When doctors get addicted
Anesthesiologists are more likely than other doctors to become addicted to drugs
Anesthesiologists, with their ready access to narcotic drugs, are more likely to be addicted to painkillers than other physicians. A Burnaby expert discusses the problem and solutions.
These drugs can take somebody who is at the top of their game, and bring them down very hard and very fast.
DR. ETHAN BRYSON AUTHOR OF ADDICTED HEALERS: FIVE KEY SIGNS YOUR HEALTHCARE PROFESSIONAL MAY BE DRUG IMPAIRED They can be great patients, they work so hard to get better, and their recovery rates are very high.
DR. DEREK PUDDESTER
UNIVERSITY OF OTTAWA
They can’t wear long sleeves in the operating room, which would hide the track marks on their arms, so they inject the drugs into less visible veins in their legs, thighs or the folds between their toes.
It’s not difficult; anesthesiologists are extraordinarily skilled at finding veins.
Some will tape an IV needle and tubing from a vein in their foot to their ankle, or from an arm vein to their back, with a port hanging over their shoulder beneath their scrubs. It makes it easier to secretly inject at work that way.
Anesthesiologists — the doctors who keep patients alive during surgery, who essentially take over our breathing — make up just three per cent of all doctors, but account for 20 to 30 per cent of drug- addicted MDS. Experts say anesthesiologists are overrepresented in addiction treatment programs by a ratio of three to one, compared with any other physician group, an occupational hazard that could pose catastrophic risks to their patients.
Their drugs of choice are most frequently fentanyl and sufentanil, opioids that are 100 and 1,000 times more potent than morphine. They “divert” a portion of the doses meant for their patients to themselves, slipping syringes into their pockets. And later, alone in the bathroom or the call room, when the drug hits their own bloodstream, the relief, the sense that all is well in the world, the mild euphoria, is immediate.
It can feel as if they’re floating.
Unlike heroin addicts, drugseeking anesthesiologists can’t shoot up with a friend, someone who knows what to do if they accidentally overdose, says Dr. Ethan Bryson, author of Addicted Healers: Five Key Signs Your Healthcare Professional May Be Drug Impaired, due to be published in September.
When everything you have worked so hard for is on the line, when your career is at constant risk, you use alone, he says.
Sometimes, that means dying alone.
“These drugs can take somebody who is at the top of their game, and bring them down very hard and very fast,” says Bryson, an associate professor in the departments of anesthesia and psychiatry at the Mount Sinai School of Medicine in New York. “It’s a story that a lot of people aren’t talking about.”
Dr. Paul Farnan has worked in the field of addiction and occupational medicine for more than 20 years. The Burnaby doctor’s specialty is assessing and followup monitoring of health professionals — doctors, nurses, dentists, pharmacists and paramedics — with substanceuse disorders.
None is more frightening than the anesthetist with an intravenous opioid addiction, he says, “because they are the colleagues who could die.”
Farnan adds: “The danger about writing about this is that it can terrify the public.”
The reality, he says, is that the phenomenon of anesthesiologists addicted to the drugs they use on their patients is relatively rare.
Shame and guilt
Yet the shame and guilt associated with addiction is so deeply entrenched and so profound — especially in professions that command so much public trust, the “pedestal professions,” as Farnan calls them — that people are unable to bring themselves to seek help.
“And the biggest risk with undiagnosed, evolving addiction in anesthesia,” Farnan says, “is accidental fatality by overdose.”
Farnan says he cannot think of a case in more than 20 years that he was involved with where a drug- addicted anesthetist “used” in the OR while their patient was under anesthesia.
But Bryson says it happens. Addicts sometimes will inject themselves during cases in the operating room, if they have access, he says, like a hidden “indwelling port” in one of their veins, or during a quick bathroom break. In many cases they use drugs intended for their patients — meaning the patient might get a diluted dose, less than they need, or nothing at all.
A drug- addicted anesthetist’s patients can arrive in recovery rooms with pain out of proportion to the amount of narcotics they supposedly received during surgery.
Bryson has described how entire cases have been conducted with other drugs that treat the body’s physiological responses to pain — drugs that lower heart rate or blood pressure — even though they were “charted” as narcotics. “If the chart says one drug was administered, but the patient is still in a lot of pain, the next logical step is to switch to a stronger agent, because obviously this drug isn’t working, and the patient ends up getting an overdose in the recovery room.”
Even when they don’t feel “high,” the drugs can make them feel as if nothing matters in the world. They become distracted and less vigilant — less bothered, Bryson says, by “minor annoyances.”
In the U. S., a Demeroladdicted anesthetist caused irreversible brain damage to a woman undergoing a routine tubal ligation after he removed her breathing tube too soon while she was still under the influence of anesthesia. Anesthesia drugs paralyze the muscles of the body, including the diaphragm.
The woman was left in a permanent vegetative state.
“There are a lot of unintended consequences that come along with drug use in the operating theatre,” Bryson said.
The anesthetist’s job is to keep patients in a drug- induced state of unconsciousness, paralyzed and unaware. They’re also involved with keeping the patient alive. That means maintaining their ventilation, maintaining their oxygen levels and making sure they’re “hemodynamically stable,” meaning their blood pressure remains constant throughout the procedure.
Surgeons concentrate on the area of surgery — whether it’s a knee, heart, lung or brain. “We’re taking care of everything else,” says Dr. Richard Chisholm, president of the Canadian Anesthesiologists’ Society, “every physiological parameter.”
“We’re dealing with patients who are at risk of instant disaster if we screw up,” said Dr. Brian Warriner, professor and chair of the department of anesthesiology, pharmacology and therapeutics at the University of B. C.
If all a drug- addicted anesthetist can think about while he’s standing at a patient’s head is how to keep from going into withdrawal, “if all you can think about is how you are going to get your next fix, you’re not going to be focused on the patient,” says Bryson, of Mount Sinai.
“It’s ridiculous to say that somebody can function at the level of vigilance that’s required of an anesthetist while they’re under the influence of these drugs, or in active withdrawal. Some people would have you believe that’s possible. It does a discredit to what anesthesiologists do.”
True scope uncertain
According to a recent medical student prize paper published by the Canadian Anesthesiologists’ Society, the true scope of addiction in anesthesia is uncertain, “but the reality is that it has affected many anesthesia departments and residency programs across the country.”
Studies suggest that the rate of known substance abuse is about one per cent among staff anesthesiologists, and 1.6 per cent among residents.
But that rate is based only on those who come to the attention of authorities, Bryson says — doctors who have overdosed, or who have been caught selfinjecting or have been referred to treatment. The actual number is likely higher, he says. Surveys based on anonymous self- reporting suggest it is probably as high as 10 to 12 per cent — similar to the general population — but that includes all drugs and alcohol.
This much is known: Addiction in anesthesia has been an issue since the discipline’s earliest days. Horace Wells, a pioneer in anesthesia, became addicted to chloroform. He killed himself in 1848.
More than 150 years later, in 2007, researchers sent email surveys to 126 academic anesthesiology training programs in the U. S. Eighteen per cent, nearly one in five, reported one or more incidents of abuse of propofol — the drug that killed Michael Jackson — during the previous 10 years. There were seven deaths; six among them were residents.
Other studies have found that anesthesiologists are at higher risk of dying from an accidental poisoning or overdose, as well as suicide, compared to the general population. The question begged is, why? Numerous theories have been floated. Anesthesiologists have access to every controlled substance imaginable, and virtually no dispensing system, no matter the checks and balances, has yet to be designed that hasn’t been defeated by an addict. They falsify patient records; they keep ampoules of drugs they tell the pharmacy were “wasted” or “broken” during surgery. Bryson has described how addicts quickly become especially “proficient” at removing a drug from an ampoule and resealing it with another substance — without any trace of tampering — and returning the “leftover” vial to the pharmacy.
Many start using to deal with stress, emotional pain or burnout, says Farnan, a former executive director of the Physician Health Program of British Columbia. Anesthesiologists work long and unpredictable hours. They work nights and weekends. Their patients are older and sicker and the pressure on OR staff is constant — the pressure to get the cases done, to “keep things rolling, keep things rolling,” in order to get waiting times down.
Warriner, of UBC, stresses that the field of anesthesia has grown increasingly safe over the years. “It’s gone from being a specialty where there was this constant cloud over your head that some disaster was likely to occur in a given period of time, that somebody would be damaged because of something that happened in the operating room.
“That simply doesn’t happen any more. But in a perverse sort of way, that increases the pressure, because if anything does go wrong, there’s this sense that it must have been the anesthetist’s [ error]. . . . There is a kind of a desire, a need to be perfect, which I’m not sure is true in other areas of medicine.”
Some anesthesiologists start using the drugs they use on their patients simply out of curiosity.
They want to experience what their patients are feeling.
In the acclaimed educational program Wearing Masks, a video series on substance abuse in anesthesia, a recovered addict describes thinking before his first hit of fentanyl when he was a resident, “It can’t hurt me to inject two or three cc’s.”
The thought of dying from it, or becoming addicted, was inconceivable. “I thought, I want to try it once, just once. Maybe twice.”
Nobody starts out with the intention of becoming addicted. But when the drugs of choice are up to 1,000 times more potent than morphine, the trajectory of addiction is rapid, and brutal. “These are not drugs that can be used casually,” Bryson says.
Withdrawal symptoms
A patient undergoing an appendectomy might receive 250 micrograms of fentanyl during the course of surgery. A fentanyl- addicted anesthetist might inject 1,000 micrograms at a time, just to stave off the symptoms of withdrawal. Fentanyl has a short “half- life.”
Within 45 minutes to an hour, “it’s basically gone,” Bryson says. Soon after that, the addict starts feeling the physical symptoms of withdrawal — sweating, chills or tremors — “which are horrendous.”
They take another hit, and so the cycle continues.
“After a while, maybe a week or so, you find you are physically dependent and have to keep using,” Bryson says.
Frequently, the fatal overdoses happen when an anesthetist makes a mistake, and ends up injecting a paralyzing agent. Unable to breathe, they collapse, dead, often in the adjoining bathroom off the operating room.
But so powerful are these drugs that addiction becomes obvious within months, Bryson says. They sign out ever- increasing amounts of narcotics, especially on Fridays, something to carry them through the weekend. They volunteer for extra shifts and extra call and refuse lunch breaks. They’re difficult to find between cases. They grow increasingly moody, irritable or withdrawn. A colleague might spot bloodstains on their sleeves around their elbows. Their spouse might discover syringes, bloody swabs or tourniquets around the house.
“The battle we see is that physicians struggle to fix it themselves,” Farnan says.
“But this is a chronic, progressive disease. It doesn’t stop, it just keeps nudging along and getting worse until somebody stops the insanity.”
Doctors who get into trouble with drugs are often hardworking, brilliant and committed to their patients in the extreme, those who work in the field say. “They can be great patients, they work so hard to get better, and their recovery rates are very high,” says Dr. Derek Puddester, director of the Faculty Wellness Program at the University of Ottawa’s faculty of medicine.
Farnan says 80 per cent of addicted doctors achieve at least five years of stable sobriety and are able to return to work successfully.
“Will they always be able to go back to where they came from — handling intravenous medications with what amounts to very difficult situations to supervise? No,” he says. “Some of them can’t go back to anesthesia.”
Meanwhile, provincial medical bodies across the country offer assistance to doctors dealing with addiction or other illnesses. Medical schools are educating undergrads, as well as faculty members, on how to identify signs and symptoms of addiction in their colleagues.
At UBC, anesthesiology residents are shown Wearing Masks, the video on substance abuse, on the very first day of residency. Some hospital pharmacies have begun checking “wasted” drugs on a random basis to verify what’s inside the vial.
Culture changing
Farnan believes the culture is changing but that even more is needed to help doctors remain resilient and physically and psychologically well throughout their career.
“The trouble is that, when society thinks that you couldn’t possibly be such a “bad” person as to develop an addiction, or depression, it’s hard to put your hand up and say, “I think I’ve developed an addiction to this stuff.’”
“Am I aware of physicians in this province who have died of accidental overdose?” Farnan asks.
“Absolutely. Do we publish that? No.
“We’re pedestal people,” he says. “We’re supposed to be bullet proof.
“There’s a myth of invincibility. Illness is for the patient, not for us, the physicians.”