A good overview of the "problem". I give a presentation on substance abuse and chemical dependence in the anesthesia professional every year to the anesthesia programs in Ohio. As a recovering "retired" CRNA, peer assistance advisor
and chair of the practitioner wellness and peer assistance committee in Ohio, I am contacted by several nurse anesthetists or anesthesia departments each month.
Substance abuse/chemical dependence is the number one health risk associated with the practice of anesthesia. Since accurate statistics are difficult to gather because of the stigma associated with this disease (if you are recovering and working, would you want anyone to know? Of course not! Our colleagues are less tolerant of addiction in nurses than they are in their "regular" patients!), there is no doubt the numbers quoted are well below the actual rate. The American Association of Nurse Anesthetists (AANA) is celebrating 26 years of peer assistance
this year. Despite the active participation of many CRNAs, both recovering and non-recovering, the association didn't really "come out of the closet" about this deadly disease until a respected association president died of an accidental overdose of sufentanil . She was a dynamic leader and an excellent anesthetist, working on numerous committees and holding elected office in state and national organizations. Only a couple of months after leaving the office of AANA president (1999-2000), she was found dead in her home by her daughter. The association did what almost all organizations (an almost everyone else) does, they kept the reason for her death quiet. Fortunately her daughter didn't want her mother's death to be "for nothing". She spoke at our first annual Peer Advisors workshop in 2007. She said, "If my mother was vulnerable to this disease, then I have no doubt anyone can develop it." She requested that the AANA develop a program about this occupational hazard in order to educate the members in order to prevent or detect the early signs of chemical dependence in a colleague in order to get them into treatment as soon as possible. Today the Jan Stewart Memorial Lecture Series
, started in 2004 at the annual meeting in Seattle, is presented every year, touching on healthy ways of dealing with the stresses associated with the profession.
Chemical dependence isn't about willpower, lack of morals, or "poor educational" status. In fact, studies have shown the "average" anesthetist seeking treatment is a male, 35 years old with eight years of experience, and finished in the upper third of their graduating class. People seem to think the more you know about controlled substances, the less likely you are to become addicted. Does that mean the more you know about cancer (like an oncologist) the less likely you are to develop cancer? Of course not! But it DOES mean those who understand and can recognize the signs and symptoms of the disease (whether addiction, cancer, or any other chronic, progressive disease) will seek treatment sooner. We all know the sooner you treat a disease the better the chance of achieving and sustaining remission. My brother-in-law died from Rocky Mountain Spotted Fever at the age of 37! Why? Because he ignored the symptoms for too long before seeking treatment. He died of overwhelming sepsis despite vancomycin and every other antibiotic they used. His son developed signs about a week after his Dad died. He took tetracycline and has a family of his own today.
If you look at the way we treat other chronic diseases (early recognition, evidence based treatment protocols, and long term follow up and continuing care) compared to the way we treat chemical dependence (myths and misunderstanding..."the addict has to hit bottom before treatment will work", or, "The addict has to want treatment or it won't work"), then it becomes glaringly clear why so many addicts relapse and/or die. We wait until their behavior becomes so abnormal we CAN'T ignore it anymore. We provide too little evidence based treatment for too little time (studies show a significant difference in sustained recovery when treatment lasts 90 days or more, yet most treatment lasts 28 days). There is little ongoing care and follow up (yet we all know that people with heart disease, diabetes, cancer and other chronic diseases do significantly better with aggressive treatment and long term follow up care). Until we treat chemical dependence as the chronic brain disease that it is (there are still those who argue addiction isn't a disease. Read the literature...and you won't be in that shrinking population), we will continue to see increasing numbers developing the disease and the same numbers relapsing. People rationalize the way addiction has historically been treated by saying the addict did it to themselves. Ummm, OK. Smokers develop lung cancer, oral cancer, COPD, heart disease, etc. because "they did it to themselves". We don't withhold treatment, limit treatment, or treat them like "low-lifes". People who sunbathe develop skin cancers, including melanoma. Didn't they "do it to themselves"? How about the person who develops Type II diabetes because they eat poorly and exercise too little?
There is no doubt a genetic link to the development of the disease of addiction. What does that mean? It means the person who "experiments" with mood altering substances is at risk to develop the disease. But let's face it, drinking alcohol is ingrained in our culture and many others. We celebrate births, new jobs, promotions, the new house, graduation, etc. with alcohol. We sell alcohol at sporting events, restaurants, comedy clubs, grocery stores, etc. Many religions use alcohol in the form of wine during their religious ceremonies. Native American tribes use peyote and other mood altering substances during many of their rituals, as do other cultures and religions. For 80 - 85% of the population, mood altering substances won't become a problem. That means they "know when to say when" and are capable of "drinking responsibly". But 15 - 20% WILL have a problem. My goodness! If there was a substance or substances that caused breast cancer (or prostate cancer) in 15 - 20% of those exposed to it there would be marches on Washington, we'd have all sorts of telethons and other fund raising activities to find a cure, and those companies that produced the substance would hounded and sued until they disappeared. The only reason the tobacco companies aren't gone is politics. While smokers are "frowned upon", there are specific areas designed at workplaces and throughout our cities to accommodate smokers. I've often thought about walking into the smoking area with a tourniquet and syringe of saline just to see the reaction. I mean come on! If they can have their nicotine break, why can't I have my fentanyl break? It's OK to sell nicotine gum as replacement therapy for smokers, but not OK to have methadone clinics available for the heroin/opioid dependent person trying to stop mainlining their drug? When you start looking at chemical dependence as a chronic, progressive, fatal (if untreated) disease...treatment makes sense, and long term recovery is possible when evidence based treatments and long term follow up care is utilized as it is for diabetes, htn, and other "acceptable" diseases.
The bottom line is this, we are ALWAYS going to have mood altering substances legally available (there is discussion of mood altering substance use in literature from ancient China and Egypt), whether it's alcohol, opioids or other substances to control pain, treat insomnia, and a variety of other conditions. I'm not advocating a new prohibition.. What I am advocating is treating substance misuse (much less negative than the term substance abuse) and chemical dependence as the "conditions", syndromes, or diseases that they are.
Intelligence has nothing to do with this disease. Neither does "moral fiber" or character. If a person has the genetic possibility of developing chemical dependence and is exposed to the right substance, in the right amount, under the right conditions, dependence will develop. The problem we have with this disease is the target organ is the brain, and the effects are seen in the most primitive areas of our brain. This area is involved in most of our instincts are found (like finding food, water, and activities that keep the species going...sex, caring for offspring, etc.), as well as learning and motivation. As the disease progresses the person is motivated to obtain and compulsively use the drug, and becomes less capable of learning from the negative consequences of their actions while under the influence of their drug of "choice" (ironic that the inability to choose to stop using a substance is known as the drug of choice). Likewise, as the brain is altered more and more by the increasing amounts of the substance they are misusing, it begins to "see" the drug as important for survival, more important than food, water, or sex! One of the lectures at our national meeting in San Diego was by a Steven D. LaRowe, Ph.D., Center for Drug and Alcohol Program, Medical University of South Carolina, and the Substance Abuse Treatment Center
Ralph H. Johnson VA Medical Center. He explained how the brain can control your actions when survival is at stake. He posed the question, "If you had lost your job, home, and all your earthly possessions, and you and your children were starving, would you resort to illegal activities to save your life and the life of your children?" Well, DUH! Of course you would! Well, because drugs that can trigger addiction alter the chemistry in the very areas of the brain necessary for that survival instinct, and actually cause the release of dopamine and other "pleasure" substances in amounts 100 to 1,000 times more than natural stimulators (like sex, food, and doing a great job or caring for our kids), the "addict" will participate in illegal activities in order to obtain their drug of "no choice". That's why a rat which has become addicted to a substance will push the lever for the substance rather than push a lever that dispenses food or water. They will continue to push the lever for the substance until they are dead despite the fact that they can have as much food and water as they want. It doesn't matter how intelligent the rat is. And I think most people agree that rats don't have a conscience or a moral code (I understand they are conducting a study right now using attorneys instead of rats......JOKING, JOKING!).
This is why time is so important in achieving recovery (or remission). Time is important for allowing the brain to recuperate (although it never recovers to the pre-addiction state) while providing time to learn new ways of dealing with cues that can lead to relapse. It takes time and repetition to develop and reinforce new synaptic pathways that are more active than the pathways that developed during addiction. This is where continued attendance at support groups, talking about cues, and remaining abstinent from all mood altering substances is so important to maintaining recovery. It's like working out to achieve physical fitness. Once you achieve the desired level of fitness, you don't stop working out. Maintaining fitness doesn't take as much effort as achieving fitness, but doing nothing guarantees you will very quickly end up out of shape again, usually worse than before since we usually increase caloric intake to feed the newly developed muscle tissue. When we stop working out, we rarely decrease our caloric intake meaning we regain all we lost and then some.
Unfortunately, this forum doesn't allow the in-depth discussion necessary to obtain the amount of knowledge necessary to fully grasp all that is known about the disease. But there are educational opportunities available, which very few nurses (or MDs and other health care providers) take advantage of in their personal practice.
Because no one believes it will happen to them. And, it's not really a disease, right?