This article is extracted from Anesthesiology News, May 2007, Vol 33:05
One addict fell asleep at his desk so often that his lolling forehead became a perpetual bruise. Another was so desperate for a fix that he started trolling through sharps bins for discarded needles with traces of drug to inject.
The addicts were two doctors, an anesthesiologist and a family physician. Their drug of choice: propofol.
If that's surprising, consider this: One in five academic anesthesiology training programs reported at least one case of abuse by physicians or other healthcare workers over the past decade, new research shows. The incidence of propofol abuse has risen fivefold over the last 10 years.
Propofol abuse shatters careers and lives-and worse. Only a few cc's more than what's required to put a person to sleep can trigger fatal respiratory arrest. That threat is an insufficient deterrent for determined users; 40% of residents who reportedly abused the anesthetic died from the high-the peril of propofol's exquisitely narrow therapeutic window.
"That's the drive to use this drug. It's amazing," said Paul Wischmeyer, MD, an anesthesiologist at the University of Colorado Health Sciences Center in Denver. "People who have abused propofol say it's pretty much their first-choice drug every time."
Because propofol is such a short-acting substance, heavy abusers must inject it frequently to stay high-as many as 50 to 100 times during a using session is not unheard of, he said. Access to the drug is not a problem, as propofol is among the most widely used anesthetic agents in both hospitals and, increasingly, office settings. "It's everywhere," Dr. Wischmeyer said.
Dr. Wischmeyer became interested in studying propofol abuse in physicians after hearing the bin-fishing physician, who had since sought treatment for his addiction, describe his ordeal. Dr. Wischmeyer and his colleagues have conducted surveys on the extent of propofol abuse, and that of inhaled anesthetics, among academic anesthesiologists. Their work was presented at the 2007 annual meeting of the International Anesthesia Research Society, and has been accepted for publication in a major specialty journal.
Although many in academia are aware of propofol abuse, most anesthesiologists in private practice probably have not heard of the troubling phenomenon, Dr. Wischmeyer said. Yet, even if anesthesiology department heads know such a problem exists, the news hasn't filtered down yet to the hospitals in which they practice. No formal system is in place for monitoring propofol, as there is for opioid drugs and other controlled substances, in 71% of programs the Colorado group polled. A statistically significant correlation exists between the incidence of propofol abuse and the lack of pharmacy control over the anesthetic, he added.
Old Problem, New Solution
Drug abuse by anesthesiologists is hardly a new topic. The American Society of Anesthesiologists (ASA) has been addressing it for decades. The group pushed for gas scavenging and air recirculation technology with the hope of reducing the exposure to operating room (OR) personnel of anesthetic gases. In 2001, the ASA became alarmed enough about substance abuse that it designed a model curriculum for residency programs to combat the problem.
"Educating residents may be an effective method for prevention of the disease and, through heightened awareness, will hasten identification and treatment of victims of the disease," according to an ASA statement about the curriculum.
In order to gain accreditation, residency programs in anesthesiology must offer trainees at least some education on chemical dependence each year.
Lately, the lay press has picked up on the subject. Men's Health magazine published an article last November titled, "The Junkie in the O.R.," claiming an "epidemic" of drug-addled anesthesiologists "who are addicted to their own drugs."
The article cited studies suggesting that "more than 400 drug-addicted anesthesiologists and residents may be working in operating rooms at this moment," and that the specialty is disproportionately treated for addiction. (Experts interviewed for this article disputed that figure, saying the real number, although nearly impossible to determine, is probably much smaller.)
The story relied in part on findings from a group of researchers at the University of Florida who believe that anesthesiologists may be unwittingly driven to substance abuse through chronic exposure to aerosolized fentanyl and propofol exhaled by patients in the OR (Med Hypotheses 2006;66:874-882).
In a letter to the magazine, ASA president Mark Lema, MD, PhD, called the story "sensationalistic," "lurid" and "bizarre."
Men's Health may have presented "unsubstantiated theories as fact," in the words of Dr. Lema. But the new findings indicate that propofol abuse is indeed a potentially serious problem facing anesthesiology departments.
At least one case of propofol abuse or diversion-theft of the drug or its use by someone other than a patient-was reported in 20% of the nation's 126 academic training programs in the specialty, according to one of the Colorado surveys.
Of the 29 cases reported to researchers, 16 involved residents and six were attending physicians; three were nurse anesthetists, and two were OR or anesthesia technicians, with two classified as "other."
In the vast majority of cases, physicians who abused propofol dropped out of anesthesiology, the researchers found, with only three of 22 remaining in the field and seven leaving medicine entirely. Slightly more than half of all abusers completed a rehabilitation program, with four reports of relapse.
Deaths attributable to abuse were alarmingly common, with nine overall. The incidence of mortality was highest for residents, among whom six deaths (37.5%) were reported.
In a related study, Dr. Wischmeyer's group conducted an online survey of the 126 anesthesiology department chairs about abuse of inhaled anesthetics among their personnel. Again, they found its incidence apparently growing, with 21 (23%) of the 90 department heads who responded to the survey reporting at least one case of abuse within the last 25 years; of those cases, 61% occurred since 2000. Residents and nurse anesthetists accounted for 43% and 21% of cases, respectively.
As before, mortality was far from uncommon, with six of 28 cases (21%) resulting in death. Dr. Wischmeyer noted that the apparent surge in cases of abuse over the past decade might be affected by recall bias. However, he added, "either way, it is alarming."
Joel Wilson, MD, a resident in anesthesiology at the University of Colorado, who helped conduct the research (abstracts S-89 and S-92), said he and his colleagues are planning several additional studies. The group is particularly interested in trying to replicate the work of the Florida investigators, and hope to correlate prolonged exposure to propofol in the OR with elevated levels of the drug in blood and hair. "We also want to see if we can find a difference in pre- and post surgery blood levels of propofol in residents working in the OR and try to determine if these levels are clinically meaningful," he said.
Link to Emotional Trauma
Unlike abusers of alcohol or most other substances, propofol addicts are unable to function on the job, said Paul Earley, MD, a physician who specializes in treating doctors and other healthcare providers. "It's not a subtle drug," Dr. Earley said. "It's not like fentanyl or narcotics, where you can be slightly inebriated on the drug and even show up for work. Most of the time, you inject it and pass out."
Treatment centers that treat physicians have seen a growing number of propofol abusers over the last two years, Dr. Earley said. Almost all of them have been anesthesiologists; the majority appear to be women. Many have admitted to a history of psychological or physical trauma, such as rape or childhood sexual abuse-which may help explain the drug's appeal, Dr. Earley said. "What it's best at is why it's used in anesthesia-making people unconscious. It's somewhat dissociative, and can lead to an out-of-body sensation."
"Propofol is a drug that in a sense doesn't get you high," said Omar S. Manejwala, MD, associate medical director at the William J. Farley Center at Williamsburg Place, an addiction treatment clinic in Virginia that focuses on physicians. "It blocks out the world."
In his experience, Dr. Manejwala said, nearly every propofol addict started injecting to overcome persistent insomnia. That aspect of the medication fits neatly with the link both Drs. Manejwala and Earley have observed between propofol abuse and a history of trauma. "One of the hallmark symptoms of post-traumatic stress disorder [PTSD] is hyperarousal. Folks with PTSD want to block that out," Dr. Manejwala said.
What's puzzling, experts said, is the strength of the connection. "I don't know of any other drug where the perceived incidence of trauma, particularly of sexual trauma [in abusers], is so high," Dr. Manejwala said. "It's really quite remarkable."
In fact, Dr. Earley suspects that the psychological factors that push certain people to misuse propofol may also underlie the difficulties they face in overcoming the addiction.
"I think we're going to learn more about how to treat it, but there's a window of time when our skill set is not what it could be," he said. "We're just now on the learning curve of figuring out how to treat these folks."