The drug seeking anesthesia care provider more

The Drug Seeking Anesthesia Care Provider Ethan O. Bryson, MD* Mount Sinai Medical Center New York, NY Heather Hamza, MS, CRNAw Los Angels County Medical Center Los Angels, CA Despite increased awareness of the issue, the potential for addiction among anesthesia care providers (ACPs) still represents a significant source of morbidity and mortality. Though the incidence of alcoholism and other forms of impairment such as mental illness is similar to other professions, ACPs have a higher rate of substance use disorders. Although the drug of choice for anesthesia personnel entering treatment for substance abuse is usually an opioid, abuse of propofol, ketamine, sodium thiopental, lidocaine, nitrous oxide, and the potent volatile anesthetics has also been reported. Many theories have been proposed to explain the high incidence of drug abuse among ACPs. The proximity to large quantities of highly addictive drugs may be contributory to the development of addiction in those at risk. Despite strict controls and accounting measures, it remains relatively easy to divert controlled substances for personal use. Some have cited the high stress environment in which ACPs work as a contributing factor, and others have suggested that exposure to trace quantities to these agents in the workplace sensitizes the reward pathways in the brain and promotes substance abuse. Still others have proposed that individuals with novelty-seeking behavior traits may be both more likely to choose a career in anesthesia and more prone to the development of addiction. It is important to note that none of the proposed theories has been able to identify a specific cause, but rather merely suggest factors that may increase the risk of developing addiction among anesthesia personnel. FROM THE *MOUNT SINAI MEDICAL CENTER AND THE wLOS ANGELS COUNTY MEDICAL CENTER REPRINTS: ETHAN O. BRYSON, MD, DEPARTMENT OF ANESTHESIOLOGY, MOUNT SINAI MEDICAL CENTER, ONE GUSTAVE L. LEVY PLACE, NEW YORK, NY 10029, E-MAIL: ETHAN.BRYSON@MOUNTSINAI.ORG INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 49, Number 1, 157–171 r 2011, Lippincott Williams & Wilkins www.anesthesiaclinics.com | 157 158 ’ Bryson and Hamza An association between chemical dependence and other psychopathology may contribute to the development of addiction in susceptible individuals. It has been suggested that a source of motivation for the self-administration of drugs of abuse is the self-medication of symptoms associated with comorbid psychiatric disorders. The observation that individuals with the same personality traits tend to self-administer drugs from the same class, that is opioids for anxiety and depression and amphetamines for attention deficit and hyperactivity states, lends credence to this theory. Others have suggested that we self-administer the drugs that we are comfortable with, those that we administer to others on a regular basis. This would explain the observation that anesthesia providers abuse opioids more frequently than any other class of drug, psychiatrists more commonly abuse benzodiazepines, and emergency medicine personnel are likely to abuse cocaine and other ‘‘street drugs’’ classically seen in the emergency room. Though it may be difficult for many to understand why someone motivated and intelligent enough to become an ACP would abuse the agents they use, when one has an appreciation of the fundamentals of addiction, it becomes clear why an addicted ACP would be willing to lose everything to obtain their drug of choice. ’ Incidence and Prevalence Healthcare professionals are not by any means immune from developing the disease of addiction. Recent evidence suggests that 10% to 15% of all healthcare providers will misuse or abuse drugs or alcohol at some point in their career.1 Estimates regarding the incidence of addiction in physicians and nurses varies by source, though most experts agree that there is not an increased prevalence among healthcare providers in general and the number of addicted individuals in this population tends to mirror that of the population as a whole.2–5 When one looks more closely at these data, however, it becomes clear that there is an increased incidence of addiction to specific types of drugs by provider types.6 For ACPs, there is a higher incidence of opioid abuse. Rates of controlled substance abuse for anesthesiologists, which typically involves fentanyl or another major opioid, have recently been reported as 1.6% for residents and 1% for attending physicians.7 Though there is little data specifically looking at the rates of addiction in Certified Registered Nurse Anesthetists (CRNAs), earlier studies involving all anesthesia providers found a similar incidence of 1% to 2%.8 It should be pointed out, however, that these numbers represent the known cases, that is, those cases which come to the attention of the authorities either through the death or respiratory arrest of the individual from overdose, witnessed self-injection, or through referral to www.anesthesiaclinics.com The Drug Seeking Anesthesia Care Provider ’ 159 treatment programs. The actual number of ACPs diverting anesthetics for personal use is likely to be much higher. In an effort to describe diversion of, but not necessarily addiction to, controlled substances by CRNAs, Bell et al mailed self-administered surveys to randomly selected CRNAs, actively practicing in the United States in both 1999 and 2006 (unpublished data, 2006).9 Response rates were good (68% to 78%), and represented 11% of actively practicing CRNAs at the time of the survey. In both surveys, 10% of the CRNAs admitted to diversion of controlled substances. The demographics of CRNAs who admitted to self-administration of these controlled substances (sex, years in practice) remained unchanged between the surveys, though the type of drug abused did change. In the 1999 survey, the most common drug diverted for personal use were benzodiazepines, followed by opiates; whereas fentanyl and propofol abuse were more common in the 2006 survey. ’ Signs and Symptoms The chemically dependent ACP generally seeks to maintain a job in close proximity to their source of drugs. The addict may volunteer for additional evening and weekend assignments or for long cases in which large opioid requirements would be expected. However, these behaviors are also exhibited by ACPs seeking to increase personal income or establish a reputation in major cases. Thus the behaviors are not unique to addicts. Rather, changes in behavior are frequently noted with periods of irritability, anger, euphoria, and depression. Some of the changes typically observed in the addicted ACP are listed in Table 1. Although addiction to alcohol may take years to become apparent, addiction to the short-acting opioids, fentanyl and especially sufentanil, becomes apparent over the course of a few months of use. Depending on the half-life of the abused agent, tolerance can develop rapidly. Selfadministration of 1000 mg (20 mL) of fentanyl in a single injection has been reported by addicts and described as simply relieving the symptoms of withdrawal. The massive tolerance can in part be attributed to the basic pharmacodynamic profile of opiates. As the ‘‘effective dose’’ rises, so does the lethal dose. This gives the abuser a wide therapeutic index. However, after only a brief period of abstinence, the dosage requirements return to normal. This is why the first sign of a relapse is commonly a fatal overdose. When actively using, an addicted ACP will often request increased quantities of opioids on Fridays in preparation for an extended period of time away from work. Early identification of the addicted ACP can prevent harm to both the impaired provider and his or her patients. Unfortunately, the entire picture is seldom appreciated by any 1 person. Friends and family may observe behavioral changes at home that may pass unnoticed by www.anesthesiaclinics.com 160 ’ Bryson and Hamza Table 1. Some of the Changes Typically Observed in the Addicted Anesthesia Care Provider Withdrawal from family, friends, and leisure activities as more time is spent at work where the drug can be used Mood swings, with periods of depression or bad moods alternating with periods of euphoria or gregariousness, depending upon whether the addicted provider is high or in withdrawal Increasing episodes of anger, irritability and hostility. Increased sensitivity to criticism Spending more time at the hospital, even when off duty, often with odd intentions (coming in on a Saturday afternoon to ‘‘set up’’ a room for a case scheduled for late on Monday) in order to obtain and use drugs Volunteering for extra call as an excuse to remain at work, offering to ‘‘set up’’ rooms for other providers Refusing relief for lunch or coffee breaks, so that their diversion of drugs for personal use is not discovered Requesting frequent bathroom breaks, during which the addicted provider frequently self-administers drugs Failure to respond to pager, difficult to arouse when on night call Signing out increasing amounts of narcotics or quantities inappropriate for the given case so that more is available for self-administration Frequent ‘‘ampoule breakage’’ and increased ‘‘waste’’ Weight loss and pale skin, as less time and energy are spent taking care of themselves Wearing long sleeves or other clothing designed to hide physical evidence of self-injection colleagues at work and are attributed to stress on the job. Hanging around work may be interpreted as stress at home. The individual who suffers from addiction is almost always the last to recognize that a problem exists. It is therefore important that the people who are most likely to observe the signs and symptoms of addiction gain a clear understanding of the disease and what to do if they suspect someone may have a problem. Education regarding the potential dangers of addiction and its clinical presentation is important for both the ACPs and their significant others. When an ACP is diverting medications, the signs are classically seen at home first. The addict may display several changes in their personality, which becomes more evident as the disease progresses. They may appear irritable, restless, or discontent and become emotionally labile and withdrawn. Family members or those who live with the addicted ACP may find needles, syringes, tourniquets, vials, and other paraphernalia in the house. When confronted with these items, the addict will have well-crafted excuses, justifications, and rationales. At work, diversion may be suspected when patients are brought into the postanesthesia care unit in great pain despite an www.anesthesiaclinics.com The Drug Seeking Anesthesia Care Provider ’ 161 Table 2. Signs and Symptoms Typically Observed in the Addicted Anesthesia Provider Experiencing Opioid Withdrawal Irritability Dysphoria Intense drug craving Nausea and vomiting Diarrhea Anorexia Muscle aches and or back pain Lacrimation Rhinorrhea Diaphoresis Mydriasis Yawning Fever Insomnia Amenorrhea anesthetic record, which indicates that large amounts of opiates were administered. The most common ‘‘drug of choice’’ for an addicted ACP is usually an opiate such as fentanyl, sufentanil, hydromorphone, or meperidine. When someone is addicted to opiates, they stop feeling ‘‘high’’ after a short period of regular use, but must continue to self-administer to avoid withdrawal symptoms. Although opiate withdrawal is rarely life threatening, it is extremely unpleasant and self-administration of opioids simply to avoid these symptoms becomes a very powerful motivation for the dependent addict. Some of the signs and symptoms typically observed in the addicted anesthesia provider experiencing opioid withdrawal are listed in Table 2. Withdrawal from any drug, including opioids, has the potential to result in physical harm to the patient and the individual should always be detoxified under medical supervision. Death is not uncommon during the unsupervised withdrawal from alcohol, benzodiazepines, or barbiturates. Although it is rare for an individual to die while in withdrawal from opioids, the potential for myocardial infarction in at-risk individuals secondary to the tachycardia associated with opioid withdrawal exists, and these patients should also be detoxified under medical supervision. ’ Intervention Unfortunately, many addicted anesthesia providers are first identified when a crisis, particularly an overdose, occurs. Because of this, www.anesthesiaclinics.com 162 ’ Bryson and Hamza anesthesia groups should have a designated individual (or group) responsible for the health and welfare of its members who has sufficient information and expertise to assist in interventions on colleagues whose behavior raises concerns. This is an extremely sensitive position that must be handled with extreme care to avoid ruining the career of a colleague. Erratic behavior may have many causes and professionals learn to avoid using the term addiction without clear support of such a diagnosis. All too often, instead of a proper and safe intervention, the addict is simply confronted inappropriately. They may be called into the office of a colleague and asked to give a urine drug screen under penalty of termination if they refuse. They may be cornered and questioned about their unusual use of intraoperative narcotics abruptly, instead of being presented with organized and irrefutable evidence in an atmosphere of care and concern. Worse still, if discovered they may be forcibly removed from the hospital by security without any plan in place for detoxification and treatment. Suggestions for how a proper intervention should be conducted are included in Table 3. It should be made clear that this is not an exhaustive list, nor do we intend that someone untrained in the proper way in which to conduct an intervention would be able to do so by simply reading this. Table 3. What You Should and Should Not Do During an Intervention Have a trained interventionist present at all times It is better to have a larger group than a smaller one. Include the individual’s spouse, family members, friends, and colleagues as well. It is appropriate to include anyone who is close with the individual so long as they are supportive of the intervention and will not be disruptive Be sensitive to gender, that is, do not have all males on the intervention team if the individual is a female Bring all of your evidence, including a properly collected drug screen (witnessed micturition, chain of custody, split specimen) Do not let a person leave the intervention by themselves. Do not let them drive. Impaired individuals may become suicidal once the gravity of the situation they are in becomes apparent, and they may have a ‘‘stash’’ in their car or locker Make arrangements for direct transfer to an inpatient facility prior to the intervention. SAMHSA search engine: http://dasis3.samhsa.gov/Accessed 01/18/ 2010 Do not let the addict decide their treatment. Remember, they are sick and they will minimize the problem Only as a last resort, when all else fails, you should threaten to call the police. Often this is what will cause them to finally admit that they have a serious problem. When someone is in the throes of addiction, they are surrounded by a wall of denial. An intervention will either build the wall higher or break it down— which is why it is so critical to do it right www.anesthesiaclinics.com The Drug Seeking Anesthesia Care Provider ’ ’ 163 Legal Issues and State Reporting Not every state requires mandatory reporting of impaired healthcare professionals if patient harm has not occurred; however, this should not preclude one from filing a complaint if you believe the individual is impaired and represents an imminent danger to themselves or others. This can be done anonymously through either the state medical or nursing board as appropriate or via direct contact with the state medical or nursing society. Often, coworkers are reluctant to report a colleague for a variety of reasons. Fear of harming someone professionally or of simply being wrong can provide strong motivation to make excuses for behavior that is clearly suspect. It cannot be stressed enough that when an individual is actively addicted, they are not capable of safely performing their duties as a trained healthcare professional. The term ‘‘active addiction’’ may cause some confusion. This refers to the disease model of addiction, in which a patient who is actively using is said to be in ‘‘active addiction.’’ Addiction is a chronic, relapsing disease and the treated addict who is in remission is still an addict, even though they are no longer using drugs, but in this context, the addict in recovery does not pose a threat to the safety of others. Not bringing an affected individual to the attention of those who can help does a great disservice to the addict, as well as the addict’s patients, the hospital, and the profession as a whole. As well, such behavior may leave people open to legal liability if the impaired anesthesia provider subsequently injures a patient. In Kadlec Medical Center versus Lakeview Anesthesia Associates, the United States court of Appeals for the Fifth Circuit found that the defendants, anesthesiologists who dismissed a member of their group for self-administration of anesthetic agents, were partially liable for injury caused by the impaired physician who subsequently gained employment based partially on their positive letters of reference. Granted there is a difference between failure to report an impaired individual and providing that individual with a positive letter of recommendation that fails to mention current untreated drug use, but the moral imperative is clear. When one has first-hand knowledge of provider impairment, there is an ethical obligation to properly report it, and to get the individual the help that they need. ’ Physician Health Programs and Other Alternatives to Discipline Whether or not an individual identified as requiring treatment for substance abuse will ultimately lose their medical license depends on the individual circumstances. Often the medical board does not become involved and the physician’s license is not in jeopardy. If the physician is www.anesthesiaclinics.com 164 ’ Bryson and Hamza not compliant with the Physician Health Program (PHP), they will be reported to the medical board and at that time the license is suspended or revoked. If patient harm has occurred, the board is usually involved from the start and the license is suspended pending due process. Most states offer an alternative to discipline option, commonly under the auspices of the state board of medicine or nursing. So long as the ACP complies with the stipulations of the program, any criminal charges or license actions are often suspended with the understanding that should the ACP drop out of the PHP they would then be subject to prosecution. These programs offer the addicted ACP the opportunity to enter recovery in a supportive environment and allow them to return to clinical practice only under close supervision. The length of posttreatment monitoring contracts is at least 5 years, during which regular urine and/or hair samples are obtained and examined for evidence of relapse. In conjunction with facilitated group and individual therapy and participation in an anonymous 12-step program, participants receive extensive follow-up and after care. ’ Treatment/Follow-up An addictionologist, an addiction psychiatrist who focuses on evaluation and treatment of individuals with alcohol, drug, or other substance-related disorders, and of individuals with dual diagnosis of substance-related and other psychiatric disorders, should direct the diagnosis and treatment of the addicted ACP. A referral may be obtained from drug treatment centers, the American Society of Addiction Medicine, or state impaired physician programs. Because of the association between chemical dependence and other psychopathology, successful treatment for addiction is less likely when comorbid psychopathology is not treated. Any individual under evaluation or treatment for substance abuse should have an evaluation with subsequent management of comorbid psychiatric conditions. ACPs who are abusing opioids or other anesthetic agents are commonly sent for residential treatment that may last anywhere from 2 months to a year or more. Inpatient treatment in a facility that specializes in the treatment of addicted medical professionals is important so that the affected individual may develop the support of other similarly affected colleagues. There are currently no programs in the United States that admit only medical professionals, but several treatment centers offer programs for medical personnel as a group within the larger inpatient population. Typically in these programs, group therapy sessions are structured so that the members of the medical professional population are separated from the general population. Treatment in such a facility where some of the other patients are healthcare professionals is perceived to be beneficial. www.anesthesiaclinics.com The Drug Seeking Anesthesia Care Provider ’ 165 Treatment typically involves detoxification, monitored abstinence, education, exposure to self-help groups, and psychotherapy. Inpatient therapy is typically intensive, with staff contact extending up to 12 hours per day, 7 days per week. In this setting, the addicted ACP is removed from the stresses of daily life as well as from access to alcohol and drugs. Participation in self-help groups is considered a vital component in the therapy. After successful completion of the inpatient treatment program, the individual is discharged to either a halfway house or directly to the community. ’ Reentry Most states allow an ACP to return to work after inpatient treatment as long as they remain under the supervision of a health and well-being organization, such as those sponsored by the state medical or nursing society. ACPs in recovery are typically required to sign a monitoring contract that includes regular contact with a caseworker at the monitoring organization, worksite observation, and random urine drug and alcohol screens for a minimum of 5 years in length. These contracts mandate complete abstinence from all mood-altering drugs, participation in facilitated group psychotherapy with other recovering medical professionals (often referred to as ‘‘Caduceus’’ meetings), and regular attendance and participation in self-help fellowships such as Alcoholics Anonymous or Narcotics Anonymous. For those ACPs in recovery wishing to return to clinical practice, full disclosure to as well as full support from the department is essential. Naltrexone, a full mu-opioid antagonist, has been shown to reduce craving in alcoholics and its use is often required of recovering ACPs who return to clinical practice. For recovering anesthesia providers, naltrexone has the additional benefit of preventing the addict from experiencing any ‘‘high’’ should they self-administer any opioid medications. Although taking naltrexone is not sobriety in and of itself, it does offer a significant safety net for the recovering ACP and their employer, and its use should be considered as part of a comprehensive program of recovery. Naltrexone can be administered daily via the oral route, or once a month in the form of an intramuscular depot injection. There is also a naltrexone pellet that can be implanted subcutaneously and provide continuous clinically effective levels of naltrexone for 3 to 4 months. The Americans with Disabilities Act (ADA) offers some protections to the addicted anesthesia provider, placing the onus of responsibility on the employer to prove that the employee is unable to perform the responsibilities of his occupation. These protections are limited in scope and have been applied differently to individuals who are dependent upon alcohol versus illegal drugs. No protection is afforded to the user www.anesthesiaclinics.com 166 ’ Bryson and Hamza of substances other than alcohol unless he is currently in a treatment or monitoring program. Diversion of controlled substances is a felony. If charges are brought, the ADA does not offer any protection. Whether anesthesia personnel should be allowed to return to the operating room after successful treatment remains highly controversial. Redirection of anesthesia providers who have successfully completed treatment into other medical specialties may allow a greater percentage to achieve successful careers. A graded reintroduction into the clinical practice of anesthesia may reduce the incidence of death as the initial presenting sign of relapse as compared to reintroduction after only a short period of treatment. The current thought is that the decision to allow an individual to return to the practice of clinical anesthesia should be made on a case-by-case basis. The success rate for those who attempt to reenter the practice of clinical anesthesia after treatment for substance abuse is a current area of research. Results vary depending what population is studied. For residents who return to anesthesia the current success rate is 40% as far out as 10 years, when the population studied includes all residents. Closer examination of the subset of people who successfully completed residency after reentry may reveal a much lower relapse rate as most of the studies show the majority of relapses occurring in the first 3 years. No one has really looked at what happens to the residents who are redirected to another specialty. Another theory that is currently being developed is to integrate ‘‘cue exposure’’ to the recovering ACP, in the safety of an operating room simulator. Environmental cues (people, places, things, situations) that were previously paired with drug use are known to cause profound, involuntary reactions after the person has been drug-free for some time.10–14 Although there is an enormous amount of cue-reactivity studies in the literature, none of them involve addicted ACPs or the cues that would be related to the hospital or operating room. When an ACP has diverted medications from the workplace, anything can become a ‘‘cue’’ and they are not always obvious. Many recovering CRNAs reported olfactory cues (alcohol prep pads, electrocautery, bathroom cleaner), in addition to the classic ones (needles, syringes, vials of opiates, or other medications). The authors propose that identifying as well as extinguishing problematic cues in a simulator might prove to be very beneficial in the reentry process. ’ Proactive Measures Random drug screening for all anesthesia personnel remains a contentious issue and very few training programs or nonmilitary hospitals employ such a policy, though some anesthesia training programs and hospitals do require a preemployment drug screen. Regarding random www.anesthesiaclinics.com The Drug Seeking Anesthesia Care Provider ’ 167 Table 4. For a Random Drug Screening to be Effective, the Following Must be Observed Micturation must be witnessed Specimen collection must be truly random and not predictable. To reduce costs, it is also possible to collect a specimen from everybody in the department, and then randomly select which samples get tested Each specimen should be split. Half of the urine gets tested and half is frozen. Drug testing is conducted via radioimmunoassay (RIA) which is sensitive but not specific. RIA is to rule out drug use Any positive result must then be confirmed with gas chromatography/mass spectrometry (GC/MS). GC/MS is to rule in drug use. This is why the specimen gets split—to save half in the event of a positive result that needs confirmation Due process is paramount Specific request must be made to include phenylpiperidines, also known as a fentanyl analog. A routine drug screen does not include this If the individual is a reentrant on naltrexone, the drug screen needs to include an assay for naltrexone as well If there is reason to suspect that the individual may be abusing propofol a specific request must be made to test for propofol-specific metabolites drug testing, if it is to be implemented, must be done in accordance with Substance Abuse Mental Health Services Administration guidelines and proper chain of custody; please see Table 4 for more specific information on random drug testing. The incidence of diversion by anesthesia providers as indicated by anonymous self-reporting may be as high as 10%. As the incidence of diversion detected by death, severe injury, or entry into an inpatient treatment facility is between 1% and 2%, it is theoretically possible that 8% to 9% of drug diversion by anesthesia providers goes undetected. Random drug testing has been shown to demonstrate a positive deterrent effect in every branch of the Unites States military15 as well as most constituents of the Department of Transportation (Fig. 1), the Federal Transit Administration, the Federal Aviation Administration, and the Federal Railroad Administration (Table 5). The implementation of a strict no-tolerance drug policy coupled with random urine testing increases safety in the workplace, as evidenced by a statistically significant decline in the number of reportable accidents after the implementation of such a policy. Perhaps it would be prudent to implement a program of random testing of anesthesia providers to both reduce the incidence of diversion and detect an individual early in the course of their addiction before they harm themselves or someone else. Although we do support a no-tolerance policy regarding drugs in the workplace and advocate a more gentile approach to intervention, the 2 philosophies are not mutually exclusive. The no-tolerance policy regarding drugs in the workplace implies that any employee found using should be immediately removed from clinical duties. The manner www.anesthesiaclinics.com 168 ’ Bryson and Hamza Transit Fatalities per 100,000,000 Vehicle Miles by Year 16 12.4 12 10.1 7.5 8 8.0 7.8 7.3 7.0 4 6.8 6.5 5.7 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Figure 1. Transit Fatalities per 100,000,000 vehicle miles by year since implementing a policy of random drug testing among federal transit workers in 1995 (Personal communication, Jerry Powers. FTA Drug & Alcohol Program Manager for the US Department of Transportation, FTA Office of Program Management—Safety & Security 400 7th Street SW, Suite 9301, Washington, DC 20590, TPM-30). in which this should be done is one in which the individual is not put at increased risk for self-harm. Because a major contributing cause of addiction in anesthesia providers may be easy access to opioids and other psychoactive substances, a number of methods for control of these agents in the operating room have been developed. Careful record keeping and evaluation of use patterns allows for tighter control and earlier detection in suspected cases of abuse. Anesthesia information management systems have been successfully used to identify patterns suspicious for diversion among anesthesia personnel. Computerized records may be examined to identify high use of opiates, high wastage of controlled substances, transactions which occur on cancelled cases or after case completion, and automated dispenser transactions which occur in a different location from the scheduled case. Waste drugs returned to the pharmacy are assayed by the pharmacist using a hand-held refractometer, with any questionable samples sent out for further analysis. Education of the anesthesia community regarding the potential for substance abuse among anesthesia providers is also very important. Widespread education of the anesthesia community may aid in the early detection of afflicted colleagues. Unfortunately, despite the increased number of hours devoted to such education, the rate of known substance abuse by anesthesia providers remains constant at about www.anesthesiaclinics.com The Drug Seeking Anesthesia Care Provider ’ 169 Table 5. Events and Positive Postevent Drug Tests by Year, Federal Railroad Administration Year 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 No. Events 179 178 161 149 157 109 128 115 82 73 86 68 80 91 82 73 100 124 119 No. Tested 770 682 607 534 552 332 403 294 225 197 240 153 200 255 210 189 249 302 310 42 41 24 17 8 7 8 7 2 1 3 4 2 5 3 2 7 9 4 No. Positives (39 D-3A) (38D-3A) (18 D-6A) (16 D-1A) (6D-2 A) (6D-1 A) (6D-2 A) (5D-2A) (2D-0A) (1D-0A) (1D-2A) (4D-0A) (2D-0A) (5D-0A) (3D-0A) (2D-0A) (6D-1A) (6D-2A, 1 Refusal) (4D) In column 4: A indicates admitted use; D, denied use. Note that the year (1989) random testing was implemented in this industry postaccident positives dropped approximately 50% (Personal communication, Lamar Allen. Alcohol and Drug Program Manager for the FRA). 1.5%. There are a number of educational videos that directly address the issue of substance abuse among anesthesia personnel and may be used as part of a program of education for individuals training in anesthesiology. Some programs have specifically organized sessions for the significant companions of the trainees to view 1 or more of these films together. ’ Conclusions Despite increased awareness of the disease of addiction and numerous policies and procedures designed to prevent the ACP from becoming affected, there is still a significant possibility that an ACP will either develop an addiction during their career or have experience with a colleague who does. This poorly understood disease is cunning, baffling, and incredibly powerful, and often the individual who is sure that ‘‘something like that could never happen to me’’ finds out the hard way that such sentiments are merely another example of the power denial has to allow the disease to flourish. www.anesthesiaclinics.com 170 ’ Bryson and Hamza In this review, we have attempted to summarize the most current and up-to-date thinking on how addiction affects the ACP community, but the most important information to take away from this is how to recognize when you or a colleague needs help and how to get it. As ACPs, we will undoubtedly encounter addiction at some point in our careers, and it is imperative that we are prepared to deal with it appropriately. ’ Appendix Where to get help if you think you or your colleague might have a problem with addiction:  AANA Peer Assistance Homepage: www.aana.com/peerassist.aspx  AANA hotline, open 24/7: 800-654-5167  Anesthetists in Recovery online (support group for CRNAs and SRNAs): 215-635-0183  Suicide hotline: 1-800-273-TALK (8255)  ASA Hotline: 847-825-5526  ASA Peer Assistance: http://www.asahq.org/clinical/substance.htm  www.aa.org  www.na.org  http://www.allanesthesia.com/  http://www.alternativeprograms.org/  http://www.foundationpamedsoc.org/PHP/PHPrograms.aspx ’ References 1. Baldssserri MR. Impaired healthcare professional. Crit Care Med. 2007;35: S106–S116. 2. Berry AJ, Arnold WP III, Bogard TD, et al. Model Curriculum on Drug Abuse and Addiction for Residents in Anesthesiology 2003 Available: http://www.asahq.org/ clinical/curriculum.pdf. 3. West MM. A kaleidoscope review of literature about substance abuse impairment in nursing: progress toward identification of early risk factor? J Addict Nurs. 2003; 14:139–144. 4. Dunn D. Substance abuse among nurses: defining the issue. AORN J. 2005;82: 573–596. 5. Bryson EO, Silverstein JH. Addiction and substance abuse in anesthesiology. Anesthesiology. 2008;109:905–917. 6. Berge KH, Seppala MD, Lanier WL. An anesthesiology community’s approach to opioid- and anesthetic- abusing personnel. Anesthesiology. 2008;109: 762–764. 7. Booth JV, Grossman D, Moore J, et al. Substance abuse among physicians: a survey of academic anesthesiology programs. Anesth Analg. 2002;95:1024–1030. 8. Gravenstein JS, Kory WP, Marks RG. Drug abuse by anesthesia personnel. Anesth Analg. 1983;62:467–472. www.anesthesiaclinics.com The Drug Seeking Anesthesia Care Provider ’ 171 9. Bell DM, McDonough JP, Ellison JS, et al. Controlled drug misuse by certified registered nurse anesthetists. AANA J. 1999;67:133–140. 10. Conklin CA, Tiffany ST. Applying extinction research and theory to cue-exposure addiction treatments. Addiction. 2001;97:155–167. 11. Heinze M, Wolfling K, Grusser SM. Cue-induced auditory evoked potentials in alcoholism. Clin Neurophysiol. 2007;118:856–862. 12. Manley DS. Acceptability and applicability of cue exposure therapy as a relapse prevention intervention for individuals who have substance misuse and mental health problems. Mental Health Subst Abuse: Dual Diagn. 2008;2:172–184. 13. Marissen MAE, Franken IHA, Blanken P, et al. Cue exposure therapy for opiate dependent clients. J Subst Use. 2005;10:97–105. 14. O’Brien CP, Childress AR, McLellan AT, et al. Classical conditioning in drugdependent humans. Ann N Y Acad Sci. 1992;1:400–415. 15. Department of Defense survey of health related behaviors among military personnel 1980-2002. http: //www.dtic.mil/cgi-bin/GetTRDOC?Location=U2&doc=GetTRDoc. pdf&AD=ADA431566. Accessed on February 6, 2010. www.anesthesiaclinics.com