Should Anesthesia Residents With a History of Substance Abuse Be Allowed to Continue Training In Clinical Anesthesia? The Results of a Survey of Anesthesia Residency … more

Journal of Clinical Anesthesia (2009) 21, 508–513 Original contribution Should anesthesia residents with a history of substance abuse be allowed to continue training in clinical anesthesia? The results of a survey of anesthesia residency program directors☆,☆☆ Ethan O. Bryson MD (Assistant Professor)⁎ Department of Anesthesiology, Mount Sinai Hospital, New York, NY 10029, USA Received 18 October 2007; revised 17 December 2008; accepted 18 December 2008 Keywords: Addiction; Anesthesia residents; Substance abuse; Reentry after treatment Abstract Study Objective: To determine the experience, attitudes, and opinions of program directors regarding the reintroduction of residents in recovery from substance abuse into the clinical practice of anesthesiology. Design: Survey instrument. Setting: Anesthesia residency training programs in the United States. Measurements: After obtaining institutional review board approval, a list of current academic anesthesia residency programs in the United States was compiled. A survey was mailed to 131 program directors along with a self-addressed stamped return envelope to ensure anonymity. Returned surveys were reviewed and data compiled by hand, with categorical variables described as frequency and percentages. Main Results: A total of 91 (69%) surveys were returned, representing experience with 11,293 residents over the ten-year period from July of 1997 through June of 2007. Fifty-six (62%) program directors reported experience with at least one resident requiring treatment for substance abuse. For residents allowed to continue with anesthesia residency training after treatment, the relapse rate was 29%. For those residents, death was the initial presentation of relapse in 10% of the reported cases. 43% of the program directors surveyed believe residents in recovery from addiction should be allowed to attempt re-entry while 30% believe that residents in recovery from addiction should not. Conclusions: The practice of allowing residents who have undergone treatment for substance abuse to return to their training program in clinical anesthesia remains highly controversial. They are often lost to follow-up, making it difficult, if not impossible to determine if re-training in a different medical specialty decreases their risk for relapse. A comprehensive assessment of the outcomes associated with alternatives to re-entry into clinical anesthesia training programs is needed. © 2009 Elsevier Inc. All rights reserved. ☆ Summary Statement: The practice of allowing residents who have undergone treatment for substance abuse to return to their training program in clinical anesthesia remains highly controversial. A comprehensive assessment of the outcomes associated with alternatives to re-entry into clinical anesthesia training programs is needed. ☆☆ Support Statement: Support was provided solely from institutional and departmental sources. ⁎ Tel.: +1 212 241 9240; fax: +1 212 876 3906. E-mail address: ethan.bryson@mountsinai.org. 0952-8180/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2008.12.026 Addiction and anesthesia residents 509 successful completion of any treatment program does not guarantee freedom from future relapse. The decision to allow a resident in recovery from substance abuse to return to clinical training in anesthesia is extremely complex. Multiple factors, such as the presence of co-existing psychiatric conditions, family history, and the strength of the residents' support system, both at home and within the institution, must be considered. This decision is almost always made by consensus, but it is often the residency program director who must implement these decisions. The decision of whether or not a resident should return to the clinical practice of anesthesia places a considerable burden on those who make it. 1. Introduction Data suggesting that addiction is common among anesthesiologists was first reported in a review of 1,000 treated physicians conducted by Talbott in 1987 [1]. At that time, anesthesia residents represented 33.7% of all residents presenting for treatment, a significantly higher percentage than one would expect if the prevalence of substance abuse were the same across all subspecialties. More recent studies have suggested that the overrepresentation of anesthesia personnel in treatment facilities is due, at least in part, to the types of agents typically abused, such as fentanyl and sufentanil. The functional deterioration that occurs with substance abuse occurs much earlier in the disease process when the abused agent has a shorter effective half-life [2,3]. Other studies have failed to show an increased incidence of substance abuse in anesthesio-logists as a group when compared to the general population [4]. A recent analysis of the cause-specific mortality risks for anestesiologists showed that the risk of drug-related death among anesthesiologists is highest in the first 5 years after medical school graduation, and remains elevated over that of other physicians [5]. The increased use of strict opioid control procedures and data analysis to uncover outliers in opioid administration within a department has likely resulted in higher detection rates of controlled substance diversion by anesthesia residents [6]. The odds are high that any given anesthesia residency program director will be faced with the dilemma of what to do with the resident who requires treatment for substance abuse at least once in their career. This survey was conducted to determine if there are consistent opinions and practices regarding reintroduction across institutions when confronted with this situation. As relapse is considered part of the disease of addiction, it is expected that a significant number of anesthesia residents in recovery will experience one or more relapses during the course of their treatment, and potentially after returning to the clinical practice of anesthesia [7]. The idea that anesthesia residents who return to residency training after successful treatment are at greater risk for relapse has not been shown to be true, but such individuals are, however, at increased risk of death in the event of a relapse [8]. Because of this, it has been suggested that residents identified as having a substance abuse disorder be encouraged to leave anesthesiology and retrain in another specialty [9]. Conversely, continuing with training in anesthesia may be safer for residents in recovery than attempting to re-train in another field with less heightened awareness of addiction issues. Hughes et al. found the rate of substance abuse in the anesthesia resident population to be no higher than that of other specialties, and in fact showed higher rates of substance abuse among emergency medicine and psychiatry residents [4]. Some highly motivated individuals have successfully re-entered the clinical practice of anesthesia and avoid relapse, but 2. Methods After obtaining institutional review board approval from the Mount Sinai Hospital Program for the Protection of Human Subjects, a questionnaire was developed. The questionnaire was designed to elicited data regarding the personal experience of anesthesia program directors with residents requiring treatment for substance abuse and their opinions regarding the practice of allowing these residents to continue their training in anesthesiology. Data requested included the number of residents identified as requiring treatment for substance abuse over the ten-year period covered by July 1, 1997 through June 30, 2007 and the number of residents enrolled in each program during the same period. Program directors who reported experience with such residents were asked to identify the substance being abused by the resident, the length of time the resident was required to remain free from clinical duties, whether or not allowances were made for recovery related obligations such as attendance at mutual-help meetings as well as individual and group therapy sessions upon return to clinical anesthesia training, and their subsequent experience with the resident. Responders were then asked their opinions regarding what protocol for reentry works best for anesthesia residents in recovery who wish to continue with their training. Program directors who reported no experience with residents requiring treatment for substance abuse were also asked their opinion. A list of current academic anesthesia residency programs in the United States was compiled using data from the Accreditation Council of Graduate Medical Education (ACGME) website; the survey was mailed to 131 program directors. Included with the survey and cover letter was a self-addressed stamped envelope to ensure anonymity. Returned surveys were reviewed and data was compiled by hand, with categorical variables described as frequency and percentage. Non-parametric data were analyzed using Fisher's exact test and the Jonckheere-Terpstra test. In order to maintain anonymity, no attempt was made to identify the respondents. Since non-responders could not be identified, it 510 was not possible to follow-up the initial survey with a second request for information. E.O. Bryson Table 2 Length of time away from clinical practice and relapse rate Time away from practice No. of residents 9 (9%) 15 (15%) 54 (54%) 7 (7%) 12 (12%) 2 (2%) Relapse rate 0 (0%) 3 (20%) 19 (35%) 0 (0%) 7 (58%) 0 (0%) 3. Results Of the 131 surveys that were distributed, a total of 91 (69%) were returned, representing experience with 11,293 residents in training. Fifty-six (62%) of the program directors reported experience with at least one resident requiring treatment for substance abuse during the ten year period covered, while thirty-five (38%) reported no experience. During the period covered by the survey, 135 residents (1.2%) were identified as requiring treatment for substance abuse. Of these residents, 87 (64%) were found to be abusing fentanyl. Table 1 lists the specific agents abused by residents and their frequency (note that some residents were found to be abusing multiple substances). Of the 135 residents with known substance abuse, only 99 (73.3%) were allowed to continue with their training, and most of these residents were required to spend three to six months out of clinical practice before returning to residency. Table 2 compares the length of time residents were required to remain away from clinical anesthesia practice with the rate of relapse. For residents allowed to continue with anesthesia residency training, the relapse rate was 29% (29 residents). There is a statistically significant difference between the period of time spent away from clinical practice and the rate of relapse (Fisher's Exact Test Pr=0.0135), and there appears to be a trend between the length of time out of clinical practice and an increased likelihood for relapse (Jonckheere-Terpstra Test 0.0636). Four residents who relapsed died, one while still undergoing treatment and three after reentering residency, representing a 3% incidence of death among residents allowed to re-enter clinical anesthesia training. Once residents returned to their training programs, all of the program directors reported making allowances for Less than one month One to two months Three to 6 months Seven to 9 months Ten to 12 months Greater than one year 99 residents were allowed to continue with anesthesia residency training. There were 29 resident relapses after resumption of clinical duties. attendance at self-help meetings and mandated therapy sessions. Of the 99 residents who were allowed to return to their clinical training programs, 59 (59%) were ultimately successful in completing the residency. Of the 40 who were not successful, 29 relapsed (three of whom died as a result of the relapse, a 10% risk for death when relapse occurs after reentry) and 11 were ultimately dismissed for other reasons such as poor clinical performance or they left voluntarily for another medical specialty. Table 3 lists the alternate medical fields identified as chosen by residents who left anesthesia (note that data is not available for all dismissed residents). Program directors were queried regarding their opinions on how residents in recovery from addiction who wish to return to the clinical practice of anesthesia should be handled. Respondents were given five answers to choose from and encouraged to add comments as they felt necessary (Table 4). Four (4.3%) of the respondents chose a brief period of inpatient treatment (30 days or less) followed by immediate reintroduction into the clinical practice of anesthesia. All of the program directors who chose this option reported experience with residents in recovery, had allowed reentry, and reported successful completion of residency training. Fourteen (15.5%) respondents chose an extended period of inpatient treatment (60-90 days or more) followed by Table 1 Primary substance abused by residents identified as requiring treatment Agent Fentanyl Alcohol Midazolam Opioid Tablets Propofol Benzodiazepine Tablets Demerol Marijuana Ambien Volatile agents Nitrous Oxide Frequency 87 22 17 14 11 4 4 4 2 2 2 Percent 64% 16.3% 12.6% 10.4% 8.1% 3% 3% 3% 1.5% 1.5% 1.5% Table 3 Choice of medical specialty after leaving anesthesiology No. of residents 13 10 9 8 2 2 2 Medical Specialty Internal Medicine Emergency Medicine Family Practice PM & R Addiction Medicine Pathology Surgery Note: some residents were identified as abusing more than one substance. Of the 72 residents who were either initially dismissed from their training programs or ultimately left anesthesia training for another medical specialty, their choice of secondary medical specialty is only known for 46 of the residents. PM & R=physical medicine and rehabilitation. Addiction and anesthesia residents Table 4 Program directors' opinions regarding attempted reintroduction correlated with the success of their strategy Option Number Number reporting who chose successful option reintroduction 511 issue of resident substance abuse at some point. The frequency with which this issue will arise obviously depends upon the size of the program and the number of residents in each class. In this survey, 62% of program directors encountered residents who required treatment for substance abuse. Of the substances identified as being abused by anesthesia residents, fentanyl was reported in the majority (64%) of residents requiring treatment, with other agents reported at much lower rates. Historically, fentanyl has been the most common drug of choice among anesthesiologists who are addicted to opioids, due to its 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. The reported percentage of propofol abuse (8.1%) is similar to the rate of 10 per 10,000 anesthesia providers per decade, as reported by Wischmeyer et al. [10]. It is unclear why the percentage of anesthesia residents found to be abusing inhalational agents in this survey (3%) is significantly lower than the incidence recently reported by Wilson et al. [11]. The percentage of anesthesia residents abusing opioid tablets has not been reported in the literature, so it is not possible to say whether the 10.4% observed incidence represents an increasing, decreasing, or stable trend. With the increased availability of opioids and other agents in tablet form via the internet, it is possible that the percentage of anesthesia residents abusing these agents is increasing. As stricter controls are placed on intravenous (IV) opioids by hospital pharmacies, it is possible that the decreased availability of these agents will result in an increased incidence in the abuse of oral agents obtained from outside sources. Since the risk of death is high when relapse occurs in this population, the decision to allow reentry should be made only when all of the factors that can contribute to relapse have been evaluated by qualified personnel. In a retrospective cohort study, Domino examined the rate of relapse among physicians involved in the Washington Physicians Health Program between 1991 and 2001 [7]. Twenty-five percent of the individuals in this study had at least one relapse after their initial treatment. Factors identified as being associated with an increased risk of relapse included a family history of substance use disorder, the use of a major opioid such as fentanyl, and the presence of a coexisting psychiatric disorder. When program directors allowed reentry, and this reentry was successful, they were more likely to state that residents should be allowed to re-enter clinical anesthesia training programs. Of the 40 program directors who stated that residents should be allowed to attempt reentry, successful completion of residency was reported in 28 cases (70%). It makes intuitive sense that someone who has been successful in the past would argue for the same treatment in the future. However, the 12 program directors who reported unsuccessful attempts still believe that attempted reentry should be allowed. A. 30 days of inpatient 4 (4.3%) 4 of 4 (100%) treatment or less followed by immediate reintroduction B. 60-90 days of inpatient 14 (15.5%) 12 of treatment followed by 12 (100%) immediate reintroduction C. 60-90 days of inpatient 14 (15.5%) 2 of 12 (16%) treatment followed by delayed reintroduction D. Disallow reintroduction 27 (30%) 0 of 8 (0%) E. No opinion 24 (26.5%) 4 of 4 (100%) Successful reintroduction is defined as the resident having completed the residency without relapse, and the “percent reporting successful reintroduction” includes only residents who were allowed to attempt reentry. Note that not all program directors who indicated a particular option as preferable allowed attempted reintroduction. immediate reintroduction into the clinical practice of anesthesia. Interestingly, two of the fourteen who chose this option had disallowed reentry. The other twelve program directors that chose this option reported experience with residents in recovery, had allowed reentry, and reported successful completion of residency training. Fourteen (15.5%) of the respondents chose an extended period of inpatient treatment (60-90 days or more) followed by a period of time away from the clinical practice of anesthesia (12 or more months) before attempted reintroduction. Interestingly, one of the fourteen who chose this option had disallowed reentry and one reported no experience within the ten-year period. Of the twelve respondents who allowed reentry, only two reported success. Twenty-seven (30%) of the respondents said that residents in recovery from addiction should not be allowed to return to the clinical practice of anesthesia. Of the 27, five reported no experience during the reporting period, twelve reported disallowing reentry, and eight reported unsuccessful attempts at reentry. Twenty-four (26.5%) respondents indicated that they had no opinion on this matter. Eighteen of the respondents who chose this option reported no experience during the period, but two reported disallowing reentry and four reported a successful reentry. 4. Discussion The frequency of anesthesia residents presenting with substance abuse issues in this survey (1.2%) is similar to the frequency reported in previous studies covering overlapping periods [9], suggesting that there is a high likelihood that any given academic anesthesia program will have to deal with the 512 Program directors with unsuccessful reentry attempts were more likely to state that residents should not be allowed to attempt reentry. Of the 27 program directors who stated that residents should not be allowed to attempt reentry, reentry was nonetheless allowed in 10 cases. Of these residents, successful completion of residency was reported in only 2 cases (20%). Once again, it makes sense that people with negative experience would argue against repeating the treatment. Of the 24 program directors who reported having no opinion on this matter, the clear majority (75%) reported having no experience with resident substance abuse at all, which also makes sense intuitively. Why two of the program directors who chose to disallow re-entry, and four of the program directors who reported successful reentry reported having no opinion, is not clear as no explanation was provided by the respondents. The ways in which the issue of reentry into clinical anesthesia training was handled varied significantly across institutions. This is an emotional issue that stirs up strong feelings in those who are involved. Strong emotions require a clearly defined plan of action based on evidence and experience. Unfortunately, this problem does not lend itself to such a simple solution. Our collective experience is extensive, but we are still lacking the strong evidence to suggest that when reentry is attempted, one protocol works better than another. Though the opinions regarding which treatment options should be used differ considerably, 43% of the program directors surveyed believe residents in recovery from addiction should be allowed to attempt reentry. On the other side of the argument, and with opinions just as strong, 30% believe that residents in recovery from addiction should not be allowed to return to the clinical practice of anesthesia. Clearly, there is no consensus on this issue. As this body of evidence and our experience continues to grow, it becomes clear that more investigation into this matter is essential. There are some significant limitations to this study that should be discussed. The survey depends upon the recall of the respondents, any number of whom may not have been the program director during the time covered by the study. In such instances, it is possible that the respondent is familiar with the previous history of the particular program, but there is no way to know for sure. Legitimate concerns regarding privacy issues, HIPPA compliance, or a desire to avoid the stigma associated with the issue of substance abuse may have influenced the degree of reporting on these issues. Since the response rate was not 100%, it is possible that the collected data do not represent a valid sample, and that those in the non-respondent group are not representative of the whole. This survey is limited in its scope as it examines only the length of time away from the clinical practice of anesthesia without investigating the specific circumstances surrounding the decision to let any particular resident return to their training program sooner or later. The statistical E.O. Bryson trend of increasing incidence of relapse observed in those residents who remained out of clinical training for a longer period of time is likely indicative of the presence of more complex issues such as co-morbid psychiatric conditions or absence of support structure, which necessitate longer treatment periods and are which associated with a greater potential for relapse, and not merely a reflection of the length of time a resident spends away from clinical anesthesia training. Further investigation into the specifics surrounding each case is difficult due to privacy and confidentiality concerns. 5. Conclusion Substance abuse will continue to be a problem in our society, and affected individuals will be found in all medical subspecialties. Anesthesia may be unique in that there remains a high level of awareness of addiction issues, perhaps because the agents we routinely use are so dangerous when self-administered. The decision that must be made once a resident who has completed treatment for addiction requests permission to continue with anesthesia training is difficult at best. Since the risks inherent in allowing reentry are so great, each case must be considered on an individual basis, in conjunction with the treatment team at the rehabilitation facility attended by the resident, and in consideration of the individual's circumstances. Acknowledgments I would like to acknowledge Dr. Hung-Mo Lin for assistance with statistical analysis. Appendix A. Survey Considering the past 10 years (the period of time covered by July 1, 1996 through June 30, 2006 or any portion thereof): 1. What is the total number of individual anesthesia residents found to be abusing controlled substances and/or alcohol during residency in your program? 2. What is the total number of ACGME certified residents in your program during the same period? 3. For each of the residents found to be abusing controlled substances and/or alcohol: A. What substance were they primarily using? Were there other substances involved? B. Were they dismissed from your program or allowed to continue with their residency training after some period of rehabilitation? Addiction and anesthesia residents C. If allowed to continue at your program, for how long were they out of clinical practice (while undergoing treatment, rehabilitation, etc.) before returning to residency? D. When they returned to clinical practice, were allowances made for attendance at group meetings and other recovery-related obligations? E. Did they relapse? If so, after what period of time? F. Were they successful in completing the residency at your institution? G. If they were dismissed from your program, did they re-enter anesthesia at a different program? If so, do you know if they successfully completed their residency? H. If not, did they stay in medicine (please indicate what specialty if you have this information) or leave medicine for another career? 4. For residents in recovery from addiction who wish to return to the clinical practice of anesthesia, what protocol, in your opinion, works best? A. A brief period of inpatient treatment (30 days or less) followed by immediate reintroduction into the clinical practice of anesthesia. B. An extended period of inpatient treatment (60-90 days or more) followed by immediate reintroduction into the clinical practice of anesthesia. C. An extended period of inpatient treatment (60-90 days or more) followed by a period of time away from the clinical practice of anesthesia (12 or more months) before attempted reintroduction. 513 D. Residents in recovery from addiction should not be allowed to return to the clinical practice of anesthesia. E. I have no opinion on this matter. 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] Aach RD, Girard DE, Humphrey H, et al. Alcohol and other substance abuse and impairment among physicians in residency training. Ann Intern Med 1992;116:245-54. [3] Silverstein JH, Silva DA, Iberti TJ. Opioid addiction in anesthesiology. Anesthesiology 1993;79:354-75. [4] Hughes PH, Baldwin DC Jr, Sheehan DV, et al. Resident physician substance use by specialty. Am J Psychiatry 1992;149:1348-54. [5] Alexander BH, Checkoway H, Nagahama SI, Domino KB. Cause-specific mortality risks of anesthesiologists. Anesthesiology 2000;93:922-30. [6] Epstein RH, Gratch DM, Grunwald A. Development of a scheduled drug diversion surveillance system based on an analysis of atypical drug transactions. Anesth Analg 2007;105:1053-60. [7] Domino KB. Risk factors for relapse in health care professionals with substance use disorders. JAMA 2005;293:1453-60. [8] Waterhouse GJ, Roback HB, Moore RF, et al. Perspectives of treatment efficacy with the substance dependent physician: a national survey. J Addict Dis 1997;16:123-38. [9] Collins GB. Chemical dependency treatment outcomes of residents in anesthesiology: results of a survey. Anesth Analg 2005;101:1457-62. [10] Wischmeyer PE, Johnson BR, Wilson JE, et al. A survey of propofol abuse in academic anesthesia programs. Anesth Analg 2007;105: 1066-71. [11] Wilson JE, Kiselanova N, Stevens Q, et al. A survey of inhalational anaesthetic abuse in anaesthesia training programmes. Anaesthesia 2008;63:616-20.