To the Editor:—
Addiction remains a disconcerting disease for anesthesiologists, and we applaud Bryson and Silverstein1for their comprehensive review. In the editorial accompanying the review, Berge et al. 2have taken an extreme position by recommending that “anesthesia caregivers who have become addicted to or abuse anesthetic drugs and supplements should be directed toward lower-risk occupational environments, either within medicine or in a different field entirely.” Although this suggestion may be appropriate for some addicted anesthesia caregivers after undergoing initial treatment, we also know that there have been many individuals who have successfully reentered the specialty of anesthesiology to become productive clinicians and academic leaders. The critical question is whether we can differentiate the treated addict who will relapse from the one who can, under the right circumstances, be integrated back into the practice of anesthesiology without adverse consequences. Is there data to support Berge et al. ’s recommendation?
The cry for redirecting recovering anesthesia personnel to other specialties began with the Menk et al. 31990 publication describing the experience of anesthesia training program directors. Data were collected on 180 residents abusing opioids or other addicting drugs. The relapse rate was 66% for the 79 opioid-dependent residents who returned to anesthesiology. It was especially disturbing that there were 14 deaths among this group. Since the relapse rate was much lower (30%) in returning residents who had abused alcohol or nonopioids, the authors recommended redirection into another medical specialty for residents who had been addicted to parenteral opioids. Collins presented similarly dark data, noting that of the 50% of anesthesia residents who continued in anesthesiology after treatment, 9% died.4
On the other hand, research that emanates from state Physician Health Programs paints a different picture. In a retrospective case control study, Paris and Canavan compared 32 anesthesiologists with 36 physician controls, and after an average follow-up of 7.5 yr, there was no difference in the relapse rates between these 2 groups.5Likewise, the outcomes of residents did not differ from attending physicians. A similar report from Pelton6involving 255 physicians who had participated in the California Diversion Program showed no difference in relapse rates for anesthesiologists.
It is of concern that none of the published studies describing the outcomes of addicted anesthesiologists contain specifics regarding the treatment, the follow-up care, or the factors that were used to determine whether to recommend return to anesthesia or redirection. Addiction treatment in physicians today is rich and sophisticated, with careful attention to the components of the addiction itself, peer-based support, family therapy, and continuing care protocols through Physician Health Programs in most states. Anesthesiologists or those in training who return to the specialty must now agree to specific terms of follow-up care, often including the mandatory use of naltrexone. From Domino’s work, we know that the risk of relapse in physicians is highly associated with the use of opioids, coexisting psychiatric disease, and a family history of addiction.7Angres et al. have published lists of factors that they used to decide whether addicted anesthesiologists were candidates to return to the specialty immediately after treatment, should be reassessed after 2 yr, or were at high risk for relapse and not recommended for return.8
Nonetheless, the science of addiction treatment remains in its infancy. An exhaustive evaluation of the addiction, psychological, psychiatric, and occupational characteristics of anesthesia providers in treatment has not been performed to date. Research that triangulates the patient characteristics, the type of treatment, and patient outcome is critical but nonexistent. Addiction is a complex disorder with varying severity, course treatment sensitivity, and outcome. Berge et al. 2by suggesting that we apply a “retrain everyone” policy, ignore this complexity.
One of the authors (PHE) directs a program that in the past 9 yr has evaluated or treated 128 addicted anesthesiologists, as well as hundreds of anesthetists. Many of them do return to anesthesia with a carefully staged reentry process. Additional assessment and management protocols have been put into place to decrease the likelihood and lethality of relapse. Most anesthesia personnel are carefully monitored, reengage slowly, and are at least partially protected by naltrexone, preferably administered intramuscularly. It is our belief that we need research, not a one-size-fits-all policy for our colleagues suffering from the disease of addiction.
Emory University School of Medicine, Atlanta, Georgia. firstname.lastname@example.org