The article by Bryson and Silverstein1and the accompanying editorial by Berge, Seppala, and Lanier2together provide a comprehensive review of much of the current literature regarding the diseases of substance abuse and addiction and their devastating impact on too many anesthesia care providers.

I completely agree with the opinion expressed by Berge et al.  that professional organizations must continuously reexamine their efforts to protect their patients and colleagues from the consequences of these diseases.2However, their editorial does not provide sufficient justification for their “one strike, you’re out” policy towards substance abusing anesthesia care providers. They offer only anecdotal reports and fail to present any unique, peer-reviewed data or novel insights to support such a dramatic shift in policy. Their approach overlooks several important aspects of these diseases as they pertain to anesthesia care providers: 1) There are important differences between addiction to “anesthetic drugs” and “supplements,” and it is inaccurate to lump them together; 2) the circumstances under which a trainee becomes chemically dependent frequently differs from that of a seasoned practitioner, with profound implications for prognosis; 3) denying reemployment treats only a symptom and may do little to impede unresolved drug-seeking behavior (this was tragically illustrated in a recent newspaper article detailing the drug- related death of an anesthesiologist);*and 4) as acknowledged in the editorial, the fact remains that data are lacking to prove that relapse and death rates would be affected by redirecting recovering anesthesiologists to other specialties.

Instead of the “one size fits all” approach advocated by Berge et al.,  2I prefer the recommendation of Bryson and Silverstein1of an individualized diagnosis and treatment plan, such as is currently employed by many chemical dependency treatment centers.3These programs provide distinct categories that define a patient’s risk factors and potential to return, under strict supervision, to various work environments, including the operating room. For example, those who fall into the most favorable category understand their disease, have no underlying psychiatric disorder, are committed to recovery, and have support from their families and colleagues. On the other hand, those in the least favorable category have coexisting psychiatric disease, continue to deny their addiction, and demonstrate no genuine interest in the recovery process. Individuals in the former group are excellent candidates for supervised reentry into practice, those in that latter should be directed to a different profession.

A reasoned approach such as this, coupled with strict supervision and aggressive efforts using modern technology to deter and detect drug diversion, should help us to avoid throwing out all of the babies with the bathwater.

Yale University School of Medicine, New Haven, Connecticut.

Bryson EO, Silverstein JH: Addiction and substance abuse in anesthesiology. Anesthesiology 2008; 109:905–17
Berge KH, Seppala MD, Lanier WL: The anesthesiology community’s approach to opioid- and anesthetic-abusing personnel: Time to change course. Anesthesiology 2008; 109:762–4
Angres DH, Talbott GD, Bettinardi-Angres K: Anesthesiologist’s Return to Practice, Healing the Healer: The Addicted Physician. Madison, CT, Psychosocial Press 1998
Madison, CT
Psychosocial Press