ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH: Special Article
Physician substance abuse is a significant societal problem that affects all aspects of medical care. Previous studies of addiction, which have included alcohol abuse, have projected that 10%–14% of physicians may become chemically dependent at some point in their careers (1–4). When alcohol is excluded from such assessments, the incidence of drug dependency is estimated to be between 1% and 2%(1,5–8). However, the incidence of physician substance abuse is not equally distributed across all medical subspecialties. Specifically, reports suggest that the incidence of chemical dependence may be most frequent among anesthesiologists (7,9). For instance, although anesthesiologists represented only 3% of physicians in 1983, 13% of physicians treated for substance abuse at one center during this period were anesthesiologists (9). Because published data are sparse and rely on potentially inaccurate or limited reporting methods, it is difficult to determine whether the published incidence in fact reflects the true incidence in our population.
Further concerns about controlled substance (CS) abuse derive from the fact that the largest rate of complications resulting from addiction occur early in a career. A recent study by Alexander et al. (10) reported that the most frequent rate of drug-related deaths for anesthesiologists occurred during the first 5 yr after medical school graduation. Factored another way, drug-related causes of death produce more than 2000 yr of life lost before age 65 for anesthesiologists (10). Occupational exposure and access to opioids and other psychotropic medication have been implicated as causes of the apparent overrepresentation of anesthesiologists with this disease (11,12). Thus, substance abuse among anesthesiologists is a vitally important issue with severe complications.
Efforts to reduce CS abuse by anesthesiologists have focused on education and tighter regulation of CSs. However, the efficacy of these approaches remains to be determined. With respect to the first approach, a 1991 survey of former anesthesiology residents found that more than 85% did not recall receiving any substance abuse education during their training (13). For the second approach, a study of anesthesiology programs found widely varying methods of CS dispensing and accounting, although at the time many institutions were implementing or planning to implement improvements (14). In this study, we sought to examine whether there have been changes in the incidence of CS abuse since 1990 and whether education and regulation policies designed to reduce CS abuse have been adopted on a widespread scale. Thus, our primary hypothesis was that the reported incidence of CS abuse was unchanged from previous reports, and our secondary hypothesis was that the control and accounting process involved in the distribution of operating room (OR) drugs has tightened. We focused our survey on anesthesiology programs at American academic medical centers.
Our substance abuse survey, along with a cover letter assuring anonymity, was sent to the department chairs of 133 US anesthesiology training programs at the end of 1997 (Appendix 1). A follow-up letter and a second identical copy of the survey were sent to all residency program chiefs, to increase the response rate. Surveys were completed and returned by June 1998.
The initial questions in the survey focused on methods of dispensing, disposing, and accounting for CS at the principal anesthetizing site in their primary teaching hospital. The second series of questions asked about resident/fellow or faculty members who had abused drugs. The residents/fellows were working between July 1990 and July 1996, and faculty were defined as attending physicians present between July 1990 and June 1997. All residents were accounted for only once between 1990 and 1996, whether they completed residency or not. Subsequent questions asked about the degree of formalized departmental education on drug abuse. The final part of the survey asked for the chair’s opinion on issues relating to drug abuse.
The surveys were hand-scored, and the data were compiled and analyzed with Systat. Continuous variables were described with means ± sd, and categorical variables were described with frequencies and percentages. Comparisons between actual practice and opinions about practice were made by using Student’s t-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 significance was two-sided P < 0.05.
Of the 133 programs surveyed, 123 surveys were received, for a response rate of 93%. Some questionnaires were incomplete, resulting in varying response rates for individual questions. The minimum response rate for any individual question was 118 (96%) of the surveys received.
A total of 167 anesthesiologists (both residents and faculty) were listed by the 123 respondents as having CS drug abuse issues. There were 133 of 8111 residents and 34 of 3555 faculty members with reported CS abuse issues. Thus, the incidence of known drug abuse was 1.0% among faculty members and 1.6% among residents over the period of the study. Fentanyl was the CS most often abused. Other drugs included ketamine and thiopental. Table 1 lists the OR drugs reported as being abused. Thirty individuals (18%) died or nearly died (required resuscitation) before any substance abuse was suspected. When department chairs were asked to compare the current incidence of drug abuse in academic programs with that existing in 1990, 62% believed that no changed had occurred, 12% believed that the incidence had increased, and 26% believed that the incidence had decreased.
The number of hours of formal education regarding drug abuse had increased in 47% of programs. For 69% of programs, this education was mandatory; partners of residents or faculty were invited in 61% of cases. There were no differences in the level of education (and regulation) between programs who reported no CS abuse cases and those who reported at least one (all P > 0.10). Despite two-thirds of the programs offering drug abuse training for faculty and residents, little more than half (55%) of the department chairs thought that increasing the number of hours of formal education would decrease the incidence. As one might expect, programs whose chairs believed that education was effective had more hours of drug abuse training for faculty (2.0 ± 1.6 h versus 1.4 ± 1.6 h;P < 0.05).
Sixty-three percent of programs surveyed had made changes in their methods for dispensing, disposing of, and/or accounting for CS over the past 7 yr. The most common method of drug dispensing was on a per-case basis, either by satellite pharmacy (42%) or via a dispensing machine (31%) (Table 2). The method for disposal of opened but unused portions of drugs was either return to the pharmacy (52%) or waste of residual with (41%) or without (7%) a witness. Regarding the methods of accountability, the majority of programs (80%) compared the amount of drugs dispensed against usage. Only 8% used random urine testing of anesthesia providers (Table 3). On this topic, 60% of chairs thought that tightening regulation of drugs would decrease the incidence of CS abuse. A similar percentage (61%) indicated that they would approve of random urine screens of anesthesia providers. The actual practice of urine testing was unrelated to the chair’s opinion on whether testing should be implemented (P > 0.1).
The rate of known CS abuse in academic anesthesiology programs during the period 1990–1997 was 1.6% for residents and 1% for faculty. This rate was calculated from 123 replies to 133 surveys, a response rate of 93%, sent out to the department chairs of every US anesthesiology program. From a study of anesthesiology 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 and 1980; they reported a drug abuse rate of 0.9% for residents and 1.3% for faculty. Their data also included alcohol. Discrepancies in calculation methods and the inclusion or exclusion of alcohol or street drugs in these and other previous studies make direct comparisons with our results difficult. However, it appears that the overall incidence of chemical dependence among anesthesiologists is unchanged.
The consequences of this incidence of CS abuse can be inferred from other reports: one study compared causes of mortality between anesthesia and internal medicine physicians and reported a 2.8-fold increased risk from drug-related deaths in anesthesiologists compared with internists (10). Although it is not certain that anesthesiologists have use rates of psychoactive substances similar to those of internists (9–11,13,16), anesthesiologists do have greater access to potent opioids in the workplace. Our study indicated that the most commonly abused drug among anesthesiologists was fentanyl, a drug associated with frequent morbidity and mortality (17,18). Furthermore, 18% of CS abusers were identified by a drug overdose producing death or a near-death event. In contrast, Menk et al. (15), in a 1975–1989 study, found death or near death to be the presenting symptom in 7.2% of abusers.
Medical training has traditionally neglected drug and alcohol abuse awareness training (19–21). Perhaps in response to this, 55% of department chairs believed that increasing the number of hours of formal education would decrease the incidence of CS abuse. Furthermore, our results demonstrate that all residents received at least one hour of drug abuse education. Although this is an improvement from the 1991 survey of anesthesiology residents, in which 85% could not recall any substance abuse education at all (13), there are still some limitations. Our study demonstrated that 24% of faculty did not receive any education, and in 31% of programs, education was elective; spouses were not invited by 39% of programs. These figures illustrate the variability in the importance with which education is regarded and incorporated into programs. It is unclear whether this educational focus is having an effect, because most department chairs (62%) believed that the incidence of CS abuse was unchanged over the past 7 years. However, it is difficult for us to ascertain whether this opinion is accurate or whether, as 38% of chairpersons asserted, the incidence of CS abuse has changed. This is because our data do not permit the calculation of the incidence of CS abuse on a year-by-year basis.
Anesthesiology drug control methods have changed since the previous surveys were conducted. For our study, 63% of department chairs reported that changes had been made in their department’s methods for dispensing, disposing of, and/or accounting for CSs. The greatest change in dispensing practice has been a shift away from nursing staff distribution of CS to the use of dispensing machines. In our survey, only 11% of programs used traditional nurse dispensing, compared with 42% in a 1990 survey. In contrast, the use of dispensing machines increased from 4% in 1990 to 29% in 1998 (Table 2). Accounting methods also showed a move toward tighter control. In 1992, Klein et al. (14) found that 21% of institutions used a daily record of CS dispensing as their only method of accounting. At the time of our survey, this had decreased to just 2% of programs using dispensing records as their only method of accountability. Furthermore, in 1990, Klein et al. found that 23% of institutions conducted random chemical analysis of residual CS. Our survey showed that this number has now increased to 48%. As noted, the survey population of Klein et al. differed slightly from ours in that theirs included affiliated hospitals, whereas we specifically targeted the primary teaching hospital. Despite this difference, the data indicate that there has been an increase in the regulation of CS distribution over the last 10 years in most institutions. Regarding the methods of accountability, the majority of programs (80%) compared the amount of CS dispensed against individual provider usage, whereas only 8% used random urine testing.
This study specifically examined the question of abuse of CS available in the work setting of an anesthesiologist. We did this to investigate whether tighter regulation of CS has occurred and whether tighter regulation had any effect on the incidence of abuse of CS. Many substances can cause addiction that are not available in the OR setting, and these, e.g., alcohol, can have a profound effect on individuals and families. We do not underestimate the importance of these substances, and in fact these other substances may have a greater effect as a whole on anesthesiologists. However, investigation of these important matters is not within the scope of this study. Indeed, it is unlikely that tighter regulation of CS in the OR will affect these other issues.
We also chose to obtain data from the departmental chairs’ (and their residency directors’) records. At the present time there is no continuing data collection at a regional or national level with regard to addiction among anesthesiologists. Thus, our data, or any other data, are open to the criticism of being unverifiable. Although this may be true, we believe that if our incidence of CS abuse is inaccurate, then it likely underestimates rather than overestimates the problem, because we relied on “discovered” cases only. Thus, our conclusions will not be altered. Of course, directly surveying anesthesiologists would only bias the data toward those still practicing (less likely to be still abusing CSs) and would miss those who have left the practice of anesthesiology (who are more likely to be abusing CSs). At the present time there are no “clean” data available, but we believe that our survey, even with this limitation, still correctly describes the problem issues. We hope that our data will encourage others to investigate these issues in more depth. Specifically, there is a need for a national registry to monitor the success or failure of efforts designed to reduce addiction.
Our survey determined that recommendations for increased accountability and regulation of CS in academic institutions have started to be implemented. Unfortunately, despite greater regulation and an increase in the education of anesthesia providers with regard to chemical dependency, the incidence of CS abuse has not decreased (at least at the time of the survey), and perhaps the lethality has increased. One possible solution to the problem is random drug testing of providers. Urine drug testing is now a common practice in the US workplace, with more than 90% of companies with more than 5000 employees using some form of testing program (22,23). Some authors claim that these programs have reduced the rate of drug-positive test results and resulted in cost savings for those companies (24). Others would argue that drug testing in the airline industry has only increased the cost of airfare. In fact, even when the best available methods are used, the validity of results is often questioned. Problems—such as false-positive results, chain of custody, reliability of assays, curtailing of individual freedoms, and cost—have generally made testing unpopular. Nonetheless, our data suggest that despite these potential disadvantages, most chairpersons of academic institutions in the United States support the random testing of anesthesia providers. The decision to implement a testing scheme in anesthesiology programs should be based on balancing the individuals’ rights against the potential effect of a major accident attributable to the use of drugs in the workplace. It is important that all anesthesiologists involve themselves in the debate on this issue.
In conclusion, this survey indicates that the frequency of CS abuse has changed little in the past few years, whereas discovery of drug-dependent physicians is often a fatal or nearly fatal overdose. At the same time, there has been an increase in the control and accounting procedures for CS, as well as increased mandatory education. It is unclear how effective these methods have been, because the timing of CS abuse cases may have occurred before or after accounting methods or education tightened. However, it is clear that new, more effective means of prevention are required if substance abuse among anesthesiologists is to be reduced.
Definitions used in the survey include
- Principal anesthetizing site: a building or hospital, not an OR.
- Controlled substances: hypnotic controlled substances, narcotics, benzodiazepines, or other mood-altering substances used in the practice of anesthesia.
- Residents/fellows: those completing CA3 year of final year to avoid counting twice. If they did not complete the program, they were included in the final year they worked.
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© 2002 International Anesthesia Research Society
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