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KEY POINTS

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KEY POINTS

  1. The incidence of opioid abuse among anesthesia trainees is 1%.

  2. Addiction is a chronic, relapsing disease with a genetic predisposition.

  3. The brain changes associated with addiction are the same for all drugs of abuse.

  4. The brain lesion associated with substance use disorders manifests a greater number of dopamine D1 receptors and fewer dopamine D2 receptors in specific brain regions, including the nucleus accumbens, amygdala, and prefrontal cortex.

  5. The craving and compulsive behavior associated with addiction is associated with impaired glutamate homeostasis in the nucleus accumbens.

  6. Substance use disorders among anesthesia providers are most commonly detected through observed behavioral changes. Interventions should be based on concern over wellness because substance use disorder is only one of several potential diagnoses that threaten wellness.

  7. Intervention at an early stage of addiction is associated with greater treatment success than intervention at later stages.

  8. Antagonist therapy with naltrexone reduces relapse rates.

  9. Most addicts have psychiatric comorbidities that must be treated concurrently to prevent relapse.

  10. Reentry requires a contract between abstinent colleagues and their employers.

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INTRODUCTION

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The United States manifests a significant ambivalence toward drugs. While the federal government wages war against drug cartels and organized medicine campaigns against the nonmedical use of prescription drugs, the entertainment and advertising industries bombard us with prodrug references daily. Comedians receive knowing laughs and applause from their audiences when they reference or parody recreational drug use. Advertisements everywhere suggest that life is more enjoyable in social settings involving alcohol and more manageable with medications (“Ask your doctor if this medication is right for you.”). Helping people to “pass” drug tests is also a big business. For example, if “urine luck” is entered into an Internet search engine, almost two million citations are offered. Physicians and major pharmaceutical companies tout the benefit of medications to relieve pain and anxiety. Anesthesia providers make their living daily demonstrating that drugs of high abuse potential can be safely administered. Even a brochure for the Wood Library Museum of Anesthesiology proclaims “Thank goodness they inhaled.” Drug and alcohol misuse associated with youthful experimentation is rationalized as expected behavior. Misuse is also triggered by internal and external pressures to improve self-confidence and performance on the athletic field, in the classroom, on competitive examinations, in the workplace, and in the bedroom, to achieve a better body image, to feel more comfortable socially, to cope with the stresses of highly competitive work and study environments, and to escape from dysfunctional social relationships and unsatisfactory living situations. College students call this “pharming.”1

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Physicians contribute significantly to the substance abuse problem in at least three ways:

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  1. They consistently fail to make the diagnosis in their patients.2 Presented with clear symptoms of alcohol abuse, 94% of them did not include substance use disorder among the five diagnoses they offered. As a result, too few patients are referred for treatment. Admittedly for anesthesiologist managing chronic ...

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