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Addiction now is recognized as a chronic relapsing disease. Unfortunately, most of the data regarding relapse come from abstinence programs that either are too short term or too limited with patients who are far less motivated than most health care providers or have been identified and treated too late in the addiction process. The reported relapse rates are so high that antagonist therapy with its goal of no relapse typically is rejected in favor of agonist therapy with methadone or buprenorphine with a goal of fewer relapses. However, there is a group of patients who do get close to optimum therapy, physicians in PHPs.9 In this group, the results for abstinence programs are far more optimistic. In their study of relapse in the Washington Physician Health Program, Domino et al17 observed an overall relapse rate of 25% over 10 years. To express the results more positively, 75% of physicians did not relapse. Three factors predicted relapse: a family history of substance abuse, a coexisting psychiatric illness, and major but not minor opioid use. Major opioids included fentanyl, sufentanil, morphine, meperidine, methadone, heroin, and controlled-release oxycodone. Minor opioids included butorphanol, codeine, hydrocodone, pentazocine, propoxyphene, and tramadol. Relapsed rates decreased with increasing time in treatment. All who avoided relapse in the first 5 years successfully returned to the practice of medicine. With specific regard to anesthesiologists, the study had insufficient power to separate out a contribution of anesthesiology as a profession independent of the abuse of major opioids. However, the authors did refer to data from the New Jersey Physician Health Program and California Physicians Diversion programs that did not reveal a risk for anesthesiologists higher than for other specialists.
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Both the Joint Commission on Accreditation of Health Care Organizations (JCAHO) and the American Board of Anesthesiology (ABA) support the intent of the Americans with Disabilities Act: protection of individuals with a history of alcohol or substance abuse who are not currently abusing alcohol or using drugs illegally. The JCAHO now mandates that hospital medical staffs have "a process to identify and manage matters of individual health for licensed independent practitioners. The purpose of this process is to help with rehabilitation, rather than discipline, to aid a practitioner in retaining and regaining optimal professional functioning that is consistent with protection of patients."64 The ABA's Booklet of Information65 contains a specific policy admitting qualified applicants with a history of alcohol or illicit drug use into the examination system, if the ABA receives "acceptable documentation" that "they do not pose a direct threat to the health and safety of others" and are "not currently engaged in the illegal use of drugs." After a candidate satisfies the examination requirements, "the ABA will determine whether it should defer awarding its certification to the candidate for a period of time" usually several years after the candidate enters a rehabilitation program, to assure a reasonable period of abstinence, monitored compliance with reentry contracts, and safe care of patients. The ABA receives notifications of actions by state medical boards from The Federation of State Medical Boards and "will initiate proceedings to revoke certification(s) of diplomats with a medical license that is revoked, suspended or surrendered in lieu of revocation or suspension upon notice of such action."
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The return of successfully treated anesthesia care providers to the clinical practice of anesthesia (reentry) remains controversial. Currently, the decision to return the practitioner to the operating room is made on an individual basis. Many studies have suggested that upon completion of treatment, anesthesiology trainees should be redirected into another specialty. In 1990 Menk et al published results from a survey of 159 anesthesiology training programs; 34% of the parenteral opioid abusing group successfully reentered training versus 70% of the nonopioid using group.66 Unfortunately death was the presenting relapse symptom in 16% of the reentering parenteral opioid using group. From a survey of academic chairs and program directors, Booth et al67 reported occurrence of addictive disorders in 1% of faculty members and 1.6% of residents. Of note, 18% of these cases were detected by death or near death. In the most recent study of treatment outcomes among 199 residents in anesthesiology involved in drug misuse, 167 returned to medicine, 100 continued as anesthesia residents, 9 died, and 91 completed their anesthesia training, for a 79% overall reentry rate in medicine and a 46% reentry rate into anesthesia.5 Fry provided dismal results from a small 10-year survey of anesthesiologists and anesthesia trainees in Australia and New Zealand.68 Only 19% of abusing trainees were successful in a return to any specialty of medicine, 15% of those reentering anesthesia were successful in training completion, and there was 31% mortality among all the trainees (5 of 16). Collins and McAllister reanalyzed Fry's data to demonstrate 14% mortality for those residents returning to anesthesia.69 Wischmeyer et al conducted a survey of academic chairs that included abuse of propofol; 18% of departments reported abuse of propofol, of which 28% presented by death.20 In 2009, Bryson published another survey of US residency program directors' experience with trainee substance abuse over a 10-year period. He reported 29% relapse rate and 10% incidence of death as the presenting symptom of relapse in residents returning to anesthesia training.70 All of these studies were retrospective studies that relied heavily on the opinion of the program director of departmental chair, who may not have been in position during the survey time period.
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Controversy over the subject of routine reentry after successful treatment has recently become a topic of considerable discussion. A review of indexed literature from 1993 to 2008 by Bryson and Silverstein51 concluded that there was no guarantee against relapse after successful completion of treatment. Stating that despite educational and program efforts "deaths from opioid abuse continue" and based on the subjective report of "nearly 100% relapse" of 12 nurse anesthetists over the course of 20 years, the ensuing editorial by Berge et al recommended "one strike, you're out" rather than return to the operating room.71 Six letters to the editor responded to both documents. Cohen described the Physician Health Committee of the Medical Society of the District of Columbia's monitoring program for reentering anesthesiologists. This program includes individual consideration, long-term close surveillance, and aftercare by a specialist in addiction medicine.72 Skipper and Dupont73 included reports by Pelton and Ikeda,74 Paris and Canavan,75 and Domino et al17 in support of individual consideration for return to the operating room. Paris and Canavan used data from the New Jersey PHP to demonstrate no difference in relapse rate between 32 anesthesiologists and 36 physician controls, as well as no significant difference between practicing physicians and residents. In addition, Skipper and Dupont cited the outcomes report of McClellan et al76 after a 5 or more year follow-up of 904 physicians from 16 PHPs, which supported individualized treatment. Earley and Berry77 cited Angres et al78 in support of using specific factors in making the decision to return immediately after treatment. Noting that none of the published studies contained specifics of treatment, follow-up care, or previously mentioned factors, they recommended research evaluating the various assessment and management protocols. Katz79 criticized Berge for not making a distinction between residents and attending physicians, the effect on relapse and death upon redirection to another specialty or not practicing medicine, as well as abuse of different drugs. Citing the "one strike, you're out" default position, Specht was concerned that individuals would be less likely to seek help due to fear of career loss.80 In the only letter of support of "one strike, you're out," Torri mentioned concerns for patient safety under the care of the relapsing anesthesia care provider before detection.81 Berge et al responded that reentry criteria that predict success upon return to anesthesia practice, particularly within the framework of a well-functioning PHP, as well as life-long monitoring may provide a platform for reentry. They also supported research with valid study design, outcome metrics, and appropriate data analyses.82
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Oreskovich and Caldeiro reviewed in 2009 the indexed literature on the subject of reentry of anesthesiologists after successful treatment for chemical dependency and found that most PHPs "did not define the role of monitoring programs, type or duration of treatment, role of hair and nail testing to confirm recent opioid use, or the effect of the use of depot naltrexone."83 Review of "the subset of PHPs that incorporated trimodal monitoring (chemical, behavioral, and workplace), aggressively tested hair and fingernails for high-potency opioids, required administration of depot naltrexone, and followed up anesthesiologists for five years after residential treatment that averaged three months" supported the individualized return to clinical practice.83 They note the need to address the inconsistency among the various states' PHP programs and the absence of PHP in several states. When available, they recommend a requirement for participation in a PHP-mandated monitoring and aftercare program. In the previously cited study from the Washington Physician Health Program,17 only 5 of 22 anesthesiologists who misused fentanyl were able to return to practice (23%), but no information about the 11 anesthesiologists whose drug of choice was not fentanyl was presented. Presumably, they were less likely to relapse and more likely to have successfully reentered practice. The authors concluded that risk of relapse was increased in those who used a major opioid, had a coexisting psychiatric illness, or family history of a substance use disorder.
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DuPont et al published results from McClellan's 5-year longitudinal cohort study involving 904 physicians enrolled into 1 of 16 responding PHPs. Over the 5-year period, 78% of the participants had negative drug testing, and posttreatment 72% of all physicians continued to practice medicine.84 Skipper et al conducted an analysis of a subset of 102 anesthesiologists from this study.85 Anesthesiologists had a higher rate of opioid and intravenous drug use in comparison with other physicians. There was no statistical difference in completion of contracts (71% anesthesiologists vs 64% nonanesthesiologists) or continuation in other medical practice specialties (76% anesthesiologists vs 73% nonanesthesiologists). There was no report of physician death or significant patient harm due to relapse. Fitzsimmons and Baker's editorial comments that Skipper et al demonstrate that recovery and successful return to practice are very likely for the trained anesthesiologist who receives the support of a PHP.86 They suggest that residents who are referred to a PHP and successfully complete a course of treatment should be considered for reentry into anesthesiology training. In response to a letter to the editor by Silverstein and Bryson,87 Skipper noted that 12% of the returning anesthesiologists changed specialties.88 Citing DuPont's study, he also refuted their suggestion that many addicted anesthesiologists, including the more severe cases, are not referred to PHPs. Thus successful reentry can occur. The question is when and how.
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Based on their experience with 5 addicted anesthesia residents, Bryson and Levine recommend a gradual return to the operating room.89 The accompanying editorial by Tetzlaff and Collins commented that relapse risk stratification could lead to development of case-by-case system for reentry.90 Criteria used by PHPs for consideration for reentry has been published. Talbot's original return to work classification has not undergone research evaluation but remains a useful template.78 The literature supports 3 criteria for a negative outcome: positive family history, comorbid psychiatric disorder, and history of relapse. The Earley Consultancy91 is in the process of developing and implementing a reentry evaluation tool: the Medical Personnel Addiction Recovery Inventory (MPARI). This was initially created for anesthesiologists (APARI). The tool is based on expert consensus only and has not been analyzed for validity or interrater reliability. The ASA Web site contains a model curriculum on drug abuse and addiction for residents in anesthesiology.92 It was developed by the Committee on Occupational Health and includes a useful section on reentry with a sample reentry agreement. Talbot's criteria for reentry are listed on the site. Successful reentry requires completion of an effective treatment program, motivation, supportive environment, involvement of family/significant others, as well as a reentry agreement, including monitoring. Although not all states have a well-functioning PHP, the Federation of State Physician Health Programs contains an active list of state programs.93 The North Carolina Physician's Health Program94 contains a list of available services: training in identification of impairment and intervention procedures, assessment of referrals and treatment recommendations, advocacy for successful treatment participants, monitoring and support, and financial assistant for indigent participants.
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Reentry should involve a work reentry contract stipulating what is expected of the reentering individual by the employer and what the reentering individual should expect from the employer if he or she meets the contractual obligations. Becoming increasingly common are last chance agreements, which clearly describe how substance abuse has affected the employee's performance in the past, how the employee's performance has put the employer at risk, what is expected of the employee if employment is to continue, and what the employee can expect if his or her performance does not meet expectations.