Clinical Ethics in Anesthesiology. A Case-Based Textbook

5. Practice issues

36. The impaired anesthesiologist - addiction

Thomas SpechtClarence Ward, and Stephen Jackson

The Case

A 43-year-old male anesthesiologist has been drug-free for 6 years following initial treatment for his sufentanil addiction and an extensive rehabilitation program administered by his state medical board. He has re-entered private practice with the support of his department and colleagues. His tightly monitored recovery program was considered to be a model of success. After 5 years, his monitoring intensity was loosened, although he continued to take naltrexone in a witnessed environment, regularly attended Narcotics Anonymous meetings, submitted witnessed random abstinence-urines for testing when required, and met every 3 months with an addiction specialist who reported his findings to the medical staff impaired physician chair. During the past 2 months, suspicion of relapse was raised by several close colleagues, but no evidence for narcotic diversion could be substantiated. Shortly after his last urine test submission, he was found unconscious in a bathroom with an empty 20 ml syringe and ampoule of propofol. This relapse was immediately followed by appropriate treatment for 18 months, once again serving as a “model” patient in recovery. He again expresses his desire to return to practice, but this time there is sharp disagreement within his department and group over re-entry.

Chemical dependence in the form of addiction is a chronic relapsing disease characterized by the overwhelming compulsion (both genetic and behavioral in origin) to use drugs in spite of adverse consequences. Drug addiction, unless identified and treated skillfully, will lead to disability and often to death. The practice of anesthesiology provides the setting for a susceptible “host” by offering an environment in which powerfully addictive drugs are immediately available for abuse.

Addiction in the specialty of anesthesiology

Prevalence

Addictive disease in the form of chemical dependency is present in all classes, cultures, and professions, including healthcare professionals. Its lifetime prevalence in the physician population is estimated to be 10%–12%, essentially the same as that of the general population.1 Among anesthesiologists, the prevalence appears to be even higher. However, support for this perception is based on diagnosis from treatment programs for chemical dependence where the specialty of anesthesiology is over-represented in relation to most other medical specialties, at least with regard to drugs other than alcohol. This may be because the specialty of anesthesiology is particularly attuned to the issue, monitors its members more closely, and therefore detects chemical dependency more often than specialties that have lower vigilance.

Furthermore, recent trends in prescription drug abuse in the US suggest that perceptions regarding drug abuse that are based on literature from past decades is no longer relevant.

Outcomes

The historic approach to the addicted anesthesiologist has been to assume that those who complete treatment for addiction should be returned to practice. But a 1990 study of chemically dependent anesthesiology residents indicated that prolonged abstinence following treatment is unusual. Startlingly, 7% of those cases presented with death. Two-thirds of the residents who were allowed to reenter their programs after treatment relapsed, and perhaps most frightening, in 16% of those who relapsed, death was the presenting sign.2 However, this study was criticized because of its poor design and inadequate inpatient treatment times. Nontheless, its conclusion are likely to be valid, as a 2005 publication found that less than half of anesthesiology residents who attempted reentry successfully completed their residency, while 9% of those attempted reentrants died.3 Such statistics raise the question of whether reentry by residents after treatment for substance abuse should even be attempted, or whether there is an ethical obligation of anesthesia training programs to prohibit residents from returning. This debate remains unresolved, but hopefully will lead to the development of effective standardized guidelines for appropriate evaluation, treatment, monitoring and aftercare (monitoring if returning to work) of the addicted anesthesiologist.

Is addiction a disability?

Addiction is approached from the perspective of a disease model in the United States, but it is not treated entirely as a disability. The Americans with Disabilities Act of 1990 prohibits discrimination based on disability, defined as “physical or mental impairment that substantially limits a major life activity.” While physicians who are in current treatment for substance abuse are afforded some legal protections by the act, current substance abuse is excluded as a protected condition.

Ethical issues

The ASA Guidelines for the Ethical Practice of Anesthesiology4 recognizes that anesthesiologists have professional responsibilities to patients, to colleagues, to facilities at which they practice, to self (meaning the duty to maintain physical, mental and emotional abilities necessary to good patient care), and to community and society. In the case of the addicted anesthesiologist, these obligations are further complicated by the fact that the anesthesiologist is not only a healthcare provider, but is also a patient, with ethical duties owed to them by others.

Anesthesiologists’ ethical responsibilities to patients and themselves

All physicians have as their primary ethical responsibility the obligation to place their patients’ interests foremost while providing competent medical care with compassion and respect for human dignity. This obligation, in turn, invokes anesthesiologists’ ethical responsibilities to themselves. According to the American Society of Anesthesiologists’ Guidelines for the Ethical Practice of Anesthesiology, they are required to

maintain their physical and mental health and special sensory capabilities [and] if in doubt about their health … seek medical evaluation and care … [and further] during this period of evaluation or treatment … should modify or cease their practice.”4

The unethical and illegal behavior inherent to the impaired anesthesiologist’s addictive disease leads to a gradual inability to provide safe and competent care to the patient. Due to the progressive nature of drug addiction, the anesthesiologist-patient becomes subservient to the incessant demands of the disease. The addicted anesthesiologist may have tangential awareness of this fact, but the same rationalization that accepts or excuses his/her diversion of drugs dims awareness of the declining quality of patient care. Feeding addiction reorders a physician’s priorities, pushing honesty and patient responsibility into the background.

As the disease progresses, there eventually is a degradation of the physician’s personal health, and the physician commonly develops organic neuropsychiatric impairment that further clouds his/her ability to provide competent and compassionate care. This failure to place a patient’s interests foremost represents a stark violation of the primary ethical obligation of any physician. It frequently is only after diagnosis and successful treatment that there is any direct awareness or acknowledgment of this inverted priority by the addicted physician.

During the course of the disease, the development of chemical (alcohol or drugs) tolerance demands ever-increasing doses and frequency of use. The pattern of use escalates, often rapidly, from off-duty occasional use to consumption while directly involved with patient care in the healthcare facility or operating room. Chemical impairment of anesthesiologists while they are involved in direct patient care clearly places patients at increased risk from cognitive errors in decision-making, diminished capacity for vigilance, and chemically induced physical discoordination. The incessant compulsion to obtain drugs is accompanied by both the continuous stress of disguising the addiction and the anxiety of impending withdrawal. In addition, the opiate-addicted anesthesiologist may divert drugs from patient use, potentially leading to inadequate postoperative pain control for patients. The potential for patient harm caused by the impaired anesthesiologist is the major impetus for prompt and effective action by the medical community.

Anesthesiologists’ ethical responsibilities to their colleagues

In the course of their disease, the addicted anesthesiologist often violates many obligations to their colleagues. These include duties of honesty and fidelity to the profession. The addicted physician is induced by self-interest to conceal their addiction (thus preventing treatment), lest they be removed from the work place – and in most cases, away from their drug supply. In addition, the anesthesiologist abusing operating room (OR) drugs (e.g., fentanyl, sufentanil, ketamine or propofol) often turns to the theft of those drugs from the OR to maintain their supply. Alternatively, they may obtain drugs using actual or forged prescriptions. Not only are such activities frankly illegal, but they are a betrayal of the trust placed in physicians by society and by their colleagues, and thus a breach of duty.

ASA guidelines also describe the ethical responsibilities of anesthesiologists to their colleagues.

“Anesthesiologists should advise colleagues whose ability to practice medicine becomes temporarily or permanently impaired to appropriately modify or discontinue their practice. They should assist, to the extent of their own abilities, with the re-education or rehabilitation of a colleague who is returning to practice.” 4

These obligations by extrapolation include the detection of addiction, intervention, treatment, and eventually rehabilitation of a colleague who is returning to practice. However, the response of an addicted physician’s colleagues to addictive behavior, as in society, reflects a wide range of understanding of the relevant issues. Even with the reported high incidence of addiction in the specialty of anesthesiology, individuals in a department often are most influenced by their own personal experience with this problem, by the broader view society takes, or even other factors such as religious beliefs, rather than by full understanding of the addictive disease process.

Because chemical dependency is a disease, in the case of an impaired anesthesiologist there are actually two patients: the patient receiving anesthesia care, and the anesthesiologist him or herself. Conflicts may arises among colleagues of the addicted provider, between concern for the safe provision of care for patients by the impaired anesthesiologist, and the support of the impaired anesthesiologist’s well-being in the event of a relapse. For physician colleagues trained to view illness with compassion, this conflict can present difficult choices.

Further complicating this matter is the potential for bias in decision-making due to lack of acceptance of the disease model for addiction, and a perception of the issue as rather a moral problem or deficiency of willpower. Moral judgments of addictive behavior may greatly influence the decision of whether or not to support the addicted colleague professionally. Concern may principally be for the care of the patient and, perhaps, for the safety of the anesthesiologist, with little consideration over the fate of the colleague professionally. Placing concerns for patients first is important, but the professional fate of the addicted provider is also a legitimate ethical concern of their colleagues. If the recovering anesthesiologist is not well respected or is thought to be professionally substandard, greedy, manipulative, or possessing a genuine personality disorder, then it is almost impossible to expect that these factors will not influence or even dominate group decision-making with respect to re-entry.

Anesthesiologists’ ethical obligations to healthcare facilities

Anesthesiologists personally handle and have easy access to many controlled and potentially addictive substances. The ASA ethical guidelines declare that:

“Anesthesiologists personally handle many controlled and potentially dangerous substances and, therefore, have a special responsibility to keep these substances secure from illicit use. Anesthesiologists should work within their healthcare facility to develop and maintain an adequate monitoring system for controlled substances.”4

Increased awareness of addiction and diversion of controlled substances in anesthesiology has been fostered by educational efforts, particularly during residency. All anesthesiologists, whether in training or not, have an ethical responsibility to learn to recognize the signs and symptoms of addiction in order to avert a possible tragic outcome, either to that individual or one of his/her patients. Unfortunately, educational efforts to raise awareness of addiction among anesthesiologists apparently have not resulted in a decreased incidence of the disease. Increased reporting and diagnosis may reflect an actual increase in addiction, or simply reflect increased awareness, adding to the confusion.

Ethical considerations regarding re-entry into the anesthesia workplace

Addiction is not only a life-threatening, but also a career-threatening disease. Many are concerned about whether the addicted anesthesiologist should return to practice or training once treatment has been completed. Opioid abusers with co-morbid psychiatric conditions (dual diagnosis) and/or a family history of drug addiction/abuse present greater risk for at least one relapse. Recidivism is a characteristic of addictive disease and focuses discussion of re-entry on the safety for both the recovering anesthesiologist and his/her patients.

Post-residency addicted physicians have years, even decades, invested in professional training and practice. This intensifies the real dilemma of deciding whether or not to support and advocate for that colleague’s return to practice.

On the other hand, the impaired provider’s substantial investment also represents enormous leverage to “encourage” compliance in recovery. There is much more literature regarding the addiction experience in academic training programs than that of the majority of anesthesiologists who are in private practice. Furthermore, information from academic programs is almost exclusively concerned with trainees, who have been in the profession for only a short period of time and have the least substantial career investment. The differences in addiction and recovery between trainees and those in long-time practice may be substantial, but are currently poorly understood and under-studied.

Does a practicing anesthesiologist have an ethical obligation to inform patients about past addictive behavior?

Although this ethical issue has received little if any comment, it certainly is a physician-impairment topic worthy of discussion. Two court rulings in the United States were divided in their legal opinions regarding such disclosure as an integral part of informed consent. Those who support informed consent disclosure by physicians who have been treated for chemical dependence build their argument on the apparent “materiality” of the risk of relapse to informed treatment decisions by patients. According to this line of belief, when the personal health problems of an anesthesiologist may endanger the welfare of the patient, this constitutes an identifiable material risk about which a patient would want to know when deciding upon a decision about treatment. In fact, however, the probability is extremely remote that a properly rehabilitated practicing anesthesiologist who is being appropriately monitored would relapse and injure a patient. Taken to the extreme, a mandate for such disclosure by a recovering anesthesiologist could be extended to a multitude of other medical diagnoses and personal situations that conceivably could have a negative impact on quality of anesthesia care. Relevant to this discussion is the fact that a significant pool of professionals with obvious impact on public safety – commercial airline pilots – includes a subset of several thousand aviators rehabilitated back to work with little or no direct mention of this fact to the flying public.

Key points

• Addiction to drugs is a chronic, relapsing disease best characterized by the overwhelming compulsion to use drugs despite adverse personal and professional consequences.

• A major occupational hazard of anesthesiologists is the development of addictive disease, which, in the light of the specialty’s powerful drugs, often involves a rapidly progressive, life- and career-threatening pattern of behavior.

• Addiction prevents the anesthesiologist from his/her primary ethical responsibility of placing the interests of his/her patients foremost, providing competent and compassionate care.

• Anesthesiologists have an obligation to themselves as well as to their patients and their health care facility to maintain their physical and mental health and special sensory capabilities.

• Anesthesiologists have an ethical responsibility to be knowledgeable about addiction, to detect it in its earliest stages, and to support the treatment, rehabilitation, and eventually, if appropriate, reentry into the workplace of a recovering colleague.

References

1* Berge, K.H.Seppala, M.D., and Schipper, A.M. (2009). Chemical dependency and the physician. Mayo Clin Proc84(7), 625–31.

2 Menk, E.J.Baumgarten, R.K., and Kingsley, C.P. (1990). Success of reentry into anesthesiology training programs by residents with a history of substance abuse. JAMA263, 3060–2.

3 Collins, G.B.McAllister, M.S.Jensen, M., and Gooden, T.A. (2005). Chemical dependency treatment outcomes of residents in anesthesiology: results of a survey. Anesth Analg101, 1457–62.

4* Guidelines for the Ethical Practice of Anesthesiology (2008). American Society of Anesthesiologists, www.asahq.org.

Further reading

Ackerman, T. (1996). Chemically dependent physicians and informed consent disclosure. J Addictive Dis15, 25–42.

Baldisseri M. (2007). Impaired healthcare professional. Crit Care Med35 (No 2 suppl), S106–16.

Berge, K.Seppala, M., and Lanier, W. (2008). The anesthesiology community’s approach to opioid- and anesthetic-abusing personnel: time to change course. Anesthesiology109, 762–4.

Booth, J.Grossman, D.Moore, J.et al. (2002). Substance abuse among physicians: A survey of academic anesthesiology programs. Anesth Analg95, 1024–30.

Bryson, E. and Silverstein, J. (2008). Addiction and substance abuse in anesthesiology. Anesthesiology109, 905–17.

Chemical dependence in anesthesiologists: what you need to know and when you need to know it. (1998). Park Ridge, IL: American Society of Anesthesiologists.

Domino, K.Hornbein, T.Pollisar, N.et al. (2005). Risk factors for relapse in health care professionals with substance use disorders. JAMA293, 1453–60.

Gallegos, K.Lubin, B.Boweres, C.et al. (1992). Relapse and recovery: five to ten year follow-up study of chemically dependent physicians: the Georgia experience. Md Med J41, 315–19.

Model Curriculum on Drug Abuse and Addiction for Residents in Anesthesiology. (2003). Park Ridge, IL: American Society of Anesthesiologists.

Oreskovich, M. and Caldeiro, M. (2009). Anesthesiologists recovering from chemical dependency: Can they safely return to the operating room? Mayo Clin Proc84, 576–80.

Specht, T. (2009). Reentry after addiction treatment: Research or retrain? Anesthesiology110, 1423–4.