Exposure of anesthesia providers in recovery from substance abuse to potential triggering agents more

Journal of Clinical Anesthesia (2011) 23, 552–557 Original contribution Exposure of anesthesia providers in recovery from substance abuse to potential triggering agents☆ Heather Hamza CRNA, MS (Instructor in Clinical Anesthesiology) a , Ethan O. Bryson MD (Associate Professor) b,⁎ Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA; and Los Angeles County Hospital, Los Angeles, CA 90033-1029, USA b Department of Anesthesiology, Mount Sinai School of Medicine and Mount Sinai Medical Center, New York, NY 10029, USA Received 27 June 2010; revised 1 March 2011; accepted 5 March 2011 a Keywords: Anesthesia care providers; Anesthesiologists: addiction; Anesthetic agents: drug abuse; Nurse-anesthetists; Recovery Abstract Study Objective: To determine the experience, attitudes, and opinions of anesthesia providers in recovery from addiction to anesthetic agents, who subsequently undergo surgery or who require opioid analgesics for injuries or other conditions. Design: Survey instrument. Setting: Academic medical center. Subjects: Physicians and nurse-anesthetists in recovery in the United States. Measurements: A link to a survey was posted on the Anesthetists in Recovery website on January 17, 2010 and allowed to remain active for a period of one week. The survey also was distributed via email to recovering anesthesiologists in a “snowball sampling” method. Completed surveys were reviewed, and data were compiled using Survey Monkey, with categorical variables described as frequencies and percentages. Main Results: A total of 30 surveys were returned, with 27 (90%) reporting a history of abusing anesthetics or drugs commonly found in the work environment, and 19 (65.5%) reporting abuse of recreational drugs and drugs used during the administration of anesthesia. Twenty-eight (93%) respondents reported finding themselves in a situation that necessitated they receive their former drug of choice for legitimate medical reasons while in recovery. Conclusions: Anesthesia care providers in recovery from addiction to anesthetic agents may undergo subsequent exposure to these agents due to medical necessity. Participation in a program of recovery with support from family members may decrease the risk of relapse but does not eliminate it. © 2011 Elsevier Inc. All rights reserved. 1. Introduction Supported solely by Mount Sinai Medical Center departmental and institutional funding. ⁎ Correspondence: Ethan O. Bryson, MD, Department of Anesthesiology, Mount Sinai Hospital, One Gustave L. Levy Place, New York, NY 10029, USA. Tel.: +1 212 241 9240; fax: +1 212 876 3906. E-mail address: ethan.bryson@mountsinai.org (E.O. Bryson). 0952-8180/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2011.03.002 ☆ Historical data suggested that addiction is common among anesthesia care providers, although a more recent study has suggested that overrepresentation of anesthesia personnel in treatment facilities is due, at least in part, to the types of agents readily available and commonly abused [1]. Addiction and anesthesia care providers Once identified, the substance-abusing anesthesia provider is typically treated as an inpatient and required to participate in a monitoring program before returning to the clinical practice of anesthesia [2]. The terms of these monitoring contracts usually include an agreement to abstain from any moodaltering substances, including alcohol and over-the-counter medications, in addition to the substances abused by the practitioner in the past. As relapse is considered part of the disease of addiction [3], it is expected that a significant number of anesthesia providers in recovery will experience one or more relapses during the course of their treatment, and possibly after returning to the clinical practice of anesthesia [4]. Since mood-altering substances, even when medically indicated, have the potential to trigger a relapse, avoidance of any potential triggering agents is an essential part of recovery from substance abuse; however, there are instances when opioids and other such agents are unavoidable. The concern for preventing relapse in this population is especially elevated, as these individuals are at significantly increased risk for death in the event of relapse [5]. The odds are high that a practitioner in recovery will be faced with the dilemma of what to do when exposure to potential triggering agents is unavoidable. The anesthesia care provider who requires a surgery or procedure necessitating the very anesthetic agents to which they were previously addicted is in a position unique to this subset of patients treated for addiction. This survey was conducted to determine the experience of anesthesia care providers in recovery who have faced this dilemma and whether there are consistent opinions and practices regarding ways to address this problem when the situation arises. 553 risks associated with unavoidable exposure to possible triggering agents. Respondents were then asked for their opinions regarding which strategies worked best for anesthesia providers in recovery who find themselves in a similar situation. They were also asked to describe how they felt after receiving such agents. To maintain anonymity, no attempt was made to identify the respondents. Since nonrespondents could not be identified, it was not possible to follow up the initial survey with a second request for information. 3. Results During the 7 days in which the link to the survey remained posted on the Anesthetists in Recovery website, a total of 30 surveys were completed. Of the 30 anesthesia care providers who responded to the survey, 27 (90%) reported a history of abuse of anesthetics or drugs commonly found in the work environment. Respondents were then asked to report abuse of nonanesthetic-related drugs in addition to drugs commonly found in the work environment. The majority of respondents, 19 (65.5%), reported abuse of recreational drugs in addition to drugs used during the administration of anesthesia. Only 11 (36.6%) reported they abused only drugs commonly found in the work environment, and three (10.3%) reported abusing only those drugs not typically used during the administration of anesthesia, though each of the three respondents specified that they had entered a program of recovery prior to entering into a career in anesthesia. The distribution of drugs of abuse and route of administration is listed in Table 1. The most commonly abused opioid was fentanyl, with 26 (76.6%) respondents reporting abuse. Respondents who abused fentanyl typically did so via the intravenous (IV) route (72.7%), with smaller numbers ingesting the drug either via the intramuscular (IM) or subcutaneous route (22.7%), intranasal route (13.6%), or orally (9%). Only 10 (34.5%) respondents reported a history of sufentanil abuse. Interestingly, one respondent reported intranasal ingestion of sufentanil. Other opioids (Demerol, hydromorphone, morphine, Lortab, Percocet) were abused by 17 (58.6%) respondents. Self-medication with agents other than opioids also was reported by anesthesia care providers. Midazolam was reportedly abused by 11 (37.9%) respondents, primarily via the IV route (90.9%), though IM, subcutaneous, and intranasal ingestion also was reported. Following midazolam, other benzodiazepine abuse was reported in significantly lower numbers. Propofol abuse, entirely via the IV route, was reported by 6 (20%) respondents, and 7 (24.1%) reported abuse of ketamine, primarily intravenously; two respondents did report intranasal ingestion of ketamine. Two respondents reported abuse of inhaled agents, one who abused sevoflurane and a second who abused nitrous oxide. 2. Materials and methods The questionnaire was designed to elicit data regarding the personal experience of anesthesia providers in recovery who underwent a procedure requiring anesthesia or who required opioids for injuries after initial treatment for substance abuse. For purposes of this survey, the definition of recovery was not formally stated by the survey instrument. Responses were collected from any individual who selfreported previous use of mood-altering substances regardless of method of treatment and current participation in any formalized program. Because the survey was anonymous no attempt was made to identify respondents; institutional review board approval also was not required. Data requested included which substance(s) were abused and the route of self-administration, history of abuse of substances typically not found in the operating room (OR) environment, and a history of the need for anesthesia after treatment for substance abuse. Anesthesia providers who reported such experiences were asked to identify which steps they took to avoid exposure, if possible, or to mitigate the 554 Table 1 Distribution of drugs of abuse and route of administration Intravenous Fentanyl Sufentanil Other opioids Midazolam Other benzodiazepines Propofol Ketamine N2O Volatile agents Other anesthetic agents 73.9% (17) 60.0% (6) 77.8% (14) 90.9% (10) 50.0% (1) 100.0% (6) 71.4% (5) 0.0% (0) 0.0% (0) 40.0% (2) IM/SQ 21.7% (5) 20.0% (2) 22.2% (4) 9.1% (1) 0.0% (0) 0.0% (0) 0.0% (0) 0.0% (0) 0.0% (0) 0.0% (0) Intranasal 13.0% (3) 10.0% (1) 5.6% (1) 9.1% (1) 0.0% (0) 0.0% (0) 28.6% (2) 0.0% (0) 0.0% (0) 0.0% (0) Sublingual 4.3% (1) 10.0% (1) 0.0% (0) 0.0% (0) 0.0% (0) 0.0% (0) 0.0% (0) 0.0% (0) 0.0% (0) 20.0% (1) Other H. Hamza, E.O. Bryson Response count 23 10 18 11 2 6 7 1 1 5 4.3% (1) 0.0% (0) 11.1% (2) 0.0% (0) 50.0% (1) 0.0% (0) 0.0% (0) 100.0% (1) 100.0% (1) 40.0% (2) Data are percentages of respondents (no. of respondents). IM/SQ=intramuscular/subcutaneous route, N2O=nitrous oxide. The overwhelming majority of respondents, 28 (93.3%), reported finding themselves in a situation in which exposure to potential triggering agents was indicated for legitimate medical reasons, while they were in recovery from substance abuse. Specific circumstances surrounding the need for exposure included the development of painful medical conditions such as spinal stenosis requiring treatment with opioids, involvement in a motor vehicle accident (resulting in three fractured ribs), dental procedures (root canal), and general surgery (hand surgery, hernia repair, cervical laminectomy, bilateral mastectomy). When respondents who reported such experience were asked if they provided full disclosure to their healthcare provider regarding their status as a recovering anesthesia provider, 23 (85.2%) indicated that they had done so and only 4 (14.8%) indicated that they had not. When asked if they had requested to avoid triggering agents, only 11 (40.7%) stated they had done so. Specific reasons given by those who chose to avoid receiving potential triggering agents were: • I'm confident with my recovery. I'm not one to avoid my problems, I would rather be confronted with it. • Tried to avoid triggering agents, but pain was so severe they were required. Second surgery was able to avoid them altogether. • I asked that I not be sent home with a prescription for opiates. I also asked that the Versed be given before the opiate for induction so that I would not remember the “high.” • I was very early in recovery, requested a spinal but given a general. • With the extent of my surgery I was told that I would not be able to go without narcotics (had double mastectomy and lymph node dissection) – I asked for no triggers – but was told I needed the meds for the initial postop period. • I did not want fentanyl because of fear of triggering me. I also asked for Toradol postop instead of Vicodin. • My motivation was my commitment to my recovery. Wisdom teeth extraction was the procedure, which I requested be done under pure local. • Wanted to try other alternatives first, but without success ended up using narcotics, monitored by drug screens and combined with other therapy. • I wanted to stay away from narcotics and be given nonnarcotics when appropriate. The primary motivation for not attempting to avoid potential triggering agents by the 16 (59.3%) respondents who indicated that they made no such effort, included these responses: • Since I was retired I saw no reason to avoid these drugs as I would not have available (injectable/abusable) forms of the drug. • Ever have rib fractures? • I was having a root canal. • Actually, I chose the triggering agents so I could take some of the same agents home with me and not get caught on a drug screen. (I relapsed). • I did not want to avoid these drugs but I requested an extra large dose of midazolam prior to surgery because I didn't want to remember the “high”. • I knew that narcotics would be necessary. • I thought I had a ‘good program’ going to meetings, etc., but I did not have a plan for postop or for prescription management. • Cocaine (pharmaceutical), my drug of choice, was not indicated for the surgical procedure. • My anesthesiologist knew my situation and actually asked me if I wanted fentanyl. I said “of course.” • I requested regional block without intraoperative narcotics; received axillary block for ORIF of wrist fracture. • My exposure was related to an accident resulting in surgery, narcotics were needed for sufficient pain control. • I thought I would be OK as long as someone else was in control of the meds. • I was having shoulder surgery and did not think I would be able to avoid triggering agents. • I provided knowledgeable people I trusted with information regarding my history and left it up to them to determine how best to take care of me. Addiction and anesthesia care providers • Absolute need for post op pain management. The anesthesiologist used fentanyl. I was not concerned about surgical use of opiates, rather postop pain management. When respondents were asked if they were able to avoid triggering agents, regardless of whether they attempted to, only 8 (30%) indicated that they were successfully able to do so. Specific reasons why 70% of respondents were unable to avoid exposure primarily included references to surgical pain or that the decision was made by the healthcare provider to use these agents despite the request not to. One respondent reported that the “minor surgery could have been done without fentanyl, they used a lot of local anyway, but I prevented myself from avoiding these agents”. This person also reported a relapse, believed to be as a result of the experience. Alternative agents that were used with success to avoid triggering agents included a combination of the following techniques: local anesthesia without sedation (21.4%), regional anesthesia without sedation (14.3%), nonsteroidal anti-inflammatory drugs (64/3%), lidocaine patch (14.3%), and transcutaneous electrical nerve stimulation (TENS; 21.4%). The following choices all received no replies: COX-2 inhibitors, alpha-2 agonists, acupuncture, acupressure, and guided imagery (Fig. 1). Measures used to avoid relapse in spite of exposure to potential triggering agents included active participation in a 12step program (86.7%), having a sponsor hold the prescription (3.3%), having a relative or loved one hold the prescription (46.7%), keeping a journal of pain and recording the times that medications were taken (13.3%), returning unused medications 555 to the pharmacy (13.3%), and full disclosure to the healthcare provider regarding status in recovery (80%) (Fig. 2). When respondents were asked if they relapsed as a result of this experience, three (10%) answered that they had relapsed, while 27 (90%) reported that they had not. 4. Discussion We recognize that the disease of addiction is chronic and the success of any initial treatment is not that a “cure” has been achieved, but that the disease has been brought under control, much in the way a newly diagnosed diabetic may be hospitalized to achieve glycemic control, then discharged taking a regimen of medications and further outpatient management. Many patients' initial treatment may be conducted on an outpatient basis, though this is usually not the case with healthcare professionals, and an even greater number achieve abstinence through their participation in mutual self-help groups such as Alcoholics Anonymous or Narcotics Anonymous. For this reason, we chose to let individual respondents define what being “in recovery” meant, and allowed answers from anyone who self-reported a history of prior drug abuse. Of substances identified as being abused by anesthesia providers, fentanyl was reported by the majority (76.6%) of respondents requiring subsequent exposure to anesthesia, with other agents of abuse reported at much lower rates. Historically, fentanyl has been the most common drug of choice among anesthesia care providers who are addicted to opioids, due to Fig. 1 What alternative agents were you able to use to avoid triggering agents? 556 H. Hamza, E.O. Bryson Fig. 2 What other measures did you use to try to avoid relapse? availability and a pharmacokinetic profile that allows the user to continue to function while at work, albeit at a significantly reduced capacity. It is not surprising that the incidence of fentanyl abuse continues to remain greater than any other agents with abuse potential. Since fentanyl is also the most frequently administered opioid in the OR, it is reasonable to assume that the majority of respondents who presented for surgical procedures had legitimately received their former “drug of choice.” The concern here is that this reexposure to an agent to which the patient had been addicted would trigger a relapse. With the specific drug, fentanyl, if the patient has access to the drug a relapse could very likely result in death. Since none of the respondents who reported a relapse specified the drug they had begun using again, it is impossible to correlate exposure to a particular agent with relapse. Regarding full disclosure, the majority of respondents (80%) disclosed their substance abuse history to their anesthesia provider, which is encouraging. Possibly this was because they were able to select their anesthesiologist. The stigma of being an addict is a harsh reality. Healthcare providers, despite education and training, may still be judgmental and intolerant of drug addicts, often viewing addiction as a weakness or a moral issue instead of a disease. Therefore, it is unsurprising that addicts are reluctant to share this information. Perhaps another consideration is that of control. Addicts and anesthesia care providers love to be in control. When the anesthesiologist is the patient, he/she must relinquish control and trust the professionals taking care of him/her. If the anesthesiologist conveys an attitude of compassion and caring, this will facilitate the process. There are some significant limitations to this study that should be discussed. The survey depended on the recall of respondents and their willingness to participate in the study. It is possible that potential respondents with a different experience after exposure to potential triggering agents chose not to participate in this survey, which may have resulted in a skewed representation of the population under investigation. Legitimate concerns regarding privacy issues, compliance with the Health Insurance Portability and Accountability Act (HIPAA), or a desire to avoid the stigma associated with substance abuse may have influenced the degree of selfreporting of these issues. Since it is impossible to determine the number of individuals who chose not to take the survey, the response rate of 100% indicates only that every person who did so completed the survey. It is possible that the collected data do not represent a valid sample, and that those in the nonrespondent group are not representative of the whole. This survey was limited in its scope as it examined only the personal experiences of a small group of anesthesia care providers in recovery; however, we believe that such experiences are important to report and may spur further investigation into this issue. Extrapolating the specifics surrounding each case is difficult due to privacy and confidentiality concerns. 4.1. Factors associated with relapse potential When the responses from the three individuals who relapsed as a result of the experience are examined more closely, the common thread that emerges is the absence of a postoperative plan to avoid relapse. While it is clear that one Addiction and anesthesia care providers individual's postoperative plan actually included relapse as a goal, three of the individuals who reported relapse also reported that they had no structured plan in place to avoid it. Those individuals who avoided relapse also reported having a specific relapse prevention plan in place. Despite experiencing cravings and, in some cases, a desire to relapse after exposure, individuals with a relapse prevention plan in place before they received anesthesia or medication were able to avoid relapse. Several respondents reported “dysphoria” and other negative subjectivities after having received a drug to which they were formally addicted. Since 90% of these people did not relapse, could this “dysphoria” have been a protective factor? Future studies are needed to investigate the link between these subjective experiences in this population of recovering addicts and the potential for relapse. The authors posit that this “dysphoria” might actually be a conditioned response, first described by Abraham Wikler in 1948. This phenomenon was originally observed in drugfree, sober opioid addicts who were participating in group therapy. Wikler noted that just talking about drugs produced reactions that mimicked opioid abstinence syndrome (yawning, sniffling, eye tearing). Wikler provided the foundation for the conditioning model for relapse [6-8] and coined the term “conditioned withdrawal”. Thus, having received their old “drug of choice” might have been a cue to trigger a negative response. Regarding the “euphoric” effects, there is some evidence to support that extremely positive “first time” experiences with addicting substances correlates with predictability of subsequent abuse and/or dependence [9-12]. There could very well be an explanation for the intense euphoria. Volkow et al have extensively researched addiction, particularly via neuroimaging (functional magnetic resonance imaging and positron emission tomographic scans). It is hypothesized that addicts have a lower density of dopamine D2 receptors, resulting in less reward from natural reinforcers. This theory might explain the motivation to seek other exciting, rewarding experiences; then, once that is discovered, the natural reinforcers cannot compete with the newfound drug of choice [13,14]. 557 because the agents used routinely are so dangerous when self-administered. The decision that must be made, once an anesthesia care provider who has completed treatment for addiction and is in recovery requires exposure to potential triggering agents, is difficult at best. Since the risks inherent with relapse in this population are so great, care must be taken to reduce the potential for relapse with subsequent exposures. References [1] Talbott GD, Gallegos KV, Wilson PO, Porter TL. The Medical Association of Georgia's Impaired Physicians Program. Review of the first 1,000 physicians: analysis of specialty. JAMA 1987;257:2927-30. [2] Bryson EO, Silverstein JH. Addiction and substance abuse in anesthesiology. Anesthesiology 2008;109:905-17. [3] McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA 2000;284:1689-95. [4] Domino KB, Hornbein TF, Polissar NL, et al. Risk factors for relapse in health care professionals with substance use disorders. JAMA 2005;293:1453-60. [5] Waterhouse GJ, Roback HB, Moore RF, Martin PR. Perspectives of treatment efficacy with the substance dependent physician: a national survey. J Addict Dis 1997;16:123-38. [6] Marissen MA, Franken IH, Blanken P, van den Brink W, Hendriks VM. Cue exposure therapy for the treatment of opiate addiction: results of a randomized controlled clinical trial. Psychother Psychosom 2007;76:97-105. [7] Reid MS, Flammino F, Starosta A, Palamar J, Franck J. Physiological and subjective responding to alcohol cue exposure in alcoholics and control subjects: evidence for appetitive responding. J Neural Transm 2006;113:1519-35. [8] O'Brien CP, Childress AR, McLellan AT, Ehrman R. Classical conditioning in drug-dependent humans. Ann N Y Acad Sci 1992;654: 400-15. [9] DiFranza JR, Savageau JA, Fletcher K, et al. Recollections and repercussions of the first inhaled cigarette. Addict Behav 2004;29: 261-72. [10] Fergusson DM, Horwood LJ, Lynskey MT, Madden PA. Early reactions to cannabis predict later dependence. Arch Gen Psychiatry 2003;60:1033-9. [11] Grant JD, Scherrer JF, Lyons MJ, Tsuang M, True WR, Bucholz KK. Subjective reactions to cocaine and marijuana are associated with abuse and dependence. Addict Behav 2005;30:1574-86. [12] Haertzen CA, Kocher TR, Miyasato K. Reinforcements from the first drug experience can predict later drug habits and/or addiction: results with coffee, cigarettes, alcohol, barbiturates, minor and major tranquilizers, stimulants, marijuana, hallucinogens, heroin, opiates and cocaine. Drug Alcohol Depend 1983;11:147-65. [13] Volkow ND, Fowler JS, Wang GJ. The addicted human brain: insights from imaging studies. J Clin Investig 2003;111:1444-51. [14] Volkow ND, Fowler JS, Wang GJ. The addicted human brain viewed in the light of imaging studies: brain circuits and treatment strategies. Neuropharmacology 2004;47(Suppl 1):3-13. 4.2. Conclusion Substance abuse will continue to be a problem in our society, and affected individuals will be found in all medical subspecialties. The anesthesia specialty may be unique in that among practitioners there remains a high level of awareness surrounding addiction issues, perhaps