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Anesthesiology. Author manuscript; available in PMC 2009 November 1.
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Anesthesiology. 2008 November ; 109(5): 905–917. doi:10.1097/ALN.0b013e3181895bc1.

Addiction and Substance Abuse in Anesthesiology

Ethan O. Bryson, MD [Instructor] and Jeffrey H. Silverstein, M.D. [Professor]

Department of Anesthesiology, Mount Sinai Hospital, New York, New York

Abstract
Despite substantial advances in our understanding of addiction and the technology and therapeutic
approaches used to fight this disease, addiction still remains a major issue in the anesthesia workplace
and outcomes have not appreciably changed. While alcoholism and other forms of impairment such
as addiction to other substances and mental illness impact anesthesiologists at similar rates to other
professions, as recently as 2005, the drug of choice for anesthesiologists entering treatment was still
an opioid. There exists a considerable association between chemical dependence and other
psychopathology and successful treatment for addiction is less likely when co-morbid
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psychopathology is not treated. Individuals under evaluation or treatment for substance abuse should
have an evaluation with subsequent management of co-morbid psychiatric conditions. Participation
in self-help groups is still considered a vital component in the therapy of the impaired physician,
along with regular monitoring if the anesthesiologist wishes to attempt re-entry into clinical practice.

Introduction
Fifteen years after the original article, Opioid Addiction in Anesthesiology 1, was published,
addiction still remains a major issue in the anesthesia workplace. Between 1991–2001, 80%
of U.S. anesthesiology residency programs reported experience with impaired residents, and
19% reported at least one pretreatment fatality. 2 Substantial advances have occurred in our
understanding of addiction as well as both the technology and therapeutic approaches used to
fight this disease, although outcomes have not appreciably changed. Starting with a brief review
of the basic concepts of addiction, this article highlights the current thoughts regarding the
pathophysiologic basis of addiction, as well as clinical manifestations, legal issues, and
treatment strategies.

Anesthesiologists (as well as any physician) may suffer from addiction to any number of
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substances, though addiction to opioids remains the most common. As recently as 2005, the
drug of choice for anesthesiologists entering treatment was an opioid, with fentanyl and
sufentanil toping the list. 3 Other agents, such as propofol, ketamine, sodium thiopental,
lidocaine, nitrous oxide, and the potent volatile anesthetics, are less frequently abused but have
documented abuse potential. 4 Alcoholism and other forms of impairment impact
anesthesiologists at similar rates to other professions. 5 Factors that have been proposed to
explain the high incidence of drug abuse among anesthesiologists include the proximity to

Corresponding author: Ethan O. Bryson, M.D., Mount Sinai Hospital, Department of Anesthesiology, One Gustave L Levy Place, New
York, NY 10029, Phone: 212-241-9240, Fax: 212-876-3906, [email protected].
Summary Statement: This article discusses the prevalence and current thoughts regarding the pathophysiologic basis of addiction among
anesthesiologists, as well as clinical manifestations, legal issues, treatment strategies, and new testing methodologies.
Footnote Statement describing the web enhancement:
Appendix 1 contains contact information for organizations available to assist impaired health care professionals.
Appendix 2 contains contact information for state medical societies and impaired physician programs
 Bryson and Silverstein Page 2

large quantities of highly addictive drugs, the relative ease of diverting particularly small
quantities of these agents for personal use, the high stress environment in which
anesthesiologists work, and exposure in the workplace that sensitizes the reward pathways in
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the brain and thus promotes substance abuse. 6

It is not the purpose of this article to present a manual for the treatment of addiction. Treatment
should be administered by qualified personnel. All anesthesia personnel, however, should be
aware of the basic nature of the problem and possess the necessary information to recognize
and assist an impaired colleague.

Prevalence
There is limited data available to determine the current prevalence of drug use by anesthesia
personnel. Records of disciplinary actions, mortality statistics, and registries for known addicts
provide some information but it is difficult to interpret these types of data in that there is no
guarantee that all cases are reported and the total population out of which the reports emanate
is rarely available. In the past it had been concluded that the true prevalence of addiction in
physicians is unknown, 7 though it had been suggested that drug abuse is at least as prevalent
as among the general population. 8

A review of 1,000 treated physicians conducted by Talbott in 1987 9 suggested that addiction
is common among anesthesiologists. Anesthesia residents represented 33.7% of all residents
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presenting for treatment, but composed only 4.6% of all U.S. resident physicians at the time
of the study, thus presenting an apparent 7.4 fold increased prevalence of anesthesia residents
in the study population.1 Subsequent studies have consistently differed from Talbott’s results.
Five years later, a study by Hughes, 5 found the rate of substance abuse in the anesthesia resident
population to be no higher than that of other specialties. Interestingly, this same study showed
higher rates of substance abuse among emergency medicine and psychiatry residents. In 2000,
Alexander published a study examining the cause-specific mortality risks of anesthesiologists
which suggested that the rate of substance abuse among anesthesiologists does not differ from
that observed in general internists and that both groups share a lower rate of substance abuse
than the general population.10 Most recently, a survey conducted in 2002 by Booth found the
incidence of known drug abuse among anesthesia personnel to be 1.0% among faculty members
and 1.6% among residents. 11

Etiology
In 1956 the American Medical Association declared alcoholism to be an illness 12 and, in 1987,
extended the declaration to include dependence on all drugs. There have been many theories
concerning the etiology of chemical dependence 13 including biochemical, genetic, psychiatric,
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and, more recently, exposure-related theories. 6 None alone has been able to identify specific
causes, only to suggest what may increase the risk of developing addiction among anesthesia
personnel.

Genetic and biochemical theories

Considerable research has been done in mice suggesting a genetic basis for addiction. Tapper
and colleagues engineered mutant mice with α4 nicotinic subunits that contained a single point
mutation, Leu9' → Ala9' in the pore-forming M2 domain. 14 The resulting nicotinic
acetylcholine receptors were hypersensitive to nicotine, with the mutant mice exhibiting
reinforcement in response to acute low dose nicotine administration. It is this exaggerated
response to lower levels of stimuli that is thought to be important in the development of
dependence in susceptible individuals. Tolerance and sensitization elicited by chronic nicotine
administration were also observed, suggesting the possibility that behaviors associated with

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the use of drugs of abuse may be reinforced by much smaller doses in some persons who are
genetically susceptible, while not in others who do not share this genetic predisposition.
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There is strong evidence to suggest that drugs of abuse that activate the reward structures in
the brain induce lasting changes in behavior that reflect changes in neuron physiology and
biochemistry. 15 While the majority of individuals who experiment with psychoactive
substances do not become dependent, there exists a subset of individuals that do. These
individuals typically exhibit pre-existing co-morbid traits such as novelty-seeking and
antisocial behavior, and there appears to be a genetic basis for both the susceptibility to
dependence and these co-morbid traits. 16 According to one recent study, this genetic
susceptibility plays a role in the transition from substance use to dependence and from chronic
use to addiction. 17 Many genes have been identified as possibly playing a role in the
susceptibility to drug addiction, but as of this publication investigators have been able to
identify a functional mechanism related to the specific effects of abused drugs in only a few.
18

Release of the neurotransmitter dopamine in the mesolimbic system of the brain is involved
with the reinforcement of drug seeking behaviors associated with several drugs of abuse,
including nicotine. Picciotto and colleagues reported on mice lacking the β2 subunit of the
high-affinity neuronal nicotinic acetylcholine receptor. 19 They found that mesencephalic
dopaminergic neurons from mice without the β2 subunit did not respond to nicotine, as did
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neurons from wild type mice. The self-administration of nicotine was observed to be attenuated
in these mutant mice.

In humans, the cholinergic muscarinic 2 receptor has been associated with the function of
memory and cognition. Wang reported that variation in the gene responsible for the production
of this receptor predisposed to both alcohol dependence and major depressive syndrome. 20
Luo looked at the relationships between the variations in the cholinergic muscarinic 2 receptor
gene and alcohol dependence, drug dependence and affective disorders in a population of 871
subjects and identified specific alleles, genotypes, haplotypes and diplotypes significantly
associated with risk for either dependence or affective disorders. 21 Since there is empirical
evidence that the disorders of substance abuse are prevalent within multiple generations of
some families it makes sense that there should be some associated genetic component. How
much of a role this component plays in the development of the disease is not yet known, as
there are many factors that contribute to the development of a substance use disorder in a
predisposed individual.

Psychiatric co-morbid conditions

There is considerable association between chemical dependence and other psychopathology.
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A 1991 review of the data found personality disorders in 57 of 100 substance abusers. 22 Of
physicians admitted to one inpatient drug/alcohol treatment facility in 1984, 5.9% had a
primary psychiatric diagnosis as well as chemical dependence. 23 Therefore, it has been
suggested that one source of motivation for the self-administration of drugs of abuse is the self-
medication of symptoms associated with co-morbid psychiatric disorders. 24 The observation
that individuals with the same personality traits tend to self-administer drugs from the same
class, i.e. opioids for anxiety and depression and amphetamines for attention deficit and
hyperactivity states, lends credence to this theory. Individuals under evaluation for or treatment
for substance abuse should have an evaluation with subsequent management of co-morbid
psychiatric conditions.

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Exposure related theories

It has bees suggested that emotional stress and access to agents may play much less of a role
in the development of addiction than was previously thought. Gold presented the hypothesis
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that the increased risk of addiction in certain occupational settings, such as within the practice
of anesthesiology, is related to exposures that sensitize the reward pathways in the brain to
promote substance use. 6 It is known that drugs of abuse physically alter the chemistry of the
addicted brain, changing the relative levels of the neurotransmitters gamma-aminobutyric acid,
dopamine, and seratonin associated with reward pathways such that drug seeking behavior is
favored over the rational evaluation of the risks of such actions. 25 26 27

Gold suggests that anesthesiologists who become addicted through such sensitization in the
workplace may continue to use the agents to alleviate the withdrawal they feel when away from
the exposure. The evidence to suggest this mechanism of addiction is based on the observation
that low doses of opiate drugs can induce sensitization, and these agents are present and
measurable in the exhaled breath of patients receiving them. 28 However, these chemical
changes result from levels of exposure typically associated with active use of drugs of abuse
and not from the trace levels found in the work environment, and it is not made clear how the
transition to active use of these agents occurs. This is certainly a novel and relatively new idea
and considerable research needs to be done in this area before any conclusions can be made
regarding its validity.
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Clinical Manifestations
While not one of the specific criteria for diagnosis of drug-related disorders, denial can present
a major obstacle to treatment of the addicted physician. 29 The addict does not recognize that
he has a problem, and treatment is seldom spontaneously sought. Denial is not lessened by
education and training, and some have even suggested that physicians and other highly
educated and highly functioning addicts may have a well developed denial mechanism in place.
29 Physician patients are often described as having grandiose ideas of invulnerability and self-
sufficiency, and as unable to accept that abuse leads to addiction and that addiction is loss of
autonomy. 30

Denial is not limited to the addict. 1 Co-workers, friends, relatives, and associates will often
make excuses for or prefer not to deal with the impaired physician. 31 It can be difficult to
accept that a problem in a colleague is a result of addiction, but failure to initiate an investigation
because of “uncertainty” masked as concern for the individual is denial.

Behavior Patterns
Because of the unique proximity of the chemically dependent anesthesiologist to his drug of
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choice while at work, behaviors that would arouse suspicion in another setting may make the
addicted physician appear quite functional. The addicted anesthesiologist becomes
extraordinarily attentive at work as maintaining a job in close proximity to the source of drugs
becomes more important than aspects of the individual’s personal life. Changes in behavior
are frequently noted with periods of irritability, anger, euphoria and depression common.

Often it is the individual who suffers from this disorder who is the last to recognize that a
problem exists. It is therefore imperative that those people most likely to observe the signs and
symptoms of addiction, i.e. the relatives, friends and co-workers, gain a clear understanding
of the disease and understand what to do if they suspect someone may have a problem. Early
identification of the affected individual can often prevent harm, both to the impaired physician
and to his or her patients. Early detection is often difficult due to the compartmentalized
relationships the individual may have with different members of their social structure. The

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spouse of an addict may observe behavioral changes that may pass unnoticed by colleagues at
work, and the entire picture is seldom appreciated by any one person.
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Some of the changes typically observed in the affected anesthesiologist include but are not
limited to the following: 32
• Withdrawal from family, friends, and leisure activities
• Mood swings, with periods of depression alternating with periods of euphoria
• Increased episodes of anger, irritability and hostility
• Spending more time at the hospital, even when off duty
• Volunteering for extra call
• Refusing relief for lunch or coffee breaks
• Requesting frequent bathroom breaks
• Signing out increasing amounts of narcotics or quantities inappropriate for the given
case
• Weight loss and pale skin
The period of time over which these changes are manifested depends on the drug to which the
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individual has become addicted. Alcohol addiction typically takes years to become apparent
while addiction to the short acting opioids, fentanyl and especially sufentalyl, becomes
apparent over the course of a few months of use.

So powerful is the disease of addiction and the need for the drug that otherwise reasonable and
intelligent people will resort to seemingly incredulous behavior in order to obtain their drug
of choice. Addicts may chart the use of an agent when in fact either an alternate agent or none
at all was administered. Entire cases may be done with inhalational agents and beta-blockers
and charted as opioid based. Addicts may substitute a syringe containing his drug of choice
for one containing saline or a mixture of lidocaine and esmolol during a relief break. Some
have admitted to rummaging through sharps containers looking for residual drug in discarded
syringes. Addicts quickly become proficient at removing controlled substances from secure
places. The security features of automated dispensing machines are easily defeated, and drugs
may be removed from glass ampules and replaced with another liquid without evidence of
tampering.

Depending on the half-life of the abused agent, tolerance can develop rapidly. It is not
uncommon for the addict in recovery to report self-administration of 1,000 micrograms of
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fentanyl in a single injection, often simply to relieve the symptoms of withdrawal. When
looking over the records of an addicted anesthesiologist, a rise in the quantity of opioids
requested, particularly on Fridays, can often be noted.

Legal Issues
When dealing with an addicted physician, there are a number of legal issues to consider. The
physician who is reported to either the state board of medicine or a physician referral program
faces a series of legal choices. Consultation with legal counsel in these matters is mandatory
for both the reported physician and the institution involved with reporting the physician, as an
individual’s license to practice medicine is in jeopardy. 1 As well, failure to report an impaired
colleague may be considered negligence, and leaves the individuals and institutions involved
open to questions of labiality should harm come to any patient. It is important to note that the
legal requirements and protections associated with physician impairment are different from

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state to state. This is particularly true for confidentiality of records and the relationship of
Impaired Physician Programs to licensure boards. 1 This section explores these issues but
should not be construed as legal advice.
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Diversion/Impaired Physician Programs

The medical licensing board of each state may suspend or revoke an individual’s license to
practice medicine. In addition to actions against licensure, state, local and federal authorities
may institute criminal action associated with an individual’s actions, including charges for
diversion of controlled substances. As an alternative to suspension or revocation, state medical
societies are allowed, under certain circumstances, to enroll physician addicts into diversion
programs designed to rehabilitate the affected physician and return him to the practice of
medicine. Enrollment in these programs is “voluntary”, though non-participation almost
always results in the case being turned over to the state licensing board. Although the licensing
agencies are generally reluctant to accept any diminution of authority, they recognize that
professional societies are more easily able to engage impaired colleagues. Many state impaired
physician programs have now negotiated a significant responsibility for the investigation,
intervention, and diversion in reported cases of impairment. 33 34 35

In this instance, diversion is defined as the process of intervening in the case of a physician or
nurse and arranging for assessment, treatment, and potentially return to practice independent
of licensure authorities. The potential for involving licensure authorities represents the coercive
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power of diversion programs. 1 The relationship between an impaired physician program and
its associated licensing board is highly variable from state to state, and subject to constant
reassessment. 36

While the issue of board certification is somewhat separated from that of medical licensure, it
is the policy of the American Board of Anesthesiology (ABA) that a physician must maintain
a permanent, unconditional and unrestricted license to practice medicine in at least one state
in the United States in order to maintain board certification. The ABA recently clarified its
position on revocation of ABA certification for physicians involved in diversion programs in
a recent issue of ABA News. According to the article: “It is the policy of the ABA that
participation in an approved treatment plan for impaired physicians is not considered a
restriction on a medical license in and of itself. If a state medical licensing board permits the
practice of medicine while a physician is compliant with an approved rehabilitation plan, the
ABA will allow certification to be maintained.” 37

State medical society diversion programs are available to provide consultation concerning
intervention strategies, state-specific legal considerations, and reporting requirements. Some
impaired physician programs sponsor group-therapy sessions for recovering health
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professionals. 1 Impaired physician programs can be a great information resource, providing

listings of available self-help groups, therapists, treatment centers, sources of legal advice, and
urine monitoring programs.

Additional information regarding the state society programs that assist impaired physicians
and nurses, including contact information and web site addresses, is available on the
Anesthesiology web site at http://www.anesthesiology.org.

Confidentiality
Once involved in treatment, physicians are expected to share their experiences with addiction
and substance abuse openly with peers and therapists through group therapy and participation
in anonymous self-help groups such as Alcoholics Anonymous (AA) or Narcotics Anonymous
(NA). In 1996, Roback examined the confidentiality dilemmas that exist in group

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psychotherapy with recovering physicians and found that because of the risk of personal and
professional harm, participants remained exceedingly concerned about breaches of
confidentiality. 38 Since the current law provides little protection to physicians who enter group
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therapy, perhaps improving legislation would result in greater or more honest disclosure in the
group setting.

Mandatory Reporting and Immunity

Failure to report an impaired physician as required by law may result in disciplinary action
against the institution or designated individual. 1 Many of these laws provide immunity for
persons who report an impaired professional, however some, specifically, do not. Each state
has its own laws regarding mandatory reporting and immunity. 39 For example, under Colorado
law, addiction to alcohol or drugs is classified as unprofessional conduct, which therefore must
be reported to the licensing board. 40 Under most circumstances, the individual making such
a report is immune from civil suit over this action so long as it is made in good faith. There are
reporting exceptions for the treating physician of the addicted physician-patient, so long as the
physician patient is not a danger to his or her patients.

The National Practitioner Data Bank functions as a repository for information concerning
professional conduct, licensure status, and malpractice claims of the nation’s physicians. 1
Voluntary entry into a substance-abuse treatment program is not reportable to the National
Practitioner Data Bank. As well, voluntary surrender of a medical license during treatment may
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not require reporting, but suspension of a physicians clinical privileges (e.g., by a hospital) for
greater than 30 days is. 1 Individuals wishing to make such a report should be familiar with
the laws in their state of practice.

The Americans With Disabilities Act

The Americans With Disabilities Act, enacted in 1992, offers some protections to the addicted
physician, though it should be noted that the protections offered by the Americans With
Disabilities Act are limited in scope and are applied differently to individuals who are
dependent upon alcohol versus illegal drugs.* No protection is afforded to the user of
substances other than alcohol unless he is currently in a treatment program, while the alcohol
dependent person need not be in treatment to be protected under this act. Recent case law has
reduced these limited protections afforded by the Americans With Disabilities Act to addicted
persons. 41 The Contract with America Advancement Act of 1996 removed substance use
disorders as a valid cause of disabling impairment. If the addictive disorder exists in the
presence of other psychiatric or medical disorders, the individual may qualify for protection if
he would remain disabled if he stopped using alcohol or drugs. 42 As well, the presence of a
substance-related disorder will not, by itself, allow an individual to collect disability benefits
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under the Veterans Administration unless another psychiatric or medical condition is also
present, due to the determination by the U.S. Supreme Court that a alcoholism involves an act
of willful misconduct, which violates Veterans Administration regulations. 43

To the extent that these regulations apply to the anesthesiologist in recovery, it should be
understood that relapse presents a significant clinical risk and danger. The first symptom of
relapse in an extraordinarily high number of involving the return of a fentanyl-addicted
anesthesiologist to the operating room anesthesia practice has been death. 44 We may define
disability as being unable to perform all or some aspects of a specific job, such as those required
of an anesthesiologist, because the individual is disabled by active addiction, the need to receive
treatment, or the need to pursue time intensive recovery activities that may preclude work.

*Further information regarding the implications of the Americans With Disabilities Act may be obtained from the Civil Rights Division
of the United States Department of Justice, Washington, D.C., at http://www.usdoj.gov/crt/ (as of June 22, 2008)

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Disability related to the potential for relapse, or a “prophylactic” disability, which is a very
real concern when the anesthesiologist in recovery returns to the clinical practice of anesthesia,
is generally not covered. 39
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Diagnosis and Treatment

An addiction psychiatrist should direct diagnosis and treatment. In 1993, addictionology was
a relatively new specialty, with addiction psychiatry formally recognized by the American
Board of Medical Specialists in 1992. The American Board of Psychiatry and Neurology began
offering added qualifications in addiction psychiatry in 1993 and, although not recognized by
the American Board of Medical Specialties at the time, the American Society of Addiction
Medicine established a credentialing and examination process for its members. Currently the
American Board of Psychiatry and Neurology recognizes addiction psychiatry as a subspecialty
of psychiatry that 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. An addiction psychiatrist referral may be obtained from drug
treatment centers, the American Society of Addiction Medicine or state impaired physician
programs.

Initial Therapeutic Period

Once it has been established that a physician is impaired and requires treatment for addiction,
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a referral is made to an inpatient facility that specializes in the treatment of physicians. It is

important that such a facility is chosen so that the affected individual may develop the support
of other similarly affected physicians. 45 While there are currently no programs in the United
States that admit only physicians, several are available that offer programs for physicians and
other medical personnel within the larger inpatient population. These groups interact with each
other during activities that involve the entire population, such as recreational therapy and
twelve step study groups, though group therapy sessions are structured to that the members of
the medical professionals population are separated from the general population. The disease
of addiction is one of isolation, and treatment in a facility where the other patients are not
physicians or health care professionals may lead to an increased sense of isolation and despair.
46 As well, such an environment may foster the false belief that the physician is a special case,
different from the other patients, and such treatment is detrimental to the individual’s recovery.
It is important that the physician see peers in the same situation, going through the same
treatment.

Most treatment centers are based on the Minnesota treatment model, 47 which is derived from
the recovery model of AA. Treatment involves detoxification, monitored abstinence, intensive
education, exposure to self-help groups, and psychotherapy. Various models of individual and
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group therapy all aim at altering key addictive behaviors. 48 Inpatient therapy is an intensive
form of treatment, with staff contact extending up to 12 hours per day, 7 days per week. In this
setting, patients are removed from the stresses of daily life and from access to alcohol and
drugs. Typical inpatient lengths of stay are between eight to twelve weeks, but may be as long
as six to twelve months if it is determined by the treatment team that the patient is not ready
for discharge.

Anesthesiologists who are abusing opioids or other anesthetic agents are commonly sent for
residential treatment that may last from 2 months to a year or more. The length of treatment
required and the very real possibility that little, if any, of the costs of treatment will be covered
by medical insurance can be financially devastating to the physician in early recovery, as most
residential treatment centers charge from $3,000 to $4,500 per week for treatment. In one recent
survey which examined the level of satisfaction of impaired health care professionals with
mandatory treatment and monitoring, 40% of Michigan respondents and 53% of Indiana

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respondents did not have insurance coverage for program costs. 49 The Impaired professionals
committee should have a basic understanding of what mental health coverage is engendered
by their health insurance coverage.
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Subsequent Therapeutic Modalities

The intention of the initial period is to lay the groundwork for long-term abstinence and
recovery. Following successful completion of the inpatient treatment program, the individual
is discharged to either a halfway house or directly to the community, where the work of early
recovery begins. A structured halfway house community, with 60–120 hours per week of staff
contact is often recommended for a 4–8 week period. Outpatient therapy may be appropriate
under certain conditions. Outpatients must be able to function in their normal daily
environment, and are expected to remain abstinent despite normal availability of alcohol and
drugs. It is our opinion that the chemically impaired anesthesiologist is best initially treated in
an inpatient setting.

Most states allow physicians to return to work after inpatient treatment so long as these
physicians remain under the supervision of a physician health and well-being organization,
such as those sponsored by the state medical society. Monitoring contracts are usually a
minimum of five years in length and include regular contact with a caseworker at the monitoring
organization, worksite observation, and random urine drug and alcohol screens. The mainstay
of long-term treatment is the complete abstinence from all mood-altering drugs, facilitated
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group psychotherapy with other recovering physicians, and regular attendance and
participation in self-help fellowships such as AA or NA. 49 Concerns specific to reentry to the
anesthesia work environment are discussed in detail below.

Abstinence Monitoring
Urine testing is still the cornerstone for monitoring and documenting abstinence in the
recovering addict. 50 The value of urine testing as a therapeutic tool has not been clarified
though it is commonly thought to have a deterrent effect on drug use. Details of urine testing
and new modalities currently under investigation are described in a subsequent section.

Compliance with mandatory urine monitoring schedules, which must be paid for out of pocket
by the individual, may be difficult when financial issues are present. The cost for collection
by an approved monitor and processing of urine or blood samples can be as much as $90 per
sample, and are often collected two or three times per week during early recovery. If the
individual has a history of abuse of fentanyl, sufentanil, propofol or any other drug that is not
routinely included in the basic screen for drugs of abuse, the cost per sample to identify these
agents is significantly increased.
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Receptor Antagonists
Naltrexone, like naloxone, is a relatively pure mu-receptor antagonist. In contrast to naloxone,
naltrexone is highly effective orally, and still remains part of the treatment for anesthesiologists
returning to the operating room. Recent studies suggest that naltrexone may reduce the cravings
for both narcotics and alcohol in the recovering addict. 51 It produces sustained competitive
antagonism of opioid agonists for as long as 24 to 48 hours and is taken as either 50 milligrams
daily or 100 milligrams three times per week. The antagonism may be overcome by large doses
of opioids, which may result in immediate respiratory arrest. The blocking of agonist activity
by an antagonist should be contrasted with the activity of a metabolic inhibitor, such as
disulfiram (Antibuse, Wyeth-Ayerst, Philadelphia, PA), which blocks an enzyme in the
pathway of alcohol metabolism, leading to the accumulation of a noxious metabolite. 52
Detoxification is mandatory before prescription of naltrexone as ingestion without

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detoxification will precipitate a severe withdrawal syndrome. Significant side effects

associated with the use of naltrexone are listed in table 1.
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Self-Help Groups
Participation in self-help groups is considered a vital component in the therapy of the impaired
physician. 53 Self-help groups originated as a response to an unmet need for support and
services available to those in recovery from addiction. 54 The AA 12-step program is the
prototype organization serving as a model for NA and other self-help programs. Meetings of
AA and NA are frequent and are available nationwide.

There are also organizations of recovering health care professionals based on the “Twelve
Steps” and “Twelve Traditions” of AA but with membership limited to those in the health care
professions. Local groups may be found by contacting the AA or NA, or the state Impaired
Physicians Program. International Doctors in AA serves as an umbrella organization for
physician recovery groups around the world, and Anesthetists in Recovery is a similar group
dedicated to recovering Certified Registered Nurse Anesthetists.

Professional Behavioral Observation

Once discharged from inpatient treatment, recovering physicians are often required to continue
therapy with a certified addiction psychiatrist on a regular basis. Individual therapy may be
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more frequent initially and later reduced to one or two office visits a month, designed to uncover
behaviors and attitudes that can threaten ongoing recovery. 1

Additional psychotherapeutic modalities

In addition to individual therapy, group therapy is often indicated for a protracted period of
time. Designed to educate the individual and modify behavioral factors to support continued
recovery, 55 weekly attendance at facilitated group therapy and individual psychotherapy is
typically mandated for physicians in early recovery. It should be noted here that if the costs of
these mandated sessions are not covered by insurance or if the physician has lost his or her
medical coverage as a result of the loss of employment, these costs must be paid out of pocket
by the individual in recovery. Inability to comply with mandated therapy and monitoring, even
if due only to financial problems can lead to removal of the physician from the monitoring
program and the inability of the individual to re-enter the clinical practice of medicine. The
worst case would obviously be relapse into active addiction or death from an unintentional
overdose.

Attention has been directed to the stresses peculiar to a medical family and to the role played
by family members in impairment. 56 Fifteen years ago, this was still a developing subject in
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substance-abuse therapy, involving the family of an impaired physician in the treatment process
is now considered critical to the establishment of a support system for recovery. 57 Involving
the family of an addicted individual allows for the development of an understanding of the
disease concept of addiction, enabling, and has been shown to improve outcomes in the
treatment process for addicted individuals. 58

The role for Ultra-Rapid Detoxification

Often the first step in treatment after intervention is detoxification of the individual. Most
inpatient facilities admit patients first to a detoxification area where they can be monitored for
signs and symptoms of withdrawal and treated accordingly. This occurs over a period of days
and often results in considerable suffering. As well, inpatient rehabilitation cannot begin until
the patient is past the withdrawal period and able to focus their attention entirely on the work
of recovery. Recently newer techniques have been developed that dramatically accelerate the

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 Bryson and Silverstein Page 11

detoxification process, often doing so in less than 24 hours. 59 Ultra-rapid detox centers operate
on the premise that continued opioid use results from the attempts to avoid withdrawal
symptoms, and that elimination of these symptoms can ensure prevention of relapse. The rapid
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induction onto maintenance treatment with opioid antagonists such as naltrexone is performed
under general anesthesia, often in an outpatient setting. 60 Patients are simultaneously relieved
of the physical symptoms of withdrawal and placed on opioid antagonist maintenance to
prevent cravings and relapse, but little, if any, emphasis is placed on treating either the
psychological issues or personal circumstances that resulted in addiction initially. The long-
term success of this method has been shown to be no more effective than traditional methods
of detoxification when the main outcome measure is the prevention of relapse. 61

Prognosis
There remain few studies specifically examining the prognosis for continued recovery in the
addicted anesthesiologist who returns to the clinical practice of anesthesiology, though the
major controversy surrounding this decision surrounds the use of parenteral opioids and their
availability in anesthesia practice. The studies available and the current thinking regarding
reentry into anesthesiology are discussed in the following section.

Prospects for Reentry into Anesthesiology

Whether anesthesia personnel should be allowed to return to the operating room after successful
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treatment remains highly controversial. Historically a distinction was made between the
anesthesia resident and attending. The thought was that the attending has fewer options and
should be given a chance to reenter practice while the resident should be encouraged to find
another specialty. Too often, however, the attending who has successfully completed a short
course of treatment is asked to return to work in the same full-time stressful practice without
any time allowed for early recovery work. The result is often disastrous. Residency programs,
however, are more able to adsorb the part time resident in early recovery and this slow reentry
into clinical practice may allow the motivated individual to pursue a career in anesthesia. 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, regardless of the level of training.

In the past it was felt that most anesthesiologists who completed therapy should be allowed to
return to work. Historical data from the Impaired Physicians Program of the Medical
Association of Georgia suggests that physicians who remain compliant with their prescribed
program are able to remain abstinent at 2-year follow-up. 62 However, because individuals lost
to follow-up were not included in the evaluation, the majority of case failures were excluded
before analysis. 1
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In 1990 a report of 180 cases of substance abuse by residents in anesthesiology published

concluded that prolonged abstinence was unusual and that redirection to another medical
specialty is the desired course for an individual who abuses parenteral opioids. 44 This study
queried directors of U.S. anesthesiology training programs regarding the abuse of parenteral
opioids and other drugs by their residents. Of the 180 reported cases, 13 (7%) presented as
death pr anoxic brain injury. Of the 167 remaining cases, 113 (67%) were allowed to reenter
anesthesiology training. Those abusing opioids had only a 34% success rate reentering
anesthesiology, and of the 66% who relapsed, 13 (25%) died as a result. Those abusing other
drugs or alcohol had a 70% success rate, and of the 30% who did relapse, only one (13%) died.
The authors defined success as an individual who underwent treatment, completed the
residency, and had no relapse in practice to the best of the program director’s knowledge.

Some have been critical of this study for a number of reasons, though the conclusions are likely
valid. The conclusions are based on an incomplete survey of directors whose recall may be

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 Bryson and Silverstein Page 12

inaccurate. 63 As well, only 37% of the residents reviewed received more than 6 weeks of
inpatient treatment, a figure considered inadequate by many experts in the field. 64 The authors
also have been criticized for suggesting that residents be redirected to other specialties without
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evaluating the outcome of those who were.

In 2005, another report on the treatment outcomes of anesthesiology residents was published
with very similar data. Collins conducted a survey of all U.S. anesthesiology residency
programs regarding experience and outcomes with chemically dependent residents from 1991
to 2001 and concluded that the redirection of residents who have successfully completed
treatment into lower-risk specialties may allow a greater percentage to achieve successful
medical careers. The majority of residents studied attempted reentry, but only 46% successfully
completed an anesthesia residency. Of those residents who attempted reentry, the mortality
rate was 9%. 65

Obviously, a mortality rate of 9% is unacceptable for any intervention, therefore we do not

advocate automatic reentry into anesthesiology for any residents, attending physicians, or
Certified Registered Nurse Anesthetists. Rather, we agree with the idea that each case must be
evaluated on an individual basis. Recent experience at our institution suggests that a graded
reintroduction into the clinical practice of anesthesia may be no better at reducing the incidence
of relapse than reintroduction after a short period of treatment. 66 Of note, this process of graded
re-introduction may be beneficial insofar as the initial presenting event that marked the relapse
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of each individual was not death.

Implicit in this discussion of reentry is the potential for denying reentry into anesthesiology.
If an addiction psychiatrist recommends that an individual should not return to the practice of
anesthesiology, we believe that denial of reentry can be successfully defended. 1 The case in
which the addiction psychiatrist recommends reentry into anesthesia presents problems for
denial of reentry. The Americans With Disabilities Act (Section IIIE) has placed the onus of
responsibility on the employer to prove that the employee is unable to perform the
responsibilities of his occupation. 1

Risk Factors for Relapse

Because of the nature of the disease of addiction, individuals who have successfully undergone
treatment are still at risk for relapse. In a retrospective cohort study, Domino examined the rate
of relapse among 292 physicians involved in the Washington Physicians Health Program
between 1991 and 2001. 67 Of the 2922 individuals studied, 74 (25%) had at least one relapse.
Factors which were associated with an increased risk of relapse included a family history of
substance use disorder, the use of a major opioid, and the presence of a coexisting psychiatric
disorder. Interestingly, the use of a major opioid increased the risk of relapse only in patients
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with a coexisting psychiatric disorder.

Work Reentry Contract

Anesthesiologists who are allowed to reenter medical practice must agree to certain conditions
of reentry. A work reentry contract should be created outlining the individuals’ responsibilities.
Key to the success of such a contract is the open communication between all involved parties.
The treating psychiatrist, members of the recovery support network, and persons responsible
for verifying compliance with the work reentry contract need to maintain contact on a regular
basis.

Some programs suggest that the first 3-month period of reentry to the operating room should
exclude night and weekend calls and the handling of opioids. At the end of this period, the
practitioner is reevaluated by treatment personnel. Our policy is to require a period of time,

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 Bryson and Silverstein Page 13

usually at least one year, away from the practice of clinical anesthesia before reentry is
attempted. This allows the individual time to concentrate on the work of early recovery, and
also to consider alternate career paths. The first year back in clinical practice is typically at 2/3
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time, or no more than 40 hours per week with no call for the first three months.

The ABA has developed a specific policy regarding entry of individuals recovering from
alcohol or drug addiction into their examination process. They currently have no written policy
regarding diplomats of the ABA who are in recovery. 37

Prevention
Clearly the prevention of chemical dependence is preferable to treatment. Unfortunately, this
remains a societal problem that is difficult, at best, to deal with. 45 Control of drug supply and
education remain the mainstay of prevention, though one study suggests that the increased
control and accounting procedures for controlled substances and increased mandatory
education has not changed the frequency of controlled substance abuse among
anesthesiologists. 11 Random drug screening for all anesthesia personnel remains a contentious
issue, and as of 2002 only 8% of anesthesiology residency training programs used random
urine testing, though 61% of departmental chairs indicated that they would approve of such a
policy. 11 One survey of individuals involved in physicians health programs reported a 39%
incidence of substance abuse or mental health difficulties prior to a career in medicine, 68
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suggesting that the use of substance abuse screening tools during interviews for medical school
or residency may be helpful.

Drug Control
It has been suggested that a major contributing cause of addiction in anesthesiology is easy
access to opioids and other psychoactive substances. 69 70 Even if access alone does not result
in drug abuse, tighter control allows for earlier detection and documentation in suspected cases
of abuse. 1

A number of methods for control of opioids and other drugs in the operating room exist that
involve careful record keeping and evaluation of use patterns. 71 72 73 74 Anesthesia
information management systems have been successfully used to identify patterns suspicious
for diversion among anesthesia personnel. 75 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. There is certainly an innocent explanation as
to why any of these transactions suspicious for diversion activity may occur, and follow up by
monitoring personnel is required to determine weather or not diversion is an issue.
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Computerized dispensing units are available for use, though in many institutions a satellite
pharmacy dispenses controlled substances. At Mount Sinai, controlled substances are
dispensed with a drug disposition form and subsequently every anesthesia record is checked
against the disposition record. Anesthesia personnel are asked to explain any discrepancy, and
all discrepancies are reported to the departmental impaired professionals committee. Since a
computerized record keeping system is in use at our institution, monthly reports regarding
individual practitioners use of controlled agents are generated and outliers identified. Such
reports may be used to facilitate early intervention in cases of suspected diversion.

All waste drugs must be returned to the pharmacy where they are analyzed on a random basis
to verify content. The Division of Quality Control, Department of Pharmacy of the Mount Sinai
Medical Center has established the following policy for evaluating returned waste drugs. All
undiluted returned drugs are analyzed by either refractometry or, for alkaloids (morphine,

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 Bryson and Silverstein Page 14

meperidine, fentanyl, cocaine, etc.), by precipitation with Mayer’s reagent. Diluted drugs are
not detected by these methods and, in cases of repeated negative qualitative assay for any
substance, quantitative analysis is requested from a forensic laboratory. Forensic laboratories
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are equipped for quantitative analysis of current anesthesia related psychoactive compounds,
including fentanyl, sufentanil, and propofol.

Education
There continues to be an effort toward education of the anesthesiology community regarding
substance abuse. Presumably, widespread education of the anesthesia community may aid in
the early detection of afflicted colleagues. In 1991, between 47 and 89% of anesthesia programs
had at least one lecture on substance abuse, but only 33% had an identifiable substance abuse
program or committee. 76 By 2001, the number of hours of formal education regarding drug
abuse had increased in 47% of programs, 11 yet the rate of known substance abuse by
anesthesiologists remains constant at 1.0% among faculty members and 1.6% among resident
physicians. 11 Whether education prevents addiction is not clear.

A number of educational videos are available which directly address the issue of substance
abuse and anesthesia personnel and may be used as part of a program of education for residents
training in anesthesiology. “Wearing Masks – the Potential for Drug Addiction in Anesthesia”
was produced in 1993 and sponsored by the Association of Anesthesia Program Directors. The
second video in this series “Wearing Masks II” and the recently released third video “Wearing
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Masks III” contain resource material for individuals concerned with addiction.# The video
“Unmasking Addiction: Chemical Dependency in Anesthesiology” was published in 1991 and
is available from Janssen. (Ortho-McNeil-Janssen Pharmaceuticals, Titusville, NJ).

Testing Methodologies
Urine testing
When urine is tested as part of a rehabilitation toxicology program, a screening test is usually
followed by a more specific confirmatory test as there is a high requirement for sensitivity to
avoid a false negative. This section discusses current technical and forensic concerns associated
with urine drug testing. 77 78 79

The general drug screen composition varies from laboratory to laboratory. Certain drugs
commonly abused by anesthesia personnel may or may not be included. Morphine, codine, and
meperidine are more commonly included, but Fentanyl, sufentanil, alfentanil and propofol are
almost never part of a standard drug screen and must be specifically added to the assay (often
for considerable additional expense) of each specimen. It is important to use a general drug
screen due to the common abuse of multiple drugs, but specific requests should be noted if
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fentanyl, sufentanil, or propofol are to be included.

Familiarity with the available laboratory procedures allows for proper test selection and
interpretation. Of the commonly available assays, thin layer chromatography is the least
sensitive and is generally performed as a screening test while gas chromatography/magnetic
resonance spectroscopy is considered the gold standard against which other methods are
compared and by which any positive result should be confirmed. 80

While some states may require that random drug screening programs guarantee privacy for
employees while providing bodily fluids for drug testing, this degree of privacy does not apply
to a documented case of substance abuse.

#These videos are available free of charge from the publisher and may be ordered at http://www.allanesthesia.com (as of June 22, 2008)

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 Bryson and Silverstein Page 15

Witnessed collection is necessary to avoid a sham urine sample. Methods to circumvent

detection include self-instillation of “clean” urine into the urinary bladder, either through
catheterization or supra-pubic injection, and the use of an artificial penis with a reservoir for
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clean urine, worn close to the skin and kept warm. Artificial urine is commercially available
from multiple vendors via the Internet and a number of teas, herbs, and extracts are marketed
with the intent of allowing the user to “conquer” the urine drug tests.

Random observed urine collection is mandatory, as an addict will simply avoid drug use if a
urine test is announced in advance or if a routine collection time becomes apparent.

Drug abuse detection requires knowledge of the suspected drug’s biologic half-life, extent of
biotransformation, and major route of excretion. 81 The primary clearance of fentanyl is
metabolic. McCain and Hug 82 estimated that renal clearance of fentanyl in volunteers was
only 6%. Based on this work, a regular user should have detectable fentanyl in urine for 3–5
days. Nanogram quantities of fentanyl can be detected in the urine, though there are a number
of reports from “recovering” addicts who report regular fentanyl abuse not detected on routine
urine tests. 1 Norfentanyl, a fentanyl metabolite, can be detected in the urine up to 96 hours
after small (100 microgram) doses of fentanyl and should probably be the analysis of choice.
1 The metabolism of sufentanil is similar to fentanyl and it is possible to detect the metabolite
for a period of time that is longer than the interval for detection of the parent compound.
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Morphine-3-glucuronide is the primary inactive metabolite of morphine. Detectable in the

plasma 1 min after intravenous administration of morphine sulfate, it is detectable in urine for
up to 72 hours. 83 Meperidine is primarily metabolized to normeperidine, a compound which
can be detected in the urine for as long as 3 days after administration. 83

Hair Analysis
The half-lives of most of the agents typically abused by anesthesiologists are short, and the
circulating concentrations are often too weak for detection at the time of urine or blood sample
collection. An alternative method developed to detect chronic exposure to these drugs of abuse
is the analysis of hair samples obtained from the individual under the same chain-of-custody
guidelines as for urine or blood samples. Depending on the length of the hair, it is possible to
test exposure over a period of time measured in months rather than hours or days. 70 Hair can
serve as a marker of chronic exposure because drugs of abuse or their metabolites are
incorporated into the structure of the hair follicle over time as the hair grows. The actual
mechanisms of substance incorporation are unclear but it is believed that drugs or chemicals
either passively diffuse from blood capillaries into growing hair cells or are deposited onto the
completed hair shaft from sweat or sebum secretions. 84
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The chromatographic–mass spectrometric techniques used today have increased test sensitivity
and improved detection limits such that picogram to microgram levels of agent or metabolite
can be detected. 85 Despite the ability to detect minute quantities of substances in the hair of
individuals suspected of illicit drug use, certain limitations do exist. The most obvious is that
the individual to be tested needs to have hair on which to perform the desired assay. It is not
infrequent for an individual to arrive at the testing location having either trimmed or shaved
their hair entirely. While such actions are telling in and of themselves, hair for forensic analysis
may be obtained from alternative areas such as the underarms, pubic area, chest or thigh if hair
from the scalp is not available. 85

When a positive result is obtained, often there is objection, and the question of contamination
arises. Experiments have shown positive test results can be obtained when hair has been
environmentally exposed to particular agents, either by proximity to drug use or intentional
contamination. Hair experimentally contaminated with both the solid hydrochloride form and

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 Bryson and Silverstein Page 16

the evaporated base of cocaine has tested positive for use in subjects who have not ingested
the drug. 86 87 Because of the implications of such a positive result, hair samples should not
be taken in a physical site where the chemical to be tested for is present. Moreover, the
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individual taking the sample should thoroughly cleanse their hands prior to and wear gloves
when obtaining the sample.

Naltrexone Assays
Naltrexone assays exist as a measure of patient compliance with mandated ingestion.
Difficulties reside in the stability of the specimen. One laboratory will only accept serum or
plasma that is wrapped in foil and shipped frozen. Because of sample instability, a negative
test may not indicate noncompliance with prescribed naltrexone ingestion. The only reliable
measure of compliance with naltrexone therapy is witnessed ingestion.

Reliability of Assays
The requirements for urine drug testing of anesthesia personnel include accurate forensic
testing for fentanyl and its derivatives, as well as other commonly abused drugs. A major
concern, given the high stakes involved with the monitoring of a physician addict, remains the
accuracy of the testing laboratories. 88 89 Performance testing, in the form of known blind
samples, should be submitted to the designated laboratory on a regular basis (e.g. 3 per 100
specimens) from high-volume testing centers. Knowledge of the laboratory’s error rate (either
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false positive or false negative) on these blind controls is essential in evaluating analytic results.
1

Misleading Positive Results

The report of significant concentrations of codeine and morphine in urine at 6 and 22 hours
after the consumption of 3 poppy seed bagels by Struempler in 1987 highlighted the necessity
for further evaluation of a positive test result. 90 This is not a false positive, as the actual
substance being assayed was present and detected. It represents a positive result with a cause
unrelated to substance abuse. When a positive test is attributable to the ingestion of poppy
seeds, specific ratios of codeine to morphine can be identified. 91 Still, recovering addicts are
advised to avoid the consumption of poppy seeds. In addition to dietary causes, non-
prescription medications may also result in misleading positive results. 92 Because of this,
many Impaired Physician Programs specifically require that participants familiarize
themselves with and abstain from any foods or non-prescription medicines that, when ingested,
might lead to a positive test result for drugs of abuse.

Cost
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The cost of initial drug screens is usually borne by the hospital or department, but the recovering
addict is often required to bear the cost of ongoing monitoring. One laboratory in New York
State currently charges $32.50 for a screening urine test with a fentanyl assay, but the price
jumps to $290 per sample if a propofol assay is requested. Hair analysis can cost well over a
thousand dollars per sample. This is a significant expense for individuals requiring six to eight
screens per month as part of a monitoring program, especially for those who do not have
insurance to help defray the costs of treatment. Responsibility for the expense of testing should
be clear and agreed to in advance. Often, arrangements for bulk discounts can be made by
medical societies or hospitals.

Conclusions
Addiction is still considered by many to be an occupational hazard for those involved in the
practice of Anesthesiology. It has been suggested in this review that the presence of readily

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 Bryson and Silverstein Page 17

available highly addictive agents in our work environment contributes to the potential for abuse
in a subset of the population at risk. Since it is not possible to identify these people before they
become addicted, it is essential that each of us learn to recognize the signs and symptoms of
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addiction when they become manifest, such that we may preserve the safety of both our
colleagues and the patients they care for. While some highly motivated individuals have been
able to successfully re-enter the clinical practice of anesthesia and avoid relapse, this is not
always the case. Successful completion of a treatment program does not guarantee freedom
from future relapse, even several years into recovery. As such, each case must be carefully
evaluated before the decision is made to allow an addicted physician to attempt a return to the
practice of anesthesiology.

Acknowledgments
Support Statement: Support was provided solely from institutional and/or departmental sources

References
1. Silverstein JH, Silva DA, Iberti TJ. Opioid addiction in anesthesiology. Anesthesiology 1993;79:354–
375. [PubMed: 8267716]
2. Collins GB, McAllister MS, Jensen M, Gooden TA. Chemical dependency treatment outcomes of
residents in anesthesiology: results of a survey. Anesth Analg 2005;101:1457–1462. [PubMed:
NIH-PA Author Manuscript

16244010]
3. Kintz P, Villain M, Dumestre V, Cirimele V. Evidence of addiction by anesthesiologists as documented
by hair analysis. Forensic Sci Int 2005;153:81–84. [PubMed: 15967611]
4. Wischmeyer PE, Johnson BR, Wilson JE, Dingmann C, Bachman HM, Roller E, Tran ZV, Henthorn
TK. A Survey of Propofol Abuse in Academic Anesthesia Programs. Anesth Analg 2007;105:1066–
1071. [PubMed: 17898389]
5. Hughes PH, Baldwin DC Jr, Sheehan DV, Conard S, Storr CL. Resident physician substance use, by
specialty. Am J Psychiatry 1992;149:1348–1354. [PubMed: 1530071]
6. Gold MS, Byars JA, Frost-Pineda K. Occupational exposure and addictions for physicians: case studies
and theoretical implications. Psychiatr Clin North Am 2004;27:745–753. [PubMed: 15550291]
7. Brewster JM. Prevalence of alcohol and other drug problems among physicians. JAMA
1986;255:1913–1920. [PubMed: 3951119]
8. Krizek TJ. The impaired surgical resident. Surgical Clinics of North America 2004;84:1587–1604.
[PubMed: 15501277]
9. 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;257:2927–2930. [PubMed: 3573291]
10. Alexander BH, Checkoway H, Nagahama SI, Domino KB. Cause-specific Mortality Risks of
NIH-PA Author Manuscript

Anesthesiologists. Anesthesiology 2000;93:922–930. [PubMed: 11020740]

11. Booth JV, Grossman D, Moore J, Lineberger C, Reynolds JD, Reves JG, Sheffield D. Substance
abuse among physicians: a survey of academic anesthesiology programs. Anesth Analg
2002;95:1024–1030. [PubMed: 12351288]
12. Report of the Board of Trustees. JAMA 1956;162:750.
13. Lettieri, DJ. Drug Abuse: A review of explanations and models of explanation, Alcohol and Substance
Abuse in Adolescence. Stimmel, B., editor. New York: Haworth; 1985. p. 9-40.
14. Tapper AR, McKinney SL, Nashmi R, Schwarz J, Deshpande P, Labarca C, Whiteaker P, Marks MJ,
Collins AC, Lester HA. Nicotine activation of α4* receptors: sufficient for reward, tolerance, and
sensitization. Science 2004;306:1029–1032. [PubMed: 15528443]
15. Mohn AR, Yao WD, Caron MG. Genetic and genomic approaches to reward and addiction.
Neuropharmacology 2004;47:101–110. [PubMed: 15464129]
16. Lesch KP. Alcohol dependence and gene x environment interaction in emotion regulation: Is serotonin
the link? Eur J Pharmacol 2005;526:113–124. [PubMed: 16288736]

Anesthesiology. Author manuscript; available in PMC 2009 November 1.

 Bryson and Silverstein Page 18

17. Hiroi N, Agatsuma S. Genetic susceptibility to substance dependence. Mol Psychiatry 2005;10:336–
344. [PubMed: 15583701]
18. Kreek MJ, Nielsen DA, LaForge KS. Genes associated with addiction: alcoholism, opiate, and cocaine
NIH-PA Author Manuscript

addiction. Neuromolecular Med 2004;5:85–108. [PubMed: 15001815]

19. Picciotto MR, Zoli M, Rimondini R, Lena C, Marubio LM, Pich EM, Fuxe K, Changeux JP.
Acetylcholine receptors containing the β2 subunit are involved in the reinforcing properties of
nicotine. Nature 1998;391:173–177. [PubMed: 9428762]
20. Wang JC, Hinrichs AL, Stock H, Budde J, Allen R, Bertelsen S, Kwon JM, Wu W, Dick DM, Rice
J, Jones K, Nurnberger JI Jr, Tischfield J, Porjesz B, Edenberg HS, Hesselbrock V, Crowe R, Schuckit
M, Begleiter H, Reich T, Goate AM, Bierut LJ. Evidence of common and specific genetic effects:
association of the muscarinic acetylcholine receptor M2 (CHRM2) gene with alcohol dependence
and major depressive syndrome. Hum Mol Genet 2004;13:1903–1911. [PubMed: 15229186]
21. Luo X, Kranzler HR, Zuo L, Wang S, Blumberg HP, Gelernter J. CHRM2 gene predisposes to alcohol
dependence, drug dependence and affective disorders: results from an extended case-control
structured association study. Hum Mol Genet 2005;14:2421–2434. [PubMed: 16000316]
22. Nace EP, Davis CW, Gaspari JP. Axis II comorbidity in substance abusers. Am J Psychiatry
1991;148:118–120. [PubMed: 1984695]
23. Udel MM. Chemical abuse/dependence: Physicians’ occupational hazard. J Med Assoc Ga
1984;73:775–778. [PubMed: 6512428]
24. Markou A, Kosten TR, Koob GF. Neurobiological similarities in depression and drug dependence:
a self-medication hypothesis. Neuropsychopharmacology 1998;18:135–174. [PubMed: 9471114]
NIH-PA Author Manuscript

25. Sekine Y, Minabe Y, Ouchi Y, Takei N, Iyo M, Nakamura K, Suzuki K, Tsukada H, Okada H,
Yoshikawa E, Futatsubashi M, Mori N. Association of dopamine transporter loss in the orbitofrontal
and dorsolateral prefrontal cortices with methamphetamine-related psychiatric symptoms. Am J
Psychiatry 2003;160:1699–1701. [PubMed: 12944350]
26. Malison RT, Best SE, Wallace EA, McCance E, Laruelle M, Zoghbi SS, Baldwin RM, Seibyl JS,
Hoffer PB, Price LH. Euphorigenic doses of cocaine reduce [123I]beta-CIT SPECT measures of
dopamine transporter availability in human cocaine addicts. Psychopharmacology 1995;122:358–
362. [PubMed: 8657833]
27. Heinz A, Ragan P, Jones DW, Hommer D, Williams W, Knable MB, Gorey JG, Doty L, Geyer C,
Lee KS, Coppola R, Weinberger DR, Linnoila M. Reduced central serotonin transporters in
alcoholism. Am J Psychiatry 1998;155:1544–1549. [PubMed: 9812115]
28. Gold MS, Melker RJ, Dennis DM, Morey TE, Bajpai LK, Pomm R, Frost-Pineda K. Fentanyl abuse
and dependence: further evidence for second hand exposure hypothesis. J Addict Dis 2006;25:15–
21. [PubMed: 16597569]
29. White RK, Kitlowiski EJ. Physicians in recovery. Md Med J 1998;37:183–189. [PubMed: 3357376]
30. Annitto, WJ.; Gold, MS. Treating the “high and mighty” and the “mighty high,” Dual Diagnosis in
Substance Abuse. Gold, MS.; Slaby, AE., editors. New York: Marcel Dekker; 1991. p. 289-295.
31. Talbott GD. The impaired physician and intervention: A key to recovery. J Fla Med Assoc
1992;69:793–797. [PubMed: 7175487]
NIH-PA Author Manuscript

32. Berry, AJ.; Arnold, WP. Chemical Dependence in Anesthesiologists: What you need to know when
you need to know it, American Society of Anesthesiologists Task Force on Chemical Dependence
of the Committee on Occupational Health of Operating Room Personnel. Park Ridge, IL: 1998.
33. Walzer RS. Impaired Physicians. An overview and update of the legal issues. J Leg Med 1990;11:131–
198. [PubMed: 2230589]
34. Gualtieri AC, Cosentino JP, Becker JS. The California experience with the diversion program for
impaired physicians. JAMA 1983;249:226–229. [PubMed: 6848809]
35. Casper E, Dilts SL, Soter JJ. Establishment of the Colorado Physician Health Program with a
legislative initiative. JAMA 1988;260:671–673. [PubMed: 3392793]
36. Carden ET. Wither the impaired physician? The politics of impairment. Md Med J 1988;37:206–210.
[PubMed: 3357380]
37. Revocation of ABA Certification. ABA News 2006 June;Vol. 19(No 1):4.
38. Roback HB, Moore RF, Waterhouse GJ, Martin PR. Confidentiality dilemmas in group psychotherapy
with substance-dependent physicians. Am J Psychiatry 1996;153:1250–1260. [PubMed: 8831431]

Anesthesiology. Author manuscript; available in PMC 2009 November 1.

 Bryson and Silverstein Page 19

39. Gendel MH. Forensic and medical legal issues in addiction psychiatry. Psychiatric Clinics of North
America 2004;27:611–626. [PubMed: 15550283]
40. Medical practices act. Colorado revised statutes. §§ 12-36-117,118. (amended 1995).
NIH-PA Author Manuscript

41. Westreich LM. Addiction and the Americans with Disabilities act. J Am Acad Psychiatry Law
2002;30:355–363. [PubMed: 12380414]
42. Metzner, JL.; Buck, JB. Psychiatric disability determinations and personal injury litigation, Principles
and practice of forensic psychiatry. London: Arnold; 2003. p. 672-684.
43. Traynor and McKelvey v Turnage, 485 US 539. 1988.
44. Menk EJ, Baumgarten RK, Kingsley CP. Success of reentry into anesthesiology training programs
by residents with a history of substance abuse. JAMA 1990;263:3060–3062. [PubMed: 2342218]
45. Hankes, L.; Bissell, L. Health Professionals, Substance Abuse: A Comprehensive Textbook.
Lowinson, JH.; Ruiz, P.; Millman, RB., editors. Baltimore: Williams and Wilkins; 1992. p. 897-908.
46. Pelton C, Ikeda RM. The California Physicians Diversion Program's experience with recovering
anesthesiologists. J Psychoactive Drugs 1991;23:427–431. [PubMed: 1813614]
47. Kirn TF. Advances in understanding of alcoholism initiate evolution in treatment programs. JAMA
1986;256:1405–1412. [PubMed: 3747053]
48. Rounsaville, B.; Karroll, K. Individual psychotherapy for drug abusers, Substance Abuse: A
comprehensive Textbook. Lowinson, JH.; Ruiz, P.; Millman, RB., editors. Baltimore: Williams and
Wilkins; 1992. p. 496-507.
49. Fletcher CE, Ronis DE. Satisfaction of impaired health care professionals with mandatory treatment
and monitoring. J Addict Dis 2005;24:61–75. [PubMed: 16186083]
NIH-PA Author Manuscript

50. Canavan DI. Screening: Urine drug tests. Md Med J 1987;36:229–233. [PubMed: 3586896]
51. Killeen TK, Brady KT, Gold PB, Simpson KN, Faldowski RA, Tyson C, Anton RF. Effectiveness
of naltrexone in a community treatment program. Alcohol Clin Exp Res 2004;28:1710–1717.
[PubMed: 15547458]
52. Haley TJ. Disulfiram (tetraethylthioperoxydicarbonic diamide): A reappraisal of its toxicity and
therapeutic application. Drug Metab Rev 1979;9:319–355. [PubMed: 385275]
53. Galanter M, Talbott D, Gallegos K, Rubenstone E. Combined AA and professional care for addicted
physicians. Am J Psychiatry 1990;147:64–68. [PubMed: 2293790]
54. Galanter, M.; Casteneda, R.; Franco, H. Group therapy and self-help groups, Clinical Textbook of
Addictive Disorders. Frances, RJ.; Miller, SI., editors. The Guilford Press: New York; 1991. p.
431-451.
55. Herrington RE, Benzer DG, Jacobson GR, Hawkins MK. Treating substance use disorders among
physicians. JAMA 1982;247:2253–2257. [PubMed: 7069878]
56. Samkoff JS, Krebs JR. Families and physician impairment. Pa Med 1989;92:38–39. [PubMed:
2922200]
57. O’Connor, PG.; Spickard, A, Jr. Medical Clinics of North America. Vol. 81. Medical Clinics of North
America; 1997. Physician impairment by substance abuse; p. 1037-1052.
58. Arico S, Zannero A, Galatola G. Family compliance to a treatment programme for alcoholics: A
NIH-PA Author Manuscript

prospective study of prognostic factors. Alcohol 1994;29:679–685.

59. Singh J, Basu D. Ultra-rapid opioid detoxification: current status and controversies. J Postgrad Med
2004;50:227–232. [PubMed: 15377814]
60. van Dorp EL. Naloxone treatment in opioid addiction: the risks and benefits. Expert Opin Drug Saf
2007;6:125–132. [PubMed: 17367258]
61. Collins ED, Kleber HD, Whittington RA, Heitler NE. Anesthesia-assisted vs buprenorphineor
clonidine-assisted heroin detoxification and naltrexone induction: a randomized trial. JAMA
2005;294:903–913. [PubMed: 16118380]
62. Gallegos KV, Browne CH, Veit FW, Talbott GD. Addiction in anesthesiologists: Drug access and
patterns of substance abuse. QRB 1988;14:116–122.
63. Matsumura JS. Substance abuse and anesthesiology training. JAMA 1990;264:2741–2742. [PubMed:
2232058]
64. Talbott GD. Elements of the Impaired Physicians Program. J Med Assoc Ga 1984;73:749–751.
[PubMed: 6512424]

Anesthesiology. Author manuscript; available in PMC 2009 November 1.

 Bryson and Silverstein Page 20

65. Collins GB, McAllister MS, Jensen M, Gooden TA. Chemical dependency treatment outcomes of
residents in anesthesiology: results of a survey. Anesth Analg 2005;101:1457–1462. [PubMed:
16244010]
NIH-PA Author Manuscript

66. Bryson EO, Levine A. One Approach to the Return to Residency for Anesthesia Residents Recovering
from Narcotic Addiction. J Clin Anesth. 2008in press
67. Domino KB, Hornbein TF, Polissar NF, Renner G, Johnson J, Alberti S, Hankes L. Risk factors for
relapse in health care professionals with substance use disorders. JAMA 2005;293:1453–1460.
[PubMed: 15784868]
68. Fletcher CE, Ronis DL. Satisfaction of impaired health care professionals with mandatory treatment
and monitoring. J Addict Dis 2005;24:61–75. [PubMed: 16186083]
69. Farley WJ, Talbott GD. Anesthesiology and addiction (editorial). Anesth Analg 1983;62:465–466.
[PubMed: 6837958]
70. Kintz P, Villain M, Dumestre V, Cirimele V. Evidence of addiction by anesthesiologists as
documented by hair analysis. Forensic Sci Inr 2005;153:81–84.
71. Adler GR, Potts FE III, Kirby RR. Narcotics control in anesthesia training. JAMA 1985;253:3133–
3136. [PubMed: 3999300]
72. Moleski RJ, Easley S, Barash PG. Control and accountability of controlled substance administration
in the operating room. Anesth Analg 1985;64:989–995. [PubMed: 4037397]
73. Shafer AL, Lisman SR, Rosenberg MB. Development of a comprehensive operating room pharmacy.
J Clin Anesth 1991;3:156–166. [PubMed: 2039646]
74. Schmidt KA, Schlesinger MD. A reliable accounting system for controlled substances in the operating
NIH-PA Author Manuscript

room. Anesthesiology 1993;78:184–190. [PubMed: 8424552]

75. 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;105:1053–1060.
[PubMed: 17898387]
76. Lutsky I, Hopwood M, Abram SE. Psychoactive substance use among American anesthesiologists:
a 30-year retrospective study. Can J Anaesth 1993;40:915–921. [PubMed: 8222029]
77. Substance-Abuse Testing Committee American Association for Clinical Chemistry: Critical issues
in urinalysis of abuse substances: Report of the substance-abuse testing committee. Clin Chem
1988;34:605–632. [PubMed: 3280166]
78. Chamberlain RT. Legal issues related to drug testing in the clinical laboratory. Clin Chem
1988;34:633–636. [PubMed: 3280167]
79. Peat MA. Analytical and technical aspects of testing for drugs of abuse: confirmatory procedures.
Clin Chem 1988;34:471–473. [PubMed: 3280161]
80. Blanke, RV. Accuracy in Urinalysis, Urine Testing for Drugs of Abuse. NIDA research monograph
no. 73. Hawks, RL.; Chaiang, NC., editors. Washington DC: Government printing office; 1986. p.
43-53.
81. Vereby, K. Diagnostic laboratory: Screening for drug abuse, Substance Abuse: A Comprehensive
Textbook. Lowinson, JH.; Ruiz, P.; Millman, RB., editors. Baltimore: Williams and Wilkins; 1992.
NIH-PA Author Manuscript

p. 425-436.
82. McCain DA, Hug CC Jr. Intravenous fentanyl kinetics. Clin Pharmacol Ther 1980;28:106–114.
[PubMed: 7389247]
83. Stoelting, RK. Pharmacology and Physiology in Anesthetic Practice. Philadelphia: J.B. Lippincott
Company; 1987. Opioid Agonists and Antagonists; p. 69-101.
84. Henderson GL. Mechanism of drug incorporation into hair. Forensic Sci Int 1993;63:19–29. [PubMed:
8138221]
85. Pragst F, Balikova MA. State of the art in hair analysis for detection of drug and alcohol abuse. Clinica
Chimica Acta 2006;370:17–49.
86. Romano N, Barbera G, Lombardo I. Hair testing for drugs of abuse: evaluation of external cocaine
contamination and risk of false positives. Forensic Sci Int 2001;123:119–129. [PubMed: 11728736]
87. Romano N, Barbera G, Spadaro, Valenti V. Determination of drugs of abuse in hair: evaluation of
external heroin contamination and risk of false positives. Forensic Sci Int 2003;131:98–102.
[PubMed: 12590046]

Anesthesiology. Author manuscript; available in PMC 2009 November 1.

 Bryson and Silverstein Page 21

88. Clark HW. The role of physicians as medical review officers in workplace drug testing programs: In
pursuit of the last nanogram. West J Med 1990;152:514–524. [PubMed: 2190419]
89. Davis KH, Hawks RL, Blanke RV. Assessment of laboratory quality in urine drug testing: A
NIH-PA Author Manuscript

proficiency testing pilot study. JAMA 1988;260:1749–1754. [PubMed: 3411757]

90. Struempler RE. Excretion of codeine and morphine following ingestion of poppy seeds. J Anal Toxicol
1987;11:97–99. [PubMed: 3599922]
91. ElSohly NH, elSohly MA, Stanford DF. Poppy seed ingestion and opiates uranalysis: a closer look.
J Anal Toxicol 1990;14:308–310. [PubMed: 2263066]
92. Fitzgerald RL, Ramos JM Jr, Bogema SC, Poklis A. Resolution of methamphetamine stereoisomers
in urine drug testing: Urinary excretion of R(-)-methamphetamine following use of nasal inhalers. J
Anal Toxicol 1998;12:255–259. [PubMed: 3226121]
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Table 1
Side effects associated with the use of naltrexone1
Abdominal pain/cramps Headache
Anxiety Impotence
Althralgia Irritability
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Chills Myalgia
Constipation Nausea
Depression Nervousness
Diarrhea Rash
Dizziness Sleep disturbances
Ejaculation disturbancesVomiting
Reprinted with permission.
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