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Anesthesiology Programs
John V. Booth, MB, ChB, FRCA*, Davida Grossman, MD, Jill Moore, BS,
Catherine Lineberger, MD*, James D. Reynolds, PhD*, J. G. Reves, MD*, and
David Sheffield, PhD
*Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; West Jersey Anesthesia
Associates, Marlton, New Jersey; School of Medicine, East Tennessee State University, Johnson City, Tennessee; and
Division of Cardiology, Department of Psychology, Staffordshire University, Stoke, United Kingdom
Efforts to reduce controlled-substance abuse by anesthesiologists have focused on education and tighter
regulation of controlled substances. However, the efficacy of these approaches remains to be determined.
Our hypotheses were that the reported incidence of
controlled-substance abuse is unchanged from previous reports and that the control and accounting process
involved in distribution of operating room drugs has
tightened. We focused our survey on anesthesiology
programs at American academic medical centers. Surveys were sent to the department chairs of the 133 US
anesthesiology training programs accredited at the end
of 1997. There was a response rate of 93%. The incidence
of known drug abuse was 1.0% among faculty members
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physicians in 1983, 13% of physicians treated for substance abuse at one center during this period were
anesthesiologists (9). Because published data are
sparse and rely on potentially inaccurate or limited
reporting methods, it is difficult to determine whether
the published incidence in fact reflects the true incidence in our population.
Further concerns about controlled substance (CS)
abuse derive from the fact that the largest rate of
complications resulting from addiction occur early
in a career. A recent study by Alexander et al. (10)
reported that the most frequent rate of drug-related
deaths for anesthesiologists occurred during the
first 5 yr after medical school graduation. Factored
another way, drug-related causes of death produce
more than 2000 yr of life lost before age 65 for
anesthesiologists (10). Occupational exposure and
access to opioids and other psychotropic medication
have been implicated as causes of the apparent
overrepresentation of anesthesiologists with this
disease (11,12). Thus, substance abuse among anesthesiologists is a vitally important issue with severe
complications.
2002 by the International Anesthesia Research Society
0003-2999/02
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2002;95:1024 30
Methods
Our substance abuse survey, along with a cover letter
assuring anonymity, was sent to the department
chairs of 133 US anesthesiology training programs at
the end of 1997 (Appendix 1). A follow-up letter and a
second identical copy of the survey were sent to all
residency program chiefs, to increase the response
rate. Surveys were completed and returned by June
1998.
The initial questions in the survey focused on methods of dispensing, disposing, and accounting for CS at
the principal anesthetizing site in their primary teaching hospital. The second series of questions asked
about resident/fellow or faculty members who had
abused drugs. The residents/fellows were working
between July 1990 and July 1996, and faculty were
defined as attending physicians present between July
1990 and June 1997. All residents were accounted for
only once between 1990 and 1996, whether they completed residency or not. Subsequent questions asked
about the degree of formalized departmental education on drug abuse. The final part of the survey asked
for the chairs opinion on issues relating to drug
abuse.
The surveys were hand-scored, and the data were
compiled and analyzed with Systat. Continuous variables were described with means ! sd, and categorical
variables were described with frequencies and percentages. Comparisons between actual practice and
opinions about practice were made by using Students
t-tests in the case of continuous variables and by using
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Results
Of the 133 programs surveyed, 123 surveys were received, for a response rate of 93%. Some questionnaires were incomplete, resulting in varying response
rates for individual questions. The minimum response
rate for any individual question was 118 (96%) of the
surveys received.
A total of 167 anesthesiologists (both residents and
faculty) were listed by the 123 respondents as having
CS drug abuse issues. There were 133 of 8111 residents
and 34 of 3555 faculty members with reported CS
abuse issues. Thus, the incidence of known drug abuse
was 1.0% among faculty members and 1.6% among
residents over the period of the study. Fentanyl was
the CS most often abused. Other drugs included ketamine and thiopental. Table 1 lists the OR drugs reported as being abused. Thirty individuals (18%) died
or nearly died (required resuscitation) before any substance abuse was suspected. When department chairs
were asked to compare the current incidence of drug
abuse in academic programs with that existing in 1990,
62% believed that no changed had occurred, 12% believed that the incidence had increased, and 26% believed that the incidence had decreased.
The number of hours of formal education regarding
drug abuse had increased in 47% of programs. For
69% of programs, this education was mandatory; partners of residents or faculty were invited in 61% of
cases. There were no differences in the level of education (and regulation) between programs who reported
no CS abuse cases and those who reported at least one
(all P # 0.10). Despite two-thirds of the programs
offering drug abuse training for faculty and residents,
little more than half (55%) of the department chairs
thought that increasing the number of hours of formal
education would decrease the incidence. As one might
expect, programs whose chairs believed that education was effective had more hours of drug abuse training for faculty (2.0 ! 1.6 h versus 1.4 ! 1.6 h; P " 0.05).
Sixty-three percent of programs surveyed had made
changes in their methods for dispensing, disposing of,
and/or accounting for CS over the past 7 yr. The most
common method of drug dispensing was on a per-case
basis, either by satellite pharmacy (42%) or via a dispensing machine (31%) (Table 2). The method for disposal of opened but unused portions of drugs was
either return to the pharmacy (52%) or waste of residual with (41%) or without (7%) a witness. Regarding
the methods of accountability, the majority of programs (80%) compared the amount of drugs dispensed against usage. Only 8% used random urine
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No. Residents
No. Faculty
Fentanyl
Sufentanil
Cocaine
Nitrous oxide
Meperidine
Midazolam
Diazepam
Ketamine
Halothane
Propofol
Others
73
12
7
5
3
3
2
2
2
1
23
16
4
2
0
0
0
1
1
0
1
9
Others indicate either drugs not listed or drugs reported by class, e.g.,
opioids, narcotics, or benzodiazepines.
n (%)
13 (11)
50 (42)
19 (16)
37 (31)
Discussion
The rate of known CS abuse in academic anesthesiology programs during the period 1990 1997 was 1.6%
for residents and 1% for faculty. This rate was calculated from 123 replies to 133 surveys, a response rate
of 93%, sent out to the department chairs of every US
anesthesiology program. From a study of anesthesiology residents between 1975 and 1989, Menk et al. (15)
reported a 2% incidence rate for chemical addiction,
which included alcohol and street drugs. Ward et al.
(7) analyzed the 10-year period between 1970 and
1980; they reported a drug abuse rate of 0.9% for
residents and 1.3% for faculty. Their data also included alcohol. Discrepancies in calculation methods
and the inclusion or exclusion of alcohol or street
drugs in these and other previous studies make direct
comparisons with our results difficult. However, it
appears that the overall incidence of chemical dependence among anesthesiologists is unchanged.
The consequences of this incidence of CS abuse can
be inferred from other reports: one study compared
ANESTH ANALG
2002;95:1024 30
n (%)
106 (85)
95 (77)
98 (80)
59 (48)
48 (39)
19 (8)
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2002;95:1024 30
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2002;95:1024 30
Appendix 1. Questionnaire
Controlled Substances Accountability and Dependence in United States Academic Anesthesiology Programs
1. Choose the method of controlled substance dispensing which most closely resembles that used at the
primary anesthesia site in your primary training hospital.
a. Traditional nurse dispensing-nurse dispenses controlled substances to anesthesia provider per patient
case
b. Traditional nurse dispensing-nurse dispenses controlled substances to anesthesia provider at one time
for use throughout the whole day
c. Satellite pharmacy-anesthesia provider checks out controlled substances to anesthesia provider at one
time per patient case
d. Locked box-anesthesia provider checks out a box of controlled substances directly from pharmacy for
use through out the whole day
e. Dispensing machines-anesthesia provider obtains controlled substance from vending machine per
patient case
1a. Is this method the same as that used at the other sites/hospitals through which your residents
rotate?
Yes
No
1b. If a second team of anesthesiologists take over an ongoing case, do they
a. Take over the pool of controlled substances already in use for that patient
b. Obtain new controlled substances for their portion of the case
2. Choose the method of disposal of opened but unused (residual) portions of controlled substances which
most closely resembles that used at the primary anesthesia site in your primary training hospital.
a. Anesthesia provider wastes excess controlled substance without witness
b. Anesthesia provider wastes excess controlled substance with witness
c. Anesthesia provider return excess controlled substance to pharmacy
2a. Is this method the same as that used at the other sites/hospitals through which your residents
rotate?
Yes
No
3. Choose all of the methods of controlled substance accountability currently in use at the primary
anesthesia site in your primary training hospital.
a. Pharmacy record of controlled substance dispensed
b. Pharmacy summation of controlled substance dispensed and returned
c. Pharmacy comparison of controlled substance dispensed and returned, with amount used according to
anesthetic record
d. Required return of residual controlled substance with random chemical analysis
e. Random tracking of pattern of controlled substance dispensing and usage for a given anesthesia
provider
f. Random urine testing of anesthesia providers for controlled substances
3a. Is this method the same as that used at the other sites/hospitals through which your residents
rotate?
Yes
No
4. Have your methods of dispensing, disposing, or accounting for controlled substances changes since the
summer of 1990?
Yes
No
5. How many faculty members are currently in the anesthesia department at your primary training
hospital?
6. How many residents/fellows began the CA-3 year or fellowship year in your program between 7/90 and
7/96?
7. How many residents/fellows have had a problem with controlled substance abuse?
8. How many faculty members have had a problem with controlled substance abuse?
9. What was the substance of abuse?
10. How was the controlled substance abuse first suspected in each case?
a. Voluntary admission
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2002;95:1024 30
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b. Witnessed admission
c. Behavioral changes
d. Change in the pattern of controlled substance request/usage
e. Controlled substance documentation discrepancy
f. Drug testing or residual portions (opened but not used in patient care) of controlled substance
g. Random drug testing of anesthesia personnel
h. Death related to controlled substance abuse
i. Other (describe)
11. How as the controlled substance abuse confirmed in each case?
a. Volunteer admission
b. Confrontation and admission
c. Witnessed administration
d. Random drug testing of anesthesia personnel
e. Death related to controlled substance abuse
f. Other
12. What happened to this person?
a. Treatment
b. Relapse
c. Return to same residency or faculty position
d. Return to anesthesia elsewhere
e. Return to a different field of medicine
f. Death related to controlled substance use
g. Currently drug free
13. Would your program offer reemployment to a previously impaired resident/fellow after successful
completion of a treatment program?
14. Would your program offer reemployment a previously impaired faculty member after successful
completion of a treatment program?
15. Is it your department policy to cover that portion of the cost of controlled substance dependence therapy
not covered by insurance for resident/fellow?
16. Is it your departments policy to cover that portion of the cost controlled substance dependence therapy
not covered by insurance for faculty members?
17. Is it your department policy to continue a residents/fellow salary during treatment?
Yes
No
18. Is it your department policy to continue a faculty member salary during treatment?
Yes
No
19. How many hours of formal education, regarding controlled substance abuse among anesthesia personnel,
does each resident/fellow currently receive per year?
19a. Is attendance mandatory or elective?
19b. Are spouses/significant other invited to attend?
19c. Has the number of hours of formal education increased, decreased or stayed the same since June
1990?
Increased
Decreased
Stay the same
20. How many hours of formal education, regarding controlled substance abuse among anesthesia personnel,
does each faculty member currently receive per year?
20a. Is attendance mandatory or elective?
20b. Are spouses/significant others invited to attend?
Yes
No
20c. Has the number of hours of formal education increased, decreased, or stayed the same since June
1990?
Increased
Decreased
Same
21. Does your department have a substance abuse committee or designated contact
person?
Yes
No
22. Do you think that the incidence of controlled substance abuse among anesthesia personnel in academic
programs throughout the country has increased, decreased, or stayed the same since June
1990?
Increased
Decreased
Same
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2002;95:1024 30
23. Do you think the incidence of controlled substance abuse can be decreased by tightening the methods
which are used to dispense, dispose of, and account for controlled substances?
Yes
No
24. Do you think that the incidence of controlled substance abuse can be decreased by increasing the number
of house of formal education which anesthesia personnel receive regarding the issue?
25. Would you advocate random urine testing of anesthesia providers for controlled substances?
26. Please use blank page for any suggestions/comments you have regarding the issues raised in this survey.
Appendix 2
Definitions used in the survey include
Principal anesthetizing site: a building or hospital,
not an OR.
Controlled substances: hypnotic controlled substances, narcotics, benzodiazepines, or other
mood-altering substances used in the practice of
anesthesia.
Residents/fellows: those completing CA3 year of
final year to avoid counting twice. If they did not
complete the program, they were included in the
final year they worked.
References
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and treatment. Wis Med J 1979;78:213.
2. Farley WJ. Addiction and the anaesthesia resident. Can J Anaesth 1992;39:R117.
3. Farley WJ, Talbott GD. Anesthesiology and addiction. Anesth
Analg 1983;62:465 6.
4. Bissell L, Jones RW. The alcoholic physician: a survey. Am J
Psychiatry 1976;133:1142 6.
5. Domenighetti G, Tomamichel M, Gutzwiller F, et al. Psychoactive drug use among medical doctors is higher than in the
general population. Soc Sci Med 1991;33:269 74.
6. Gravenstein JS, Kory WP, Marks RG. Drug abuse by anesthesia
personnel. Anesth Analg 1983;62:46772.
7. Ward CF, Ward GC, Saidman LJ. Drug abuse in anesthesia
training programs: a survey1970 through 1980. JAMA 1983;
250:9225.
8. Ward CF. Substance abuse: now, and for some time to come.
Anesthesiology 1992;77:619 22.
9. Talbott GD, Gallegos KV, Wilson PO, Porter TL. The Medical
Association of Georgias Impaired Physicians Program: review
of the first 1000 physiciansanalysis of specialty. JAMA 1987;
257:292730.