12.03.2013

Rates of apparent substance use disorders among anesthesiology residents have recently been at their highest level since 1975, researchers said.

Disciplinary records and other data sources on more than 44,000 individuals starting anesthesiology residencies from 1975 to 2009 identified 384 with evidence of substance use disorders during training, for an overall rate of 2.16 per 1,000 resident-years, according to David O. Warner, MD, of the Mayo Clinic in Rochester, Minn., and colleagues.

The incidence has shown an unevenly increasing pattern, with sharp increases followed by declines, the researchers reported in the Dec. 4 issue of the Journal of the American Medical Association.

But the rate from 2003 onward has been the highest on average, with a mean of 2.87 cases per 1,000 resident-years (95% CI 2.42-3.39), compared with rates of 0.5 to 1.5 per 1,000 from 1975 to 1985.

Among 284 residents with substance use problems whose specific drugs-of-abuse were known, the most popular were IV opioids such as fentanyl (137 individuals), followed by alcohol (85), anesthetic and hypnotic drugs such as benzodiazepines (46), marijuana (33), and cocaine (30).

Warner and colleagues also found that relapse rates remained mostly unchanged during the study period.

“To our knowledge, this report provides the first comprehensive description of the epidemiology and outcomes of substance use disorder for any in-training physician specialty group, showing that the incidence of substance use disorder has increased over the study period and that relapse rates are not improving,” they wrote.

They also suggested that the many limitations to their study mean that their findings “reflect the lower bound of the true incidence.”

Key data for the study were “flags” in trainee records maintained by the American Board of Anesthesiology, indicating possible substance use disorder as communicated to the board from different sources. These include reports from training program directors, information provided by trainees themselves, and reports from the Disciplinary Action Notification Service (DANS) of the Federation of State Medical Boards.

Also, Warner and colleagues examined cause-of-death data for 28 trainees who died during their residencies. In all cases, the death certificates indicated that substance abuse was involved.

Previous studies have shown that all these systems are spotty in catching cases of substance use disorders, the researchers indicated. They noted that residency program directors do not “consistently report” cases to the anesthesiology board, and some manifestations of substance use disorders do not trigger licensure-related actions flagged in the DANS system. And, death certificates are well known to be frequently incomplete or frankly erroneous.

Nevertheless, Warner and colleagues wrote, their results were consistent with previous survey-based findings that indicated drug-abuse rates among medical trainees in the range of 1.4 to 5.6 per 1,000 resident-years.

Detailed findings in the current study included the following:

• Rates were far higher among men than women (2.68 versus 0.65 per 1,000 resident-years)
• Relapse rates (defined as later instances of substance abuse after training) stood at approximate 20% at 5 years and 35% at 15 years, with no difference over time or by the specific type of drug abused
• Fourteen residents who survived substance use disorders during residency subsequently died from relapse
• Among residents whose records indicated a specific drug of abuse, 69% completed training and 51% obtained board certification in anesthesiology

Warner and colleagues stressed that the study’s limitations “highlight the need for better data to guide policy and practice.”

They argued that the inconsistent reporting of substance abuse during training “represent[s] lost opportunities to improve physician well-being and patient safety.”

And, they noted, other specialties do an even worse job of tracking substance use problems, making it difficult to tell whether drug abuse is “of special concern to anesthesiologists or is merely representative of the larger physician issue.”

• Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

LAST UPDATED 12.04.2013