesthetic recordd. Required return of residual controlled substance with random chemical analysise. Random tracking of pattern of controlled substance dispensing and usage for a given anesthesia

providerf. Random urine testing of anesthesia providers for controlled substances

3a. Is this method the same as that used at the other sites/hospitals through which your residentsrotate? Yes No

4. Have your methods of dispensing, disposing, or accounting for controlled substances changes since thesummer of 1990? Yes No

5. How many faculty members are currently in the anesthesia department at your primary traininghospital?

6. How many residents/fellows began the CA-3 year or fellowship year in your program between 7/90 and7/96?

7. How many residents/fellows have had a problem with controlled substance abuse?8. How many faculty members have had a problem with controlled substance abuse?9. What was the substance of abuse?

10. How was the controlled substance abuse first suspected in each case?a. Voluntary admission


b. Witnessed admissionc. Behavioral changesd. Change in the pattern of controlled substance request/usagee. Controlled substance documentation discrepancyf. Drug testing or residual portions (opened but not used in patient care) of controlled substanceg. Random drug testing of anesthesia personnelh. Death related to controlled substance abusei. Other (describe)

11. How as the controlled substance abuse confirmed in each case?a. Volunteer admissionb. Confrontation and admissionc. Witnessed administrationd. Random drug testing of anesthesia personnele. Death related to controlled substance abusef. Other

12. What happened to this person?a. Treatmentb. Relapsec. Return to same residency or faculty positiond. Return to anesthesia elsewheree. Return to a different field of medicinef. Death related to controlled substance useg. Currently drug free

13. Would your program offer reemployment to a previously impaired resident/fellow after successfulcompletion of a treatment program?

14. Would your program offer reemployment a previously impaired faculty member after successfulcompletion of a treatment program?

15. Is it your department policy to cover that portion of the cost of controlled substance dependence therapynot covered by insurance for resident/fellow?

16. Is it your department’s policy to cover that portion of the cost controlled substance dependence therapynot covered by insurance for faculty members?

17. Is it your department policy to continue a residents/fellow salary during treatment? Yes No18. Is it your department policy to continue a faculty member salary during treatment? Yes No19. How many hours of formal education, regarding controlled substance abuse among anesthesia personnel,

does each resident/fellow currently receive per year?19a. Is attendance mandatory or elective?19b. Are spouses/significant other invited to attend?19c. Has the number of hours of formal education increased, decreased or stayed the same since June

1990? Increased Decreased Stay the same20. How many hours of formal education, regarding controlled substance abuse among anesthesia personnel,

does each faculty member currently receive per year?20a. Is attendance mandatory or elective?20b. Are spouses/significant others invited to attend? Yes No20c. Has the number of hours of formal education increased, decreased, or stayed the same since June

1990? Increased Decreased Same21. Does your department have a substance abuse committee or designated contact

person? Yes No22. Do you think that the incidence of controlled substance abuse among anesthesia personnel in academic

programs throughout the country has increased, decreased, or stayed the same since June1990? Increased Decreased Same


23. Do you think the incidence of controlled substance abuse can be decreased by tightening the methodswhich are used to dispense, dispose of, and account for controlled substances? Yes No

24. Do you think that the incidence of controlled substance abuse can be decreased by increasing the numberof house of formal education which anesthesia personnel receive regarding the issue?

25. Would you advocate random urine testing of anesthesia providers for controlled substances?26. Please use blank page for any suggestions/comments you have regarding the issues raised in this survey.

Appendix 2Definitions used in the survey include

Principal anesthetizing site: a building or hospital,not an OR.

Controlled substances: hypnotic controlled sub-stances, narcotics, benzodiazepines, or othermood-altering substances used in the practice ofanesthesia.

Residents/fellows: those completing CA3 year offinal year to avoid counting twice. If they did notcomplete the program, they were included in thefinal year they worked.

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