1. 2011DCSK1 DEATH OF THE ANAESTHETIST ……UNDER ANAESTHESIA ANZCA ASM HONG KONG 2011 Dr Diana C Strange Khursandi FRCA FANZCA Director of Clinical Training Acknowledgements: Dr Richard Morris, St. George Hospital, Sydney, Australia Drs. Michael Cooper & Erik Diaz, MD

2. 2011DCSK2 Some of the risks to us in our profession  Toxicity of anaesthesia agents  Blood borne infections  Fire & electrocution  Ionising radiation  Latex allergy  Stress & mental illness  Substance abuse

3. 2011DCSK3 RECOGNITION OF SUBSTANCE ABUSE “ All anesthesia personnel […] should be aware of the basic nature of the problem, and possess the necessary information to recognize and assist an impaired colleague.” Addiction and Substance Abuse in Anesthesiology. Bryson EO, Silverstein JH. Anesthesiology.2008; 109:905-17

4. 2011DCSK4 EXAMPLES  Theatre cleaner found dead in a cupboard with a hanky & bottle of halothane  Registrar found dead at home with fentanyl “self treating his migraines”  Anaesthetist found unconscious in toilet after self- administering propofol  Registrar found dead at home with intravenous cannula and multiple drugs

5. 2011DCSK5 Statistics – not a new problem 1983 Ward et al survey:  334 drug-dependent persons in 184/247 (74%) of responding US anaesthesia programs  Pethidine+ fentanyl most common  Long term follow-up available for 201 persons 55% rehab ~ 2/3 of these (71) offered return to original place of employment 30/201 (15%) dead of drug overdose

6. 2011DCSK6 MORE STATISTICS Lutsky et al, 1992  16% of anaesthetic registrars or fellows reported problematic substance abuse during their training

7. 2011DCSK7 MORE STATISTICS Nurse anesthetists USA: 2 surveys by Bell, 1999, 2006 10% admitted to self administration of controlled drugs 1999 benzos, opiates 2006 fentanyl, propofol

8. 2011DCSK8 MORE STATISTICS Collins et al (US) survey, 1991-2001  An impaired resident identified in 80% of 169 responding programs  20% experienced pre-treatment fatality

9. 2011DCSK9 MORE STATISTICS Booth et al (US) survey, 2002 Anesthesiologists Drug abuse:  1% of faculty members  1.6% of registrars

10. 2011DCSK10 MORE STATISTICS Fry (Aus/NZ) survey, 2005  44 substance abuse cases in 100 responding programs  Death in 25% of cases

11. 2011DCSK11 Characteristics of Addicted Anaesthetists  67-88% male  76-90% use opioids (approx 1.6% in USA) (propofol x 10 less common, 0.1% in USA)  33-50% are poly-drug users  33% have family history of addictive disease  65% associated with academic departments  Often associated with psychiatric illness

12. 2011DCSK12 Anaesthetists vs. other doctors Talbott et al, JAMA 1987  Anaesthetic trainees comprise 4.6% of trainee population Anaesthetist trainees are 33.7% of those presenting for treatment  Anaesthetists account for 5% of all doctors 13-15% of physician treatment population

13. 2011DCSK13 Why does it happen to some people? Themes common to general population, as well as other doctors:  Genetic predisposition  Psychiatric co-morbidities ? Self medication of symptoms  Social factors [alienation, family issues]

14. 2011DCSK14 Why does it happen to some people?  Experimentation – Risk-takers  Self-medication - acceptable  Regulation of sleep patterns –night shifts  Escape from pain of traumatic events – drugs will “numb memories”

15. 2011DCSK15 Why Anaesthetists?  Ease of diversion ?  High-stress environment ?  Proximity to highly addictive drugs ?  Direct administration and their witnessed effect ? (“We know our drugs”)  Exposure to picograms of drugs ?

16. 2011DCSK16 Why Anaesthetists?  Selection Bias ?  Choosing the speciality deliberately ? Medical students/residents with predisposition to drug abuse more likely to enter anaesthetic training ? do medical students/doctors choose anaesthesia as a speciality because of ease of access to powerful drugs ?

17. 2011DCSK17 Why Anaesthetists ?  Do risk-takers choose anaesthesia more frequently because of the buzz of the theatre environment ?  Does the risky nature of our professional activities – brain death in 5 minutes if you get it wrong – encourage risk-taking activity ?  “I can get away with it, because I know how to use these drugs” ?  “I am clever enough to hide what I am doing” ?

18. 2011DCSK18 Exposure-related theories  Increased risk is related to opioid or propofol sensitization through inhalation or absorption of picograms of these agents ?  Low-dose exposures sensitize brain’s reward pathways to promote substance use ?  Anaesthetists may use drugs to alleviate the withdrawal they feel when away from the exposure ? Gold et al 2006, McAuliffe et al 2006

19. 2011DCSK19 Why is it so important ? Because anaesthetists die from intravenous drug overdose (accidental or deliberate)  “20% experienced pre-treatment fatality”  “Death in 25% of cases”  “15% dead of drug overdose”

20. 2011DCSK20 Why so important ? And… Suicide accounts for up to 10% of anaesthetists’ deaths Some of these deaths are associated with substance abuse

21. 2011DCSK21 So much for the theory What are we going to do about it ?

22. 2011DCSK22 Sometimes we can do nothing Because:  Abuse is not always recognised Addicts are extremely clever at hiding their use  So…  Sometimes the first indication of abuse is the death of the abuser

23. 2011DCSK23 What can we do ?  Prevention - difficult  Preparation – essential education  Response - planned  Recovery - prolonged A strategy to prevent substance abuse in an academic anesthesiology department. Tetzlaff et.al J. Clin. Anesthesia. (2010) 22: 143 – 150

24. 2011DCSK24 PREVENTION - CONTROL SYSTEMS Agent control Regulated dispensing – occurs with opiates Locking up the propofol & midazolam ? – hasn’t worked with opiates ! Witnessed discarding – ditto  good practice anyway Always empty syringes  good practice anyway

25. 2011DCSK25 PREVENTION  Monitoring use ? Has been tried  Usage profiling ? Has been tried Both time-consuming

26. 2011DCSK26 Prevention  Random drug testing ? Has been tried ?  Screening during recruitment ? Has been tried ? Both also time consuming

27. 2011DCSK27 Prevention… Disappointingly Does not appear to have reduced the incidence ….

28. 2011DCSK28 PREPARATION - EDUCATION  Regular trainee & specialist seminars  Compulsory web based training  A visiting expert  Consultant – trainee mentoring  Consultant – consultant buddy systems

29. 2011DCSK29 RESPONSE – EARLY SIGNS Time to detection of abuse depends on the drug Alcohol >20 years Fentanyl 6-12 months Propofol ?

30. 2011DCSK30 MAJOR SIGNS 1  Finding an intravenous needle or cannula in situ; observation of injection marks on the body  Direct observation of diversion or self- administration  Drugs, bloody swabs, tissues, pills, syringes, ampoules, etc in any non-workspace environment, eg at home, or in the change room

31. 2011DCSK31 MAJOR SIGNS 2  Signing out increasing quantities of (usually opiate) drugs, or quantities of drug which are inappropriately high for the use specified  Inconsistencies in recording drug use for patients, or unaccountably missing drugs  Increasingly illegible, inaccurate, altered, or otherwise inadequate or unusual record-keeping

32. 2011DCSK32 MAJOR SIGNS 3  Falsification of records, misuse of anaesthetic drugs  Observation of tremors or other withdrawal symptoms  Observation of intoxicated behaviour

33. 2011DCSK33 MAJOR SIGNS 4  A consistent pattern of complaints regarding Excessive pain, by recovery or ward staff, in patients of a particular anaesthetist The patients’ pain is out of proportion to the recorded amounts of analgesic drugs given.  Reports of a major change in attitudes or behaviours

34. 2011DCSK34 MINOR SIGNS 1  Willing to relieve others in theatre, volunteering for more cases, more on call  Working alone, refusing breaks  Unavailability, irregular hours, decrease in reliability, poor punctuality  Increasing time in toilet/bathroom

35. 2011DCSK35 MINOR SIGNS 2  Being in the hospital when not working, off duty, and not on call, especially out of hours  Increased sick leave, and/or absenteeism  Spots of blood on clothing, carrying syringes or ampoules in clothing

36. 2011DCSK36 MINOR SIGNS 3  Wearing long-sleeved gowns in theatre or warmer clothes than necessary conceal arms eg needle marks, in-dwelling cannulae sensitivity to temperature

37. 2011DCSK37 MINOR SIGNS 4  Leaving the patient unattended in theatre  Being found in unusual places in the theatre complex when expected to be in theatre.  Personally administering medication normally others' responsibility  Significant changes in behaviour, presentation, personality or emotions

38. 2011DCSK38 MINOR SIGNS 5  Elaborate rationalisations of bizarre conduct  Obtaining an unusual medical diagnosis for bizarre conduct or symptoms (arising from drug usage)  Increase in accidents or mistakes  Deterioration in personal hygiene

39. 2011DCSK39 MINOR SIGNS 6  Wide mood swings, periods of depression, euphoria, caginess or irritability, social withdrawal, increased isolation or elusiveness  Intoxicated behaviour, pin point pupils, weight loss, pale skin  Deterioration of personal relationships, development of domestic turmoil, decrease in sexual drive

40. 2011DCSK40 MINOR SIGNS 7  Numerous health complaints, impulsive behaviour  Frequent moving or changing jobs, unsatisfactory work records  Health concerns expressed by partner or family  Other inappropriate conduct, eg o verspending

41. 2011DCSK41 What to do if you suspect ?  Read RD 20  Confirm evidence – Important How ?  If confirmation: Medical Board or Council must be informed  Structured team intervention Immediate therapeutic support Initial inpatient care – in drug & alcohol centre

42. 2011DCSK42 Welfare of Anaesthetists SIG Substance Abuse Resource Document 20

43. 2011DCSK43 After the Intervention  Long term treatment – overseen by Medical Board or Council May involve psychiatric help  Engage with impaired registrants’ program MBA, MCNZ, local registration authority

44. 2011DCSK44 After the Intervention  “Because of the association between chemical dependence and other psychopathology, successful treatment for addiction is less likely when comorbid psychopathology is not treated” Bryson & Hanza 2011  Return to work and conditions of work determined by the Medical Board/Council or local registration authority

45. 2011DCSK45 RECOVERY  Ongoing treatment  Ongoing monitoring  Ongoing mentoring  Staged through nonclinical -> supervised

46. 2011DCSK46 RECOVERY  Re-entry to anaesthesia ? A high risk but high gain decision More junior trainees may be advised against this but there have been successes  Retraining outside anaesthesia ?

47. 2011DCSK47 RETURN TO ANAESTHESIA ? Should the policy be “One Strike and you’re out” ? Some think so – high % of relapse and death Some do not – if good care & rehabilitation

48. 2011DCSK48 RETURN TO ANAESTHESIA - Trainees ? Should anesthesia residents with a history of substance abuse be allowed to continue training in clinical anesthesia?  135 trainees needing treatment -10 years  73 % (99) returned to training (36 did not)  29% (29) of these relapsed (70 did not)  14 % (4) of these died Bryson E. Journal of Clinical Anesthesia (2009) 21, 508–513

49. 2011DCSK49 RETURN TO ANAESTHESIA - Trainees ? Retraining in Australasia? Fry et al 2005 survey (128 Aus/NZ programs)  16 registrars (44 total)  5/7 returning relapsed - 1 died  19% (1 out of 5) of abusers made a long-term recovery within the specialty

50. 2011DCSK50 Re-entry to anaesthesia ? In summary, for trainees: More junior trainees may be advised against re-entry but there have been successes

51. 2011DCSK51 RETURN TO ANAESTHESIA ? Oreskovich & Caldeiro 2009 July Mayo Clin Proc. 84:576-580 A guarded “yes”, but it depends significantly on the quality of the intervention and rehabilitation What is the quality of these processes in Australia, New Zealand and HK ?

52. 2011DCSK52 RETURN TO ANAESTHESIA ?  So - is it worth the risk to the doctors & the patients?  Probably, but we must choose carefully

53. 2011DCSK53 IN CONCLUSION - 1  This is a serious issue  We need to look after each other  Prevention by closer control  Preparation with education

54. 2011DCSK54 IN CONCLUSION - 2  Recognition and/or suspicion of substance abuse – major and minor signs  Respond in a pre-planned way  Think carefully about recovery & re-entering training

55. 2011DCSK55 REFERENCES 1 Addiction and Substance Abuse in Anesthesiology. Bryson EO, Silverstein JH. Anesthesiology (2008); 109:905-17 A strategy to prevent substance abuse in an academic anesthesiology department. Tetzlaff et al. J. Clin. Anesthesia (2010) 22: 143 –150. Should anesthesia residents with a history of substance abuse be allowed to continue training in clinical anesthesia? Bryson E. J. Clin. Anesthesia (2009) 21, 508–513

56. 2011DCSK56 REFERENCES 2 Substance Abuse by Anaesthetists in Australia and New Zealand. Fry RA Anaesthesia and Intensive Care; 2005; 33:248-255 The Medical Association of Georgia’s Impaired Physician’s Program: review of the first 1000 physicians: analysis of specialty. Talbot GD, Gallagos KV, Wilson PO, et al JAMA; 1987; 257:922-925 Psychoactive Substance Use among American Anesthesiologists: a 30 year retrospective study. Lutsky I et al. Can J Anaes 1993, Vol 40, no 10: 3060-3062

57. 2011DCSK57 REFERENCES 3 A survey of propofol abuse in academic anesthesia programs. Wischmeyer et al. International Anesth Research Society vol 105, no4, Oct 2007 1066-1071 The Drug Seeking Anesthesia Care provider Bryson & Hanza 2011 Int Anesth Clinics 49, 1:157-171 Ward et al survey 1983

58. 2011DCSK58 REFERENCES 4 Chemical dependency treatment outcomes of residents in Anaesthesiology. Collins et al (US) survey Anesth Analg. 2005:101(5) 1457-1462. Substance abuse among physicians: a survey of academic anesthesiology programs. Booth et al (US) survey Anesth Analg, 2002 95(4) 1024-1030 Anesthesiologists recovering from chemical dependency: Can they safely return to the operating room ? Oreskovich & Caldeiro 2009 July Mayo Clin Proc. 84:576-580

59. 2011DCSK59