Abstract
Addiction is a chronic disease characterized by relapse and low recovery rates in the general population. Outcome research in these populations indicates that diverging results are because of factors including length of treatment, pharmacotherapy for cravings, and long-term monitoring.
Keywords
addiction, opiates, opioids, propofol
Case Synopsis
A 38-year-old anesthesiologist is found unresponsive and cyanotic in the call room after failing to return from a break in the case of a patient undergoing a craniotomy for tumor. Both fresh and recent venipuncture sites are found on his left forearm, along with a 1-mL insulin syringe and a rubber tourniquet.
Acknowledgment
The authors wish to thank Dr. Adrie Bruijnzeel for his contribution to the previous edition of this chapter.
Problem Analysis
Definitions
The American Medical Association defines an impaired physician as “one unable to fulfill professional or personal responsibilities due to psychiatric illness, alcoholism or drug dependency.” This definition is in stark contrast to that for a professional athlete or a pilot, who is defined as impaired if “he or she is unfit for duty, shows up at work under-the-influence, or with residual effects.”
Recognition
Although drug testing is not mentioned in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), it is used to support clinical diagnosis because in addictive disorders, history from the patient is unreliable. A medical history with collateral information and physical examination coupled with confirmatory laboratory testing are needed to diagnose drug addiction. Direct observation of a health professional using drugs, obviously under the influence, diverting drugs as evidenced by inappropriately carrying or procuring drugs, or having withdrawal symptoms should trigger such an evaluation. The intensity and timing of opioid withdrawal depends on the particular opioid used and the dose and frequency of use. Abrupt withdrawal from opioids usually results in yawning, runny nose and eyes, anxiety, diffuse body aches, sleep disturbances, nausea, vomiting, diarrhea, goose flesh or piloerection, dilated pupils, diaphoresis, increased vital signs (pulse rate, respiratory rate, blood pressure), and a delusional fear that death will occur without opiates. These symptoms are associated with a very strong drive for the drug. Many anesthesiologists initiate opioid use taking them orally or snorting diverted liquid opioids but usually rapidly progress to intravenous use. Track marks and other physical evidence of parenteral use may be found on examination of an opioid-addicted anesthesiologist. Most anesthesiologists, however, are quite adept at using small-gauge needles and finding discreet intravenous injection sites. Because of a “conspiracy of silence,” often loved ones, physicians, and other professional colleagues will be in denial themselves that opioid addiction is the explanation for the aberrant behavior that the addict exhibits. Frequently the addiction will progress until an overdose situation leaves no other explanation. Addiction medicine professionals and experienced addicts recognize that a protracted withdrawal syndrome, which may last for months and include episodes of sweats, night terrors, dysphoria, drug craving, and malaise, generally follows the acute withdrawal phase with its dramatic symptoms.
Laboratory diagnosis is the gold standard for confirmation of drug use. Drug testing is available and reliable when the correct methodology is used and the correct specimen for the particular opioid being abused is tested. Urine is the most commonly tested specimen. Point-of-care immunoassay testing provides immediate presumptive screening results. Thin-layer chromatography is the most inexpensive and commonly used comprehensive test. Gas chromatography with mass spectroscopy is the most exact confirmatory testing method. Hair or nail testing provides a much longer window of detection of drug use and should be part of comprehensive evaluations of suspected opioid-addicted anesthesiologists, especially if urine testing results are negative. It is crucial to specifically request testing for synthetic opioids such as fentanyl and its analogs because the usual standard drug test for opiates only screens for morphine, codeine, hydrocodone, and hydromorphone.
Risk Assessment
Opiates have been important analgesics and drugs of abuse for centuries. With the availability of parenterally administered opiates and the invention of the hypodermic syringe, opiate addiction and withdrawal distress became major issues following the American Civil War, with morphine addiction being known as soldier’s disease. The shift in the prescribing paradigm for oral opioids in this country from the mid-1990s through the present has created a full-blown opioid epidemic. Drug addiction is a disorder characterized by craving, compulsive drug use, continued use despite adverse consequences, and relapses or failed attempts to cut down with tolerance and withdrawal symptoms with cessation of drug use especially in the case of opioids.
The concept of drug tolerance was originally based on the observation that opioids lose their physiologic effects with repeated use. As tolerance develops, drug-dependent subjects progressively increase the dose of the drug to achieve the originally experienced euphoric effects. In the psychopharmacologic context, tolerance is an organism’s adaptive response to supraphysiologic levels of an exogenous substance. A major consequence of this adaptation is that on cessation of drug use, the physiologic adaptations remain unopposed and induce a physiologic withdrawal syndrome specific to the class of drug. After chronic opioid use, cessation can induce a severe physical withdrawal syndrome including diarrhea, hypertension, tachycardia, vomiting, and muscle cramps. Depression, dysphoria, or negative affective symptoms (e.g., anhedonia) are associated with the cessation of almost all drugs of abuse, including opioids. Depression and suicide are common comorbidities with drug abuse and dependence, especially after intervention. Anesthesiologists have both the knowledge and means of successfully completing a suicide attempt, and a safety plan should be in place to reduce this risk, especially from the time of intervention until the time of admission for addiction treatment.
Addiction among health professionals is a significant public health problem. Health care professionals are in safety-sensitive occupations. Without intervention and treatment, impaired professionals harm themselves, their families, and their patients. Although treatment outcomes for physician addicts are remarkably positive, there is a dearth of research on the primary prevention of substance abuse and dependence in this population. Researchers have studied opioid-addicted physicians for decades, reported on the use of clonidine and naltrexone in this population, and followed them for many years after detoxification and initial formal treatment. Although physicians are overrepresented among prescription drug addicts, their rates of alcohol abuse and dependence are similar to those of appropriately matched controls.
All medical schools and hospitals encounter cases of physician opioid abuse, dependence, and overdose. However, they attribute these events to poor self-regulation or ease of drug access. Substance abuse and addiction appears to be an occupational hazard among physicians, especially anesthesiologists. To become a physician, one must be a high achiever throughout high school and college to obtain the required grades and test scores for medical school admission. Additionally, potential physicians must continue to excel throughout medical school to gain internships and residencies.
Physicians seem unlikely candidates for opioid injection and self-administration. However, they are 30 to 100 times more likely to become addicted to narcotics than the general population. One study estimated that 12.5% of male physicians are drug dependent, compared with 0.1% of men in the general population. Although alcohol-related disorders and cigarette smoking rates were comparable between physicians and other Harvard University graduates, physicians had higher rates of drug use and prescription drug abuse, depression, depression with substance abuse, and suicide than other age- and sex-matched professionals. At least 15% of all physicians will become markedly impaired during their careers. Stress and access have dominated the theories for physician use and dependence, but basic scientists who conduct research with cocaine or narcotics do not usually use these drugs themselves. Not all medical subspecialties are equally represented among physicians with substance use disorders ( Fig. 4.1 ). Anesthesiologists administer highly potent anesthetics including extremely potent opioids to patients; they work in a confined space around the patient’s head and are exposed in the workplace to discarded drugs (e.g., opioids, propofol, benzodiazepines) that affect the brain, emotions, and behavior. This exposure sensitizes their brains to these highly addictive drugs such that if they are then used by the sensitized anesthesiologist, addiction develops more rapidly than it would otherwise.
