Substance use disorders are a serious public health issue, and physicians are not immune to these problems. “Anesthesiologists have long been considered at risk for substance use disorders because of their access to potent drugs, such as opioids,” explains David O. Warner, MD. Few studies, however, have explored the epidemiology of these disorders in physicians in general and anesthesiologists in particular. Current estimates have been based on surveys and reports from clinicians as well as physician health programs, but these data have limitations. “The long-term outcomes of substance use disorders in physicians are not known,” says Dr. Warner. “Gathering more data on substance use disorders can help educate us about preventing and managing these problems.”
Compelling New Data on Outcomes of Substance Use
In a retrospective study published in JAMA, Dr. Warner and colleagues described the incidence and outcomes of substance use disorders among anesthesiology residents in the United States who entered training between 1975 and 2009. The study included 44,612 residents who contributed 177,848 resident-years for analysis. “One important goal was to inform residency program directors and others about the long-term outcomes for anesthesiology residents who experience substance use disorders. We also wanted to better inform both individual treatment decisions and overall policies,” Dr. Warner says.
According to the results, the incidence of substance use disorders increased over the study period, and relapse rates did not appear to improve. Overall, 0.86% of anesthesiology residents entering primary training from 1975 to 2009 had evidence of substance use disorders during their training. Of the residents involved in the study, 384 experienced substance use disorders during training, with an overall incidence of 2.16 per 1,000 resident-years (Figure 1). An initial rate increase was followed by a period of lower rates in 1996-2002, but the highest incidence occurred since 2003. The risk of death was also high, with at least 11% of those with evidence of substance use disorders dying from a cause directly relating to the disorder.
In an analysis of relapse rates, the study found that relapses involving substance use disorders did not change significantly from 1975-1994 to 1995-2009 (Figure 2). “In addition, we found that an estimated 43% of survivors of substance use disorders who completed residency training will experience at least one relapse over the course of their career,” says Dr. Warner. The most common substances that were abused in the study were intravenous opioids, followed by alcohol, marijuana or cocaine, anesthetics and hypnotics, and oral opioids. Of note, the rates of relapse and death did not depend on the category of substance that was used.
Solutions Needed to Address High Mortality
“Our findings show that outcomes related to substance use disorders among anesthesiology residents have not improved over the past 35 years,” Dr. Warner says. “To put this data into context, 28 residents in our study died during training. The mortality rate caused by substance use among anesthesiologists in training is comparable with job-related mortality in the most dangerous professions, including fishing and law enforcement. With the incidence steadily rising and relapse rates remaining consistent, we as a profession clearly need to better address this problem.”
Many hospitals and medical centers throughout the U.S. have started offering educational programs on the hazards of substance use disorders. Systematic changes have also been implemented to better regulate controlled substances during residency training, but Dr. Warner says a more concerted effort is still needed. “Substance use disorders among anesthesiology residents are a safety issue for both physicians and patients,” he says. “These disorders can impair the ability of anesthesiologists to perform their duties and can result in drug diversion away from patients, meaning that patient care can be compromised. The problem of substance use disorders will never be fully eliminated, but increasing awareness of the problem may empower clinicians to engage in programs and interventions that treat these disorders.”
Examining Trends Among Other Specialties
In the future, Dr. Warner is hopeful that more research will be conducted to look at the incidence of substance use disorders in other medical specialties. “The trends we have seen in anesthesiology may extend to other physician groups,” he says. “Research is lacking on whether substance use disorders are of special concern to anesthesiologists or if they are merely representative of a larger physician issue. Until these data emerge, the key is to increase awareness of these issues and involve key stakeholders in outreach efforts to address them. This information can help guide policy and practice and enable us to take advantage of opportunities to improve physician well-being and patient safety.”
Readings & Resources (click to view)
Warner DO, Berge K, Sun H, Harman A, Hanson A, Schroeder DR. Substance use disorder among anesthesiology residents, 1975-2009. JAMA. 2013;310:2289-2296. Available at: http://jama.jamanetwork.com/article.aspx?articleid=1787405.
Berge KH, SeppalaMD, Schipper AM. Chemical dependency and the physician. Mayo Clin Proc. 2009;84:625-631.
Skipper GE, CampbellMD, Dupont RL. Anesthesiologists with substance use disorders: a 5-year outcome study from 16 state physician health programs. Anesth Analg. 2009;109:891-896.
Collins GB, McAllisterMS, Jensen M, Gooden TA. Chemical dependency treatment outcomes of residents in anesthesiology: results of a survey. Anesth Analg. 2005;101:1457-1462.
DuPont RL, McLellan AT, Carr G, Gendel M, Skipper GE. How are addicted physicians treated? a national survey of Physician Health Programs. J Subst Abuse Treat. 2009;37:1-7.