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.)