Chemical Dependence in Anesthesiologists: What you need to know when you need to know it - Part 2

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Chemical Dependence in Anesthesiologists: What you need to know when you need to know it - Part 2

Intervention*

Intervention is the process of proving to an addict that he or she is ill and is in need of immediate evaluation and treatment. Its primary purpose is to overcome the denial that is inevitably present. Rather than being punitive, an intervention is advocacy, or in the words of recovering addicts, a demonstration of “tough love”. Only when substantial evidence confirming the presence of addiction has been collected should intervention be attempted.

Interventions should be undertaken by a group of people who are genuinely concerned about the individual. They should be led by an individual who has both training and experience in the process. Interventions should never be conducted by a single person, no matter how experienced. The participants, ideally numbering from three to about eight, may include friends, colleagues and family of the addicted physician. They should be selected carefully.

The intervention should be scrupulously planned and not be limited by time. Each participant should prepare a detailed list of his or her observations that demonstrate the individual’s addictive behavior. This information should be presented during the intervention. If possible, at least one member of the group should be a physician who is recovering from the disease. Most addicts feel remorseful, isolated and unique, sure that their plight has never happened to anyone else. To have one of the participants say, “I know where you are coming from; I’ve been there myself” may be an extremely important component in a successful intervention.

Plans must be made in advance for immediate referral of the individual to a facility skilled in conducting a comprehensive medical and psychological evaluation of addicts. Arrangements should be made for transportation of the person to the facility, and someone should be selected to accompany the addict. Should long-term treatment be indicated, it is best carried out in a program experienced in managing addicted physicians.

The conduct of the intervention depends on the specific circumstances of the case, but should always stress advocacy for the individual. That person will probably not realize that addiction is a disease that if left untreated will lead to irreparable damage to his or her health, personal and professional life, and that it may end in death. Conversely, the individual probably does not realize that if the disease is treated, the likely result is long-term recovery

A well-planned and -managed intervention will usually result in the physician agreeing to enter a substance abuse treatment program. However, the intervenors must be prepared for a refusal and should use all available coercive measures if necessary. The possibility of returning to medical practice is a powerful motivation for recovery. Thus, the threat of being reported to a state medical board, which will likely result in loss of one’s medical license and professional career, is the usually the best of these measures.

Not all interventions are successful. Every effort should be made to minimize the chance of the physician “bolting” following a failed intervention. The potential for self-harm under these circumstances is real.

Treatment

Successful treatment of an impaired physician is a multidisciplinary effort. Detoxification, intensive education and behavior modification in early recovery are usually best achieved during inpatient treatment. However, the current climate of cost cutting in medical care may reduce this option from several weeks to only a few days. The majority of time now spent in treatment is usually on an outpatient basis but with the same goals in mind.

Many feel that it is vital that physicians be treated at a facility whose personnel are skilled in managing addicted physicians. Although this may not always be possible, it is important that a physician in early treatment see that there are peers who share the same disease. In addition, the veneer of the medical degree should be stripped away as soon as possible. Unless there are other physicians in treatment, it is likely that the isolated physician will be placed on a pinnacle, both by those in treatment and by those who are providing the therapy.

During the initial phase of treatment, the impaired physician should undergo intense medical evaluation. Physicians skilled in internal medicine, psychiatry, neurology and addiction medicine should all be involved. Other specialists should be consulted as needed. Detoxification, if needed, should be carried out simultaneously

Long-term treatment may require several months. Many programs have their patients reside in “halfway houses,” where they can begin to learn how to interact with one another. The key elements of the therapy during this phase are complete abstinence from all mood-altering drugs, facilitated group psychotherapy with other recovering addicts, and regular participation in self-help fellowships such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). The use of specific blocking drugs such as disulfiram (Antabuse) for alcohol, and naltrexone (Trexan) for both alcohol and opiates is recommended by many therapists. Most believe the use of these drugs is an important adjunct to long-term recovery. Frequently, this therapy begins during treatment and in continued for up to a year following discharge.

Family members are also adversely affected by the disease. Usually, they develop their own denial patterns, anger and inability to deal with feelings about addiction and its adverse consequences. Accordingly, treatment should not be limited to the recovery physician but should also involve the family. Many programs offer weekend sessions specifically designed to provide vital information about the disease of addiction to spouses and children. Often included in these meetings is an introduction to Al-Anon and other self-help groups that are targeted at the family

Aftercare

Aftercare should begin the moment the recovering physician is discharged from formal treatment. It is a life-long process of maintaining a healthy, drug-free life. Many treatment programs insist that their patients sign an aftercare contract prior to discharge. Stipulations in these documents usually include some or all of the following:

1. Regular attendance at 12-step meetings; usually daily for at least 90 days following treatment. Some may require at least three to five meetings per week for years. Failure to adhere to this stipulation is almost a certain sign of relapse.

2. Attendance at regular self-help meetings for physicians (like the “Caduceus Club” that was established by G. Douglas Talbott, M.D., in Atlanta, Georgia).

3. Obtaining a primary care physician who will be responsible for prescribing all drugs needed by the recovering physician, including those that are available over-the-counter.

4. Recommendations concerning returning to work should be made in writing by the treating facility, state medical society and/or other organization with expertise in managing aftercare in anesthesiologists. Contracts may address details such as whether or not the person should return to the practice of anesthesiology, the administration of controlled drugs, rate of resumption of responsibilities, hours worked and others.

5. Regular monitoring of recovery by a physician who has been trained to perform this task.

6. Mandatory collection of random urine or blood screens for a period of five years or more are mandated by most programs. Collection of specimens should be witnessed to avoid the possibility of deception. Fentanyl, sufentanil and their metabolites are challenging but not impossible to detect. If indicated by the drug of choice, these relatively expensive assays should be specifically requested.

7. Many recovery programs include weekly facilitated meetings of recovering physicians. The rationale for these meetings include: a) the fact that recovering physicians are usually more sensitive than monitors at detecting subtle signs of impending relapse, and b) that urine screens detect relapse only after it has occurred, while the group may identify it before the fact.

8. Many feel that physicians recovering from addiction to opioids should take naltrexone for at least six months following the termination of treatment. The drug and its metabolites are relatively easy to detect.

9. Management in the event of relapse should be addressed in the contract. It usually will include re-evaluation by experts and return to treatment if indicated by the evaluation.

Return

Home Return to living at home may be a difficult process for both the recovering addict and the family. It will be facilitated during treatment if family members attend educational sessions specifically designed for them. Work Whether a recovering anesthesiologist should return to the practice of anesthesiology is a hotly debated topic for which there are no firm answers. The attitudes of departmental colleagues, surgeons, other members of the medical staff and the administrators of the hospital play a major role. If these individuals are unwilling to accept the recovering physician and the stipulations outlined in the after-care contract, then the likelihood of successful return will be slim. On the other hand, if they have a basic understanding of the disease of addiction and are amenable to gradual return to work in keeping with the contract, then the outcome in most cases will be positive.

Should a health care entity decide not to permit the recovering anesthesiologist to return to practice solely on the basis of his or her history of addiction, it may be vulnerable to legal action by the anesthesiologist. The Americans With Disabilities Act (ADA), a federal law that protects disabled workers, defines addiction as a disability. It states that a recovering individual may not be refused employment solely on the basis of that disability. One key for the entity is whether or not it has a real or imputed employer-employee relationship with the anesthesiologist. If this relationship does not exist, then the law would not be applicable. In addition, the ADA does not offer protection to addicts who are currently engaging in the illegal use of drugs.

The potential for successful return to work may be in part related to the drug of abuse. Preliminary analysis of data obtained in the ASA survey of anesthesia training programs, indicated that only about 50 percent of physicians with a history of fentanyl abuse returned to the specialty following treatment. Of those who returned, nearly half were terminated either voluntarily or involuntarily. In that group, the apparent relapse rate was nearly 20 percent per year over a maximum period of 18 months. In contrast, for those who abused nonopioid drugs, the relapse rate was about 4 percent per year. These figures must be regarded with caution since they do not take into account the length and type of treatment, the willingness of the department to accept the individual and other factors that are felt to be important to longterm recovery

For Help

Every state medical society has a program for the identification and management of chemically dependent physicians. [A few do not.] Most of these will provide assistance with confidential investigation, intervention, treatment referral and aftercare monitoring, and will advocate for the recovering physician in matters of interest to the state board of medicine. A telephone call to the medical society in your state will begin this important process.

The telephone number for the ASA’s Hotline on Chemical Dependence is (847) 825-5586. It is printed at the bottom of the inside cover of every edition of the ASA Newsletter. With attention to strict confidentiality, personnel will provide callers with the appropriate telephone numbers for their locality and, if possible, will offer the name of a confidential consultant who can provide additional information and resources.

Reprinted with permission from the American Society of Anesthesiologists.

* Johnson VE. Intervention: How to Help Someone Who Doesn’t Want Help. Johnson Institute Books, Minneapolis, 1986.

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