Edmond I Eger II, Lawrence J. Saidman and Rod N. Westhorpe (eds.)The Wondrous Story of Anesthesia10.1007/978-1-4614-8441-7_18
© Edmond I Eger, MD 2014
18. A History of Drug Addiction in Anesthesia
Department of Anesthesiology and Pain Medicine, University of Washington, 1959 NE Pacific Street, 98195-6540 Seattle, WA, USA
Christopher D. Kent
Addiction has been the dark shadow companion of anesthesia since the earliest days of the discovery of the remarkable effects of its central actions. The recognition of the dangers that anesthetic medications pose to anesthetists has slowly developed, with accelerated growth in recent years. Although anesthetists have taken many steps to identify, prevent and treat addiction among the members of the profession, the stigma attached to addiction has added to the complex challenges associated with broadening and deepening our understanding of it. The evaluation of the effectiveness of treatment and monitoring programs for addicted practitioners is limited at best and may, by nature of the problems faced, always be imperfect. The vigilance that anesthetists apply to their patient care must also include vigilance regarding the possibility of addiction among their colleagues to ensure that more anesthetists do not suffer the tragic fates of some pioneers in the profession.
KeywordsAddiction in anesthesiaAnesthesia and addictionPhysician addictionHistory of anesthesia addictionAnesthesia history
Heroes from the early history of anesthesia, Davy, Wells, Glover, and Halsted, all displayed a sometimes fatal addiction to inhaled anesthetics, cocaine, or opioids. Even before the 1900s, society debated whether addiction was a disease or an immoral weakness of will. In the 1890s, states (but not the Federal US government) passed anti-morphine laws to stem addiction. Observations at this time indicated that physicians might be at increased risk of addiction. In 1906, the Federal Pure Food and Drug Act banned importation of potentially harmful drugs, and the 1914 Harrison Narcotic Tax Act required the Treasury Department to enforce the law. In the 1930s, the US Public Health Service established drug addiction treatment hospitals having features consistent with a view of addiction as both disease and vice.
In his 1955 treatise on drug addiction among physicians, Marks estimated that roughly “…one out of every hundred physicians in the United States has been, or is, addicted to narcotics…”, and several (but not all) observers considered that anesthesiologists were at greater risk than other physicians. In 1975, the Georgia Medical Association funded an Impaired Physician Program to treat impaired physicians. In 1983, it found that anesthesiologists comprised 9.6% of its first 507 patients but made up only 4% of the physicians in the US. Studies from 1983 and 1984 corroborated the Georgia data. Surveys in the 2000s revealed that anesthesiologists frequently abused synthetic opioids, with propofol also emerging as a drug of abuse.
In the 1980s and 1990s, the anesthesia community responded to the addiction “epidemic” with tools for preventing drug abuse, for early detection of abuse, and for assisting in recovery. No study has shown that these tools are effective.
A retrospective survey of anesthesiology program directors in 1983 found a large incidence of relapse with death in anesthesiology residents using parenteral opioids, concluding that such residents should be redirected to an alternative career. However, a 1984 review of addiction among anesthesiologists by Spiegelman and colleagues suggested that 60–80% of addicted physicians sustained recovery after a return to practice, with the same recovery success as that of other physicians. Estimates from treatment programs in the 1990s suggested that up to 70% of addicted health care professionals successfully returned to medical practice, with a sustained recovery among anesthesiologists similar to that of physicians working in other areas. Independent reviews in 1994 and 2005 did not reveal that any patient injury resulted from errors made by impaired anesthesiologists.
The problem of addiction in anesthesia is real and substantial. Although much of the discussion applies to anesthesiologists, parallel problems and solutions appear for nurse anesthetists. For both groups, the history of addiction’s causes and management indicates that it is a soluble problem.
“It’s a poor sort of memory that only works backwards.”
’Lewis Carroll fromThrough the Looking Glass and What Alice Found There
Despite what Jefferson Airplane may have implied in their songWhite Rabbit, no evidence indicates that drug use inspired the fantastic scenes from Lewis Carroll’s stories. This introductory quotation merely reminds us that we need to project what we learn from our memories and history onto the future.
Discoveries and innovations in anesthesia and patient care are largely triumphs of hard work and celebrations of brilliant insights. But much might be learned from darker stories. The history of drug addiction in anesthesia reveals few triumphs, but does provide opportunities for insight, and perhaps redemption, in the stories of the lives affected and sometimes ended by this occupational hazard. Our burden of this disease has made us leaders in the struggle against it. By facing the problem of addiction in our profession, we better insure that our patients do not become additional victims of the disease.
Perhaps no other story in the history of anesthesia evokes such powerful emotional responses from anesthetists. At its heart are fundamental human questions; what are the limits of free will and of responsibility for choices affected by environment and genetics. It raises questions specific to our role as self-regulating professionals. How should we respond to the violation of professional trust? How do we simultaneously protect our patients while assisting and providing a safe second chance for each colleague in recovery? This chapter reviews the history of addiction, particularly as it broadens our understanding of the history of addiction among anesthetists. The review focuses on the medications used in daily anesthetic practice, those to which anesthetists have direct and sometimes unique access. We examine the stages of our recognition, as a specialty, of our problem with addiction, and the history of our evolving response to it.
Some terms we use require clarification. Drug addiction, drug abuse, and chemical and controlled substance misuse can be found in source materials on this topic but are not synonymous. Aside from alcohol, the substances most abused and the primary focus of addictions among anesthetists are opioids, so we frequently employ the terms opioid abuse and opioid addiction. The term narcotic originally meant any drug that produces narcosis or sleep, but now this term refers to substances whose use is legally restricted and includes activating substances such as cocaine, so the term is avoided except in direct quotation.
Finally, we note that the problem of addiction extends to all of the anesthesia community. The present chapter focuses on the problem in physicians. Nurse anesthetists and organizations such as the American Association of Nurse Anesthetists have confronted the same problem (see Chapter 22).
Pioneers in Discovery and Addiction
The story of addiction and anesthesia coincides with the discovery of inhalational anesthesia. In 1795, building on the work of Joseph Priestley, Humphry Davy isolated, contained and inhaled nitrous oxide. He briefly noted nitrous oxide’s potential as an anesthetic agent, but as the center of a group of creative luminaries such as the potter Josiah Wedgwood, and the poets Samuel Coleridge and William Wordsworth, Davy focused much of his attention on its recreational use. From 1798 to 1800, Davy inhaled nitrous oxide compulsively, providing evidence for an addiction in this description; “I ought to have observed that a desire to breathe the gas is always awakened in me by the sight of a person breathing, or even by that of an air-bag or an air-holder.” Although he eventually controlled his use of the drug and went on to unparalleled success as a chemist (e.g., he discovered the element sodium), Davy seems to have suffered short term health consequences from its use and the consequent inactivation of methionine synthase from prolonged exposure to nitrous oxide: “increased sensibility of touch: my fingers were pained by anything rough, and the tooth-edge produced from slighter causes than usual. I was certainly more irritable and felt more acutely from trifling circumstances .”
Fifty years later, Horace Wells in the U.S. and Robert Glover in the U.K. were not as fortunate as Davy. They lived out parallel stories of thwarted recognition and addiction that led to their deaths. Wells considered himself to be the discoverer of inhalational anesthesia. He provided a proof of concept with nitrous oxide use in his dental practice, and a partially successful demonstration with nitrous oxide in 1845 at the Massachusetts General Hospital. But William Morton’s triumph at the same site eclipsed Wells’ efforts on what became known as Ether Day in 1846 . The perception that Wells’ anesthetic was “humbug” while Morton’s was a miraculous success plagued Wells, as he vied, largely unsuccessfully with Morton and Charles Jackson, for recognition as the discoverer of anesthesia. Similarly, Glover felt cheated by James Simpson from the recognition of his (Glover’s) discovery of chloroform’s anesthetic potential. Glover had published the results of his studies with chloroform in animals 5 years before Simpson’s reports of chloroform anesthesia in humans .
The greatest tragedy in the lives of Wells and Glover was not the lack of recognition of their roles in the discovery of anesthesia, but their lack of recognition of the consequences of self-experimentation with chloroform. Wells was among the first practitioners to use it in the US but failed to appreciate the hazards that might result from its frequent use. Upon moving to New York City in 1848, Wells advertised his arrival in theHerald:
H. Wells, Surgeon Dentist, who is known as the discoverer of the wonderful effect of ether and various stimulating gases in annulling pain, would inform the citizens of New York that he has moved to this city, and will for the present attend personally to those who may require his professional services. It is now over three years since he first made this valuable discovery, and from that time to the present, not one of his patients has experienced the slightest ill effects from it; the sensation is highly pleasurable .
Wells asserted that breathing chloroform was “highly pleasurable”, a view arising from his frequent personal use of the anesthetic. What may have started as “scientific” experimentation to master the use of chloroform changed to something more sinister. Wells turned from its use as an anesthetic to its use for pleasure.
In an incident in the days leading up to his death, Wells recounted helping a male acquaintance obtain revenge upon a woman by providing sulfuric acid used subsequently to attack her. Three days later, after a prolonged chloroform binge, Wells apparently went on his own sulfuric acid rampage. Allegedly, he threw acid on two women. He claimed his chloroform-induced delirium impaired his memory of what happened. Wells was arrested and imprisoned. He was tortured by guilt over the effect that his actions would have on his personal and professional reputation, and the reputation of his family. He was escorted to his home to obtain toiletries for his stay in prison, and while there surreptitiously obtained chloroform and a razor. After returning to his cell, Wells wrote to his wife and others outlining his actions and remorse over the events of the preceding days. Then in the desperate isolation of his cell, Wells soaked a handkerchief with chloroform, secured it in his mouth, and slashed an artery in his left thigh. His death was reported as “suicide while under temporary insanity.”
Confounding our ability to make sense of the circumstances surrounding Wells’ death is the contemporaneous report of a police officer who could not find evidence of any women injured in an attack with acid. Nor could the officer find anyone who corroborated the initial testimony of the accusers appearing in court when Wells was arrested . Did Wells die in part as a result of the guilt and shame over hallucinatory experiences produced by chloroform intoxication? Wells’ death tragically parallels the deaths of others who desperately thought that they were trapped by the consequences of their drug use.
Glover’s equally tragic death from addiction was less dramatic and more protracted. He appears to be the first physician with documented poly-substance abuse. He became addicted to both opium and chloroform after treating himself for symptoms associated with dysentery acquired during the Crimean War in 1856. His death followed a slow decline over the next three years from heavy chloroform and opium use and was ruled an “accidental death by overdose of chloroform ingested to produce intoxication.”
William Halsted: Addiction to Cocaine and Morphine
In the first century after the introduction of ether, few physicians dedicated their practice to the delivery of anesthesia. Many who practiced anesthesia were surgeons like William Halsted. While he was a faculty member at Columbia University, Halsted experimented with the use of cocaine as a local anesthetic, demonstrating its capacity to block superficial nerves . He produced plexus anesthesia by direct application of cocaine to the nerves after open dissection and exposure, a lengthy process that should put in perspective present complaints by surgeons about delays associated with peripheral nerve blocks. While developing this expertise, Halsted became addicted to cocaine. The severity of his addiction prompted his closest friend and fellow physician, William Welch, to take Halsted on a long sea voyage to attempt a cure . Halsted demonstrated the depth of his addiction first by sneaking a stash of cocaine on board and then by breaking into the Captain’s locked medicine chest when his supply ran out.
Following this unsuccessful treatment, Halsted checked into a psychiatric hospital where in addition to the holistic treatments of “seclusion, fresh air, exercise, a healthful diet, and a gradual withdrawal from cocaine” he received morphine to treat the symptoms of cocaine withdrawal’thereby starting his lifelong addiction to morphine. In the first two years of his battle with morphine addiction, he re-entered the treatment facility and struggled to re-establish his reputation as a physician. Despite signs that he secretly used morphine and possibly cocaine for the rest of his life, Halsted became the Chief Surgeon at Johns Hopkins, recognized as both a great surgeon and pioneer in patient safety. In a diary unsealed in 1969, William Osler recounted having seen Halsted suffering from extreme chills. His conversation with Halsted on this subject led Osler to write, “[Halsted] has never been able to reduce the amount to less than three grains [of morphine] daily, on this he could do his work comfortably and maintain his excellent physical vigor…. I do not think that anyone suspected him… .” An entry in a letter from Halsted to Osler illustrates Halsted’s good fortune relative to some other colleagues, “Poor Hall and two other assistants of mine acquired the cocaine habit in the course of our experiments on ourselves’injecting nerves. They all died without recovering from the habit .”
Addiction: Moral Failure or Disease?
Halstead acquired his first addiction’to cocaine’through self-experimentation with a substance unrecognized as addictive, and his second addiction’to morphine’as treatment for the first. His life-long secrecy on the matter suggests that neither his accidental path to addiction nor the fact that opioids were widely and legally available in patent medicines could mitigate his shame in this matter. The recreational use of opioids in the US in the 19th century was primarily thought to be confined to opium smoking, a practice symbolically associated with Chinese immigrants. The most common path to opioid addiction, however, was through prescription and non-prescription medical use. Opium and its derivatives were used to treat acute and chronic pain, stress, insomnia, and menstrual pain .
Although 19th century control over opioid importation and distribution was limited, addiction to opioids appears to have been stigmatized. Some medical literature characterized opioid addiction as a loss of “moral will” or a problem that affected susceptible, weak individuals in the lower social classes [8,9]. In a brief chapter on the “Morphia Habit” in his textbook of 1892, Osler wrote, “Persons addicted to morphia are inveterate liars, and no reliance whatever can be placed upon their statements. In many instances this is not confined to matters relating to the vice .” Osler’s words have a moralizing tone absent from those used by his contemporary JB Mattison, the medical director of a home in Brooklyn for treatment of opiate addiction. Mattison wrote in 1894, “it is easy to moralize on the weak will’as many, mistakenly, are wont to put it … but talk about weak will as a reason why strong men succumb to morphia …is twaddle .”
The idea that addiction, starting with alcohol and later encompassing other drugs, is a disease rather than a sign of moral intemperance is more than 2000 years old. References to chronic drunkenness as a sickness of the body and soul, and the existence of specialized roles to care for people suffering from “drink madness” appear in writings from ancient Egypt and Greece . Benjamin Rush (1745–1813), a prominent American physician, advanced this idea, asserting that alcoholism was a disease in which alcohol is the causal agent, loss of control over drinking behavior the characteristic symptom, and total abstinence the only effective cure . Since the 1930s, the successful treatment approaches used by Alcoholics Anonymous and Narcotics Anonymous incorporate the idea that addiction is a disease requiring multi-faceted treatment [14,15].
In contrast, many societies and individuals, including physicians, held and continue to hold conflicting views as to the idea of addiction as disease. Physicians surveyed by the Treasury Committee’s 1919 reportTraffic in Narcotic Drugs were almost evenly divided on whether drug addiction was a disease or a vice . This idea of addiction as something other than disease has persisted, as apparent in this statement from a 1962 review article by a psychiatrist purportedly specializing in addiction: “Addiction is caused far more by human weakness than the drugs themselves and from the psychiatric point of view is essentially a symptom of personality maladjustment .” Even recently, psychologists and psychiatrists expressed dissenting opinions in response to the Recognizing Addiction as a Disease Act of 2007. This act was intended to change the name of the National Institute on Drug Abuse to the National Institute on Diseases of Addiction and the name of the National Institute on Alcohol Abuse and Alcoholism to the National Institute on Alcohol Disorders and Health. Some may consider this an empty battle over semantics, but therapists resisting the change assert that the disease terminology is bad for the public’s “mental health literacy” and is excessively fatalistic and disempowering, implying that users cannot fully free themselves of their drug or alcohol problems .
These opposing viewpoints underlie the conflicting responses to societal and individual problems associated with opioid addiction in US governmental policies, policies that have sometimes focused on the restriction of access to opioids and enforcement of legal penalties for abuse, while at other times centered on treating a disease. In the 1890s, although no federal laws restricted opioid distribution, various states began to pass anti-morphine laws, ostensibly to stem the rapidly increasing numbers of addicted individuals . Federal regulation of narcotics started with the passage of the Pure Food and Drug Act of 1906 which banned importation of any drug that could be considered harmful to the health of the people . But no practical means of regulating narcotic distribution existed before the 1914 Harrison Narcotic Tax Act that made the Treasury Department responsible for enforcement of the law. This required that physicians, pharmacists, dentists and veterinarians register to dispense certain opioids and cocaine. It made possession of these drugs illegal without a license or a prescription from a licensed professional. Initially, the Supreme Court ruled that the Harrison Act regulated a vice, and that professionals could not dispense opioids solely for the maintenance of an opioid addiction in the absence of another reason such as chronic pain .
Although there is a long history of private hospitals, retreats, and homes in the U.S. for the treatment of drug addiction, treatment at the federal level started in the 1930s with establishment of drug addiction treatment hospitals by the US Public Health Service in Fort Worth, Texas and Lexington, Kentucky. Having features of hospitals and prisons, these facilities manifested the divided view of drug addiction as both vice and disease. Drug-addicted individuals convicted of other crimes could be remanded involuntarily for treatment while persons without a criminal record but with a drug addiction could also apply for treatment .