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Addiction and Substance Abuse in Anesthesiology Ethan O Ⅵ REVIEW ARTICLES David S. Warner, M.D., and Mark A. Warner, M.D., Editors Anesthesiology 2008; 109:905–17 Copyright © 2008, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Addiction and Substance Abuse in Anesthesiology Ethan O. Bryson, M.D.,* Jeffrey H. Silverstein, M.D.† Despite substantial advances in our understanding of addic- idents, and 19% reported at least one pretreatment tion and the technology and therapeutic approaches used to fatality.2 Substantial advances have occurred in our fight this disease, addiction still remains a major issue in the understanding of addiction as well as both the tech- anesthesia workplace, and outcomes have not appreciably changed. Although alcoholism and other forms of impair- nology and therapeutic approaches used to fight this ment, such as addiction to other substances and mental ill- disease, although outcomes have not appreciably ness, impact anesthesiologists at rates similar to those in changed. Starting with a brief review of the basic other professions, as recently as 2005, the drug of choice for concepts of addiction, this article highlights the cur- anesthesiologists entering treatment was still an opioid. rent thoughts regarding the pathophysiologic basis of There exists a considerable association between chemical dependence and other psychopathology, and successful addiction, as well as clinical manifestations, legal is- treatment for addiction is less likely when comorbid psycho- sues, and treatment strategies. pathology is not treated. Individuals under evaluation or Anesthesiologists (as well as any physician) may suffer treatment for substance abuse should have an evaluation from addiction to any number of substances, though with subsequent management of comorbid psychiatric con- addiction to opioids remains the most common. As re- ditions. Participation in self-help groups is still considered a vital component in the therapy of the impaired physician, cently as 2005, the drug of choice for anesthesiologists along with regular monitoring if the anesthesiologist wishes entering treatment was an opioid, with fentanyl and to attempt reentry into clinical practice. sufentanil topping the list.3 Other agents, such as propo- fol, ketamine, sodium thiopental, lidocaine, nitrous ox- FIFTEEN years after the original article, “Opioid Addic- ide, and the potent volatile anesthetics, are less fre- 4 tion in Anesthesiology,”1 was published, addiction still quently abused but have documented abuse potential. remains a major issue in the anesthesia workplace. Be- Alcoholism and other forms of impairment impact tween 1991 and 2001, 80% of US anesthesiology resi- anesthesiologists at rates similar to those in other 5 dency programs reported experience with impaired res- professions. Factors that have been proposed to ex- plain the high incidence of drug abuse among anes- thesiologists include the proximity to large quantities This article is featured in “This Month in Anesthesiology.” of highly addictive drugs, the relative ease of diverting ᭛ Please see this issue of ANESTHESIOLOGY, page 9A. particularly small quantities of these agents for per- This article is accompanied by an Editorial View. Please see: sonal use, the high-stress environment in which anes- ᭜ Berge KH, Seppala MD, Lanier WL: The anesthesiology thesiologists work, and exposure in the workplace community’s approach to opioid- and anesthetic-abusing that sensitizes the reward pathways in the brain and personnel: Time to change course. ANESTHESIOLOGY 2008; thus promotes substance abuse.6 109:762–4. It is not the purpose of this article to present a manual for the treatment of addiction. Treatment should be Additional material related to this article can be found on the ANES- THESIOLOGY Web site. Go to http://www.anesthesiology.org, click on administered by qualified personnel. All anesthesia per- Enhancements Index, and then scroll down to find the appro- sonnel, however, should be aware of the basic nature of priate article and link. Supplementary material can also be the problem and possess the necessary information to accessed on the Web by clicking on the “ArticlePlus” link recognize and assist an impaired colleague. either in the Table of Contents or at the top of the Abstract or HTML version of the article. Prevalence There are limited data available to determine the cur- * Assistant Professor, † Professor. rent prevalence of drug use by anesthesia personnel. Received from the Department of Anesthesiology, Mount Sinai Hospital, New Records of disciplinary actions, mortality statistics, and York, New York. Submitted for publication May 11, 2007. Accepted for publi- registries for known addicts provide some information, cation June 19, 2008. Support was provided solely from institutional and/or departmental sources. but it is difficult to interpret these types of data in that Mark A. Warner, M.D., served as Handing Editor for this article. there is no guarantee that all cases are reported and the Address correspondence to Dr. Bryson: Mount Sinai Hospital, Department of total population out of which the reports emanate is Anesthesiology, One Gustave L. Levy Place, New York, New York 10029. [email protected]. This article may be accessed for personal use at rarely available. In the past, it had been concluded that no charge through the Journal Web site, www.anesthesiology.org. the true prevalence of addiction in physicians is un- Anesthesiology, V 109, No 5, Nov 2008 905 906 E. O. BRYSON AND J. H. SILVERSTEIN known,7 though it had been suggested that drug abuse is There is strong evidence to suggest that drugs of abuse at least as prevalent as among the general population.8 that activate the reward structures in the brain induce A review of 1,000 treated physicians conducted by lasting changes in behavior that reflect changes in neu- Talbott et al.9 in 1987 suggested that addiction is com- ron physiology and biochemistry.15 Although the major- mon among anesthesiologists. Anesthesia residents rep- ity of individuals who experiment with psychoactive resented 33.7% of all residents presenting for treatment substances do not become dependent, there exists a but composed only 4.6% of all US resident physicians at subset of individuals who do. These individuals typically the time of the study, thus presenting an apparent 7.4- exhibit preexisting comorbid traits such as novelty-seek- fold increased prevalence of anesthesia residents in the ing and antisocial behavior, and there seems to be a study population.1 Subsequent studies have consistently genetic basis for both the susceptibility to dependence differed from the results of Talbott et al. Five years later, and these comorbid traits.16 According to one recent a study by Hughes et al.5 found the rate of substance study, this genetic susceptibility plays a role in the abuse in the anesthesia resident population to be no transition from substance use to dependence and from higher than that of other specialties. Interestingly, this chronic use to addiction.17 Many genes have been same study showed higher rates of substance abuse identified as possibly playing a role in the susceptibil- among emergency medicine and psychiatry residents. ity to drug addiction, but as of this publication, inves- In 2000, Alexander et al.10 published a study examin- tigators have been able to identify a functional mech- ing the cause-specific mortality risks of anesthesiolo- anism related to the specific effects of abused drugs in gists that suggested that the risk of drug-related death only a few.18 among anesthesiologists is highest in the first 5 yr after Release of the neurotransmitter dopamine in the me- medical school graduation, and remains increased solimbic system of the brain is involved with the rein- over that of other physicians. Most recently, a survey forcement of drug-seeking behaviors associated with sev- conducted in 2002 by Booth et al.11 found the inci- eral drugs of abuse, including nicotine. Picciotto et al.19 ␤ dence of known drug abuse among anesthesia person- reported on mice lacking the 2 subunit of the high- nel to be 1.0% among faculty members and 1.6% affinity neuronal nicotinic acetylcholine receptor. They among residents. found that mesencephalic dopaminergic neurons from ␤ mice without the 2 subunit did not respond to nicotine, Etiology as did neurons from wild-type mice. The self-administra- In 1956, the American Medical Association declared tion of nicotine was observed to be attenuated in these alcoholism to be an illness,12 and in 1987, it extended mutant mice. the declaration to include dependence on all drugs. In humans, the cholinergic muscarinic 2 receptor There have been many theories regarding the etiology of has been associated with the function of memory and chemical dependence,13 including biochemical, genetic, cognition. Wang et al.20 reported that variation in the psychiatric, and, more recently, exposure-related theo- gene responsible for the production of this receptor ries.6 None alone has been able to identify specific predisposed to both alcohol dependence and major causes, only to suggest what may increase the risk of depressive syndrome. Luo et al.21 looked at the rela- developing addiction among anesthesia personnel. tions between the variations in the cholinergic mus- carinic 2 receptor gene and alcohol dependence, drug Genetic and Biochemical Theories dependence, and affective disorders in a population of Considerable research done in mice suggests a genetic 871 subjects and identified specific alleles, genotypes, basis for addiction. Tapper et al.14 engineered mutant haplotypes, and diplotypes significantly associated ␣ mice with 4 nicotinic subunits that contained a single with risk for either dependence or affective disorders. point mutation, Leu9= ¡ Ala9=, in the pore-forming M2 Because there is empirical evidence that the disorders of domain. The resulting nicotinic acetylcholine receptors substance abuse are prevalent within multiple genera- were hypersensitive to nicotine, with the mutant mice tions of some families, it makes sense that there should exhibiting reinforcement in response to acute low- be some associated genetic component. How much of a dose nicotine administration.
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