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DURHAM, N.C. -- Despite improved control of operating room medications and increased education, the rate of substance abuse among anesthesiologists remains unchanged, according to a new Duke University Medical Center survey.
The anonymous survey of more than 100 academic medical centers found substance abuse rates of 1 percent for anesthesiology faculty members (34 out of 3,555) and 1.6 percent for anesthesiology residents (133 out of 8,111) during the 1990s.
The researchers emphasize that actual use of the controlled substance occurred outside of the operating room setting during the doctors' personal time, and that there were no reports of patient harm occurring as a result of impaired physicians.
"Efforts to reduce substance abuse among anesthesiologists have focused on education and tighter regulation of controlled substances, but it appears that these efforts have had little effect," said Duke anesthesiologist John Booth, M.D. "It is clear that new and more effective means of prevention are required if substance abuse among anesthesiologists is to be reduced."
Booth is the lead author of a study in the October 2002 issue of the journal Anesthesia and Analgesia.
For Booth, a national databank of all doctors who are having substance abuse problems should be established to identify at-risk doctors and get them help before it becomes too late.
"Another possible solution is random drug testing, which is now commonplace in most work settings in the U.S.," Booth said. "While many of the issues involved in testing has made it unpopular, our survey found that a majority of the department chairpersons at American academic institutions would support such an idea. It is important that all anesthesiologists involve themselves in the debate on this issue."
The 26-question survey was sent to the chairpersons of anesthesiology at 133 academic medicals centers, and 123 responded. The questions covered hospital policies and practices, as well as reported cases of substance abuse, for the period 1990 to 1997.
The survey found that 47 percent of centers had increased the number of hours of formal substance abuse education, and 63 percent of programs had tightened their methods for dispensing, disposing of or accounting for controlled substances. Additionally, the survey found that 80 percent of programs compared the amount on controlled substances dispensed to individual anesthesiologist usage, whereas only 8 percent performed random urine testing.
Booth points out that the data about substance abuse among anesthesiologists is spotty at best, but his survey would appear to indicate that rates have changed little during the past 30 years. A study from 1970 to 1980 indicated a rate of 0.9 percent for residents and 1.3 percent for faculty. Another study conducted from 1975 to 1989 reported a combined 2 percent overall rate.
"Direct comparisons between the studies are difficult because they were conducted differently," Booth said. "Also, the earlier studies included alcohol abuse, which we didn't. So it appears that the overall rate of chemical dependence among anesthesiologists has changed little over the decades."
The Duke survey found that by a large margin, the medication most commonly abused was fentanyl, a "super" morphine medication that is typically combined with agents that put patients to sleep and those that act as muscle relaxants.
"Fentanyl is a narcotic that works much quicker than morphine and provides very effective pain relief," Booth explained. "But, like other drugs of the same class, it is addictive and over time, larger doses are needed to achieve the same effect."
Booth speculates that those doctors who are abusing fentanyl will order more of the drug needed for a specific case, and then "skim" off the unused medication for later use. Also, since the drug can be infused continuously during a surgical case, the abusing doctor may "pocket" leftover and unused medication at the end of the case.
Unfortunately, the most common way these substance-abusing doctors are discovered is by an overdose on fentanyl -- too much of the pain-relieving drug can cause breathing cessation. Booth's survey found that 18 percent of substance abusers were identified by an overdose causing death or a near-death event.
The other ways these physicians are discovered are through programs that "match" drugs dispensed with the individual physicians. By tracking these trends over time, it is possible to detect unusual activity.
Booth suspects that most of the abusing doctors may have had substance abuse problems before entering medicine, and the seemingly readily available supply of potent narcotics might pose a temptation too great to resist.
The survey was funded by Duke's department of anesthesiology. Joining Booth were Davida Grossman, M.D., Jill Moore, Catherine Lineberger, M.D., James Reynolds, Ph.D., J.G. Reves, M.D., and David Sheffield, Ph.D.
Journal
Anesthesia & Analgesia