Adventures in Ethics and Science

Anesthesiology and addiction.

There’s an interesting story on The New Republic website at the moment, “Going Under” by Jason Zengerle, that relates the sad story of a young anesthesiologist’s descent into addiction. What I find interesting about it is the larger questions it raises about why this particular anesthesiologist’s story is not so unusual. Indeed, the article offers an:

Observation: Anesthesiologists seem to suffer from addiction in greater numbers than physicians in other specialties.

And, it lays out

Three hypotheses as to why this might be so:


H1: Anesthesiologists have greater access to the addictive substances.

Anesthesia is the only medical specialty in which physicians draw up, label, and account for their own drugs. As such, they have more opportunities than other physicians to abuse those drugs. “Anesthesiologists are left alone with open ampules of highly potent narcotics, ” explains [Mayo Clinic anesthesiologist Keith] Berge, “and it’s easy to divert for their own use.” [Anesthesiologist Brent] Cambron [the subject of the article] was proof of that. Beth Israel Deaconess Medical Center, according to its vice president for education Richard Schwartzstein, has multiple policies and procedures in place to prevent such diversion–including the requirement that anesthesiologists “waste” whatever drugs they don’t use on a patient in front of a witness or that they return the unused drugs to the pharmacy, which are then verified through random tests. But these safeguards proved no match for a determined addict like Cambron. “Addicts are smart, we’re smart; they’re desperate, we’re not desperate,” says Berge. “So they’re going to outsmart us every time.”

Objection: Pharmacists and drug addiction researchers have similar access to anesthesiologists but lower rates of addiction.

H2: Anesthesiologists are exposed to “second-hand anesthesia” which starts the addiction ball rolling.

Using gas chromatography-mass spectroscopy equipment, [psychiatrist and former chief of addiction medicine at the University of Florida’s McKnight Brain Institute Mark] Gold had researchers scour several working operating rooms for traces of anesthetic agents. Sure enough, even though the anesthetics were administered intravenously, the researchers found throughout the operating rooms trace amounts of fentanyl and propofol, which the patients had exhaled. The highest concentrations were found around the patients’ heads–which is where the anesthesiologists typically sit during surgeries. Gold, who did some of the pioneering work on secondhand cigarette addiction during the 1990s, had his new hypothesis. “It wasn’t a great leap,” he explains, “to say, possibly, that some number of anesthesiologists who become drug abusers and drug-addicted may have as an important contributory factor exposure to secondhand drugs in the O.R. Their brains changed in response to the secondhand drugs, and they developed cravings as if they were taking the drugs themselves.”

Objection: The levels of exposure are very small — seemingly too small to have a physiological impact on the anesthesiologists.

H3: The personality type that makes for a successful anesthesiologist also puts one at higher risk of addiction.

Because only the top medical students are able to enter anesthesia residencies, it’s a specialty stocked with overachievers. “They’re driven and they don’t know how to take care of themselves well, they’re too compulsive about their work, they can’t let cases go, they’re almost wound too tight,” [Paul] Earley [medical director of the Talbott Recovery Campus in Atlanta] says of anesthesiologists. “And then, when the drug comes along, they just feel like, ahhhhhhhhh, I can finally relax. And it’s in that experience that the setup for continued use occurs. If you’ve been wound tight all your life, the first time you use narcotics, you say to yourself, this is how normal people must feel.” …

Compounding the problem is the fact that anesthesiology doesn’t only draw overachievers but overachievers who, in order to succeed in the specialty, must also be control freaks–and, in particular, control freaks about drugs and the human body. “So much of what we do as a physician and as a specialist is control someone else’s physiology,” says [Mount Sinai hospital anesthesiologist Ethan] Bryson. “We give what would be equivalent to a lethal injection on a daily basis if we didn’t intervene. A lot of what we do is controlling the body’s reaction to drugs. And I think that creates a false sense that, if we can control what’s going on with somebody else, we should be able to control this in ourselves.”

Objection: What about all the over-achieving, tightly wound, body-obsessed control freaks in other medical specialties? What are their rates of addiction?

* * * * *

Now, the hard part: What are the best ways to test these competing hypotheses?

Since we’re talking about addiction in people, obviously we need to abide by the ethical principles that are supposed to govern research with human subjects (i.e., those described in the Belmont Report).

Among other things, in the process of trying to answer the scientific question, we don’t want to expose any of the human subjects of the research to unnecessary harms, nor do we want the harms to which they are exposed to outweigh the expected benefits of the research.

We also need to be guided by the principle of respect for persons, not violating the autonomy of any of the humans we’re studying. (Is respecting the personhood of an addict relevantly different from respecting the personhood of a non-addict?)

And, we need to ensure justice as far as who bears the risks of the research and who has access to the benefits of the research.

From a scientific point of view, as much as one wants to control variables to get unambiguous results, it also seems like we need to understand how medical professionals behave “in the wild”, as it were.

Any general ideas for how to get to the bottom of this?

(Of course, since these three hypotheses don’t come close to exhausting all the possibilities, you’re welcome to propose alternative hypotheses as well.)

Comments

  1. #1 bioephemera
    January 8, 2009

    I’ve wondered about this extensively myself! Glad you’re asking the question and hope someone has a new idea or two. . .

  2. #2 PalMd
    January 8, 2009

    From a strictly operational standpoint, i think a high-quality survey of abuse in anaest.ists needs to be done, to truly gauge the problem.

    If it is actually a problem, out of proportion to other professions, it would be VERY reasonable for practices and hospitals to implement better systems controls on narcs, and, since these docs are holding lives in their hands and are well-payed for it, require random testing and non-punitive diversion programs.

  3. #3 Abel Pharmboy
    January 8, 2009

    This post brought back a haunting case for me where an anesthesiology resident died from an OD of “pills” in the doctor’s sleeping room at the hospital across the street from where I did my postdoc. He got his MD the same year I got my PhD.

    Without any data, I favor hypothesis #2. I believe that a similar hypothesis was generated to account for the unusually high percentage of alcoholism among painters back when oil-based paints were more common.

  4. #4 ArtK
    January 8, 2009

    My guess would be that it’s a combination of the three, with #1 and #2 being more heavily weighted. In the cases of #1 and #3, the groups cited in the objections are disjoint — neither pharmacists nor drug addiction researchers are in nearly as high-pressure jobs as anesthesiologists. A surgeon (as high pressure a medical specialty as there is) won’t have the same level of access to “wasted” narcotics as an anesthesiologist.

    It was rather interesting to see this post crop up — my SO (a nurse) and I had been discussing this very topic not ten minutes earlier. One of the areas of computers that I work in is the use of technology to track objects from origin to consumption. All the technology in the world can’t prevent this kind of tragedy, though.

  5. #5 Janne
    January 8, 2009

    Suggestion #4: Some proportion of medical students are prone to addiction and may be high-volume users of legal drugs or already abusing illegal substances. These students may be disproportionally likely to consciously and unconsciously choose anesthesiology as a specialty. The field may thus not produce addicts at a greater rate than other specialties but may attract people prone to addiction at a greater rate.

  6. #6 Scicurious
    January 9, 2009

    I’m always really interested by this topic. We had a speaker for the med/biomed school who talked to us about finding his friend, an anesthesiologist, dead in a hospital bathroom after overdosing on fentanyl. Hearing about that will scare you good.

    But ArtK, I do want to say as a drug addiction researcher, we are under plenty of pressure, thanks. You wouldn’t believe the number of alcohol researchers out there who are, interestingly enough, alcoholics.

    Also, we are required to log and balance every milligram of drug (or microliter, depending) that we use, and if we do not have a correct balance come out at the end, there is hell to pay. The potential is still there, of course, you could lie about what the drug is going for, lie about how much you “spilled”, etc. I don’t really know what the specific regulations are for anesthesiologists, though.

    I think I would go for a combination of H1 and H3, with a dash of Janne’s H4 thrown in. The personality type (which may be different from those who go in to research or pharmacy) my be a factor, combined with increased access.

    I suppose you could come at it from several angles, look for certain factors of personality (impulsivity, for example) in anesthesiology compared to other disciplines, as well as looking at increased access compared to researchers or pharmacists, and possibly see what happens in institutions that may control their access more tightly than others. It would have to be a VERY large epidemiology study, but it probably could be done. To test hypothesis #2, you could have a certain proportion wear face masks, but it’d be difficult as that would probably have to be a long term study.

  7. #7 Janet D. Stemwedel
    January 12, 2009

    I’ve heard that, probably on account of the MT upgrade and allied gremlins, this post was not allowing comments for awhile. Assuming this comments shows up, I’m hoping that situation has been resolved.

  8. #8 chris
    June 30, 2009

    I work in the o.r and these docs have unlimted acess to these drugs. sure they are suppose to waste the drugs in front of the nurse, but most of the time i find viles on the floor or suringes full of drugs. I also heard a story of an anestesia tech who overdosed in the bathroom.

  9. #9 Eric
    July 3, 2009

    How about an extension to H1: What sets anesthesiologists apart from others who have access to similar drugs is that anesthesiologists are trained to use them – so there could be a certain illusion of control and safety that isn’t present with the other groups mentioned. In fact drug addiction researchers and pharmacists may be more attuned to the dangers of the drugs. The addiction researchers are studying negative effects, and pharmacists likely never see the drugs in action – but must continually warn patients of the danger when dispensing them. Anesthesiologists, however, are the ones who control and tame the beast.

The site is currently under maintenance and will be back shortly. New comments have been disabled during this time, please check back soon.