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Anesthesiology:
doi: 10.1097/ALN.0b013e3181a207ab
Correspondence

One Strike, You’re Out: One Size Fits None

Berge, Keith H. M.D.§; Seppala, Marvin D. M.D.; Lanier, William L. M.D.

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In Reply:—

We thank the authors of the six letters to the editor, as well as the many other concerned readers of Anesthesiology who have contacted us personally, in response to our editorial1 on the abuse of narcotics and other anesthesia-associated drugs by anesthesiologists and related professionals (e.g., Certified Registered Nurse Anesthetists [CRNAs], Student Nurse Anesthetists, and Anesthesia Assistants), hereafter collectively referred to as anesthesia care providers (ACPs). The goal of our editorial was to promote scholarly discussion about the strengths and limitations of the anesthesiology community’s current approach to dealing with drug-abusing ACPs. All who have commented seem to agree that the anesthesiology community is faced with a serious problem, but the question remains, “What should we do about it?” Underlying the messages of all who have spoken is a concern about striking a balance between preserving the personal and professional rights of ACPs found abusing these drugs versus protecting the health and safety of both the drug abusers and the vulnerable patients in their care. Clearly it is difficult to make optimally informed decisions given the lack of information on the scope of the problem, deficiencies in the current approach, and the outcomes of all drug abusers (including drug-abusing ACPs involved in ideal treatment programs vs. those receiving suboptimal monitoring and care).
Despite these limitations, the Federation of State Physician Health Programs (dealing with physician programs) and the National Organization of Alternative Programs (dealing with nursing programs) have labored to provide uniform standards for Health Professionals Programs (HPPs; i.e., the individual state’s programs primarily responsible for monitoring and caring for drug-abusing physicians and nurses). Those who have embraced these standards and designed optimal treatment and aftercare programs, and the ACPs who have diligently participated in those programs and returned to meaningful employment, are to be commended for their efforts. Although not all 50 states have such well-functioning HPPs, and although the exemplary programs are not universally successful in treating drug-abusing ACPs and returning them to the workplace, the exemplary programs nevertheless represent an ideal worth striving for. Successful HPPs should be celebrated, replicated, and required for addicted ACPs who seek to return to healthcare employment.
Consistent with this view, authors of four of the six letters commenting on our article (i.e., Cohen, Earley, Skipper, and Specht) shared with readers the results reported by several studies conducted by state HPPs showing narcotic and related-drug abuse relapse rates for anesthesiologists no higher than with physicians in other specialties addicted to other drugs (most commonly alcohol). Of note, the authors of the 4 letters reported no deaths among the drug abusers. Skipper et al. refer to a subset of 102 addicted anesthesiologists with “slightly better outcomes and no deaths” in a recently published review of United States HPPs,2 although there are no published data in the reference that would allow us to confirm this conclusion. Thus, we must take this claim at face value, without the ability to critique and criticize the underlying evidence.
Despite the optimistic picture provided by many of the letter authors, anesthesiologists continue to relapse and die, as documented by the literature.3–5 That no deaths were captured in the data sets provided by the letter authors, and considering the small sample sizes involved in the various letter-writers’ comments, we must reflect on a point made by one of the corresponding authors, Dr. Berry, in an 2000 editorial where he and a coauthor introduced an article that had studied cause-specific mortality risk in 40,000 anesthesiologists.6 According to Berry and Fleisher, even with this large sample, the finding of a 34% excess risk of death of accidental poisoning (i.e., fatal overdose) in male anesthesiologists when compared with the risk of the general population did not reach statistical significance. Berry and Fleisher suggested that an even larger sample or a longer period of follow-up would be necessary to detect small yet statistically significant increases in risk.7 It is difficult to square this statement based on data from 40,000 anesthesiologists with the willingness of the current letter authors to rely on data sets that consist of 32,8 35,9 33,10 and 1022 presumably highly selected anesthesiologists to assert the relative safety of returning addicted anesthesiologists to the practice of clinical anesthesia. Skipper acknowledges the weakness of these data in a recent 2008 paper he coauthored concerning the effectiveness of HPPs, stating, “It is not possible from the evidence here to prove whether this form of support and monitoring for physicians with substance use disorders is appropriate, too harsh, or too permissive. Any episode of substance use in the context of patient care has the potential for considerable harm.”2 That an ACP who has suffered a relapse will almost certainly be caring for many patients between relapse and intervention is emphasized by Torri.
Others who contacted us independently of the correspondence section of Anesthesiology (and, for readily apparent reasons, did not want to publicly share their information because of the personal and professional consequences of doing so) emphasized the negative aspects of our current approach to dealing with drug-abusing ACPs. Some described to us their experiences in dealing with personality disorders, dishonesty, and uncollegial behavior that accompanied drug-abusing ACPs and their (and others’) efforts to cover up the abuse. Clearly these issues are not conducive to the type of cohesive work efforts required of a well-functioning anesthesia care team. And speaking of the anesthesia care team, we are troubled that only one author, Cohen, mentioned our CRNA colleagues, and then only to take us to task for not providing evidence of long-term monitoring of these individuals. The failure of the other authors to mention CRNAs and other nonphysician ACPs is perhaps explained by the fact that four of the six letters were authored by physicians who either work in programs specializing in the treatment of physician addiction or work with their state’s HPP. As such, the authors might reasonably be expected to focus more on physicians. However, our dismal experience with relapse in drug-abusing nonphysician ACPs, when contrasted with the excellent results these authors claim in their letters, may, in part, explain these letter authors’ bias against our proposed policy. But to answer Cohen, all but one of the CRNAs caught abusing workplace drugs left our employment by their own choice. Whether or not there was long-term monitoring in such cases is impossible to know, and the only follow-up we receive is from sad tales through old friends of multiple relapses and, in several situations, deaths. The one CRNA who remained in our employ relapsed multiple times and was ultimately dismissed. This episode occurred in the mid-1980s, and the records of the level of aftercare are unavailable to us because of confidentiality concerns.
While some of the letter authors referenced best-practice models of care and the (possible) acceptable outcomes they provide, it is clear that not all ACPs, including many of our CRNA colleagues, receive such superb care and aftercare. The expense of residential chemical dependency care (approximately $25,000 for the first month and $7,000–$10,000 for subsequent months [Marvin Seppala, M.D., personal communication, e-mail January 6, 2009] is a significant obstruction to many lacking the financial wherewithal of a physician’s income. Many have lost their job at this point, and such treatment would be financially ruinous. As such, they are often left to seek care in the outpatient setting, which many experts in chemical dependency feel may not offer the services and support required for successful long-term recovery. Even so, at approximately $5,000 to $9,000 for 6 to12 months of outpatient care, the cost may still be prohibitive (Marvin Seppala, M.D., personal communication, e-mail January 6, 2009). As well, the cost of the frequent (e.g., initially 4–6-times monthly) monitoring of biologic specimens can be quite daunting (e.g., a gas chromatography mass spectrometry test for fentanyl costs approximately $40 per sample, with an additional collection fee of $10 in one facility [Jones S, MN, Office Manager, Health Professionals Services Program, telephone conversation January 7, 2009]). Generally, this cost is borne by the employee, not the employer or an insurance company.
At present, the system (or, in some locales, lack of system) used to address drug-abusing anesthesiologists has wide disparities between best-practices and worst-practices. Hedberg* has proposed criteria that portend a good chance of success for return to the workplace. As suggested by several of the respondents when all of these criteria have been met, and the individual is reentering the workplace within the framework of a well-functioning HPP, we would concede that a second chance at anesthesia employment is not inappropriate. As these letter authors state, when all of these elements are present, considerable success can be expected. However, when one or more elements are missing, failure—assessed by recidivistic behavior and potentially death—becomes more likely.* As well, it must be pointed out that California, the state with the largest physician population in the United States, has recently shut down its HPP. Quoting the President of the California Medical Board, “… the diversion (HPP) program not only did not protect the public, but it was a failed concept, despite 27 yr of efforts to improve it.” He added, “Audit after audit showed the plan did not work for some participants. Abuse of the privilege of the program by some participants repeatedly put consumers at risk. Repeat offenders were pointed out in several audits as well as the ability for the participants to game the system.” Clearly, not every HPP is an unmitigated success.
Despite statements to the contrary by many of the letter authors, it remains our belief that in many instances the current approach to the drug-abusing ACP is to assume that a premium should be placed on returning the provider back to anesthesiology practice, even when some of the critical elements of the aforementioned formula of Hedberg* are missing. We believe that, in the minds of many, this constitutes the “default” position. Our view was simply to approach this problem from the other end of the spectrum: i.e., the default should be to not return the drug-abusing ACP to the practice of anesthesiology until we can ensure that all of the elements of the aforementioned formula are addressed. While we do not question the importance of clinical judgment in determining the treatment and aftercare most appropriate for an individual patient, we also believe that any omissions in the patient fulfilling all of the obligatory criteria of Hedberg will dictate that the drug-abusing ACP is “out” of anesthesiology practice. Our recommendations suggest that anesthesiologists who have become addicts should move to a practice setting with a less access to potent anesthesia drugs. Nonphysician ACP colleagues would move into a clinical setting where narcotic control mechanisms (e.g., witnessed administration and wasting) is possible, although doubtless at some loss of income and prestige.
In reply to Katz’s concern about our lumping together of “anesthetic drugs” and “supplements,” we concur that this was awkward wording. It was our desire to avoid verbosity while still conveying that we were speaking not only of parenteral opioid dependence, but also of propofol and volatile anesthetic abuse with their apparently equivalent risk of relapse and death. We stand corrected.
Clearly more research and practical application of the research findings are needed if we are to most appropriately care for those ACPs discovered to be abusing drugs. For example, are there any data to support the traditional 3- or 5-yr monitoring period? Given that one often hears chemical dependency experts state that “physicians are good at getting into compliance, but not good at getting into recovery,” would not a lifelong monitoring program be more appropriate? We would admit that a “one strike, you’re out” policy is overzealous should future research reveal that all addicted ACPs are receiving optimal care and aftercare, and that they in fact have no higher risk of death than practitioners in other areas of medicine. Until some future time when such data might become available, we believe that the path that presents the least potential harm is redirection into another area of practice those ACPs who have abused addictive drugs diverted from the workplace.
In closing, we applaud those authors who wrote to this journal to share with readers their exemplary experiences. Hopefully their experiences can be used as a beacon to guide others toward an ideal approach to dealing with drug-abusing ACPs, and to influence those locales where the approach to this problem is far less enlightened. However, before we concede that these programs represent a final solution for drug-abusing anesthesiologists and other ACPs, it is imperative that we have adequate research data (using valid study designs and outcome metrics, and appropriate data analysis) demonstrating these programs appropriately care for at- risk practitioners and the patients otherwise destined to be in their care.
Keith H. Berge, M.D.,§
Marvin D. Seppala, M.D.
William L. Lanier, M.D.
§Mayo Clinic, Rochester, Minnesota. berge.keith@mayo.edu
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References

1. Berge KH, Seppala MD, Lanier WL: The anesthesiology community’s approach to opioid- and anesthetic-abusing personnel: Time to change course. Anesthesiology 2008; 109:762–4

2. McLellan AT, Skipper GS, Campbell M, DuPont RL: Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ 2008; 337:2038

3. Menk EJ, Baumgarten RK, Kingsley CP, Culling RD, Middaugh R: Success of reentry into anesthesiology training programs by residents with a history of substance abuse. JAMA 1990; 263:3060–2

4. Wischmeyer PE, Johnson BR, Wilson JE, Dingmann C, Bachman HM, Roller E, Tran ZV, Henthorn TK: A survey of propofol abuse in academic anesthesia programs. Anesth Analg 2007; 105:1066–71

5. Wilson JE, Kiselanova N, Stevens Q, Lutz R, Mandler T, Tran ZV, Wischmeyer PE: A survey of inhalational anaesthetic abuse in anaesthesia training programmes. Anaesthesia 2008; 63:616–20

6. Alexander BH, Checkoway H, Nagahama SI, Domino KB: Cause-specific mortality risks of anesthesiologists. Anesthesiology 2000; 93:922–30

7. Berry AJ, Fleisher LA: Cause-specific mortality risks of anesthesiologists. New evidence for the existence of old problems. Anesthesiology 2000; 93:919–21

8. Paris RT, Canavan DI: Physician substance abuse impairment: Anesthesiologists vs. other specialties. J Addict Dis 1999; 18:1–7

9. Pelton C, Ikeda RM: The California Physicians Diversion Program’s experience with recovering anesthesiologists. J Psychoactive Drugs 1991; 23:427–31

10. Domino KB, Hornbein TF, Polissar NL, Renner G, Johnson J, Alberti S, Hankes L: Risk factors for relapse in health care professionals with substance use disorders. JAMA 2005; 293:1453–60

* Hedberg EB. Anesthesiologists: Addicted to the drugs they administer. ASA Newsletter 2001; 65 (http://www.asahq.org/Newsletters/2001/05_01/hedberg0501.htm) Last accessed 1/27/09. Cited Here...
http://www.mbc.ca.gov/licensee/diversion.html. Last accessed 1/27/09. Cited Here...
‡ Hedberg EB. Anesthesiologists: addicted to the drugs they administer. ASA Newsletter 2001; 65 (http://www.asahq.org/Newsletters/2001/05_01/hedberg0501.htm). Last accessed 1/27/09. Cited Here...

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