Anesthesiologists and Substance Use Disorders

In this issue’s historical article, “Freeman Allen: Boston’s Pioneering Physician Anesthetist,” we learn of Dr. Allen’s many contributions to the field of anesthesiology as well as his qualities as a sensitive, moral, and highly intelligent human being.1 We also learn that he is the first documented and prominent physician anesthesiologist to become addicted to morphine. The article describes his tragic death from suicide during one of several hospitalizations for morphine addiction at Butler Hospital in Providence, RI. What do we know about substance use disorders today that we did not know in the early 1900s? In 1935, pioneers of drug abuse research began to study and treat heroin addicts at the Addiction Research Center at the Public Health Service Hospital in Lexington, KY. When Congress created the National Institute on Drug Abuse (NIDA) in 1974, the Addition Research Center was folded into NIDA’s Intramural Research Program. NIDA was created in response to the rising problem of drug abuse and addiction in the late 1960s and the resultant societal consequences. Research largely funded by NIDA has produced an explosion of knowledge in the neurobiology of addiction, as well as epidemiology, prevention, diagnosis, treatment, and monitoring of individuals with substance use disorders. We now know that addiction is not a moral deficiency but a primary chronic disease, much like diabetes.a,b In diabetes, the defective organ is the pancreas. The result is altered glucose homeostasis. Some the consequence are foot ulcers and blindness. In addiction, the defective organ is the brain. The result is altered neurotransmitter homeostasis. The consequences include lying, cheating, stealing, and general badness. The socially unacceptable behaviors associated with addiction naturally elicit a response to blame the addict for his or her behavior. However, addiction is not a disease of choice.a Addiction is a disease that impairs areas of the brain’s ability to make healthy choices. Like other chronic diseases, addiction is relapsing in nature, is rarely cured, and requires sustained treatment, including addressing the biopsychosocial and spiritual factors that influence the development and manifestation of addiction. As defined by McCauley,2 “Addiction is a stress-induced defect acting on a genetic vulnerability in the reward learning areas of the mid brain and the emotion choice areas of the frontal cortex.” The defining behaviors of addiction are loss of control, craving, compulsion, and continued use despite harm.c Addiction is considered a substance use disorder, along with illicit drug use, problematic drug use, drug misuse, and drug abuse. The DSM-5 divides substance abuse disorders into mild, moderate, and severe categories depending on how many diagnostic criteria out of 11 a given patient meets. Craving has been added as a diagnostic criteria in DSM-5, while legal issues have been eliminated.d The definition of addiction adopted by the American Society of Addiction Medicine in 2011 is an important contribution and reflects our current understanding of substance use disorders.c Genetic load accounts for about 50% of the risk of addiction.3 Additional major risk factors include Axis I/II disorders, adverse childhood experiences,4 and early initiation of substances of abuse including alcohol and tobacco.5 Contributing risk factors include poor coping skills to deal with stress, dysphoria, and anxiety as well as a lack of resilience. Traits such as impulsivity, compulsivity, control issues, risk taking, and the desire for immediate gratification can be seen in people with substance use disorders. It seems intuitive that all human beings including physicians can have risk factors for addiction. It follows that if appropriate environmental triggers are present, physicians may develop substance use disorders. It is therefore no surprise that such prominent physicians as the neurologist Sigmund Freud and the surgeon William Halsted developed substance use disorders. Both of these giants of medicine were practicing in the 1880s, Freud in Vienna and Halsted at New York’s Bellevue Hospital. Freud used cocaine as a treatment for morphine addiction, which was overprescribed then as it is now, and as a treatment for depression. Freud began to experiment on himself with cocaine. The resulting article, Uber Coca, published in 1884, described cocaine’s physiological and potential therapeutic effects but essentially ignored cocaine’s local anesthetic properties. This fascination with cocaine’s perceived positive effect on his own depression may have contributed to Freud’s abandoning basic neurobiology research and instead focusing on the human mind.6 Meanwhile Freud’s colleague at the Vienna Allgemeines Krankenhaus, Carl Koller, focused on the local anesthetic properties of cocaine for cataract surgery while working as an intern in Ophthalmology. At Bellevue Hospital, William Halsted was aware of Carl Koller’s work and began to inject cocaine into his arm. He ultimately became addicted to cocaine. Halsted was hospitalized on several occasions for cocaine addiction at Butler Hospital in Rhode Island, the same hospital where Freeman Allen was treated for morphine addiction and committed suicide. Much of what we know about William Halsted’s substance use disorder is based on a Journal of the American Medical Association article in 1969 by Penfield,7 the famous Canadian neurosurgeon, titled “Halsted of Johns Hopkins: The Man and His Problem as Described in the Secret Records of William Osler.” Sir William Osler, another renowned Canadian physician, revealed that Halsted was addicted to morphine as well as cocaine by the age of 34 when he was invited to join Osler, Welch, and Billings in what would later be called the “Big Four” founders of Johns Hopkins Medical School. At first, Halsted was given a minor appointment as Welch knew of his addiction. Eventually, this was overlooked because of Halsted’s brilliant surgical skills. Osler and Welch assumed Halsted was “cured” because of his excellent performance and promoted him to full surgeon. Osler describes that several months after Halsted’s promotion he observed Halsted in morphine withdrawal. Subsequently, Halsted admitted to not being able to wean himself below 180 mg morphine daily. The contributions to medicine and mankind of Freud, Halsted, and Allen and many other addicted physicians should motivate us to provide treatment to our colleagues with substance use disorders. We are motivated because addicted colleagues are often both personal friends and suffering patients. However, we too easily forget the substantial contributions to society by many addicted individuals, including physicians. One of the lessons of Freeman Allen’s story is that addicted colleagues, properly treated, may make lasting contributions. In light of what we know today about substance use disorders, what can we say about Freeman Allen’s struggle with his addiction to morphine? Dr. Allen had a genetic load for addiction. We know his mother was addicted to morphine. Less well known is that his uncle, Fredrick William Stowe, was an alcoholic.e Fredrick attended Harvard Medical School but left to enlist in the Union Army for the Civil War. He was wounded in the Battle of Gettysburg. Fredrick had a lifelong struggle with alcohol addiction. It appears that Fredrick was the inspiration for the character Tom Bolton in My Wife and I and We and Our Neighbors, written by his mother, Harriet Beecher Stowe. As noted on the Harriet Beecher Stowe Center Web site, “Stowe insightfully described alcoholism as an illness, at a time when most people believed it was a moral failure.”f As is common among addicts, Freeman Allen was a risk taker, exposing himself to yellow fever. Perhaps risk-taking behavior was necessary for anesthetists of his time, given the risks imposed by the limited knowledge and primitive technology applied to the profound physiologic trespass of the new discipline. We can conjecture that he was desensitized to using morphine, which he championed as a premedication for his patients. He certainly had ready access to morphine. We also know that he was despondent, depressed, and ultimately committed suicide. Little was known about substance use disorders or their treatment during his life. That is, in part, why he succumbed to his disease. So what do we know today about physicians in general, and anesthesiologists in particular, with substance use disorders? The lifetime prevalence of substance abuse disorder in the general population is approximately 10% to 14%.8–10 The lifetime prevalence in physicians is thought to be similar. This means that among the approximately 850,000 physicians and 50,000 anesthesiologists in the United States, there may be as many as 120,000 physicians and 7000 anesthesiologists who will be affected by a substance use disorder during their lifetime. If these figures are even remotely accurate, this represents an important public health issue, given the risks of being cared for by an impaired physician. The problem of substance use disorders among physicians has been addressed, in part, by the creation of physician health programs (PHPs)11 to treat affected physicians. Unfortunately, data suggest that only 1% of physicians with a lifetime prevalence of substance use disorders are referred to a PHP.12 As part of our dedication to patient safety, physicians in general, and anesthesiologists in particular, must do a better job of identifying colleagues with substance abuse disorders to facilitate intervention, diagnosis, and earlier referral to treatment. This can be accomplished, in part, by educating colleagues and their families about substance abuse disorders. There are also policies that can be put into place, such as random urine and/or hair drug testing, and mandatory drug testing when substance abuse is suspected. Knowledge and understanding of signs and behaviors that may signal a substance use disorder and active surveillance in anesthesia training programs and practice sites increase early referral and patient safety. Data suggest that anesthesiologists, emergency department physicians, and psychiatrists are overrepresented among physicians referred to PHPs.13 However, because very few physicians with substance abuse disorders are referred to PHPs, we do not know whether anesthesiologists, emergency department physicians, and psychiatrists are at a higher risk of substance use disorders, or are simply more likely to be detected (or to self-identify) and be referred for treatment. There are several unique features of substance abuse disorders in anesthesiologists. First, no other specialty has easier access to the equipment (needles, syringes) than anesthesiologists. Second, no other specialty has greater proficiency at venous cannulation. Third, no other specialty has easier access to commonly abused IV drugs, including potent IV opioids. Last, no other specialty is as skilled at precisely controlling the effects of IV opioids and other abusable drugs. This combination of access to equipment and drugs, and proficiency with both, creates a unique risk for abuse among anesthesiologists confronted with biological, psychological, social, or spiritual stressors. Occasional self-administration of IV short-acting opioids can lead to tolerance, escalating doses, and full-blown addiction in a matter of weeks to months. Death may follow quickly if the addiction is not discovered and treated. Opioid addicts often paradoxically describe opioids as energizing, which may explain why addicted physicians can appear to function well, at least initially, while actively injecting into a hidden IV port. Anesthesiologists are especially stigmatized for opioid addiction. This may be due to the fact that an anesthesiologist trusted to provide care for the patient is instead diverting the opioid from the patient, who needs opioids for analgesia, to his or her own use. The addicted anesthesiologist steals from the patient, which is a crime. This stigma causes further shame and guilt in the addicted anesthesiologist, which he or she already has no shortage of, furthering the need for relief with more opioids. Thus, the rapid downward cycle may reflect not only the pharmacology of short-acting IV opioids, but also the overwhelming psychosocial and spiritual turmoil of the addicted anesthesiologist. The unique risk factors for substance abuse disorders among anesthesiologists may explain why anesthesiologists have a much higher rate of IV drug abuse than other physicians (odds ratio, 6.3)12 when enrolled in a PHP. Fortunately, anesthesiologists in rigorous PHPs have excellent outcomes, similar to other specialties in terms of survival, abstinence, completion of monitoring, and return to work in their specialty. They are also less likely to fail a drug test during monitoring. These favorable outcomes for anesthesiologists may be due to additional features in treatment and monitoring not used for other physicians, including witnessed naltrexone administration (or more recently the advent of sustained release parenteral naltrexone), regular hair drug testing, and increased technological surveillance in the operating room suite.14 It is our view that anesthesiologists who have a substance use disorder should sign a contract with a PHP and generally undergo residential care for a minimum of 90 days in a physician-oriented program. After completing adequate treatment, the PHP provides subsequent outpatient monitoring, including appropriate drug testing, counseling, group therapy, and attendance in a 12-step–based support group such as Narcotics Anonymous for at least 5 years. It is controversial whether anesthesiologists with substance use disorders should return to work in their specialty. We recommend that each anesthesiologist be evaluated on a case-by-case basis by a qualified addictionologist with experience in treating anesthesiologists. Relapses among anesthesia providers have produced strong, even visceral reactions in the medical community. Some question whether any anesthesiologist should return to the operating room environment. We believe systematic assessment tools and clinical research should guide who should and who should not safely return to a high drug access environment. If return to work is deemed appropriate, it should be done slowly and in combination with the above steps to detect relapse and protect our patients. It is important and possible for all those suffering from a substance abuse disorder to achieve biological, psychological, social, and most importantly spiritual recovery. Quoting Dr. Thomas Hora, “all problems are psychological, but all solutions are spiritual.”15 Freeman Allen was never was given an opportunity for recovery. He died of his disease. The lesson of his tragic trajectory is that we must all be vigilant to substance use disorders in our friends, family, and professional colleagues. We owe it to ourselves. We owe it to our colleagues. Most critically, as physicians, we also owe it to our patients. DISCLOSURES Name: Gabriel Schonwald, MD. Contribution: This author helped in manuscript preparation. Attestation: Gabriel Schonwald approved the final manuscript. Name: Gregory E. Skipper, MD, FASAM. Contribution: This author helped in manuscript preparation. Attestation: Gregory E. Skipper approved the final manuscript. Name: David E. Smith, MD, FASAM, FAACT. Contribution: This author helped in manuscript preparation. Attestation: David E. Smith approved the final manuscript. Name: Paul H. Earley, MD, FASAM. Contribution: This author helped in manuscript preparation. Attestation: Paul H. Earley approved the final manuscript. This manuscript was handled by: Steven L. Shafer, MD.

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