Best Practice & Research Clinical AnaesthesiologyVol. 20, No. 4, pp. 637e643, 2006

doi:10.1016/j.bpa.2006.10.005available online at http://www.sciencedirect.com

10

Substance abuse and dependence

in anaesthetists

David SaundersRetired consultant anaesthetist, Southampton

The incidence of substance abuse amongst anaesthetists in the United Kingdom is unknown. Inthe interests of patient safety, it is essential that the dependent doctor is identified and enteredinto a treatment regime. No national strategy is in place to treat and, where possible, return theanaesthetist in recovery to work. It is important therefore, that individual employers havea standing operating procedure to deal with the addicted doctor. It is essential that the initialapproach is made by a competent panel, each of whom has experience of dealing with depen-dent doctors. This is an extremely stressful time for the doctor involved; it is therefore essentialthat active support is given. It is not always necessary to suspend the doctor from work whilsttreatment is undertaken. In the dependent doctor sudden withdrawal of the substance of addic-tion can be life-threatening. It is therefore essential that the supervising physician has specialistknowledge of the treatment of addiction. Residential care probably provides the greatest hopeof success. In the United States, Canada, Australia and New Zealand ‘impaired physician’ pro-grammes are in place which allow some doctors to return to work, initially under strict super-vision. Registration with a self-help organisation is essential; a list of such groups in the UnitedKingdom is appended.

Key words: substance abuse; drug dependence; substance abuse testing; physician health.

A definition of substance abuse is ‘the misuse of a psychoactive drug to the detrimentof the individual but which fails to meet the criteria for dependence’. Criteria fordependence include: compulsion, tolerance to the drug where greater doses arerequired to produce an effect, withdrawal symptoms and multiple unsuccessful at-tempts to desist from, or at least control, substance use. Dependence has been shownto have a neurochemical basis and is widely considered as a disease process. Thisdifference between abuse and dependence is important as it may affect the way inwhich the impaired anaesthetist is treated.

E-mail address: dasaunders@doctors.org.uk

1521-6896/$ - see front matter ª 2006 Elsevier Ltd. All rights reserved.

638 D. Saunders

Doctors have been shown to be particularly susceptible to drug and alcohol addic-tion. As a generalisation younger anaesthetists tend to be addicted to sedative and opi-ate drugs whilst older anaesthetists favour alcohol. Abuse of both drugs and alcohol iscommon. Factors which make doctors at greater risk include the easy access to drugsof dependence and the stress of work. In a world where injection of recreational drugsis common, the taboo of self-injection with recreational drugs is reducing.

The incidence of substance abuse and dependence amongst anaesthetists is notknown with any certainty. Figures from a relatively small geographical population inthe USA range widely from 1% amongst faculty to 16% of resident anaesthetists; a fig-ure of 2% is usually taken as being a working hypothesis. In 1999 The Association ofAnaesthetists of Great Britain and Ireland commissioned a study by the Alcohol andDrug Research Centre, Edinburgh, to assess the extent of alcohol and drug abuseproblems amongst anaesthetists in the UK. One hundred and thirty cases were re-ported over a ten-year period with a 70% response rate from all anaesthetic depart-ments in the United Kingdom. Lacking denominator data this gives no clue to theincidence of substance abuse amongst anaesthetists in the UK. However, other ques-tions in the survey cast light upon the lack of awareness of schemes to deal with prob-lems of alcohol and drug abuse within hospital trusts. Only about 60% of respondentswere aware of local mechanisms to deal with alcohol problems and only 50% wereaware of policies to deal with drug problems. Only 2% of respondents felt ‘completelyconfident’ that they could manage a case concerning an addicted anaesthetist.

The physical signs of substance abuse and dependence are widely recognised andneed not concern us here. Diagnosis, however, is not easy. A colleague may maintainan outward air of competence and be of smart appearance; not all alcoholics come towork with a three-day growth of beard, smelling strongly of alcohol. Frequently thefirst sign of a problem is a drink-related driving offence or a professional problem inwhich a patient is put at risk. Suspicion may be raised by unexplained disappearanceof controlled drugs from the operating theatre. Attempted suicide or death by suicideor accidental overdose is not an infrequent presentation of addiction. In the past col-leagues would overlook incidents. This would now be considered mistaken loyalty andis uncommon. One of the duties of a doctor registered with the General MedicalCouncil is to ‘act quickly to protect patients from risk if you have good reason to be-lieve that you or a colleague may not be fit to practise’. Thus, to ignore the signs ofaddiction in a colleague is an act of complicity, and would be regarded as such bythe Council. In the NHS, under the concept of clinical governance, the clinical directoris responsible for creating an environment of excellence to safeguard clinical care. Partof this responsibility is to examine the ability of individual doctors to practise safely.This would include identifying and managing the addicted doctor. It would appearthat this process is effective as support groups, of which more later, are receivingfar less calls for advice about colleagues with dependence; neither colleagues northe clinical director can ignore a problem either observed or reported. It goes withoutsaying that an addicted doctor is a danger to patients. There is growing awareness thatit is in the doctor’s own best interests to be identified and treated at the earliest pos-sible time. There is a much greater chance of a doctor being ‘cured’ and returning towork if the problem is addressed at the first opportunity.

Self-reporting to ones employer is uncommon. The problem may be detected bya clinical colleague, a nurse, technical support staff or a combination of these. The sys-tem of governance in the NHS makes the reporting of suspicions fairly straight-forward. A consultant anaesthetist recognising signs in a consultant or traineecolleague should report the facts to the clinical director. A trainee suspecting

Substance abuse and dependence in anaesthetists 639

problems with a consultant anaesthetist should either speak to a consultant whomthey trust or the clinical director. If the clinical director is suspected the medicaldirector should be informed and if the medical director appears to have problems areport should be made to the chief executive. There is a natural inclination toapproach the doctor directly; it is widely accepted that this is most unwise and thetemptation must be resisted.

THE MANAGEMENT OF AN ANAESTHETIST SUSPECTEDOF SUBSTANCE ABUSE OR DEPENDENCE

Although patient safety is of paramount importance it must be remembered that em-ployers have a responsibility to treat their employee fairly. It is essential that hospitalunits (Trusts in the UK) have a standing operating procedure for dealing with a doctorwho is suspected of being addicted. Ad hoc arrangements are unfair to the doctor con-cerned and are unlikely to resolve the issue satisfactorily. The procedure can be, andusually is initially, a local process which takes account of national guidelines. In the earlystages it is essential, as far as is possible, to maintain confidentiality. This is likely to bea life-changing period for the doctor involved and it may be that the suspicions areunfounded. I was involved in a case in which a colleague in another discipline wasreported as ‘smelling of alcohol’ for several consecutive mornings. The smell was, infact, ketone bodies and disappeared when his undiagnosed diabetes was treated.Before any interview it is essential to gather all the available facts; if possible physicalsigns should be verified by someone directly involved in the process. Written reportswill clearly carry more weight but patient safety cannot be jeopardised if these cannotbe obtained.

The initial interview must not be conducted by one person alone. The outlineconstitution of the panel considering the case should be defined in operating proce-dures but will need to be varied to take account of individual circumstances. A typ-ical panel considering a consultant anaesthetist might consist of the clinical director,a doctor with experience of treating doctors with addiction and someone to see fairplay, perhaps a member of a medical society with previous experience of this type ofpanel. It may well be appropriate for the doctor concerned to be accompanied bya family member or friend. The panel can come to one of two conclusions, firstlythat there is no case to answer or secondly that a specialist evaluation is necessary.The panel, at this stage, cannot confirm the diagnosis. If the doctor suspected of ad-diction is a trainee the matter should be dealt with by the appropriate training body;in the UK the postgraduate dean would take the lead. However, the basic rules forthe initial interview remain the same; more than one person must be involved andthe findings of this panel can only be either ‘no case to answer’ or a referral forassessment.

At this stage it is essential that the welfare of the doctor under investigation shouldbe considered. It goes without saying that this will be an immensely stressful time.Addicted doctors are at higher risk of taking their own lives and the additional stressof investigation may well be the last straw. If specialist assessment is called for, theemployer has a duty to have a system of referral in place which can be implementedquickly. The doctor is at increased risk until the assessment process has begun. One ofthe signs of addiction is the withdrawal from friends and family and it will probably benecessary to provide external support. Some medical disciplines have instituted a for-mal mentoring system and this should be implemented. Currently, anaesthesia in the

640 D. Saunders

UK has no formal scheme but doctor-led support schemes are available and will bediscussed later. In some hospital units the Occupational Health Department may be-come involved. It is probably fair to say that support for doctors in difficulty ismuch better in some units than others. Some doctors regard the service as an armof management and would prefer to be treated outside their immediate environment.

A decision must be made at this time concerning the employment status of the doc-tor. The easy way out is to suspend all doctors under investigation and some em-ployers do this. It is extremely unhelpful to the doctor concerned who will nolonger have the direct moral support of colleagues and continuing medical educationwill become difficult. For the employer it is a costly process as the doctor who is sus-pended on full pay contributes nothing to the efficient running of the hospital. A gov-ernment initiative in the UK has sought to reduce the number of doctors suspended.The attitude of the doctor concerning assessment and possible treatment should beconsidered. If the doctor recognises that a problem does exist and consents to assess-ment and treatment, suspension may be unnecessary and suitable employment foundto allow continuation of practice. From the start, distinction has been drawn betweensubstance abuse and dependence. A doctor who consistently arrives at work smellingof drink may, or may not, show signs of dependence. The shock of investigation alonemay be sufficient to prevent the alcohol abuser who is not dependent to stop or rad-ically modify a drinking habit. If the doctor will not acknowledge that a problem existsvarious sanctions exist, including suspension; indeed it would be impossible to allowa doctor who denies an addiction to continue clinical practice.

Referral to the licensing body (the General Medical Council (GMC) in the UK)should not be seen as a sanction but should be used in the best interest of patients,the doctor concerned and the employers. Whether licensing body referral is neces-sary or desirable should be based on the individual circumstance of the case andthe guidelines of that body. In 2006 the GMC issued the recommendations from a re-view of its procedures for dealing when a doctor’s fitness to practice is impaired by ill-health. Two-thirds of cases considered by the Health Committee of the GMC in 2002concerned addiction. These recommendations recognised that the best place to dealwith substance abuse was often in the workplace. The GMC wished their policy ondrug abuse to complement local arrangements.

TREATMENT OF ADDICTION

Following a clinical assessment confirming dependence, treatment consists firstly ofsafe detoxification; sudden withdrawal of alcohol and opiates can be life-threatening.This is followed by the development of a chemical-free lifestyle which might includea process of education and psychiatric support. It is vital that this process is under-taken by a specialist unit. It is probably preferable in the early stages that this is under-taken in a residential unit. This is obviously not without financial implication but fundsmay be available from the NHS. The long-term recovery programme must be under-taken by a supervising physician specialising in the treatment of addiction. This doctorwill be able to advise whether re-entry to work is possible and would continue to beinvolved during the re-entry process. It is not possible to cure addiction and the re-covering addict will require life-long support. This is best achieved by integrationinto self-help groups such as Alcoholics Anonymous. Doctors will probably find theprocess of recovery more difficult in a group which does not recognize their particular

Substance abuse and dependence in anaesthetists 641

problems. Several support groups have been founded for doctors and dentists aloneand a list of these may be found at the end of this chapter.

RETURN TO WORK

When considering return to work it must not be assumed that the recovering doctorwill return to work as a consultant or even as an anaesthetist and perhaps not even asa practising physician. Quite clearly the process of recovery will be less difficult forsome doctors than others. For those who are managing recovery well it may bethat a return to clinical anaesthesia is possible, accepting all the risks of working inan environment where opiate drugs are freely available. In the younger doctor itmay possible to retrain in a specialty where opiate or sedative drugs are not so readilyavailable. In the older doctor it may be that the best advice that can be given is to takeearly retirement. There are no hard-and-fast rules.

In the USA, state sponsored ‘impaired physician’ schemes are the norm. The recov-ering doctor is frequently responsible for providing the finance required to run theprogramme; this may run into hundreds of thousands of dollars. Successful schemeshave been established for anaesthetists in recovery in Australia and New Zealand. De-spite calls for similar schemes in the UK the doctor who wishes to return to workfaces tremendous difficulties not least the question of who will finance the programmeof reintroduction. A few chief executives and medical directors in the UK have shownan enlightened attitude to the reintroduction of doctors in recovery to clinical practiseand have come to specialise in the work. It takes considerable courage to accept re-sponsibility for a doctor who has previously been shown to be a potential danger topatients.

Again in the USA re-entry classifications have been devised with criteria whichinclude:

1. Evidence of recovery and the resolve to continue the programme2. The desire to return to anaesthesia as a specialty3. Knowledge of the nature of addiction and an acceptance of the diagnosis4. Integration in a self-help group, for example Alcoholics Anonymous5. Strong support from family and friends6. Evidence of successful re-entry into community life

If all of these criteria are present, if return to work is supported by the supervisingphysician and if the recovering doctor is prepared to enter into a five-year recoverycontract, re-entry can be recommended. If all of the criteria are not met, a furtherperiod of recovery and monitoring may be recommended with a view to future assess-ment of suitability to enter a re-entry programme. The doctor may fail to meet thenecessary criteria to such an extent that redirection to another specialty should beconsidered. It is difficult, however, to envisage any specialty taking responsibility fora doctor who fails to meet most of the criteria. The advice in this case would be tomove out of medicine altogether; it may be necessary to withdraw the licence to prac-tise of a physician who continues to deny that a problem exists.

The objectives of any re-entry programme must recognize that the main priority ispatient safety; rehabilitation of the doctor is of secondary importance. Assuming thatthe finance is in place the scheme will provide the re-entering doctor with an income.It is highly likely that absence from work has been prolonged and even if recovery has

642 D. Saunders

been strong an element of retraining will be necessary. This will involve, following aninitial period of assessment of knowledge, skills and attitudes, a system of diminishingsupervision until independent practice can be recommended. The personnel undertak-ing re-training and supervision should have wide experience of training, be sufficientlysure of their own ability to establish the respect of the doctor being retrained and theemploying authority and have experience in assessments and appraisals. The experi-ence should at no time be confrontational which would require trainers to havegood communication skills and an empathetic nature. The process of ‘sign-off ’ fromretraining is problematic and should be agreed from the outset by the doctor, the su-pervising physician, the members of the retraining team, the academic body responsi-ble for anaesthetic training and the national licensing body. No such widely acceptedset of criteria currently exist in the UK and until they do, the responsibility of dis-charge from a supervised program will be made on a case by case basis. It may wellbe that examinations testing knowledge (the Fellowship examinations in the UK)may need to be retaken and that skills and the ability to put knowledge into practiceshould be assessed using simulation. It must be recognised that not all doctors can beretrained and that some doctors will fail the retraining element of re-entry to practice.If, after a pre-agreed period of time of retraining has elapsed, it is the consensus viewof the trainers that further training would have no effect the doctor should be in-formed of this fact and the medical director of the hospital unit involved notified. Itmay be that the doctor realizes that further training will be futile; however, it is quitepossible that the response will be hostile. This situation should be sympathetically han-dled and the doctor will require considerable support.

A written recovery contract should be entered into before formal re-entry occurs.This is usually for a period of three to five years and might contain the doctor’sagreement;

1. to continue to be under the care of the supervising physician for an agreed periodof time

2. to abstain from all mood-altering drugs including alcohol3. not to self-prescribe4. to attend an agreed number of self-help group meetings per week5. to allow their re-entry status to be known to medical and non-medical colleagues6. to undergo a drug screening programme with a random element

It is advisable that the re-entering anaesthetist is denied access to drugs of addictionuntil a re-assessment is made early in the re-entry programme; three months wouldappear to be a minimum. Similarly, it is inadvisable for the doctor to be on-call duringthe evenings and at weekends, times when the access to drugs of addiction isfacilitated.

From 2006, in the UK if doctors are found to have impaired fitness to practicelinked to substance misuse, they will be subject to GMC restrictions. They will be re-quired to comply with the arrangements that the GMC makes for the testing of andanalysis of samples of blood, urine, oral fluids or hair for the presence of alcohol, drugsor their metabolites. The frequency of testing will be determined by a risk assessmentof the likelihood of relapse. The results will be made available to the doctor, the doc-tor’s medical supervisor and the GMC.

The results of the formal re-entry programmes in the USA, Australia and NewZealand have been encouraging. In the report by Paris and Canavan, the relapserate in a group of 32 anesthesiologists was 40%; a sustained recovery rate of longer

Substance abuse and dependence in anaesthetists 643

than two years was reported as being 80%. The question of whether a doctor who hasbeen rehabilitated can ever be safe arises. If two years successful re-entry has beenachieved and if the doctor concerned volunteers to continue to be a member ofa self-help group and submit to regular monitoring the risk to patients is probably sim-ilar to that posed by the general body of anaesthetists. If these criteria cease to be metalarm bells should ring in the minds of administrators of anaesthetic departments.

SUPPORT FOR THE ADDICTED ANAESTHETIST

The Sick Doctors Scheme of the Association of Anaesthetists of GreatBritain and Ireland (AAGBI) is currently undergoing review and a national networkof counsellors will shortly be established. Non-urgent advice for the anaesthetist indifficulty can be obtained through the Co-ordinator of the Sick Doctors Scheme on020 7631 1650.

The British Medical Association offers a 24 hour service which is endorsed bythe AAGBI. Telephone 08459 200169.

Sick Doctors Trust operates a 24 hour support service to doctors suffering fromaddiction to alcohol and other drugs. Telephone 0870 444 5163.

The British Doctors and Dentists Group is a support group of recovering medicaland dental drug and alcohol misusers. Telephone 0207 487 4445.

Further reading

Berry CB, Crome IB, Plant M & Plant M. Substance misuse amongst anaesthetists in the United Kingdom and

Ireland. The results of a study commissioned by the Association of Anaesthetists of Great Britain and

Ireland. Anaesthesia 2000; 55: 946e952.

Booth JV, Grossman D, Moore J et al. Substance abuse amongst physicians: a survey of academic anesthesi-

ology programs. Anesthesia and Analgesia 2002; 95: 1024e1030.

Strang J, Wilks M & Wells B Marshall J. Missed problems and missed opportunities for addicted doctors.

British Medical Journal 1998: 316.

Paull J & Warhaft N. Back to work? Returning anaesthetists to the workplace after treatment for substance

abuse. In Australasian Anaesthesia. Published by the Australian and New Zealand College of Anaesthetists,

2001, pp. 13e18.

American Society of Anesthesiologists. Model curriculum on drug abuse and addiction for residents in

anesthesiology. www.asahq.org/clinical/curriculum.pdf