Nov. 12, 2008 -- Certain occupations are so high-risk that the public feels compelled to subject people to drug testing: military pilots, train engineers, bus drivers ... but, anesthesiologists?
Two renowned hospitals -- Massachusetts General Hospital in Boston and the Cleveland Clinic Foundation in Ohio -- seem to think the profession needs it and recently implemented random urine drug testing in their anesthesia residency teaching departments.
Given the history of addiction within the anesthesiology community, few anesthesiologists are surprised.
A 2005 survey by the Cleveland Clinic estimated that 80 percent of anesthesiology residency training programs reported problems with drug-impaired doctors, and an additional 19 percent reported a death from overdose.
"The problem is that we are exposed to, and we have the use of, very highly addictive and potent medications," said Dr. Michael G. Fitzsimons, administrator for the substance abuse program of the department of anesthesia and critical care at Massachusetts General Hospital in Boston.
But testing doctors can be problematic.
Doctors familiar with the signs of addiction are sometimes able to mask their drug use from coworkers, making it difficult to detect when they are using and need help. And those determined to hide their habits have been known to find creative ways of beating drug tests -- even submitting fake urine samples.
Despite the difficulties, the administrators of the programs in Boston and Cleveland believe they have been successful, and now hope more comprehensive studies will be done to determine whether such programs help stave off drug use long-term.
A Tragic Shock
Dr. Raymond Roy of Wake Forest University in Winston-Salem, N.C., is still moved by an experience he had 10 years ago with a promising doctor he recruited into his anesthesiology residence program.
"We thought this guy was wonderful, but one day he and his wife showed up in my office saying, 'I'm going to an addiction treatment program in Atlanta,'" said Roy, who asked to keep the doctor anonymous out of concern for his family.
After some further questioning, Roy discovered the doctor had had an addiction problem since high school, but was smart and savvy enough to make it through college, medical school and a previous specialty program.
"He would come to work early to require drugs to inject to keep him from going into withdrawal, not to get high, but enough to make it through the day where he could get drugs at home," said Roy. "We had no clue."
That same doctor died from an overdose in Roy's program, even after completing drug rehabilitation and returning to an area without access to drugs.
Trying to Fix the Addiction Problem
Struck by how clueless he was to the young man's problem, Roy decided to ask his staff if they saw signs of addiction.
"When he died, I sent out a questionnaire out to every single resident, any nurse who had worked with him, any doctor," said Roy. "I got 100 percent response on the questionnaire, and nobody suspected anything."
Yet, after this experience, Roy said he would still be wary of implementing urine drug testing to screen for drug abuse.
"He was too smart. He would have figured out the testing so fast," said Roy. "That sounds good in theory, but there are so many flaws in it."
For decades, anesthesiologists have tried addiction education programs and accounting safeguards in hospitals to detect drug abuse.
"In spite of our efforts, the incidence remains about the same," said Dr. Arnold Berry, an anesthesiologist and a member of the Committee on Occupational Health of the American Society of Anesthesiologists.
Berry said estimates of anesthesiologists who are addicted to medication range from only 1 to 2 percent.
"The most recent study in training programs suggests the (addiction) rate has stayed the same for 20 years," he said.
The low number is, at once, a motivation to steer clear from extreme measures like urine testing, and a misleading figure for the size of the problem.
"Although the percentages are not high, when you do have a case, often you discover it when they're dead," said Dr. Gregory B. Collins, section head of the Alcohol and Drug Recovery Center, at the Cleveland Clinic Foundation. "The first thing you often realize in these cases, it's a kid dead in the bathroom with a needle in his arm."
After his experience, Roy said his department considered doing urine testing but was put off by the extra cost and the work it takes to make sure urine testing isn't being subverted with fake urine or strategic drug use.
"Also, this is demeaning for people. They don't want somebody watching them," Roy said. "We were happy that at least another program was willing to do it to find out where they were encountering difficulties."
Is Drug Testing Worth It?
Fitzsimons, who headed the effort to test urine at Massachusetts General for the last four years, said he found few difficulties.
Both Fitzsimons and Collins say their two departments don't have enough people to statistically prove that urine testing can affect addiction among anesthesiologists. But both doctors said they are happy with the results of the programs.
"I feel that our results are significant, and that further study is needed, but so far, we are pleased," said Fitzsimons. "All I can basically tell you is that our incidence is down, but ... to really determine if this is an effect to detect or defer substance abuse, a multi-institutional study needs to be done."
Fitzsimons and Collins argue that early detection and deterrents can significantly reduce the impact of addiction among anesthesiologists. Fitzsimons estimates that treatment and rehabilitation costs alone can run as high as $100,000 per doctor, not including time spent out of work.
Even when a resident anesthesiologist returns from treatment, a risk of relapse and death lingers.
"Our death rate for treated residents who return to anesthesia is horrible: one out of nine is going to die," said Collins.
"Drug testing gives the realization that it's not just a rule that we have to follow, but that there's some teeth in this," Collins added. "Knowing that, people are generally reluctant to break the rules."
Yet, despite their excitement, and despite the static rate of addiction in the past 20 years, Berry said the American Society of Anesthesiologists (ASA) has decided to use other tactics to stave off addiction, rather than recommending urine testing.
The ASA is implementing a "wellness initiative" to help anesthesiologists deal with stressors in their lives, in addition to the existing recommended education materials to help other doctors recognize addiction, he said
Other agencies have tried to tackle the problem as well. The Anesthesiology Residency Review Committee of the ACGME mandates all residency programs to include drug addiction awareness, and according to rules by the Drug Enforcement Administration, all programs use a check system for the powerful drugs used by anesthesiologists.
"Narcotics are controlled substances; they have a very tight regulation," said Berry.
Dealing With Potent Narcotics
According to Berry, some hospitals have a checkout system at an in-house pharmacy for anesthesiologists. The doctor goes to the pharmacy, writes down how much medicine is needed for a patient, uses it, and then returns with the waste.
Berry said hospitals are expected to perform random checks to see that the returned waste is actually the medicine and not a substitute, or in a diluted form.
Other hospitals use an automated technique to test for patterns.
"There are actually machines, like an ATM machine, where you put in your information, the name of the patient that it's going to be used for, and then a draw opens with the medication," said Berry. "When I'm done, I have to bring back the waste."
Yet, when those systems are skirted, veteran anesthesiologists and addiction specialists say that the drugs that are lifted -- most often fentanyl and sufentanyl -- are some of the most potent around.
"Fentanyl is 1,000 times more powerful than morphine," said Collins. "Sufentanyl is 1,000 times more powerful than that."
According to Collins, the highest risk for anesthesiologists to become addicted is in the early, high-stress training period of residency when they have seen the powerful effects of the drug, but do not have a lot of experience.
"These kids think they can manage this, that they know how to use the drugs. They'll take that risk and do it," said Collins. "They think they'll just take a little bit and be done, but it really doesn't work that way."