Resident addiction hits home

[Fastrach]

I know this has been covered in prior posts, but I wanted to bring up the topic once more. A resident in my program has been put on leave for an addiction to Fentanyl. This person was upfront with our PD about it (i.e. wasn't caught in the act), admitted there was a problem, requested help, and as of now less than a handful of peeps in our program know about this. My question is, how would you folks recommend handling this within the program with regards to letting people know why the extra call shifts need to be taken, and generally explaining where this resident is now in a politically correct manner? How could this be done in a tactful way which could potentially allow this resident a supportive and hospitable environment to work in should they be allowed to come back after treatment? Or should they even be allowed back?? I have some thoughts of my own on all this, but I just wanted a few opinions on the matter to see what other people think, as well as to see if perhaps anyone else has found themself in a similar position. Thanks.

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[Precedex]

My opinion:

He should be allowed back
No one should no about it who doesn't absolutely need to
Easy to say he had to take off time for family reasons.

 

[powermd]

I know this has been covered in prior posts, but I wanted to bring up the topic once more. A resident in my program has been put on leave for an addiction to Fentanyl. This person was upfront with our PD about it (i.e. wasn't caught in the act), admitted there was a problem, requested help, and as of now less than a handful of peeps in our program know about this. My question is, how would you folks recommend handling this within the program with regards to letting people know why the extra call shifts need to be taken, and generally explaining where this resident is now in a politically correct manner? How could this be done in a tactful way which could potentially allow this resident a supportive and hospitable environment to work in should they be allowed to come back after treatment? Or should they even be allowed back?? I have some thoughts of my own on all this, but I just wanted a few opinions on the matter to see what other people think, as well as to see if perhaps anyone else has found themself in a similar position. Thanks.

From what I read, the odds of using again after treatment are very, very high, so this person should probably get out of anesthesia all together before he ODs and croaks. Why don't you just say the resident is out on medical leave? It's true, and if people really want to know what it's for, they can ask him or her.

 

[SoCuteMD]

I know this has been covered in prior posts, but I wanted to bring up the topic once more. A resident in my program has been put on leave for an addiction to Fentanyl. This person was upfront with our PD about it (i.e. wasn't caught in the act), admitted there was a problem, requested help, and as of now less than a handful of peeps in our program know about this. My question is, how would you folks recommend handling this within the program with regards to letting people know why the extra call shifts need to be taken, and generally explaining where this resident is now in a politically correct manner? How could this be done in a tactful way which could potentially allow this resident a supportive and hospitable environment to work in should they be allowed to come back after treatment? Or should they even be allowed back?? I have some thoughts of my own on all this, but I just wanted a few opinions on the matter to see what other people think, as well as to see if perhaps anyone else has found themself in a similar position. Thanks.

I would either say that the person is on medical leave or had some personal issues. It's not political correctness that matters, it's discretion and privacy.

 

[swpm]

This person was upfront with our PD about it (i.e. wasn't caught in the act), admitted there was a problem, requested help,

I've never understood why people believe this matters. Asking for help vs getting caught is always raised as a mitigating factor in these cases, but it shouldn't obscure the first issue: it takes a series of very bad decisions to steal a stick of blue stuff and inject it in your own vein to get high. This is reckless, stupid behavior and it's pointless to sugarcoat the matter.

Once you've crossed that line, you should give up the right to ever again practice medicine on an unsuspecting, trusting public.

Coming forward and asking for help is encouraging from a recovery standpoint. His addiction is sad and tragic, and I hope he gets the help he needs. I hope he recovers and never uses again. I hope he finds meaningful work outside medicine. I hope getting fired from residency doesn't wreck his family relationships.

I hope I never have to entrust my life to an anonymous (ex?) junkie whose impairment is concealed by some touchy-feely addicted-doctor-reintegration program. As doctors we serve the public in a position of unique power and trust. If you betray that trust, there should be no second chance.


To answer your other question, I'm in agreement with the other posters - he has a medical problem and should be afforded the privacy and courtesy all patients are entitled to. No one needs to know he's an addict unless he chooses to tell them.

 

[Monty Python]

A resident in my program has been put on leave for an addiction to Fentanyl. ..... and generally explaining where this resident is now in a politically correct manner?

For one thing, HIPAA might apply here.

 

[Arch Guillotti]

Wow, tough crowd. This is an unfortunate situation. If someone aks, I would just tell them that particular individual is out for personal reasons and would leave it at that. People will talk anyway btu I would leave the information given out at a bare minimum.

Nationwide there are many physicans in various recovery programs from all disciplines. Many do well w/recovery and go on to lead productive careers. I would bet that many of us know someone in such a program, except that we don't know it because they are anonymous.

Now I know anesthesia is a different beast than pretty much every other specialty because of our easy access.

Recently, anonymous physician help programs came under fire in Cali:

http://www.signonsandiego.com/uniontrib/20080125/news_1n25docs.html


Substance abuse and addiction are very, very tough to beat. I know personally. I dipped a can of KODIAK a day or more (not that Copenhagen crap that is for *******) for a long time. I quit 10+ years ago and damnit, I have thought about taking a big growler EVERY SINGLE DAY since then.

 

[Monty Python]

I dipped a can of KODIAK a day or more (not that Copenhagen crap that is for *******) for a long time. .

Hey Jet, what was that pinch between your cheek and gum?

 

[swpm]

Nationwide there are many physicans in various recovery programs from all disciplines. Many do well w/recovery and go on to lead productive careers. I would bet that many of us know someone in such a program, except that we don't know it because they are anonymous.

Many do well, yes.

Many do not. The question is whether or not the risk posed by those who relapse outweighs our compassionate desire to give our colleagues a second chance. We all know the time, sacrifice, and debt involved in medical school and residency. It's horrible to see one of our own get tangled up in substance abuse. Furthermore, we're taught to see addiction as a disease, so it's very tempting to want to treat the individual and help him get back to his normal life and career.

The arguments for rehab and continued practice all ultimately rest on compassion for the doctor and a desire to minimally disrupt the doctor's life.

We're not plumbers or secretaries or landscape architects, whose greatest obligation is to take care of a customer's pipes or telephone messages or favorite shrubbery. Public safety and our patients' welfare really ought to come before an addict's 2nd chance at a particular career.

To say nothing of the additional risk posed to the doctor himself by leaving him in an job (especially anesthesia!) with ready access to drugs.

 

[dfk]

I've never understood why people believe this matters. Asking for help vs getting caught is always raised as a mitigating factor in these cases, but it shouldn't obscure the first issue: it takes a series of very bad decisions to steal a stick of blue stuff and inject it in your own vein to get high. This is reckless, stupid behavior and it's pointless to sugarcoat the matter.

Once you've crossed that line, you should give up the right to ever again practice medicine on an unsuspecting, trusting public.

Coming forward and asking for help is encouraging from a recovery standpoint. His addiction is sad and tragic, and I hope he gets the help he needs. I hope he recovers and never uses again. I hope he finds meaningful work outside medicine. I hope getting fired from residency doesn't wreck his family relationships.

I hope I never have to entrust my life to an anonymous (ex?) junkie whose impairment is concealed by some touchy-feely addicted-doctor-reintegration program. As doctors we serve the public in a position of unique power and trust. If you betray that trust, there should be no second chance.


To answer your other question, I'm in agreement with the other posters - he has a medical problem and should be afforded the privacy and courtesy all patients are entitled to. No one needs to know he's an addict unless he chooses to tell them.

personally, i don't think this is a fair blanket thing to say..
granted, problems are problems, but i know several people (attendings and CRNAs) that have dealt with this issue, recovered (some for over 30 years), and have dealt with productive lives and careers. i'm sure there will always be some degree of question with the provider and peers, but it's not truly fair to kick people to the curb for a mistake, if you will. repetition/reoccurrence is always a possibility, but deal with it then. i also don't mean to belittle human life, but not for anything, you might be taken care of by someone in a similar situation, and you won't be none the wiser. disclosure is not a requirement from provider to patient.

 

[urge]

less than a handful of peeps in our program know about this. How could this be done in a tactful way which could potentially allow this resident a supportive and hospitable environment to work in should they be allowed to come back after treatment? I have some thoughts of my own on all this,

That's what you think. I bet even the security guards know.
No explanations are needed for anyone.
State law dictates wether he'll be back or not.
What are your thoughts?

 

[powermd]

Once you've crossed that line, you should give up the right to ever again practice medicine on an unsuspecting, trusting public.

...

If you betray that trust, there should be no second chance.

This is way, way harsh, and off base. Diverting drugs for personal use does not cross the line the way using at work, showing up for work impaired, or actually hurting a patient do. If you ask for help BEFORE hurting a patient, you are taking RESPONSIBILITY for your mistake in order to maintain your fiduciary duty toward your patients. This should be rewarded, not punished. Anesthesia may be the wrong field for an addicted physician, but let's not ignore all the alcoholics among us. How many residents have gotten freakin' hammered and shown up to work ehem.. slightly impaired without consequence. Just because it's legal doesn't make it any better.

For the true addict, anesthesia may be too great a temptation to resume abuse, but that should not preclude retraining in a field where your hands are not so close to the cookie jar.

 

[pd4emergence]

This is way, way harsh, and off base. Diverting drugs for personal use does not cross the line the way using at work, showing up for work impaired, or actually hurting a patient do. If you ask for help BEFORE hurting a patient, you are taking RESPONSIBILITY for your mistake in order to maintain your fiduciary duty toward your patients. This should be rewarded, not punished. Anesthesia may be the wrong field for an addicted physician, but let's not ignore all the alcoholics among us. How many residents have gotten freakin' hammered and shown up to work ehem.. slightly impaired without consequence. Just because it's legal doesn't make it any better.

For the true addict, anesthesia may be too great a temptation to resume abuse, but that should not preclude retraining in a field where your hands are not so close to the cookie jar.

I agree. I think this guy took responsibility and asked for help. I think anesthesiology is probably not the field for this person. I think the easy access will increase the risk of relapse for this person and a relapse could be deadly. I do believe there are multiple fields he or she could train/retrain and still be a physician.

pd4

 

[InductionAgent]

I've never understood why people believe this matters. Asking for help vs getting caught is always raised as a mitigating factor in these cases, but it shouldn't obscure the first issue: it takes a series of very bad decisions to steal a stick of blue stuff and inject it in your own vein to get high. This is reckless, stupid behavior and it's pointless to sugarcoat the matter.

Once you've crossed that line, you should give up the right to ever again practice medicine on an unsuspecting, trusting public.

Coming forward and asking for help is encouraging from a recovery standpoint. His addiction is sad and tragic, and I hope he gets the help he needs. I hope he recovers and never uses again. I hope he finds meaningful work outside medicine. I hope getting fired from residency doesn't wreck his family relationships.

I hope I never have to entrust my life to an anonymous (ex?) junkie whose impairment is concealed by some touchy-feely addicted-doctor-reintegration program. As doctors we serve the public in a position of unique power and trust. If you betray that trust, there should be no second chance.


To answer your other question, I'm in agreement with the other posters - he has a medical problem and should be afforded the privacy and courtesy all patients are entitled to. No one needs to know he's an addict unless he chooses to tell them.

Self-reporting is a signficant factor because:

1) an addict who comes forward, admits he has a problem, and asks for help is more likely to get and stay clean than one who is not willing to do so.

2) if there is no worse treatment of physicians who are "caught" (i.e. all addicted physicians are severely punished with a lifetime ban from medicine of any specialty, nevermind simply anesthesia), then addicted physicians will have more incentive to hide their disease until the bitter end. This means they practice under the influence for a longer duration and more messed up, thus hurting more patients than if they came forward and got help sooner.

3) Effective physicians health programs are not "touchy-feely." They have strict guidelines for treatment and monitoring, with relapsing physicians facing serious consequences.

 

[Noyac]

I can't bare to read all the posts here b/c they seem to be saying the same crap. In this business fentanyl addiction is REAL. I know that this is appreciated by everyone here but I doubt that many of you really appreciate it. We are talking life or death here. Anesthesiologists get caught once, THEY GET FOUND THE NEXT TIME.

I don't think medicine is out though. I would tell him/her to find another specialty in medicine.

I also wouldn't lie for him/her. TELL THE TRUTH about what happened to the fellow resident. Next, there needs to be some addiction education for the rest of the residents, if this hasn't happened already. This will help others understand what the resident is going through and will help make everyone aware of the real risk of addiction.

I finished residency in 2001. I have seen more than one anethesiologist or crna addicted for every year that I have been out of residency. I just lost a friend to Sevo this year. Yeah Sevo, no ****. We practice in a field that is not conducive to addictive behavior. Everyone thinks they can beat it but life throws some real curveballs from time to time and relapse is too easy. I even have friends currently in anesthesia who are clean from fentanyl addiction and are practicing. I pray to God that they stay clean. They are wonderful anesthesiologists and I would trust them with my family any time. So the argument that they shouldn't be taking care of the public doesn't wash with me. This is strictly about their life in my eyes.

Switch to radiology or something like that.

 

[bubalus]

I think it's great the person came forward on his/her own. That said, he or she should be helped into treatment and not allowed back into anesthsiology ever--partly out of concern for their patients, but even more out of concern for the resident. I'm not trying to be a hardass, but as I understand, those with addiction problems in residency are far more likely to relapse and die than those who develop them after residency. My program has zero tolerance. We use and we're out. They would help us get into treatment and help us into another specialty. Staying in medicine is fine, and radiology, psychiatry, or addiction medicine could be very good choices. I don't know how to deal with the HIPAA issues, but I'd like to see the program deal with this as openly as possible because the rest of the residents need to be reminded of it. I'm with Noy on this one.

 

[coprolalia]

I personally know two people who were addicted. Both came forward before caught. For what it's worth, both are still practicing anesthesiology. For one (where I know the specifics), he has to pee in a cup once a month - until he decides not to practice anesthesia anymore. He is also subject to random testing at anytime during that month. Awesome anesthesiologist. And, has been clean for over 4 years now.

-copro

 

[scotchnwater]

For one (where I know the specifics), he has to pee in a cup once a month - until he decides not to practice anesthesia anymore. He is also subject to random testing at anytime during that month.

Copro brings up an interesting point I've wondered about over the past couple years while reading about addiction (which appears to primarily opioid in nature) amongst anesthesiologists: would it be entirely out of line for residency programs to routinely drug-test all residents for opiates/other high-potential drugs-of-abuse?

Before you freak on me re: civil liberties/privacy/etc, I want to make it clear that I'm pretty libertarian in my political views. I believe that private matters should be out of the purvey of government, administrations, etc as much as possible.

To me, it seems like drug testing would be a reasonable idea for several reasons:

1: We already know the rate of addiction is higher in our field

2: The consequences of addiction can be quite dire

3: People in medicine are pretty smart. I would guess that a good deal of the problems start with people thinking "Hey, I can totally get away with this". Having drug testing would possibly serve as a deterrent, a way of saying "no, you're not going to be able to get away with this". Admittedly, people abuse stuff that there's no quick/cheap test for (Sevo has been brought up before) and there will undoubtedly be those people who will find a way to get high if they so desire. You may not catch those people until it's too late. I think that overall, however, this actually protects potential abusers from even beginning to go down that road.

Before the flames begin, I want to reiterate that I'm pretty big (huge, some would say) on individual rights, personal freedom, etc. It just appears that addiction in anesthesia is a sizeable problem out there that is not currently being adequately addressed (as evidenced by posts such as this) and maybe it's time to think of new strategies.

 

[Noyac]

Copro

I hope your friend can stay clean. We all know some who have. But the odds are against him. I have a friend that was clean for over 15yrs. Relapsed 3yrs ago. Now he practices in another specialty.

Regarding the person in the original post. If this person were to return to the OR it must not be b/4 1 full year of treatment and recovery. The relapse rate is much greater for those that return within 1 yr. Not that it isn't high enough as it is.

Also it is not the residents fault that this person used. It is therefore, not their responsibility to pick up the extra call. There are many options. The attendings for one. Shouldn't they be watching the residents for these issues. They accepted him into the program, not the fellow residents. Go get another person to fill the spot. This happened to two people during my residency and we did not get strapped with extra call. I wouldn't expect that you guys should have to either.

 

[Coastie]

Wow..

Just how common is this sort of thing in our field?

 

[Gern Blansten]

Wow..

Just how common is this sort of thing in our field?

Huge problem. Chances are that you will know someone that will succumb to this temptation. If you practice for many years, you will probably know a few. Unfortunately, you will probably know someone who dies because of it.

If you are unaware of the extent of the problem, I would suggest that you ask your program director to schedule a lecture for the department(especially for the residents) on the topic. It should be part of the yearly curriculum.

As for the original poster, people will know why the resident is suddenly missing. Anytime an anesthesia resident disappears for an unknown reason, people understand that it is abuse until proven otherwise.

I would echo the sentiments of others. They need to be in another specialty. The odds are not in their favor for a return to anesthesiology and the stakes are high.

 

[Noyac]

Wow..

Just how common is this sort of thing in our field?

I would bet that there are a few on this board that are following this thread. They have either been caught, turned themselves in, or are currently using and yet to be caught.

It is that prevalent.

 

[swpm]

This is way, way harsh, and off base. Diverting drugs for personal use does not cross the line the way using at work, showing up for work impaired, or actually hurting a patient do.

The definition of an addict is one who has lost control of their drug abuse. Someone who is using at home is very likely to expand their use as tolerance develops. It's a short path to using when pulling home call ... then between cases ...

Everyone who is defending or supporting these physician reintegration and monitoring programs is still ignoring the most fundamental and important issue:

A physician who has abused narcotics has a high likelihood of relapsing at some point. Why should the public accept any additional risk, simply so a recovering addict can continue to work in his favored field?

It's not about the doctor's lifestyle and career dreams, it's about the patients. They expect a licensed physician to be held to higher standards and to place their welfare above his own ambition or student loan payments.

If you ask for help BEFORE hurting a patient, you are taking RESPONSIBILITY for your mistake in order to maintain your fiduciary duty toward your patients. This should be rewarded, not punished.

If you mean "rewarded" by "not thrown in prison" then sure, I'll go along with that. Sure, we don't want to dissuade people from seeking help, but they should not be rewarded.

Anesthesia may be the wrong field for an addicted physician, but let's not ignore all the alcoholics among us. How many residents have gotten freakin' hammered and shown up to work ehem.. slightly impaired without consequence. Just because it's legal doesn't make it any better.

I'm not real thrilled with tolerating the presence of drunk physicians, either.

For the true addict, anesthesia may be too great a temptation to resume abuse, but that should not preclude retraining in a field where your hands are not so close to the cookie jar.

Staying in medicine is fine, and radiology, psychiatry, or addiction medicine could be very good choices.

Here's one more area where I disagree with the common consensus. True, there is less risk to patients when the impaired physician is a psychiatrist, but the risk isn't close to baseline. A psychiatrist with poor judgment, ethical lapses, or a buzz when he's prescribing medications can certainly harm a patient. Just because his error isn't as likely to result in a patient coding and dying the way an impaired anesthesiologist's error might doesn't mean he's safe.

would it be entirely out of line for residency programs to routinely drug-test all residents for opiates/other high-potential drugs-of-abuse?

Some programs do. I'm a very liberal guy on most things. However, physicians and pilots and guys who turn wrenches on thermonuclear weapons fall into a special group. We hold a position of special trust and power, and accept (or should accept) a certain degree of scrutiny that the average citizen shouldn't have to.

Every intern and resident in every program at my hospital gets tested on day 1, and is subject to random tests. I have no problem with this.

 

[Fastrach]

Thanks to everyone for their replies to my original post.

To address a couple of points, yes, our program has a sit-down meeting with us at the start of CA-1 year where we watch a video about a resident (not at our institution) who OD'd and was found after it was too late. Obviously this video didn't have a huge impact on our presently addicted resident, sad to say.

I personally don't think you ought to be given a second chance to come back to anesthesia if you are an abuser, even if you are upfront about your problem. As mentioned above, there are plenty of other fields out there which won't put you in that dangerous position of relapsing. And I agree, a good year of rehab is likely the wisest route before potentially returning to any other field of medicine. And if a return to anesthesia is embarked upon, very strict surveillance and daily testing should be instituted for this person.

While I wish our program could be honest with our fellow residents about this person's problems rather than saying they're on sick leave or some such, I can see it as not entirely being necessary information, and it could hamper this person's ability to make a fresh start down the road. So I'm fine with keeping this info under wraps.

As far as taking up the extra call burden, yeah, it kinda sucks, but hopefully it'll only be until the next academic year starts. Is it really the staff's fault this person abused and didn't get caught? I don't think so; I don't think anyone can know what everyone is doing behind closed doors at all times, so I don't blame them. And really it probably only amounts to maybe one more call shift per person to cover, so no huge deal.

In the end, I do hope this person is able to work this all out. Like they tell ya in the pamphlets, I wouldn't have expected this individual to do this sort of thing; I'm just grateful they came forward seeking help before something even more tragic resulted.

 

[Arch Guillotti]

Copro brings up an interesting point I've wondered about over the past couple years while reading about addiction (which appears to primarily opioid in nature) amongst anesthesiologists: would it be entirely out of line for residency programs to routinely drug-test all residents for opiates/other high-potential drugs-of-abuse?

Before you freak on me re: civil liberties/privacy/etc, I want to make it clear that I'm pretty libertarian in my political views. I believe that private matters should be out of the purvey of government, administrations, etc as much as possible.

Nobody is going to freak on you here, they are mostly right wingers with a few libertarians. On the other hand, I am a left-winger always. I do, however; support mandatory random drug testing for all residents without any reservation.

 

[drccw]

Our line of work is very susceptible to drug abuse. when I was a kid my friend's dad was an anesthesiologist and got busted. He went through the program, etc etc, rehab, went back to work eventually, and in the end, got busted again.... for some people it's just not the right line of work. I've heard a lot of similar stories about other anesthesiologist... for every 1 person sucessfully rehabbed i bet there are at least 3-5 who dont make it....

unfortunately I have a friend who turned himself for help last year-> it shocked me and I have mixed feelings about his future in this field...

 

[Pilot Doc]

So, just out of curiosity, why aren't regular (e.g. weekly) drug tests a viable way to treat this? That's a pretty low burden of treatment for a chronic disease and it seems like it should protect doc and public alike.

 

[pd4emergence]

Fentanyl is detectable. Hair tests are pretty sensitive. Some states have great physician health programs that are truly helpful in getting physicians out of bad situations with drugs and alcohol. I think in this resident's case, he or she is using an anesthesia specific drug that will be easily accessable for the rest of his or her career. To me that is like having a rehabilitated alcoholic as a bartender. It is time for them to find another field of medicine. After they are truly rehabed and the appropriate monitoring system is in place there is no reason why they should not be able to practice in a field of medicine where access is not so readily available. This should not be a career ending problem for that person. I think that the attitude that physicians should be above these problems or that they are now a public health risk is the reason why many physicians don't get help before it is too late. I have heard the number are around 1 in 10 anesthesiologists struggle with these kinds of problems. Recently there has been alot of press about physician suicides. There is about 1 physician a day who commits suicide in the US. Alot of the reason that this number is so high is that physicians have a very high incentive not to admit that they need help. Think about it, every time you have to fill out a priviledges packet you have to state whether or not you have been treated for a mental illness or drug addiction. I think it is a greater public health risk to have physician too afraid to get the help they need.

 

[zippy2u]

Last time I checked, Sevo don't come in no tank, Slick. How the Sevo freaks get their "joy-joy time": Saturate a gauze/paper towel/cotton balls with Sevo from a BOTTLE, place in a plastic baggy quickly before it has time to evaporate and huff it. Remember when ya built plastic models as a kid and ya used the contact cement glue. Hell, us hoodlums would squirt some of the glue in a paper bag, take a couple of huffs and pass it around the circle; we didn't give two shiits about the model. I suggest ya not try this. Regards, ---Zippy

 

[balls]

I've never understood why people believe this matters. Asking for help vs getting caught is always raised as a mitigating factor in these cases, but it shouldn't obscure the first issue: it takes a series of very bad decisions to steal a stick of blue stuff and inject it in your own vein to get high. This is reckless, stupid behavior and it's pointless to sugarcoat the matter.

Once you've crossed that line, you should give up the right to ever again practice medicine on an unsuspecting, trusting public.

Coming forward and asking for help is encouraging from a recovery standpoint. His addiction is sad and tragic, and I hope he gets the help he needs. I hope he recovers and never uses again. I hope he finds meaningful work outside medicine. I hope getting fired from residency doesn't wreck his family relationships.

I hope I never have to entrust my life to an anonymous (ex?) junkie whose impairment is concealed by some touchy-feely addicted-doctor-reintegration program. As doctors we serve the public in a position of unique power and trust. If you betray that trust, there should be no second chance.

This is the most conceited load of **** I've ever read on here.

 

[zippy2u]

Damm SWPM, I'm gonna have to pull out that 12 foot extension ladder I got in the garage to get on that horse of yours. Regards, ----Zippy

 

[Noyac]

SWPM,
Back when I was playing ball we had a saying, follow it around see what it eats. We used it when people made an error and the ball ate their lunch. It was a funny way of saying you have no clue what your doing.

I think you may have intentions here. Maybe you have experience in this area but your point of view is dangerous. You want to treat these people like they are intentionally doing this. If every person in medicine that had an addiction was chased out then no one would ever come forward asking for help. And then more people will get hurt, either the pt, the Dr or both. These are still physicians with a wealth of knowledge and training which can be utilized. Most of these folks just need good addiction treatment and a change in environment, IMHO. Not to be booted out of medicine all together. They still have much to offer and maybe even more.

 

[Apollyon]

I have heard the number are around 1 in 10 anesthesiologists struggle with these kinds of problems.

The figure accepted across the board (all comers) is that 17% of US doctors in practice or residency right now are impaired by alcohol and/or drugs (either prescribed and being abused, or illicitly obtained), and not detected/under treatment. That's one out of 6.

I don't have numbers for specific specialties, but dentists and anesthesiologists/CRNAs are frequently mentioned because those are two fields where the providers physically have their hands on the drugs being abused. That's how things differ for me in the ED - I can't even get into the equipment Omnicell, much less the (completely tracked) medication Pyxis.

 

[Noyac]

Last time I checked, Sevo don't come in no tank, Slick. How the Sevo freaks get their "joy-joy time": Saturate a gauze/paper towel/cotton balls with Sevo from a BOTTLE, place in a plastic baggy quickly before it has time to evaporate and huff it. Remember when ya built plastic models as a kid and ya used the contact cement glue. Hell, us hoodlums would squirt some of the glue in a paper bag, take a couple of huffs and pass it around the circle; we didn't give two shiits about the model. I suggest ya not try this. Regards, ---Zippy

Exactly the way my buddy died last December.

 

[Noyac]

The figure accepted across the board (all comers) is that 17% of US doctors in practice or residency right now are impaired by alcohol and/or drugs (either prescribed and being abused, or illicitly obtained), and not detected/under treatment. That's one out of 6.

I don't have numbers for specific specialties, but dentists and anesthesiologists/CRNAs are frequently mentioned because those are two fields where the providers physically have their hands on the drugs being abused. That's how things differ for me in the ED - I can't even get into the equipment Omnicell, much less the (completely tracked) medication Pyxis.

When I was more involved in this I remember quotes regarding anesthesiologists that were astounding. For example, as anesthesiologists we make up less than 10% of all the physicians out there. If you look those physicians in treatment, we make up more than 30%. Now that is some seriously twisted numbers.

 

[pd4emergence]

Is it detectable in urine?

Not in the regular UDS but there are specialized urine screens that it does show up in. If someone is looking for it and the person is on it they will find it.

pd4

 

[bubalus]

Here's one more area where I disagree with the common consensus. True, there is less risk to patients when the impaired physician is a psychiatrist, but the risk isn't close to baseline. A psychiatrist with poor judgment, ethical lapses, or a buzz when he's prescribing medications can certainly harm a patient. Just because his error isn't as likely to result in a patient coding and dying the way an impaired anesthesiologist's error might doesn't mean he's safe.

My statement has nothing to do with protecting patients from addicted physicians, though I will certainly agree that's important. It's about protecting the addicted physician from themselves. Too many anesthesiologists with addiction problems present by overdosing. Getting them out of anesthesia is how we can save their lives.

 

[swpm]

I think you may have intentions here. Maybe you have experience in this area but your point of view is dangerous. You want to treat these people like they are intentionally doing this.

No. Actually I'm quite sympathetic to anyone, physician or not, who is an addict. I'm just not willing to go along with this idea that it's appropriate to permit an addict to work in a field where the potential to harm another person is so high.

It's not a matter of forgiveness, or punishment, or revenge. My experience with physicians who were "in recovery" and "being monitored" is painful and personal.

Never trust a junkie.

 

[TX515]

I've never understood why people believe this matters. Asking for help vs getting caught is always raised as a mitigating factor in these cases, but it shouldn't obscure the first issue: it takes a series of very bad decisions to steal a stick of blue stuff and inject it in your own vein to get high. This is reckless, stupid behavior and it's pointless to sugarcoat the matter.

Once you've crossed that line, you should give up the right to ever again practice medicine on an unsuspecting, trusting public.

Coming forward and asking for help is encouraging from a recovery standpoint. His addiction is sad and tragic, and I hope he gets the help he needs. I hope he recovers and never uses again. I hope he finds meaningful work outside medicine. I hope getting fired from residency doesn't wreck his family relationships.

I hope I never have to entrust my life to an anonymous (ex?) junkie whose impairment is concealed by some touchy-feely addicted-doctor-reintegration program. As doctors we serve the public in a position of unique power and trust. If you betray that trust, there should be no second chance.


To answer your other question, I'm in agreement with the other posters - he has a medical problem and should be afforded the privacy and courtesy all patients are entitled to. No one needs to know he's an addict unless he chooses to tell them.

I disagree with this. I think a lot of doctors need to come down off that high horse. Yes there is a responsibility doctors need to have during patient care, read, not being intoxicated while caring for a patient. But denying a second chance is a bit tragic, and I'm sure we've all been addicted to something during our lives, whether caffeine, nicotine, pornography, etc...we've all made a bad choice. Doctors are not perfect people.

I personally know two people who were addicted. Both came forward before caught. For what it's worth, both are still practicing anesthesiology. For one (where I know the specifics), he has to pee in a cup once a month - until he decides not to practice anesthesia anymore. He is also subject to random testing at anytime during that month. Awesome anesthesiologist. And, has been clean for over 4 years now.

-copro

Awesome.

 

[pgg]

I'm an anesthesiology resident at a military hospital. We get tested a few times per year, on average. I got tested again before doing an out rotation at Univ of Virginia so I know some civilian programs do drug testing. The Navy's position is one of absolute zero tolerance - you'll get the treatment you need followed by a dishonorable discharge. I can't say that I disagree.

The Air Force wouldn't let a recovering addict fly a stealth bomber. I believe that a history of drug use more or less guarantees that an application for a top secret security clearance will be denied. A single DUI is a career ending mistake for a military officer (and alcohol is a legal drug). I've never heard one bit of disagreement (much less outrage) about the military's zero tolerance policy for drug use or DUIs.

So I have to wonder why so many people think that the lives of patients are less important than a $2 billion airplane or state secrets.

How are patients better served by permitting recovering addicts to practice medicine? Can anyone provide an argument for allowing them to practice that doesn't ultimately rest on kindness to the addict and HOPE that a relapse won't harm a patient?

Is there any actual data to support the notion that the existence of confidential rehab programs that permit continued practice reduce risk to patients (perhaps by making it more likely that a doctor will seek treatment vs keep using on the job)?

 

[TX515]

I'm an anesthesiology resident at a military hospital. We get tested a few times per year, on average. I got tested again before doing an out rotation at Univ of Virginia so I know some civilian programs do drug testing. The Navy's position is one of absolute zero tolerance - you'll get the treatment you need followed by a dishonorable discharge. I can't say that I disagree.

The Air Force wouldn't let a recovering addict fly a stealth bomber. I believe that a history of drug use more or less guarantees that an application for a top secret security clearance will be denied. A single DUI is a career ending mistake for a military officer (and alcohol is a legal drug). I've never heard one bit of disagreement (much less outrage) about the military's zero tolerance policy for drug use or DUIs.

So I have to wonder why so many people think that the lives of patients are less important than a $2 billion airplane or state secrets.

How are patients better served by permitting recovering addicts to practice medicine? Can anyone provide an argument for allowing them to practice that doesn't ultimately rest on kindness to the addict and HOPE that a relapse won't harm a patient?

Is there any actual data to support the notion that the existence of confidential rehab programs that permit continued practice reduce risk to patients (perhaps by making it more likely that a doctor will seek treatment vs keep using on the job)?

A recovering alcoholic who also happens to be a doctor saved my dad's life.

But to answer your question, I'm sure the government missed out on a lot of great people.

 

[goodoc]

Gotta weigh in again, no reason for a recovering addict not to practice MEDICINE. Lots of reasons not practice ANESTHESIA. The availability of of these drugs makes recovery just to difficult. As one poster put it would you make an alcoholic a bartender. As for disclosure to others it is none of their damn business any more then any information about a patient they are not treating.

 

[Pharm Life]

Wow..

Just how common is this sort of thing in our field?

It's common enough that when I was at the ASA meeting last fall, I saw that they had NA meetings on the schedule every single day for the entire week. There was also a session about it but it was one of the ones you had to pay for.

I'm curious, do you guys think that anesthesiologists (and CRNAs) are more likely to become addicted just because they have access to the drugs, or are people with addictive kind of personalities more likely to choose to become anesthesiologists and CRNAs to get access to drugs? If it's the second thing, what do you do about that? Give people psych tests?

Also, what would you guys do if you found out someone was using but they hadn't come forward? Especially if they outrank you? (I'm not in this situation, just thinking about what I would do if I was.)

 

[coprolalia]

I got tested again before doing an out rotation at Univ of Virginia so I know some civilian programs do drug testing. The Navy's position is one of absolute zero tolerance - you'll get the treatment you need followed by a dishonorable discharge. I can't say that I disagree.

What about false positives? Are you certain that the person doing the testing is adhering to good clinical practice? What about contamination? What about chain of custody? What happens to your pee after you turn it over?

There are a lot of issues in hanging someone out to dry because of a positive drug screen. What is the due process if it comes back positive? I have a major 4th Amendment issue with the way a lot of these "screens" are conducted, not that they shouldn't be part of the process of uncovering illicit drug addiction and diversion (etc.). It's just that they shouldn't be the only process, like a lot of people want to make them. There is clearly a "polygraph factor" in drug screens, in that it's ulitmately a human endeavor prone to human mistakes.

-copro

 

[cowboy71]

For those interested here are some of the more recent articles.

Collins GB et al. Chemical Dependency Treatment Outcomes of Residents in Anesthesiology: Results of a Survey. Anesth Analg 2005; 101: 1457-62.

Domino KB et al. Risk Factors for Relapse in Health Care Professionals with Substance Abuse Disorders. JAMA 2005; 293: 143-1460.

May JA, Warltier DC and Pagel PS. Attitudes of Anesthesiologists About Addiction and Its Treatment: A Survey of Illinois and Wisconsin Members of the American Society of Anesthesiologists. J Clin Anesth 2002; 14: 284-9.​

 

[deleted126335]

.

 

[pgg]

What about false positives? Are you certain that the person doing the testing is adhering to good clinical practice? What about contamination? What about chain of custody? What happens to your pee after you turn it over?

The false positive rate can never be zero, but this is one thing the military does well. Samples are tested multiple times to confirm positives. First there's a pooled sample (many samples mixed and tested) - if this is positive, each individual sample from that pool is tested. A positive from that is then retested by mass spec twice. If at any point the chain of custody isn't perfect, everything is thrown out.

The Navy/USMC are very conservative about it. When I was in Iraq, one of my Corpsmen was stealing morphine. We knew it, though we never caught him in the act, and he never admitted it. We did two rounds of drug testing, but the sample chain of custody was broken so the samples were thrown out without even being tested.

But yes, every time I pee in a cup for the Navy, I think about false positives. No system is perfect.

 

[buckhorn]

What about false positives? Are you certain that the person doing the testing is adhering to good clinical practice? What about contamination? What about chain of custody? What happens to your pee after you turn it over?

There are a lot of issues in hanging someone out to dry because of a positive drug screen. What is the due process if it comes back positive? I have a major 4th Amendment issue with the way a lot of these "screens" are conducted, not that they shouldn't be part of the process of uncovering illicit drug addiction and diversion (etc.). It's just that they shouldn't be the only process, like a lot of people want to make them. There is clearly a "polygraph factor" in drug screens, in that it's ulitmately a human endeavor prone to human mistakes.

-copro

The more drug tests you run the higher the number of false positives. If we test every Anesthesiologist there will be hundreds of false positives, Hundreds of innocent Anesthesiologists whose careers will be ruined by a single positive drug test.

This would be a great way to selectively target individuals. Older anesthesiologists are more likely to take meds that will produce false positives or you could stock the cafeteria and doctors lounge with poppy seed buns and bagels or dozens of other common foods, thus guaranteeing positive drug tests.

from;
http://www.intuitor.com/statistics/BadTestResults.html

The Probability of Penalizing the Innocent Due to Bad Test Results​

In modern society two-outcome tests are everywhere. They include drug tests, sobriety tests, disease tests, genetic tests, etc.. The outcome of these tests are either positive or negative, yes or no. We like to think these tests are at least 99% accurate, and yet, horror stories of spurious results seem to abound. Take company-wide drug testing, opponents may claim that at least a third of those identified as drug users will actually be innocent. If we assume the test is 99% accurate, this claim sounds ridiculous. But is it?To analyze the claim we will "grow" a decision tree. Decision trees are a wonderful little device for analyzing anything with two possible outcomes. Every time we reach the end of a branch and have two possibilities we simply create a set of two new branches. For our analysis, we will assume that 2% of all employees actually use drugs. This is lower than the general population but keep in mind that a lot of drug users are unemployed. Also, a company with a clearly stated anti-drug policy will probably have a low proportion of users. The tree's trunk represents the population of all employees. The first set of branches (see figure 1) represent the two possible conditions: drug user, not drug user. The expression Pd = .02 indicates that there is a 2% probability of a person being a drug user. Pc = .98 indicates a 98% probability that a person is clean or drug free.
Next, we add two sets of branches representing the drug test* as shown in figure 2 . One set of branches is attached to each of the original two branches. Pw = .01 indicates that there is a 1% chance of getting a wrong or incorrect result from the test. Pr = .99 indicates that there is a 99% chance of getting a right or correct result from the test. Note that the probabilities associated with each set of branches must add up to 100%.
Finally we add the tree's leaves (see figure 3). Each leaf represents a possible final outcome of the entire process. Note that there are four possibilities. Two of the four possibilities are correct: drug users and drug free individuals are both correctly identified. However, two of the four possibilities are spurious: drug users and drug free individuals are not correctly identified. We are unlikely to hear complaints from a drug user who is incorrectly identified as being drug free. The drug free person identified as a user is another matter. This would be a very upsetting situation.
To find the probability of each final outcome as represented by the four leaves simply multiply the probabilities of each branch one must "climb" on the way to reaching the leaf. For example, the probability of a drug user being rightly identified is represented as Pdr and is calculated as follows:

Pdr = Pd * Pr
= 0.02 * 0.99
= 0.0198 or 1.98%
​

Note that all the leaf probabilities have to add up to 100%.
The population of people identified as drug users consists of individuals who actually are drug users (1.98% of the employees tested) and incorrectly identified individuals who actually are not drug users (0.98% of the employees tested). The percentage of people identified as drug users who are actually innocent can be calculated as follows:
Pinnocent = Pcw /( Pcw +Pdr )
= (0.98%) /(0.98% + 1.98%)
= .331 or 33.1%
The wild eyed claim that a third of all people accused of drug use will be innocent is not so ridiculous after all.
Figure 4 shows that the proportion of spurious results among people identified as drug users is surprisingly sensitive to test accuracy. An accuracy of 99% is marginal at best. However the biggest surprise is the fact that the proportion of spurious results among people failing drug tests approaches 100% as the proportion of drug users in the general population approaches zero. Drug testing in a drug free population amounts to a witch hunt.

figure 1. First set of Branches

figure 2. Second set of Branches

figure 3. Complete Decision Tree

​

Drug testing can be administered in a manner which minimizes the proportion of innocent people among those dismissed for failing drug tests. First, test only when evidence for drug use exists, such as erratic behavior. A much higher percent of people showing drug abuse symptoms will actually be drug users and this reduces the the percentage of innocent people who are falsely accused. Second dismiss an employee only after failing multiple tests.
No one should accept the results of a single test if acceptance carries severe or far reaching consequences. In the case of diagnostic tests for medical conditions it can lead to dangerous or unnecessary procedures. In the case of a drunk driving arrest it can lead to unjustified imprisonment. A low SAT score can lead to denial of admission to a well qualified candidate. Corroborating observations or data and multiple independent tests are the best defenses against spurious test results.


* Note: The analysis assumes that the probability of a false positive result is identical to the probability of a false negative test. In reality this is usually not the case. One will be at least slightly higher than the other. However, the decision tree analysis still works and still gives similar results. Testing in a compliant group is still a witch hunt.

 

[BADMD]

This would be a great way to selectively target individuals. Older anesthesiologists are more likely to take meds that will produce false positives or you could stock the cafeteria and doctors lounge with poppy seed buns and bagels or dozens of other common foods, thus guaranteeing positive drug tests.

Using the higher level 2000 ng/ml standard for opiates, it takes a heck of a lot of poppies to trip a positive drug test. So many, that you'd have to wonder if they're eating whole poppy pods...

All positive drug tests (for non-medical purposes) have to be confirmed by a second method, typically a form of chromotography, such as GC/MS. The false positive is rate is going to be extremely low (far less than 1%). Secondary confirmation also picks out cross reacting drugs.

 

[Pilot Doc]

How are patients better served by permitting recovering addicts to practice medicine? Can anyone provide an argument for allowing them to practice that doesn't ultimately rest on kindness to the addict and HOPE that a relapse won't harm a patient?

The reason to allow these people to practice is to minimize the overall burden of addicted/impaired physicians on patients.

If medicine has a zero-tolerance death penalty for substance abuse
1) almost no one would turn themselves in
2) almost no one would turn colleagues in

As it is, the policy of allowing addicts back facilitates self and colleague reporting.