The incidence of substance abuse, including alcohol, among physicians is unknown. The incidence of substance abuse by anesthesiologists in training or in practice is also uncertain. Although the incidence of alcohol abuse among physicians appears to be no more prevalent than among other professionals, physicians may display a higher misuse of prescription opioids. Anesthesiology residents appear to have one of the highest known incidences of addiction to pharmaceutical substances of all groups of health care providers. The incidence of substance abuse is estimated as 1.6% of anesthesiology residents in the United States. This high incidence of substance abuse is believed due to a combination of workplace stress inherent in commencing this demanding profession (i.e., assuming responsibility for the safe induction, maintenance, and emergence of the anesthetized, paralyzed, often critically ill surgical patient), theorized second-hand occupational exposure and sensitization to the effect of opioids, and the ready availability of potent drugs used to anesthetize patients (particularly narcotics). Collins et al.’s survey of 111 training programs in 2005 reported that 80% of programs had experience with trainee impairment, primarily opioid abuse. Nineteen percent of programs reported at least one death due to overdose or suicide between 1991 and 2001. The highest risk of drug-related death for anesthesiologists is within the first 5 years after completion of medical school. Residents in anesthesia are over-represented in the Medical Association of Georgia’s Impaired Physicians Program. Additionally, anesthesiology residents and attending anesthesiologists have more years of life lost due to suicide and drug-related deaths than internists.
For the past decade, anesthesiology residency programs have relied on education (lectures by recovered physicians, movies depicting the impact of physician drug addiction including loss of career or life, etc.) and strict control of substances (daily accounting, establishing operating room [OR] pharmacies, etc.), to detect and discourage substance abuse by anesthesiologists. These measures have not reduced the incidence of substance abuse. Recent technologic advances, including surveillance of drug transactions via anesthesia drug dispensing systems (Pyxis) along with analysis of anesthesia information managements systems and pharmacy information management systems may allow earlier detection of diversion by analysis of abnormal patterns of usage. These practices are not yet widely adopted.
Other professions responsible for the lives of others (aviation, transportation, etc.) that have experienced problems with substance abuse are now required by the United States Congress to conduct random urine testing to attempt to reduce risk to the public. Illicit drug use decreased significantly after random testing was initiated in the US military in the early 1980s. Among impaired physicians, recovery is improved when random urine monitoring occurs because of the consequences of a positive substance screen. Presumably, physicians who understand the consequences of a positive urine screen would avoid use of illicit substances. Pre-employment drug testing of housestaff physicians at a teaching hospital has been reported. We are not aware of any civilian anesthesiology residency programs that require random drug testing. Mandatory random substance testing is common among physicians in recovery programs.
Over the past two decades, substance abuse within the residency of the Department of Anesthesia and Critical Care (DACC) at the Massachusetts General Hospital (MGH) has reflected the national incidence, despite education and strict accounting of drugs. We therefore decided to initiate preplacement and post-employment random urine testing of all anesthesia residents to attempt to deter and detect substance abuse.
