Psychiatric Annals

Case Challenges 

A 40-year-old Anesthesiologist Who Collapses in the Operating Room

Abstract

Mr. M, a 40-year-old fellowship-trained cardiac anesthesiologist, collapses while providing anesthesia for a coronary bypass operation. He has pinpoint pupils and a syringe nearby. His urine test was negative but he appeared to have a recent needle track and was revived with 1.2 mg of intravenous naloxone.

Mr. M's colleagues have noticed that he has been looking pale and recently has lost weight. In recent months, operating room staff members have noticed that he has had frequent mood swings, but no one suspected that he was having any problems. In retrospect, they agree that he has had a slow and subtle decline in health. However, he was the first anesthesiologist in his group to arrive at work each morning and had increasingly volunteered to take extra cases and give breaks to his partners. He was seen as the hardest, most diligent worker. He has not missed any work for sickness or personal leave. He covers for everyone so that they can attend their children's athletic competitions or other meaningful events. Everyone likes him.

However, when one of the surgeons approached Mr. M about his illegible writing on charts, he became angry and threatened the surgeon. While numerous hospital and staff noted these changes, the cause was not apparent until his loss of consciousness in the operating room. After medical treatment, the chief of staff said it appeared that he had been injecting prescription analgesics for some time.

Mr. M is married and has four children. After graduating with honors from medical school, he completed an anesthesiology residency at a major university medical center and then a highly competitive cardiac anesthesiology fellowship.

He does not have a family history of addiction. He never smoked tobacco, tried marijuana once in medical school while dating an artist, and drank socially. At age 30, he had briefly experimented with sublingual fentanyl but did not use it during the fellowship. At age 35, after entering a busy private practice, he began to use sufentanil sublingually, sometimes up to 30 milliliters (1,500 micrograms) daily, and later progressed to injecting the drug. After 5 years of use, he collapsed in the operating room.

Temporarily remove Mr. M from his position as anesthesiologist through medical leave.

Admit Mr. M to a treatment center designed for physicians.

Refer Mr. M. to an addictionologist for evaluation.

Evaluate Mr. M for pharmacologic and psychotherapeutic interventions.

In this case, Option 2 was chosen. Intervention by the chief of staff and the administrator of the hospital was followed by admission to a center that specializes in chemically dependent physicians. After 4 months of inpatient treatment, he unsuccessfully returned to his practice. He complained of sweats, palpitations, diaphoresis, nausea, and even gag reflex when he saw the operating room. He filed for disability but was denied. Eventually, he successfully completed a 5-year aftercare and monitoring program with the state physician health agency.

This case presents some of the typical symptoms of opioid abuse and dependence among anesthesiologists: working long hours, even preferring work to all other activities; careful prescription medicine diversion; covering tracks; sloppy charting; mood swings; and an emergency providing the evidence of a major problem. Fentanyl and its analogues, including sufentanil, are easily diverted by anesthesiologists despite measures such as monitoring the check out and return of these medications. Refractometry of returned “waste” syringes can be used to help prevent the substitution of IV fluid as “waste.” However, the anesthesiologist remains the sole controller of the amount checked out and actually administered to the patient. By simply checking out enough to administer to the patient and to divert while charting that the…

Patient Status

Mr. M, a 40-year-old fellowship-trained cardiac anesthesiologist, collapses while providing anesthesia for a coronary bypass operation. He has pinpoint pupils and a syringe nearby. His urine test was negative but he appeared to have a recent needle track and was revived with 1.2 mg of intravenous naloxone.

Mr. M's colleagues have noticed that he has been looking pale and recently has lost weight. In recent months, operating room staff members have noticed that he has had frequent mood swings, but no one suspected that he was having any problems. In retrospect, they agree that he has had a slow and subtle decline in health. However, he was the first anesthesiologist in his group to arrive at work each morning and had increasingly volunteered to take extra cases and give breaks to his partners. He was seen as the hardest, most diligent worker. He has not missed any work for sickness or personal leave. He covers for everyone so that they can attend their children's athletic competitions or other meaningful events. Everyone likes him.

However, when one of the surgeons approached Mr. M about his illegible writing on charts, he became angry and threatened the surgeon. While numerous hospital and staff noted these changes, the cause was not apparent until his loss of consciousness in the operating room. After medical treatment, the chief of staff said it appeared that he had been injecting prescription analgesics for some time.

Patient History

Mr. M is married and has four children. After graduating with honors from medical school, he completed an anesthesiology residency at a major university medical center and then a highly competitive cardiac anesthesiology fellowship.

He does not have a family history of addiction. He never smoked tobacco, tried marijuana once in medical school while dating an artist, and drank socially. At age 30, he had briefly experimented with sublingual fentanyl but did not use it during the fellowship. At age 35, after entering a busy private practice, he began to use sufentanil sublingually, sometimes up to 30 milliliters (1,500 micrograms) daily, and later progressed to injecting the drug. After 5 years of use, he collapsed in the operating room.

Treatment Options

  1. Temporarily remove Mr. M from his position as anesthesiologist through medical leave.

  2. Admit Mr. M to a treatment center designed for physicians.

  3. Refer Mr. M. to an addictionologist for evaluation.

  4. Evaluate Mr. M for pharmacologic and psychotherapeutic interventions.

Treatment Choice

In this case, Option 2 was chosen. Intervention by the chief of staff and the administrator of the hospital was followed by admission to a center that specializes in chemically dependent physicians. After 4 months of inpatient treatment, he unsuccessfully returned to his practice. He complained of sweats, palpitations, diaphoresis, nausea, and even gag reflex when he saw the operating room. He filed for disability but was denied. Eventually, he successfully completed a 5-year aftercare and monitoring program with the state physician health agency.

This case presents some of the typical symptoms of opioid abuse and dependence among anesthesiologists: working long hours, even preferring work to all other activities; careful prescription medicine diversion; covering tracks; sloppy charting; mood swings; and an emergency providing the evidence of a major problem. Fentanyl and its analogues, including sufentanil, are easily diverted by anesthesiologists despite measures such as monitoring the check out and return of these medications. Refractometry of returned “waste” syringes can be used to help prevent the substitution of IV fluid as “waste.” However, the anesthesiologist remains the sole controller of the amount checked out and actually administered to the patient. By simply checking out enough to administer to the patient and to divert while charting that the total amount checked out was administered, the anesthesiologist can obtain an undetectable supply. Without another professional actually monitoring the amount administered, there remains unchecked diversion potential.

Fortunately, the anesthesiologist's addiction in this case was treated early enough to prevent an untimely death. Treatment of physician addicts is well understood, and success rates at or near 90% at 5-year follow-up are not uncommon.1 While early recognition and intervention is important, we have recently discussed primary prevention strategies. We have reported that anesthesiologists are overrepresented among the population of physician addicts.2 Up to one-fourth of all physicians with substance abuse disorders are anesthesiologists, yet they make up no more than 5% or 6% of the licensed physicians.3 Anesthesiologists like this patient have an excellent recovery rate as confirmed by interviews and urine testing, but unlike other physician addicts often have problems returning to work.

What is it that makes anesthesiologist have the greatest risk of addiction among all subspecialties? Current explanations revolve around access to the anesthesiologist holding and administering narcotics, but can increased access to highly addictive substances really explain late-onset opioid dependence and overdose? We have proposed that our experience and research with children of cigarettes smokers can provide insights and hypotheses. Children of smokers smoke at higher rates and have higher rates of dependence.4 Rather than access or modeling, new theories explain this increased risk as a result of secondhand exposure to cigarette smoke — smoking against their will and knowledge.

From this, we have hypothesized that exposure to secondhand drugs in the operating room places anesthesiologists at risk.3 This hypothesis is difficult to support without evidence that anesthetic and analgesic agents are present in the air that anesthesiologists would breathe during surgery. We now know opening multiple glass ampules of sufentanil and drawing it up into syringes results in potent opioids becoming airborne; these can then be inhaled in the operating room.

Some may question if fentanyl can be aerosolized and active in the air, but recent events, such as its use to subdue terrorists who took hostages in a theater, in Moscow, Russia, clearly demonstrate its potential potency in the air.5 We have completed preliminary testing and can now confirm that analgesics like fentanyl and anesthetics such as propofol, which are injected intravenously, are present in the operating room environmental air.6–8 Although anesthetic cases are scavenged and vented out of the operating room, leakage occurs and air exchange is not optimal. This results in additional exposure to anesthesiologists positioned next to the patient and the gas machine. Our initial work has been summarized previously.5,9

Fentanyl and derivatives are extremely potent and could be inhaled by anesthesiologists. Narcotic agents are known to sensitize the brain, change the brain, and make use and abuse more likely. Sensitization, rather than access, may explain the problems that many anesthesiologists have after successful treatment in returning to their work in the operating room. Our ongoing studies will attempt to quantify exposure and estimate the effects of chronic exposure to opioids on the risk of future development of addiction.

Editor's Note: This monthly feature is based on a series of talks related to the annual Psychiatric Annals Symposium in New York, NY. Each presentation describes a case of a psychiatric disorder, discusses past treatment attempts, offers options for continuing treatment, and explains the reasons the solution was selected. The third annual Psychiatric Annals Symposium, on treatment-resistant and bipolar depression, will be held April 1–3, 2005, in New York.

Submissions of interesting psychiatric case reports are now being accepted for this department. Please e-mail soconnor@slackinc.com for further information.

This case was provided by Mark S. Gold, MD, distinguished professor and Chief, McKnight Brain Institute, Departments of Psychiatry, Neuroscience, Anesthesiology, Community Health & Family Medicine, University of Florida, Gainesville, FL. Co-authors were Kimberly Frost-Pineda, MPH, associate in psychiatry and coordinator, Public Health Research Group, Division of Addiction Medicine, University of Florida; and William S. Jacobs, MD,. Medical Director, Wekiva Springs Wellness Center, and assistant professor, Division of Addiction Medicine, University of Florida.

References

  1. Gold MS, Pomm R, Kennedy Y, Jacobs W, Frost-Pineda K. 5-Year state-wide study of physician addiction treatment outcomes confirmed by urine testing. Presented at: Society for Neuroscience's 31st Annual Meeting. ; San Diego, CA. ; November 10–15, 2001. .
  2. Jacobs WS, Hall JD, Pomm R, et al. Prognostic factors for physician addiction outcomes at five years. J Addict Dis. 2003;22(2):140.
  3. Gold MS, Frost-Pineda K, Pomm R, Melker RJ. Is addiction an occupational hazard for anesthesiologists? Presented at: The College on Problems of Drug Dependence. ; June 14, 2004. ; San Juan, Puerto Rico. .
  4. Gold MS. Drugs of Abuse: A Comprehensive Series for Clinicians ( Vol. IV: Tobacco). New York, NY: Plenum Medical Book Company; 1995.
  5. Gold MS, Byars JA, Frost-Pineda K. Occupational exposure and addictions. Psychiatr Clin North Am. 2004;27(4): 745–753. doi:10.1016/j.psc.2004.07.006 [CrossRef]15550291
  6. Gold MS, Dennis DM, Morey TE, Frost-Pineda K, Melker RJ. Addiction is an occupational hazard for anesthesiologists: how and why?Anesthesiology. 2004;101(4):A1323.
  7. Gold MS, Melker RJ, Pomm R, et al. Anesthesiologists are exposed to fentanyl in the operating room: addiction may be due to sensitization. Int J Neuropsychopharmacol. 2004;7(S1):1–23.
  8. Gold MS, Melker RJ, Frost-Pineda K, Morey TE, Dennis DM. Secondhand exposure to propofol and fentanyl in the operating room: anesthesiologists' occupational opiate addiction. Presented at: Society for Neuroscience's 34th Annual Meeting. ; San Diego, CA. ; October 23–27, 2004. .
  9. Gold MS, Dennis DM, Morey TE, Melker R. Exposure to narcotics in the operating room poses an occupational hazard for anesthesiologists. Psychiatr Ann. 2004; 34(10):794–797. doi:10.3928/0048-5713-20041001-21 [CrossRef]
Authors

10.3928/00485713-20050101-03

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