Causes
Stress
Occupational stressors first surface in residency, where long
hours preclude much time for relaxation and certain patients may evoke negative emotions.
There are also nonprofessional pressures, such as separation from parents, marriage,
raising of children, and financial matters, to contend with during the time spent
away from work. A sense of professional inadequacy is nearly universal.[174]
The death of a patient under one's care may cause these feelings to surface for
the first time.[175]
Without doubt, the practice
of medicine can be stressful, and it is tempting to assume that stress is a major
cause of drug addiction among physicians. Contrary to common belief, however, scant
evidence suggests that stress is a precipitating factor in a physician's addiction
to drugs. In contrast, preexisting personality traits, a family history of substance
abuse, and previous recreational drug use are readily associated with substance abuse
among physicians.[159]
[165]
Availability
Anesthesiologists are unique among physicians in that they administer
drugs directly rather than order their administration by others. Drugs are immediately
available, which is perhaps the most important cause of addiction in the specialty.
To quote many recovering anesthesiologists, "We work in the candy store." One report
indicated that 85% of anesthesiology residents treated in one large program stated
that having drugs within reach influenced their career choice.[167]
Over the last 15 years anesthesia departments have introduced measures to closely
monitor the use of controlled substances by staff and resident physicians. It is
discouraging that an increased level of accountability of controlled substances in
U.S. residency programs has not correlated with a decreased incidence of drug dependence.
[176]
The most recent data from a survey of 123
academic anesthesia departments was reported in 2002. In this study, measures to
regulate the use of controlled substances included changes in drug dispensing, disposing,
and accountability. The study covered a span of 7 years, during which time drug
dispensing was shifted from nurses to satellite pharmacies (42%) or dispensing machines
(31%). Opened, but unused drugs were either returned to the pharmacy (52%) or wasted
in front of a witness (41%), and the amount of drug administered was compared with
the amount dispensed (80%). Despite these changes in drug dispensing and accountability,
the incidence of drug abuse did not decrease.[177]
It is not clear whether ongoing measures to regulate controlled substances in the
operating room will significantly decrease the incidence of abuse by anesthesiologists
in the future.
Drug Potency
Abuse of drugs by physicians is much more common than addiction.
Patterns of abuse differ by specialty and are influenced by familiarity and availability.
Psychiatrists most frequently abuse oral benzodiazepines, whereas anesthesiologists
preferentially abuse potent narcotics. Casual abuse of alcohol obviously does not
always lead to addiction, and though exceedingly risky, nor does abuse of morphine,
meperidine, or codeine.[178]
In contrast, the addictive
potential of fentanyl and other potent opioids is so great that anyone who experiments
with these drugs is at enormous risk of becoming chemically dependent[167]
( Fig. 88-2
). Some have
said that a single experience with sufentanil is so overwhelming that it is impossible
to stop using the drug. The doses needed to sustain a habit or to prevent the symptoms
of withdrawal skyrocket once abuse begins. Rapidly developing tolerance stimulates
the ever-increasing doses needed to attain the desired sensation. The use of 50
to 100 mL of fentanyl or 10 to 20 mL of sufentanil per day is common in an addicted
physician. These doses are easily reached within a few months for fentanyl and a
few weeks for sufentanil. The potency of these drugs is reflected in associated
fatality statistics. Between 1990 and 1997, 18% of identified substance abusers
in academic departments either died or required resuscitation before substance abuse
was suspected.[162]
Not surprisingly, fentanyl
was most often the drug of choice.
Other Factors
Chemical dependence is a complex disease with multiple factors
modifying one's genetic predisposition. Although it
*From
the ASA Curriculum on Drug Abuse.
Figure 88-2
Time course of addiction illustrating the relative addictive
potential of several drugs. Because the intent is to display a concept visually
rather than to present data, no numeric values are given. Dependence on alcohol
typically requires years to become apparent, whereas addiction to sufentanil develops
almost instantaneously. The slopes are roughly proportional to the addictive potential
for each drug.
is tempting to point to a single factor, such as potency and availability, as the
cause in anesthesiologists, this approach overlooks many possibilities. Other elements
to be considered include the previous use of drugs and a family history of drug abuse.
A history of experimental use of drugs increases the risk of future addiction.[178]
Genetic predisposition to chemical dependence may contribute to the progression
from abuse to addiction. Lack of self-respect, denial that one's pattern of drug
abuse can lead to addiction, and the false assumption that an understanding of pharmacology
prevents one from becoming addicted are all involved.
