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Substance Abuse Among Physicians: A Survey of Academic

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

hysician substance abuse is a significant societal


problem that affects all aspects of medical care.
Previous studies of addiction, which have included alcohol abuse, have projected that 10%14% of
physicians may become chemically dependent at
some point in their careers (1 4). When alcohol is
excluded from such assessments, the incidence of
drug dependency is estimated to be between 1% and
2% (1,5 8). However, the incidence of physician substance abuse is not equally distributed across all medical subspecialties. Specifically, reports suggest that
the incidence of chemical dependence may be most
frequent among anesthesiologists (7,9). For instance,
although anesthesiologists represented only 3% of
John V. Booth and Davida Grossman contributed equally to this
article.
Presented in part at the annual meeting of the American Society
of Anesthesiologists, San Francisco, CA, October, 2000.
Accepted for publication May 29, 2002.
Address correspondence and reprint requests to John V. Booth,
MB, ChB, FRCA, Box 3094, Department of Anesthesiology, Duke
University Medical Center, Durham, NC 27710. Address e-mail to
booth006@mc.duke.edu.
DOI: 10.1213/01.ANE.0000026379.66419.DB

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Anesth Analg 2002;95:102430

and 1.6% among residents. Fentanyl was the controlled


substance most often abused. The number of hours of
formal education regarding drug abuse had increased
in 47% of programs. Sixty-three percent of programs
surveyed had tightened their methods for dispensing,
disposing of, or accounting for controlled substances.
The majority of programs (80%) compared the amount
of controlled substances dispensed against individual
provider usage, whereas only 8% used random urine
testing. Sixty-one percent of departmental chairs indicated that they would approve of random urine screens
of anesthesia providers.
(Anesth Analg 2002;95:1024 30)

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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BOOTH ET AL.
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Efforts to reduce CS abuse by anesthesiologists have


focused on education and tighter regulation of CSs.
However, the efficacy of these approaches remains to
be determined. With respect to the first approach, a
1991 survey of former anesthesiology residents found
that more than 85% did not recall receiving any substance abuse education during their training (13). For
the second approach, a study of anesthesiology programs found widely varying methods of CS dispensing and accounting, although at the time many institutions were implementing or planning to implement
improvements (14). In this study, we sought to examine whether there have been changes in the incidence
of CS abuse since 1990 and whether education and
regulation policies designed to reduce CS abuse have
been adopted on a widespread scale. Thus, our primary hypothesis was that the reported incidence of CS
abuse was unchanged from previous reports, and our
secondary hypothesis was that the control and accounting process involved in the distribution of operating room (OR) drugs has tightened. We focused our
survey on anesthesiology programs at American academic medical centers.

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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Fishers exact tests in the case of categorical variables.


For all analyses, the criterion for statistical significance
was two-sided P " 0.05.

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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Table 1. Operating Room Drugs Reported as Abused by


Residents and Faculty (Raw Numbers)
Drug

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.

Table 2. Dispensing Method of Controlled Substances


(n $ 119)
Method

n (%)

Traditional nurse dispensing


Satellite pharmacy
Locked box
Dispensing machine

13 (11)
50 (42)
19 (16)
37 (31)

testing of anesthesia providers (Table 3). On this topic,


60% of chairs thought that tightening regulation of
drugs would decrease the incidence of CS abuse. A
similar percentage (61%) indicated that they would
approve of random urine screens of anesthesia providers. The actual practice of urine testing was unrelated to the chairs opinion on whether testing should
be implemented (P # 0.1).

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

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Table 3. Methods of Controlled-Substance Accountability


(n $ 123)
Method
Pharmacy record
Pharmacy summation
Pharmacy comparison
Analysis of residual returned controlled
substance
Random tracking of controlled substance
Random urine testing

n (%)
106 (85)
95 (77)
98 (80)
59 (48)
48 (39)
19 (8)

causes of mortality between anesthesia and internal


medicine physicians and reported a 2.8-fold increased
risk from drug-related deaths in anesthesiologists
compared with internists (10). Although it is not certain that anesthesiologists have use rates of psychoactive substances similar to those of internists (9
11,13,16), anesthesiologists do have greater access to
potent opioids in the workplace. Our study indicated
that the most commonly abused drug among anesthesiologists was fentanyl, a drug associated with frequent morbidity and mortality (17,18). Furthermore,
18% of CS abusers were identified by a drug overdose
producing death or a near-death event. In contrast,
Menk et al. (15), in a 19751989 study, found death or
near death to be the presenting symptom in 7.2% of
abusers.
Medical training has traditionally neglected drug
and alcohol abuse awareness training (19 21). Perhaps in response to this, 55% of department chairs
believed that increasing the number of hours of formal
education would decrease the incidence of CS abuse.
Furthermore, our results demonstrate that all residents received at least one hour of drug abuse education. Although this is an improvement from the 1991
survey of anesthesiology residents, in which 85%
could not recall any substance abuse education at all
(13), there are still some limitations. Our study demonstrated that 24% of faculty did not receive any education, and in 31% of programs, education was elective; spouses were not invited by 39% of programs.
These figures illustrate the variability in the importance with which education is regarded and incorporated into programs. It is unclear whether this educational focus is having an effect, because most
department chairs (62%) believed that the incidence of
CS abuse was unchanged over the past 7 years. However, it is difficult for us to ascertain whether this
opinion is accurate or whether, as 38% of chairpersons
asserted, the incidence of CS abuse has changed. This
is because our data do not permit the calculation of the
incidence of CS abuse on a year-by-year basis.
Anesthesiology drug control methods have changed
since the previous surveys were conducted. For our
study, 63% of department chairs reported that changes
had been made in their departments methods for

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dispensing, disposing of, and/or accounting for CSs.


The greatest change in dispensing practice has been a
shift away from nursing staff distribution of CS to the
use of dispensing machines. In our survey, only 11%
of programs used traditional nurse dispensing, compared with 42% in a 1990 survey. In contrast, the use
of dispensing machines increased from 4% in 1990 to
29% in 1998 (Table 2). Accounting methods also
showed a move toward tighter control. In 1992, Klein
et al. (14) found that 21% of institutions used a daily
record of CS dispensing as their only method of accounting. At the time of our survey, this had decreased to just 2% of programs using dispensing
records as their only method of accountability. Furthermore, in 1990, Klein et al. found that 23% of institutions conducted random chemical analysis of residual CS. Our survey showed that this number has now
increased to 48%. As noted, the survey population of
Klein et al. differed slightly from ours in that theirs
included affiliated hospitals, whereas we specifically
targeted the primary teaching hospital. Despite this
difference, the data indicate that there has been an
increase in the regulation of CS distribution over the
last 10 years in most institutions. Regarding the methods of accountability, the majority of programs (80%)
compared the amount of CS dispensed against individual provider usage, whereas only 8% used random
urine testing.
This study specifically examined the question of
abuse of CS available in the work setting of an anesthesiologist. We did this to investigate whether tighter
regulation of CS has occurred and whether tighter
regulation had any effect on the incidence of abuse of
CS. Many substances can cause addiction that are not
available in the OR setting, and these, e.g., alcohol, can
have a profound effect on individuals and families.
We do not underestimate the importance of these
substances, and in fact these other substances may
have a greater effect as a whole on anesthesiologists.
However, investigation of these important matters is
not within the scope of this study. Indeed, it is unlikely that tighter regulation of CS in the OR will affect
these other issues.
We also chose to obtain data from the departmental
chairs (and their residency directors) records. At the
present time there is no continuing data collection at a
regional or national level with regard to addiction
among anesthesiologists. Thus, our data, or any other
data, are open to the criticism of being unverifiable.
Although this may be true, we believe that if our
incidence of CS abuse is inaccurate, then it likely underestimates rather than overestimates the problem,
because we relied on discovered cases only. Thus,
our conclusions will not be altered. Of course, directly
surveying anesthesiologists would only bias the data
toward those still practicing (less likely to be still
abusing CSs) and would miss those who have left the

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practice of anesthesiology (who are more likely to be


abusing CSs). At the present time there are no clean
data available, but we believe that our survey, even
with this limitation, still correctly describes the problem issues. We hope that our data will encourage
others to investigate these issues in more depth. Specifically, there is a need for a national registry to
monitor the success or failure of efforts designed to
reduce addiction.
Our survey determined that recommendations for
increased accountability and regulation of CS in
academic institutions have started to be implemented. Unfortunately, despite greater regulation
and an increase in the education of anesthesia providers with regard to chemical dependency, the incidence of CS abuse has not decreased (at least at the
time of the survey), and perhaps the lethality has
increased. One possible solution to the problem is
random drug testing of providers. Urine drug testing is now a common practice in the US workplace,
with more than 90% of companies with more than
5000 employees using some form of testing program
(22,23). Some authors claim that these programs
have reduced the rate of drug-positive test results
and resulted in cost savings for those companies
(24). Others would argue that drug testing in the
airline industry has only increased the cost of airfare. In fact, even when the best available methods
are used, the validity of results is often questioned.
Problemssuch as false-positive results, chain of
custody, reliability of assays, curtailing of individual freedoms, and cost have generally made testing unpopular. Nonetheless, our data suggest that
despite these potential disadvantages, most chairpersons of academic institutions in the United States
support the random testing of anesthesia providers.
The decision to implement a testing scheme in anesthesiology programs should be based on balancing the individuals rights against the potential effect of a major accident attributable to the use of
drugs in the workplace. It is important that all anesthesiologists involve themselves in the debate on
this issue.
In conclusion, this survey indicates that the frequency of CS abuse has changed little in the past few
years, whereas discovery of drug-dependent physicians is often a fatal or nearly fatal overdose. At the
same time, there has been an increase in the control
and accounting procedures for CS, as well as increased mandatory education. It is unclear how effective these methods have been, because the timing of
CS abuse cases may have occurred before or after
accounting methods or education tightened. However, it is clear that new, more effective means of
prevention are required if substance abuse among
anesthesiologists is to be reduced.

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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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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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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.

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