Keith H. Berge

The anesthesiology community's approach to opioid- and anesthetic-abusing personnel: time to change course.

Time to Change Course IN this issue of ANESTHESIOLOGY, Bryson and Silverstein provide an excellent detailed summary of addiction and substance abuse among anesthesiologists, and a review of “state-of-the-art” theories on the mechanisms of addiction, as well as recognition, intervention, treatment, and aftercare of addicted caregivers. Their thoughtful review once again reminds us that anesthesiology, as a specialty, has made a sincere and earnest effort to diminish substance abuse and addiction within its ranks through education and the creation of ever more intrusive and cumbersome drug-dispensing and -control mechanisms. While new information is continually emerging on these issues, it is apparent from the authors’ analysis that despite multiple programatic efforts, there has been little, if any, positive impact on the specialty-wide incidence of substance abuse and addiction. Deaths from opioid abuse continue, and additional reports of deaths from nonopioid anesthesia-related drugs (such as propofol or inhalational anesthetic abuse) periodically appear. Although the drugs most commonly abused by the general population are nicotine and alcohol, multiple studies have shown that the drugs of abuse for which most anesthesia providers enter chemical dependency treatment are the potent opioids, with alcohol following far behind. The rate of abuse of other anesthesia-related drugs is largely unknown. Anesthesiologists clearly present a skewed subset of the general population, and there is no question that they get in trouble with very dangerous and often rapidly lethal drugs. Further, anesthesiologists abuse these highly potent drugs more than other physicians. In the United States, considerable efforts have been made to reduce the incidence of drug diversion by anesthesia practitioners through the implementation of systems such as those mentioned in the Bryson and Silverstein discussion. However, at Mayo Clinic, Rochester, Minnesota, the Department of Anesthesiology has carried these systems a step further. While Bryson and Silverstein use a qualitative random assay of returned waste in their own practice, Mayo Clinic uses a more expensive quantitative assay of randomly selected returned narcotic samples in conjunction with the other methods the authors describe (e.g., computer charting and Pyxis machine [Cardinal Health, Dublin, OR] drugdispensing records). Division of Pharmacy personnel rigorously review all available data and, in concert with a representative of the Department of Anesthesiology Chemical Abuse Committee, relentlessly investigate any apparent discrepancies in charting or variations from typical practice patterns. For such a system to be effective, there must be excellent cooperation between the Division of Pharmacy and Department of Anesthesiology to support the auditors in order to avoid “us-againstthem” conflicts. In every instance of suspected narcotic diversion, all waste narcotic returned by the individual in question is assayed until diversion is either confirmed or disproved. With this system in place, Mayo Clinic has seen its rate of recognized diversion of narcotics—in a department that has a combined population of some 475 staff anesthesiologists, residents and fellows, nurse anesthetists, and nurse anesthesia students—decrease from approximately one incident per year for many years to one incident in the past 7 yr. Having said that, we understand that there will continue to be practitioners who divert anesthesia-related drugs for their personal use, and we suspect that at Mayo Clinic Rochester, the problem is simply in remission, not cured. We are hesitant to suggest that this system change is solely responsible for the apparent decrease in diversion, although we are cautiously optimistic that the trend will continue. One issue not addressed by Bryson and Silverstein is that other anesthesia care providers (e.g., nurse anesthetists, sedation nurses) are at similar, if not increased, risk of addiction simply because their practices are often in remote settings, and they may not fully appreciate the risks of a first-time experiment with diverted anesthetic drugs. Unfortunately, there is very limited comment in the literature on this topic. However, one of us (K.H.B.) frequently lectures to large nurse anesthesia groups on this problem, and in response to the question, “Who here has lost a friend or colleague to narcotic addiction?” nearly every hand in the audience will go up. The American Association of Nurse Anesthetists has an active support line in an effort to help with the recognition and appropriate handling of drug diversion, and the death of a former American Association of Nurse Anesthetists president to a fentanyl overdose in 2002 makes the point vividly clear that abuse of diverted anesthetic drugs does not choose its victims by the letters after their names. This Editorial View accompanies the following article: Bryson EO, Silverstein JH: Addiction and substance abuse in anesthesiology. ANESTHESIOLOGY 2008; 109:905–17.

Substance use disorder among anesthesiology residents, 1975-2009.

IMPORTANCE Substance use disorder (SUD) among anesthesiologists and other physicians poses serious risks to both physicians and patients. Formulation of policy and individual treatment plans is hampered by lack of data regarding the epidemiology and outcomes of physician SUD. OBJECTIVE To describe the incidence and outcomes of SUD among anesthesiology residents. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of physicians who began training in United States anesthesiology residency programs from July 1, 1975, to July 1, 2009, including 44,612 residents contributing 177,848 resident-years to analysis. Follow-up for incidence and relapse was to the end of training and December 31, 2010, respectively. MAIN OUTCOMES AND MEASURES Cases of SUD (including initial SUD episode and any relapse, vital status and cause of death, and professional consequences of SUD) ascertained through training records of the American Board of Anesthesiology, including information from the Disciplinary Action Notification Service of the Federation of State Medical Boards and cause of death information from the National Death Index. RESULTS Of the residents, 384 had evidence of SUD during training, with an overall incidence of 2.16 (95% CI, 1.95-2.39) per 1000 resident-years (2.68 [95% CI, 2.41-2.98] men and 0.65 [95% CI, 0.44-0.93] women per 1000 resident-years). During the study period, an initial rate increase was followed by a period of lower rates in 1996-2002, but the highest incidence has occurred since 2003 (2.87 [95% CI, 2.42-3.39] per 1000 resident-years). The most common substance category was intravenous opioids, followed by alcohol, marijuana or cocaine, anesthetics/hypnotics, and oral opioids. Twenty-eight individuals (7.3%; 95% CI, 4.9%-10.4%) died during the training period; all deaths were related to SUD. The Kaplan-Meier estimate of the cumulative proportion of survivors experiencing at least 1 relapse by 30 years after the initial episode (based on a median follow-up of 8.9 years [interquartile range, 5.0-18.8 years]) was 43% (95% CI, 34%-51%). Rates of relapse and death did not depend on the category of substance used. Relapse rates did not change over the study period. CONCLUSIONS AND RELEVANCE Among anesthesiology residents entering primary training from 1975 to 2009, 0.86% had evidence of SUD during training. Risk of relapse over the follow-up period was high, indicating persistence of risk after training.

Diversion of Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention

Mayo Clinic has been involved in an ongoing effort to prevent the diversion of controlled substances from the workplace and to rapidly identify and respond when such diversion is detected. These efforts have found that diversion of controlled substances is not uncommon and can result in substantial risk not only to the individual who is diverting the drugs but also to patients, co-workers, and employers. We believe that all health care facilities should have systems in place to deter controlled substance diversion and to promptly identify diversion and intervene when it is occurring. Such systems are multifaceted and require close cooperation between multiple stakeholders including, but not limited to, departments of pharmacy, safety and security, anesthesiology, nursing, legal counsel, and human resources. Ideally, there should be a broad-based appreciation of the dangers that diversion creates not only for patients but also for all employees of health care facilities, because diversion can occur at any point along a long supply chain. All health care workers must be vigilant for signs of possible diversion and must be aware of how to engage a preexisting group with expertise in investigating possible diversions. In addition, clear policies and procedures should be in place for dealing with such investigations and for managing the many possible outcomes of a confirmed diversion. This article provides an overview of the multiple types of risk that result from drug diversion from health care facilities. Further, we describe a system developed at Mayo Clinic for evaluating episodes of potential drug diversion and for taking action once diversion is confirmed.

Occult Cardiac Tamponade Detected by Transesophageal Echocardiography

Transesophageal echocardiography is a safe, minimally invasive procedure that should be considered when the diagnosis of cardiac tamponade is a possibility and when conventional methods fail to provide conclusive diagnostic information. In this report, we describe a 74-year-old man in the intensive-care unit whose condition was unstable postoperatively because of an occult loculated pericardial effusion and cardiac tamponade. Routine noninvasive and invasive monitoring, including hemodynamic monitoring and transthoracic echocardiography, failed to confirm definitively the suspected diagnosis of cardiac tamponade. In addition, because of the hemodynamic instability of the patient, transporting him for definitive tests (such as fast computed tomographic scanning of the mediastinum, which could not be performed at the bedside) for assessment of cardiac tamponade was relatively contraindicated. In our patient, the diagnostic information obtained by transesophageal echocardiography may have been lifesaving.

Ten Common Questions (and Their Answers) on Medical Futility

The term medical futility is frequently used when discussing complex clinical scenarios and throughout the medical, legal, and ethics literature. However, we propose that health care professionals and others often use this term inaccurately and imprecisely, without fully appreciating the powerful, often visceral, response that the term can evoke. This article introduces and answers 10 common questions regarding medical futility in an effort to define, clarify, and explore the implications of the term. We discuss multiple domains related to futility, including the biological, ethical, legal, societal, and financial considerations that have a bearing on definitions and actions. Finally, we encourage empathetic communication among clinicians, patients, and families and emphasize how dialogue that seeks an understanding of multiple points of view is critically important in preventing or attenuating conflict among the involved parties.

New-Onset Neurologic Deficits After General Anesthesia for MRI

Two patients with spine disease were unable to tolerate supine placement for magnetic resonance imaging (MRI) because of severe back pain. General anesthesia was administered to enable the patients to undergo MRI. Both patients awakened from anesthesia with new-onset paraplegia and underwent emergency decompressive laminectomy. Acute paraplegia after anesthesia occurs infrequently and is most commonly associated with mechanical injury, vascular compromise, or anesthetic technique. The physical limitations of the MRI environment make it difficult to position some patients in a manner that accommodates their pathophysiology and may place certain patients at risk of neurologic compromise. For this subset of patients, the necessity of MRI with general anesthesia should be reassessed and alternative imaging methods considered.

Prolonged coma from refractory status epilepticus

ObjectiveStatus epilepticus is a life-threatening medical condition. In its most severe form, refractory status epilepticus (RSE) seizures may not respond to first and second-line anti-epileptic drugs. RSE is associated with a high mortality and significant medical complications in survivors with prolonged hospitalizations.MethodsWe describe the clinical course of RSE in the setting of new onset lupus in a 31-year-old male who required prolonged barbiturate coma.ResultsSeizure stopped on day 64 of treatment. Prior to the resolution of seizures, discussion around withdrawal of care took place between the physicians and patients family. Medical care was continued because of the patients age, normal serial MRI studies, and the patients reversible medical condition.ConclusionFew evidence-based data exist to guide management of RSE. Our case emphasizes the need for continuous aggressive therapy when neuroimaging remains normal.

Risk and Outcomes of Substance Use Disorder among Anesthesiology Residents: A Matched Cohort Analysis.

Background:The goal of this work is to evaluate selected risk factors and outcomes for substance use disorder (SUD) in physicians enrolled in anesthesiology residencies approved by the Accreditation Council for Graduate Medical Education. Methods:For each of 384 individuals with evidence of SUD while in primary residency training in anesthesiology from 1975 to 2009, two controls (n = 768) who did not develop SUD were identified and matched for sex, age, primary residency program, and program start date. Risk factors evaluated included location of medical school training (United States vs. other) and anesthesia knowledge as assessed by In-Training Examination performance. Outcomes (assessed to December 31, 2013, with a median follow-up time of 12.2 and 15.1 yr for cases and controls, respectively) included mortality and profession-related outcomes. Results:Receiving medical education within the United States, but not performance on the first in-training examination, was associated with an increased risk of developing SUD as a resident. Cases demonstrated a marked increase in the risk of death after training (hazard ratio, 7.9; 95% CI, 3.1 to 20.5), adverse training outcomes including failure to complete residency (odds ratio, 14.9; 95% CI, 9.0 to 24.6) or become board certified (odds ratio, 10.4; 95% CI, 7.0 to 15.5), and adverse medical licensure actions subsequent to residency (hazard ratio, 6.8; 95% CI, 3.8 to 12.2). As of the end of follow-up, 54 cases (14.1%) were deceased compared with 10 controls (1.3%); 28 cases and no controls died during residency. Conclusion:The attributable risk of SUD to several adverse outcomes during and after residency training, including death and adverse medical license actions, is substantial.

Opioid overdose: when good drugs break bad.

See also page 462 A ctor Philip Seymour Hoffman died on February 2, 2014, at age 46 years of an apparent accidental overdose (OD) of an opioid drug. He is yet another in a long series of talented entertainers to succumb to this class of drug; others include Elvis Presley, John Belushi, Heath Ledger, and many more. Although these celebrity deaths generate great interest in the media, journalists and the public often underappreciate that these celebrity deaths are but a single manifestation of an ongoing population-wide epidemic of opioid OD deaths. These deaths have been associated with the use of pharmaceutical-grade drugs (“good drugs”) and nonepharmaceuticalgrade drugs (“bad drugs”). We review these 2 categories and share with readers why this categorization, when applied to opioid-related deaths, is often a distinction without a difference. Furthermore, we place our speculative synthesis in the context of the opioid OD article by Hasegawa et al in the current issue of Mayo Clinic Proceedings. In the early 1990s, there began a welldocumented explosion in the sales of prescription opioid pain relievers believed to result from a variety of factors, including the release of new opioid drugs and formulations, the aggressive marketing of these drugs to physicians, the declaration of pain as the “fifth vital sign” by the American Pain Society and the Joint Commission, and an increased willingness on the part of physicians to treat chronic nonecancer-related pain with opioid drugs. Unfortunately, in concert with liberalization of the indications for the use of opioid drugs there have been parallel increases in the diversion and abuse of these same drugs and deaths attributable to them. In the age group 25 to 64 years, death due to unintentional drug poisoning is now the leading cause of accidental death in the United States, surpassing automobile accidents. Seventy-five percent of these drug poisoning deaths involved opioids. In its efforts to raise public awareness of the problem, the Centers for Disease Control and Prevention declared in 2011 that prescription drug abuse is now an epidemic.

Detectable Blood Alcohol After a Motor Vehicle Crash and Screening for Alcohol Abuse/Dependence

OBJECTIVE To determine the percentage of patients hospitalized after an alcohol-related motor vehicle crash (MVC) who underwent a screening evaluation for alcohol abuse/dependence and had a diagnosis of alcohol abuse/dependence. PATIENTS AND METHODS Medical and emergency trauma records were reviewed retrospectively for 1994 through 1996 to identify patients who were hospitalized as a result of being involved in an MVC with any detected blood alcohol at the time of admission to a large midwestern Level I trauma center. The primary outcome measure was the performance of alcohol abuse/dependence screening by a psychiatrist or a chemical dependency counselor. A univariate analysis was performed to identify factors associated with the performance of alcohol abuse/dependence screening. The Fisher exact test and the 2-sample rank sum test were used in the analyses. RESULTS Of the 294 study patients, 78 (26.5%) underwent a screening evaluation for alcohol abuse/dependence by a psychiatrist or a chemical dependency counselor during hospitalization, and 69 (88%) of the 78 patients screened had a diagnosis of alcohol abuse/dependence. Factors associated with the performance of alcohol abuse/dependence evaluation included a known prior history of alcohol abuse, suspicion of alcohol consumption documented by emergency department personnel, higher blood alcohol level at admission, and longer length of hospitalization (all P < .001). CONCLUSION While the high rate of alcohol abuse/dependence may be explained partially by distinguishing factors in those screened, these findings suggest that routine alcohol abuse/dependence screening of persons presenting with a detectable blood alcohol level following an MVC may identify patients who would benefit from a chemical dependency intervention.