Deborah Brauser
December 11, 2013
Substance use disorders (SUDs) are increasing among medical residents, with the risk for relapse “very high,” new research suggests.
A retrospective cohort study of more than 44,000 anesthesiology residents who began training programs between 1975 and 2009 showed that 384 (0.86%) had a confirmed SUD during their training. Of these, 43% experienced at least 1 relapse after detection and treatment.
In addition, 28 of the study participants died during training, with all of the deaths directly related to an SUD.
“In terms of an absolute number, it’s not a great number of residents affected. But looking at the about 6000 anesthesiology residents that are in training each year, that’s about 20 people a year who develop this problem and 1 or 2 who die from this problem,” lead author David O. Warner, MD, professor of anesthesiology at Mayo Clinic in Rochester, Minnesota, told Medscape Medical News.
Dr. Warner added that the incidence rate also increased significantly during the study period.
Intravenous opioids were the most used substance in the study, but marijuana use, excessive alcohol use, and prescription opioid use were also high.
The study was published in the December 4 issue of JAMA.
Wake-up Call for Other Specialties?
“We don’t know what drugs other specialties might abuse or whether the problem is more serious in anesthesiology than elsewhere. But I think it would be good for other specialities’ societies to analyze and report these data to see if our findings are generalizable among other physicians,” said Dr. Warner.
According to investigators, data regarding the epidemiology of SUDs in physicians in general, and anesthesiologists in particular, are limited.
Still, because of their easy access to substances such as intravenous opioids, anesthesiologists have drawn particular attention, the investigators note.
“The specialty has been aware of this particular problem for some time, and the professional societies have developed some outreach materials to try and educate the residents in training about the potential and seriousness of this issue,” said Dr. Warner.
“But we haven’t known the magnitude of the problem and what the outcomes for people who develop these problems might be.”
As reported by Medscape Medical News, a recent study showed that a group of addicted physicians, including anesthesiologists, cited self-medication to help manage physical pain and emotional problems as the top reason for their abuse of prescription drugs.
Pain, Stress Factors?
“We don’t really know among anesthesiology folks why they do this,” said Dr. Warner.
“Addiction is a disease characterized by denial and evasion. So I think what the real reasons might be is a very interesting question. Certainly self-medicating for pain or for stress is quite plausible,” he added.
For the current study, the investigators examined data from the American Board of Anesthesiology (ABA) on 44,612 physicians (84% men) who began anesthesiology residency programs between July 1975 and July 2009.
Possible SUD was flagged in the ABA data through Clinical Competence Reports, examination applications, direct communications with the residents, and the Disciplinary Action Notification Service. Follow-up was conducted periodically until the end of residency training. Follow-up to assess relapse was conducted through December 2010.
The Social Security Administration Death Master File was used to identify residents who died during their training, and the National Death Index was used to determine the cause.
Results showed that 1042 of the study participants were flagged for an SUD and that 896 had a confirmed SUD. Of the latter group, 384 (92% men) were found to have abused substances during their primary anesthesiology training.
This broke down to an overall SUD incidence per 1000 resident-years of 2.16 (95% confidence interval [CI], 1.95 – 2.39). The incidence per 1000 residents for men was 2.68 (95% CI, 2.41 – 2.98); for women, it was 0.65 (95% CI, 0.44 – 0.93).
Highs and Lows
The incidence rates over time followed a bit of a roller-coaster pattern. There was an increase at the beginning of the study, followed by lower rates from 1996 to 2002, and then the highest incidence rate occurred after 2003 ― with 2.87 per 1000 resident-years (95% CI, 2.42 – 3.39).
However, the rates of relapse did not change significantly between 1975-1994 and 1995-2009.
“The cumulative percentage who experienced at least 1 relapse by 30 years after the initial episode…was 43% (95% CI, 34% – 51%),” report the researchers. Of those whose SUD was detected during their residency, 6% relapsed at least once while still in training.
Intravenous opioids were the most commonly used substance in the initial SUD episode, followed by alcohol, marijuana or cocaine, anesthetics/hypnotics, and oral opioids. A total of 22% of the participants used more than 1 substance.
The median time to first use was 29.5 months after the start of residency, and the median time from first episode to detection was just 4 months.
“To our knowledge, this report provides the first comprehensive description of the epidemiology and outcomes of SUD for any in-training physician specialty group, showing that the incidence of SUD has increased over the study period and that relapse rates are not improving,” write the investigators.
Patient Harm
“While we have no direct data to show harm to patients, impaired physicians may put patients at risk, and certainly put themselves at risk,” Dr. Warner said in a release.
“It’s incumbent upon us as medical professionals to do what we can to identify and address [SUDs] as quickly as possible to protect both the involved physicians and their patients.”
Dr. Warner noted that there are “some controversies in this area,” including what should be done when a resident is identified as having an SUD.
“Should they be allowed to return to residency? Should they be counseled to go into another specialty where they might not have the access to substances of abuse? These types of discussions have been hampered by the lack of real data about how bad a problem this is,” he said.
“I think many people had assumed that public education efforts in the early ’90s were effective and that this was not as bad a problem now. But our data showed that, while that seemed to help in the mid-’90s, the incidence has gone back up and is now higher than it’s ever been,” said Dr. Warner.
Generalizeable Results
“I think it’s important and timely to acknowledge that these problems affect physicians as well as the public at large,” A. Thomas McLellan, PhD, chief executive officer of the Treatment Research Institute in Philadelphia, Pennsylvania, toldMedscape Medical News.
“The findings did not surprise me other than I thought it was a little low, but they were focusing on the training period. Physicians and nurses are an at-risk group because of ease of accessibility to these drugs,” said Dr. McLellan.
He added that although the study looked specifically at anesthesiology residents, the results are generizable. In fact, he published a study in BMJ in 2008 that assessed 904 physicians with SUDs who were from several different specialities.
“We found that it was primarily family care doctors that were included, but they’re also the largest proportion of physicians. I would say anesthesiologists are at special risk, but the rest of the medical profession is not invulnerable,” he said.
“Physician health plans should be the model for the way addiction is treated. Our studies and other studies have shown 75% to 80% excellent outcomes up to 5 years among addicted physicians who get the proper management and treatment.”
Dr. McLellan, who was not involved with the current research, is a former senior scientist and deputy director of the White House Office of National Drug Control Policy (ONDCP). While with the ONDCP, he coauthored a strategy that made addiction treatment part of healthcare reform.
“Addiction is not a moral character failing; it’s a chronic illness that can respond well to treatment,” he said.
“No physician wants to rat on his buddy, and that drives substance abuse underground, delays its reporting, and increases the untoward effects to patients from poor practice. But the best thing to do is have an environment where risk of addiction is treated like risk of infectious disease or other type of highly prevalent illness.”
This includes vigilance, early intervention where necessary, treatment, and continued monitoring and management, he said. “Do this and you’ll get very good outcomes.”
The study was funded by the ABA, the Mayo Foundation, and a grant from the National Institutes of Health Clinical and Translational Science Award. Four of the 6 study authors and Dr. McLellan have disclosed no relevant financial relationships. One of the remaining authors chairs the American Society of Anesthesiologists Task Force on Chemical Dependency and is vice president of the Minnesota Board of Medical Practice. Dr. Warner is a director of the ABA.
JAMA. 2013;310:2289-2296. Abstract