A survey of inhalational anaesthetic abuse in anaesthesia training programmes

Preventing controlled substance diversion in perioperative settings: a narrative review

PURPOSE

Diversion of controlled substances in the perioperative setting is an ongoing challenge, with consequences for patients, anesthesiologists, perioperative staff, and health care facilities alike. Perioperative environments are at high risk for diversion, since controlled substances are frequently handled in these settings, with varying levels of oversight. In this narrative review, we summarize strategies for preventing diversion of controlled substances in perioperative settings (i.e., operating rooms, endoscopy suites, and postanesthesia recovery units).

SOURCE

We performed a targeted literature search in PubMed MEDLINE, Embase, Scopus, Web of Science, the Cochrane Register of Controlled trials, and the Cochrane Database of Systematic Reviews, as well as a manual search for additional references. We used terminology related to drug diversion, drug abuse, anesthesiologists, pharmacists, physicians, operating room personnel, and controlled substances.

PRINCIPAL FINDINGS

Many strategies have been described for preventing diversion in perioperative settings, and these are broadly categorized into: education, distribution, auditing, or provider screening. Some of these approaches may be time- and resource-intensive. There is limited evidence to inform anesthesia departments' choice of which strategies to adopt.

CONCLUSION

Although awareness of perioperative controlled substance diversion has been improving, there are too few data to suggest an optimal approach. Anesthesia departments will need to work collaboratively with hospital pharmacies and actively select strategies that are reasonable given local resources.

Substance use disorder in the anaesthetist: Guidelines from the Association of Anaesthetists: Guidelines from the Association of Anaesthetists

Anaesthetists have a higher incidence of substance use disorder when compared with other doctors. This might be due to the ease of access to intravenous opioids, propofol, midazolam, inhalational agents and other anaesthetic drugs. Alcohol use disorder continues to be the most common problem. Unfortunately, the first sign that something is amiss might be the anaesthetist's death from an accidental or deliberate overdose. While there are few accurate data, suicide is presumed to be the cause of death in approximately 6-10% of all anaesthetists. If we are to prevent this, substance use disorder must be recognised early, we should ensure the anaesthetist is supported by their department and hospital management and that the anaesthetist engages fully with treatment. Over 75% of anaesthetists return to full practice if they co-operate fully with the required treatment and supervision.

Postmortem qualitative analysis of psychological, occupational, and environmental factors associated with lethal anesthetic and/or opioid abuse among anesthesiologists: case series

BACKGROUND

Anesthetic and/or opioid abuse is more prevalent among anesthesiologists than in other medical specialties and it has been associated with high mortality. The aim of this study was to evaluate factors associated with lethal anesthetic and/or opioid abuse among anesthesiologists.

METHODS

We evaluated psychological factors, and occupational history and circumstances of death of anesthesiologists who died from anesthetic abuse. Data were obtained post-mortem from colleagues, and relatives. After finding eligible cases, we identified the key informants, who were interviewed personally or via email, through the qualitative method known as "Psychological Autopsy".

RESULTS

Eighteen cases of death were identified, but we were able to interview 44% of them (n = 8), most of whom were young males. They died at home or at the hospital and were found "at the scene". Being an introspective person who did not share personal issues at workplace was the most prevalent personal characteristic. At work, they seemed to perform very well their functions, but some presented subtle changes such as to staying more than usual at the workplace and/or neglecting some of their responsibilities. The main reported factors to explain their substance abuse were emotional problems including psychiatric, excessive hours of work, and other health factors.

CONCLUSION

This study identified that emotional disturbances, compulsive work, and general health problems were the more prominent factors involved with those deaths. Further, larger studies are needed to better understand how these factors could be early identified in order to timely prevent anesthetic and/or opioid abuse and several deaths among anesthesiologists.

Success Rates of Monitoring for Healthcare Professionals with a Substance Use Disorder: A Meta-Analysis

In the past decades, monitoring programs have been developed for healthcare professionals with substance use disorders. We aimed to explore estimates of abstinence and work retention rates after participation in such monitoring programs. A literature search was performed using PubMed, Embase, PsycINFO, and CINAHL. Twenty-nine observational studies reporting on success rates (abstinence and work retention) of monitoring for healthcare professionals with a substance use disorder were included in the meta-analysis. Quality-effects models calculated pooled success rates and corresponding 95%-Confidence Intervals (CI), with subgroup analyses on monitoring elements and patient characteristics. Pooled success rates were 72% for abstinence (95%-CI = 63–80%) and 77% for work retention (95%-CI = 61–90%). Heterogeneity across studies was partly explained by the starting moment of monitoring, showing higher abstinence rates for studies that started monitoring after treatment completion (79%; 95%-CI = 72–85%) compared to studies that started monitoring with treatment initiation (61%; 95%-CI = 50–72%). About three-quarters of healthcare professionals with substance use disorders participating in monitoring programs are abstinent during follow-up and working at the end of the follow-up period. Due to selection and publication bias, no firm conclusions can be drawn about the effectiveness of monitoring for healthcare professionals with SUD.

The Anesthesiologist's Armamentarium: From Recreation to Medication and Back

For millennia, mankind has sought a means of altering consciousness, often aided by naturally occurring elements. Psychotropic substances have been an integral part of spiritual, medicinal, and recreational aspects of life. The origin of anesthesiology stems directly from the use of recreational drugs; early inhaled anesthetics were first used as a means of entertainment. Hence, it is no surprise that many medications in the anesthesiologist's armamentarium are diverted for recreational use. In the 172 years following the first successful public demonstration of ether anesthesia, many drugs with abuse potential have been introduced to the practice of anesthesia. Although anesthesiologists are aware of the abuse potential of these drugs, how these drugs are obtained and used for recreational purposes is worthy of discussion. There are articles describing the historical and recreational use of specific drug classes. However, to the best of our knowledge, this is the first comprehensive review focusing on the breadth of drugs used by anesthesiologists.

[Addictive disorders in physicians]

Despite their knowledge about the risks and treatment options for substance abuse disorders, physicians are not immune to them. Meanwhile, a number of studies have shown that physicians have an increased risk of depression, addictive diseases and burnout due to the occupation-linked mental and physical burden and in particular an increased prevalence of substance-related disorders, especially alcohol abuse or dependence and drug abuse. Drug dependence among physicians seems to be even higher than in the general population due to the relatively easy access to psychoactive medications, in particular hypnotic drugs, benzodiazepines, ketamine and opioids; however, the prognosis is good. According to data from the medical associations, three quarters of those affected for the first time and every sixth relapsed physician can be helped with preservation of the license and working as physicians.

Non-opioid anesthetic drug abuse among anesthesia care providers: a narrative review

PURPOSE

The objective of this narrative review is to provide an overview of the problem of non-opioid anesthetic drug abuse among anesthesia care providers (ACPs) and to describe current approaches to screening, therapy, and rehabilitation of ACPs suffering from non-opioid anesthetic drug abuse.

SOURCE

We first performed a search of all literature available on PubMed prior to April 11, 2016. The search was limited to articles published in Spanish and English, and the following key words were used: anesthesiology, anesthesia personnel, AND substance-related disorders. We also searched Ovid MEDLINE^® databases from 1946-April 11, 2016 using the following search terms: anesthesiology OR anesthesia, OR nurse anesthetist OR anesthesia care provider OR perioperative nursing AND substance-related disorders.

PRINCIPAL FINDINGS

Despite an increased awareness of drug abuse among ACPs and improvements in preventive measures, the problem of non-opioid anesthetic drug abuse remains significant. While opioids are the most commonly abused anesthesia medications among ACPs, the abuse of non-opioid anesthetics is a significant cause of morbidity, mortality, and professional demise.

CONCLUSION

Early detection, effective therapy, and long-term follow-up help ACPs cope more effectively with the problem and, when possible, resume their professional activities. There is insufficient evidence to determine the ability of ACPs to return safely to anesthesia practice after rehabilitation, though awareness of the issue and ongoing treatment are necessary to minimize patient risk from potentially related clinical errors.

Prevalence of Substance Abuse Among Oral and Maxillofacial Surgery Residents From 2006 to 2015

PURPOSE

Substance abuse in oral and maxillofacial surgery (OMS) training programs is an important and under-represented topic in the literature. This study's purpose was to assess the prevalence of substance abuse in OMS training programs in the United States during a 10-year period and to determine the substances most abused by OMS residents.

MATERIALS AND METHODS

A cross-sectional survey study was conducted by sending an online questionnaire to program directors and chairpersons of all OMS graduate training programs accredited by the Commission on Dental Accreditation. The content- and validity-tested survey asked respondents to report on substance abuse cases at their program from 2006 to 2015. Auxiliary questions asked opinions on substance abuse. To analyze the data, percentages were calculated, including the estimated prevalence of abuse; results were presented as bar charts.

RESULTS

Forty-six of the 101 OMS training programs (45.5%) responded. Sixteen of the responding 46 programs (34.8%) reported at least 1 suspected or encountered incident of substance abuse. The 2 most abused substances were alcohol and narcotics. During the decade studied, the prevalence of resident substance abuse was estimated to be 1.2%.

CONCLUSION

The estimated prevalence of resident substance abuse has gone unchanged since Rosenberg's initial study in 1986 (J Oral Maxillofac Surg 44:458, 1986). With the introduction of new drugs and despite more stringent protocols, substance abuse continues to be a germane issue for OMS requiring ongoing attention clinically and in the literature.

Help seeking by health professionals for addiction: A mixed studies review

BACKGROUND

When health professionals practice with active and untreated addiction, it is a complex occupational and professional issue impacting numerous stakeholders. Health professionals are responsive to evidence-based addiction interventions and their return-to-work has been demonstrated to be achievable, sustainable and safe. Facilitating help seeking in health professionals with addiction is a priority for reducing associated risks to their health and to patient safety.

AIM

The purpose of this study was to identify the process by which health professionals seek help for addiction, and factors that facilitate and deter help seeking, through a review of the qualitative and quantitative literature.

METHODS

Both phases of this sequential mixed studies review followed the standard systematic review steps of: (1) identifying the review question, (2) defining eligibility criteria, (3) applying an extensive search strategy, (4) independent screening of titles and abstracts, (5) selecting relevant studies based on reviewing the full text, (6) appraising the quality of included studies, and (7) synthesizing the study findings. Our two searches of five databases from 1995 to 2015 resulted in the inclusion of eight qualitative and twenty-three quantitative studies. We first conducted a meta-synthesis of the qualitative literature to garner an understanding of the help seeking process for health professionals for addiction. We then conducted a narrative synthesis of the quantitative studies to generalize these findings through examining the data for convergent, complementary or divergent results.

RESULTS

Synthesis of the included qualitative studies revealed that the professional and experiential context of healthcare compromised the health professional's readiness to seek help for addiction. Typically, a pivotal event initiated the help seeking process. The studies in the quantitative review identified that help seeking most often resulted from reports of adverse events to formal organizations such as their employer and regulatory bodies. This process does not adequately address the scope of health professionals requiring help for addiction. Informal sources such as colleagues and family, often aware of the addiction earlier, preferred referral to voluntary, confidential treatment programs.

CONCLUSIONS

Facilitating the help seeking process for health professionals with addiction in as effective strategy to reduce the associated risks to the health professional, their families and colleagues, their employers and regulatory bodies, and to the general public. Our findings suggest that intervention is possible at multiple points in the help seeking process for health professionals with addiction. Confidential, compassionate and supportive alternatives offer potential for closing this gap.

A Retrospective Survey of Substance Abuse in Anaesthetists in Australia and New Zealand from 2004 to 2013

A questionnaire on substance abuse was distributed electronically to the heads of 185 Australian and New Zealand College of Anaesthetists accredited anaesthesia departments in Australia and New Zealand. The response rate was 57%. From January 2004 to December 2013, 61 cases of substance abuse were identified, giving an estimated incidence of 1.2 cases per 1000 anaesthetist years. Of 44 detailed reports completed, the majority were aged between 30 and 49 years, were male and of specialist grade. However, when corrected for gender and grade, the estimated overall incidence was higher in females and twice as high for trainees compared with specialists. When compared with prior surveys, the pattern of substance abuse in Australia and New Zealand appears to have changed significantly, with a notable increase in propofol and alcohol abuse and a decrease in reported cases of opioid abuse. Common presenting features of abuse included intoxication and witnessed abuse. Seventy percent of cases had more than one comorbid condition, most frequently either mental health or family problems. Only 32% of abusers had made a long-term recovery within the specialty. Death was the eventual outcome in 18% overall, with a particularly high mortality associated with propofol abuse (45%). Trainee suicide from all causes was reported at three times the rate of specialists. The findings indicate that substance abuse remains a significant problem in Australia and New Zealand and is associated with a significant mortality rate.

[Life-threatening fentanyl and propofol addiction: interview with a survivor]

Anesthesiologists have a well-known increased risk of substance abuse including the intravenous administration of opioids and propofol. However, katamnestic reports from the point of view of propofol-addicted anesthesiologists themselves are missing which would aid a better understanding of the dynamics and progress of addiction. This article presents an interview with a formerly addicted female anesthesiologist who after long-term abuse with oral tilidine combined with naloxone switched to intravenous administration of fentanyl and later on propofol. Several life-threatening incidents occurred but after some severe setbacks occupational rehabilitation outside the field of anesthesiology was successful following inpatient treatment. This case shows exemplarily in accordance with the current literature that warning signs in addicted physicians are often ignored by colleagues and supervisors and rehabilitation is possible under professional therapy and continuous surveillance. Additionally, this case emphasizes the necessity of controlling the distribution of propofol to reduce the life-threatening professional risk to anesthesiologists.

Substance use disorder among anesthesiology residents, 1975-2009

IMPORTANCE

Substance use disorder (SUD) among anesthesiologists and other physicians poses serious risks to both physicians and patients. Formulation of policy and individual treatment plans is hampered by lack of data regarding the epidemiology and outcomes of physician SUD.

OBJECTIVE

To describe the incidence and outcomes of SUD among anesthesiology residents.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of physicians who began training in United States anesthesiology residency programs from July 1, 1975, to July 1, 2009, including 44,612 residents contributing 177,848 resident-years to analysis. Follow-up for incidence and relapse was to the end of training and December 31, 2010, respectively.

MAIN OUTCOMES AND MEASURES

Cases of SUD (including initial SUD episode and any relapse, vital status and cause of death, and professional consequences of SUD) ascertained through training records of the American Board of Anesthesiology, including information from the Disciplinary Action Notification Service of the Federation of State Medical Boards and cause of death information from the National Death Index.

RESULTS

Of the residents, 384 had evidence of SUD during training, with an overall incidence of 2.16 (95% CI, 1.95-2.39) per 1000 resident-years (2.68 [95% CI, 2.41-2.98] men and 0.65 [95% CI, 0.44-0.93] women per 1000 resident-years). During the study period, an initial rate increase was followed by a period of lower rates in 1996-2002, but the highest incidence has occurred since 2003 (2.87 [95% CI, 2.42-3.39] per 1000 resident-years). The most common substance category was intravenous opioids, followed by alcohol, marijuana or cocaine, anesthetics/hypnotics, and oral opioids. Twenty-eight individuals (7.3%; 95% CI, 4.9%-10.4%) died during the training period; all deaths were related to SUD. The Kaplan-Meier estimate of the cumulative proportion of survivors experiencing at least 1 relapse by 30 years after the initial episode (based on a median follow-up of 8.9 years [interquartile range, 5.0-18.8 years]) was 43% (95% CI, 34%-51%). Rates of relapse and death did not depend on the category of substance used. Relapse rates did not change over the study period.

CONCLUSIONS AND RELEVANCE

Among anesthesiology residents entering primary training from 1975 to 2009, 0.86% had evidence of SUD during training. Risk of relapse over the follow-up period was high, indicating persistence of risk after training.

Physiological concentrations of zinc reduce taurine-activated GlyR responses to drugs of abuse

Taurine is an endogenous ligand acting on glycine receptors in many brain regions, including the hippocampus, prefrontal cortex, and nucleus accumbens (nAcc). These areas also contain low concentrations of zinc, which is known to potentiate glycine receptor responses. Despite an increasing awareness of the role of the glycine receptor in the rewarding properties of drugs of abuse, the possible interactions of these compounds with zinc has not been thoroughly addressed. Two-electrode voltage-clamp electrophysiological experiments were performed on α1, α2 α1β and α2β glycine receptors expressed in Xenopus laevis oocytes. The effects of zinc alone, and zinc in combination with other positive modulators on the glycine receptor, were investigated when activated by the full agonist glycine versus the partial agonist taurine. Low concentrations of zinc enhanced responses of maximally-effective concentrations of taurine but not glycine. Likewise, chelation of zinc from buffers decreased responses of taurine- but not glycine-mediated currents. Potentiating concentrations of zinc decreased ethanol, isoflurane, and toluene enhancement of maximal taurine currents with no effects on maximal glycine currents. Our findings suggest that the concurrence of high concentrations of taurine and low concentrations of zinc attenuate the effects of additional modulators on the glycine receptor, and that these conditions are more representative of in vivo functioning than effects seen when these modulators are applied in isolation.

Should anesthesia residents with a history of substance abuse be allowed to continue training in clinical anesthesia? The results of a survey of anesthesia residency program directors

STUDY OBJECTIVE

To determine the experience, attitudes, and opinions of program directors regarding the reintroduction of residents in recovery from substance abuse into the clinical practice of anesthesiology.

DESIGN

Survey instrument.

SETTING

Anesthesia residency training programs in the United States.

MEASUREMENTS

After obtaining institutional review board approval, a list of current academic anesthesia residency programs in the United States was compiled. A survey was mailed to 131 program directors along with a self-addressed stamped return envelope to ensure anonymity. Returned surveys were reviewed and data compiled by hand, with categorical variables described as frequency and percentages.

MAIN RESULTS

A total of 91 (69%) surveys were returned, representing experience with 11,293 residents over the ten-year period from July of 1997 through June of 2007. Fifty-six (62%) program directors reported experience with at least one resident requiring treatment for substance abuse. For residents allowed to continue with anesthesia residency training after treatment, the relapse rate was 29%. For those residents, death was the initial presentation of relapse in 10% of the reported cases. 43% of the program directors surveyed believe residents in recovery from addiction should be allowed to attempt re-entry while 30% believe that residents in recovery from addiction should not.

CONCLUSIONS

The practice of allowing residents who have undergone treatment for substance abuse to return to their training program in clinical anesthesia remains highly controversial. They are often lost to follow-up, making it difficult, if not impossible to determine if re-training in a different medical specialty decreases their risk for relapse. A comprehensive assessment of the outcomes associated with alternatives to re-entry into clinical anesthesia training programs is needed.

Update on inhalational anaesthetics

PURPOSE OF REVIEW

Inhalational anaesthetic agents are a cornerstone in modern anaesthetic practice. The currently used compounds are very effective and have a good safety profile. In addition, it has been demonstrated that they possess organ-protective properties that might provide an additional tool in the treatment or prevention of the consequences of organ ischaemia-reperfusion injury or both. The present review summarizes some of the most recent findings on this subject.

RECENT FINDINGS

The mechanisms underlying the organ-protective effects of inhalational anaesthetics continue to be further unravelled. The main challenge, however, is to determine the clinical importance of these protective effects and their potential benefits for patients. Initial observations in cardiac surgery are encouraging, and the first clinical studies on other organ systems are being published. Noble gases share these organ-protective properties and may provide an additional tool for this purpose both in situations in which anaesthesia is needed (xenon) or in cases in which anaesthesia is not necessary (helium).

SUMMARY

In the experimental setting, inhalational anaesthetics have protective effects against ischaemia-reperfusion injury. Initial perioperative data suggest that these effects may also result into clinically relevant improved organ function. However, further research will be needed to reveal whether these organ-protective properties will ultimately translate into an improved short-term and long-term postoperative outcome.