PBLD Table #9 Title: One is Too Many and A Thousand is Never Enough: How to Identify and Approach Suspected Opioid Diversion Moderator 1: Emmett E. Whitaker, M.D., Attending Pediatric Anesthesiologist, Nationwide Children’s Hospital; Clinical Assistant Professor of Anesthesiology, The Ohio State University Moderator 2: Vidya T. Raman MD , Director of Preoperative Assessment Testing, Pediatric Anesthesiologist , Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH. Moderator 3: Joseph D. Tobias MD, Chairman, Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH. Goals: 1. Discuss how to recognize possible opioid diversion and outline steps to be taken when substance abuse is suspected. 2. Discuss the challenges of dealing with a physician with suspected of opioid diversion. Discuss the additional challenges dealing with practitioners in a training environment. 3. Summarize the available evidence concerning to return to anesthesia practice after treatment for substance abuse. Description: A 16‐year‐old adolescent presents for total hip arthroplasty. She has a history of juvenile rheumatoid arthritis, obesity, and chronic pain. The patient takes multiple chronic pain medications at home, including a fentanyl patch. The anesthesia team (CA2 resident and attending anesthesiologist) elect to place an epidural at the beginning of the procedure to best handle acute‐on‐chronic pain post‐operatively. Placement of an epidural catheter is successful under sedation. An intravenous induction with fentanyl, propofol, rocuronium and lidocaine is then performed. Direct laryngoscopy and endotracheal intubation are performed without incident. Large‐bore intravenous access is obtained. During the maintenance phase of the case, the attending gives the CA2 resident a break. The patient’s vital signs remain stable and seem to indicate that a surgical block has been achieved with the epidural. The attending anesthesiologist notes that the resident has documented that he administered fentanyl, 250 µg, despite evidence of an adequate regional block. When the resident returns from his break, the attending anesthesiologist asks the resident why he gave such a large dose of narcotic to a patient with an epidural, and he is unable to provide a rational answer. The resident has some prior opioid discrepancies that are still under investigation. Key Questions 1.
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What is the difference between abuse, addiction, and dependence? What are the signs of drug abuse in anesthesia practitioners? What drugs do anesthesia providers abuse? Once an anesthesia provider is in active addiction, what are the risks and/or possible results? 5. How can a department or group help prevent drug abuse? 6. How do you approach suspected opioid diversion safely in a colleague? 7. Does the history of prior discrepancies in the resident’s opioid prescribing affect your course of action? 8. Are you required, legally or otherwise, to act in this situation? 9. Is it appropriate to confront the resident directly? 10. What minimum treatment should an anesthesiologist receive in the setting of confirmed opioid abuse? 11. Are there factors that predict successful return to practice? Are there factors suggesting an anesthesia provider should not return to anesthesiology? 12. What are the requirements for a successful re‐entry to anesthesia practice? 13. Should other specialties be considered other than anesthesiology? Model Discussion 1. Abuse: use of a psychoactive substance in a manner detrimental to the individual or society but not meeting criteria for dependence. Addiction: a primary, chronic medical DISEASE; manifested by compulsive use of an addictive drug, loss of control and irrepressible craving of the drug. May be associated with criminal activity. Dependence: a generic term relating to psychological or physical dependency or both on an exogenous substance. 2. What are the signs of drug abuse in anesthesia practitioners? The following are not all‐inclusive: a. unusual changes in behavior b. sign‐out of increasing quantities of narcotics and frequent breakage of narcotic vials c. inappropriately high doses of narcotics for procedures being performed d. increasingly sloppy and unreadable charting e. desire to work alone f. refusal of lunch relief or breaks g. frequently relieving others h. volunteer for extra cases (especially cardiac, where narcotics are being used in large quantities) i. volunteering for extra call j. at the hospital when off duty to stay near supply k. frequent bathroom breaks l. difficult to find between cases, often napping after using m. unexplained absences n. desire to administer narcotics personally in the PACU o. patient postoperative pain out of proportion to narcotic record p. wearing long‐sleeved gowns to hide needle marks and stay warm q. pinpoint pupils r. signs and symptoms of withdrawal, especially diaphoresis, tremors, mydriasis, rhinorrhea, myalgias, nausea and vomiting s. weight loss and pale skin t. undetected addicts are found comatose 3. What drugs do anesthesia providers abuse? Any drug can be abused by anesthesia providers, but by far, the most commonly abused drug in this group is opioids. Fentanyl and sufentanil are the most commonly used opioids. Other commonly abused drugs include alcohol, illicit drugs such as cocaine, midazolam, oral benzodiazepines, propofol, and even inhalational anesthetic agents. 4. Once and anesthesia provider is in active addiction, what are the risks and/or possible results? Once an anesthesia provider is in active addiction, there are risks to the provider, his or her patients, and the hospital or institution: a. Risks to the addicted physician: i. Death ii. Loss of license, job, family iii. Concomitant mental illness (depression) iv. Loss of insurability (health, life, disability, malpractice) b. Risks to patients i. Possible harm due to physician impairment ii. Higher risk for malpractice claims iii. Many physicians in recovery admit to having practiced while under the influence or in withdrawal c. Risk of liability/defamation of character? i. Many states have laws that protect those on “physician assistance” committees as long as they are acting in good faith and in the best interest of the impaired physician d. Risk to hospital of lawsuit from affected patients i. “Medical Staff Committee” or its equivalent usually fulfills a more disciplinary role with its goal to protect the patients and/or medical staff 5. How can a department or group help prevent drug abuse? The first step to prevention of drug abuse is preparation. Addiction is a disease, and it should be treated as such. Anesthesia groups and departments should have developed plans in advance, such as where to refer the addicted professional and who to contact for help. Poorly executed interventions may lead to poor outcomes. Another aspect of preparation is education. Members of your department should know the signs of addiction and should know what to do if they have suspicions: “If you see something, say something”. Random drug screening is controversial. There are institutions where random testing of all staff is performed. Critics of this strategy point out that it is extremely expensive, cumbersome, and that no evidence exists to suggest it prevents abuse or abuse‐related morbidity and mortality. Urine testing for cause or suspicion is probably the most appropriate course of action, keeping in mind that a low threshold for testing is advisable. Most experts agree that insistence upon meticulous narcotic reconciliation practices. This includes witnessed accounting for controlled substances at the beginning and end of the day, random narcotic utilization reviews, and random testing of narcotic waste syringes. Finally, denial is rampant when it comes to drug abuse in our colleagues. Each department must be willing to believe that it could be happening in their midst. 6. How do you approach suspected opioid diversion safely in a colleague? When signs of abuse are identified, care must be taken to avoid emotional, rather than medical, responses to the situation. Information should be gathered confidentially, and observations should be verified and documented before any action is taken. Once signs of potential abuse are verified, the department’s “wellness committee” should be convened. As indicated above, it is helpful to have this committee in place and available before the crisis occurs. Discussion of the next steps should include where to refer the individual for evaluation. An intervention should be executed with firm concern and compassion. It should be made clear that the intervention is not pejorative. Remember that addiction medicine is not your area of expertise, it is inappropriate for anyone other than a trained mental health provider to make the diagnosis. In most cases, referral to a substance abuse treatment facility with expertise in treating anesthesiologists for an evaluation is the most appropriate course of action…addiction professionals will decide what, if any, treatment is required. Of course, urine drug screening is mandatory. Chain of custody is very important at this stage. Once the intervention takes place, the individual should be escorted to employee health or comparable location for a urine drug screen. Ideally, the specimen donation should be observed, but this is not always possible. Remember that a negative drug screen does not rule out abuse. Finally, it is important to have a plan in place in the event that the individual refuses urine screening and or evaluation/treatment. This is where careful information gathering and documentation are key. Some states have mandatory reporting laws, meaning that once abuse is suspected or identified, one must identify the state medical board. In any case, it is paramount to ensure the safety of the individual. Providers who are suspected of abuse are at high risk for suicide during the period between the intervention and their arrival at a treatment/evaluation center. The wellness committee should ensure that a plan has been made for a loved one to be present with the individual until he or she is safe at the treatment center. 7. Does the history of prior discrepancies in the resident’s opioid prescribing affect your course of action? The history of prior discrepancies certainly raises the degree of concern in this case. There are often patterns of diversion seen in an impaired practitioner’s narcotic usage when it is examined after abuse is confirmed. However, it is important to note that none of the information in this case is pathognomonic for drug abuse. 8. Are you required, legally or otherwise, to act in this situation? Different states have different laws with regards to mandatory reporting. It is important to be familiar with the laws in your state. Ethically, most would agree that the attending in this situation is obligated to at least present his concerns to the appropriate person in the department. Then, someone with more experience can handle the situation from there, gathering information and deciding on the next most appropriate course of action. Confidentiality is crucial at this stage, because abuse has not been confirmed, and may not be occurring. Rumor and innuendo can do irreparable damage to an anesthesia provider’s reputation and self‐esteem. Only individuals who “need to know” should be included in the conversation. Reporting: 
Admission to alcohol or drug addiction treatment is not itself reportable if it can be a medical leave of absence  It is unlikely that there will be liability for the reporter if action was in good faith  National Practitioner Data Bank Reporting is mandated if: 
adverse actions are taken by medical societies, hospital boards and licensure boards 
medical malpractice payments have been disbursed (Health Care Quality Improvement Act, Public Law 990660, 11/86) 9. Is it appropriate to confront the resident directly? No. It is never appropriate to approach a practitioner who may be abusing drugs unless there is a clear and present danger to the practitioner or a patient. Even in that case, it is useful to have an authority figure (eg, department chairperson) involved. One‐on‐one intervention should be avoided. 10. What minimum treatment should an anesthesiologist receive in the setting of confirmed opioid abuse? The “industry standard” for confirmed drug abuse in anesthesia providers is 90‐
day inpatient treatment. Treatment should include safe detoxification at the outset. Thereafter, complete abstinence from mood and mind altering substances is expected, and maintenance of this lifestyle is often based upon assimilation into 12‐step programs such as Alcoholics Anonymous and/or Narcotics Anonymous. There is, at present, no cure for addiction. As with many chronic diseases, relapse rates are high in the absence of continued treatment. An addict who has gone through treatment is said to be in “recovery”, which is a lifelong process. Addicts who work a program of recovery are happier than they were before treatment. They lead a comfortable life without use of drugs or alcohol. Continued recovery depends upon continued treatment after rehab, including:  Long‐term care and follow‐up  Treatment by an addictionologist (addiction psychiatrist)  Counseling (individual, family, or couples as situation dictates)  Continued attendance at 12‐step meetings  Maintenance of good general health practices  Pharmacologic therapy: o Naltrexone (oral or depot intramuscular (Vivitrol)) 
State physician’s health program and/or consent agreement with the state medical board is often mandatory When the above conditions are met, there is a 60‐95% sustained recovery rate for physicians 11. Are there factors that predict successful return to practice? Are there factors suggesting an anesthesia provider should not return to anesthesiology? Generally, reentry into anesthesiology should be decided on a case‐by‐case basis. The recommendations of a qualified, experienced treatment program for physicians be followed. The following is the 3‐category re‐entry classification developed by the Talbott Recovery Program in Atlanta, GA and the ASA, and is followed by many state programs.X Category I: Certain return to anesthesiology immediately after treatment  tremendous love for or career investment in anesthesiology  accepts and understands the disease  exhibits bonding with Alcoholics Anonymous (AA) or Narcotics Anonymous (NA)  healthy and strong family support  commitment to recovery contract (five years, includes therapy and random urine screenings)  balanced lifestyle  no evidence of dual diagnosis (depression, bipolar disorder, codependency)  treatment team/representative supports return to anesthesiology  Department of Anesthesiology and hospital are supportive of return and will create accommodations for the returning anesthesiologist  Many departments will not allow a new resident to return, but will counsel them to a new specialty Category II Possible return to anesthesiology (need to take one to two years off, then decide)  relapsed with recovery underway  dysfunctional but improving family  involved, but not bonded with AA/NA  healthy attraction to anesthesiology  improving recovery skills  some denial remains  mood swings without other psychiatric diagnosis Category III: Redirected into another specialty  prolonged intravenous use  prior treatment failure and relapses 
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disease clearly remains active the patient went into anesthesia to get the drugs dysfunctional family noncompliant with recovery contract poor recovery skills no bonding with AA/NA obvious and severe psychiatric diagnosis 12. What are the requirements for a successful re‐entry to practice? Successful reentry requires the following: 
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Recovering physician must have completed an effective, structured treatment program that includes involvement of family or significant others. well motivated, honest, minimal denial with a good recovery program returning to a supportive environment for self‐esteem and career re‐entry agreement implemented before starting work, which should minimally require: o a five‐year monitoring period o should include recovering addict, medical staff committee, state society/diversion o supervised administration of naltrexone three times a week (or monthly depot injections) for at least six months o abstinence from all mood‐altering substances o attendance at a minimum of four 12‐step (AA/NA) group meetings per week o random, monitored urine drug screens o weekly aftercare or outpatient treatment for a few months o a single primary care physician who prescribes all medications o The following is strongly recommended:  no night/weekend call for three months  not handle narcotics for three months  random testing of returned syringes for drug content Prior Presentation: No References: Berry M.D., M.P.H., Arnold J. et al. Model Curriculum on Drug Abuse and Addiction for Residents in Anesthesiology 1. Angres DH, Talbott GD, Bettinardi‐Angres K. Healing the Healer. Madison, CT: Psychosocial Press; 1998.