CRNA Drug Addiction

subee, MSN, CRNA · Oct 6, 2006

In a recent lecture by a peer assistance counseler from AANA, we were told the rate of crna drug abuse was proportional to the country. Does anyone know if this is true? I assumed yes, but have never read anything.....
And to open up another topic, what do you all think about recovered addicts returning to practice? I have a strong opinion on that, always just thinking "what if my mother was the patient" type of approach, what do you guys think?

Some can return to work and some can't. If they're back to work with a frequent monitoring and conforming to the other items in the RTW contract, relapses can be picked up quickly. That's more than you know about the CRNA who's not being monitored. Having a co-existing psychiatric disorder makes all the difference in the world. If we never gave people the chance to RTW, there would be a lot of OR rooms closed down!

TrudyRN · Oct 6, 2006

I don't know why but some good reasons have been suggested here. I do know that I am still angry that I was once falsely accused (20 years ago) of stealing the Librium, I think it was, out of PAR because I was the only nurse on 11-7 and, of course, carried the keys. Turned out it was a CRNA. When they finally caught him, they allowed him to resign and he just went down the street and got another job as a CRNA. No one ever apologized to me.

I learned then, if I hadn't already learned, that appearances can be deceiving and that things are not always what they might look to be, and never to decide something based on only circumstantial evidence. I hope the *(^@#^+* who accused me learned the same lesson.

TrudyRN · Oct 6, 2006

In a prior career as an anesthesiologist, I saw 2 CRNAs become addicted to fentanyl. One quit practice immediately, one went through a drug addiction program requiring monitoring for one year with naltrexone being given orally (witnessed) daily. Within a month after the year probation, the CRNA relapsed sadly again, and quit practice. He was a friend of mine and I was very distraught at his demise. I have seen anesthesia residents addicted to fentanyl, halothane, sufentanil, ketamine, and demerol. One resident that had been on probation once already for substance abuse (fentanyl) had a positive urine drug screen for ketamine 2 days before the end of residency. He never practiced anesthesiology thereafter.
Many who became addicted were the thrill seekers...the base jumpers, mountain climbers, mountain bikers, downhill skiiers....those that like a little living on the edge. But some were quiet and had rather bland lives....
Addiction is a very sad reality of our profession that can bite any of us at any time. Many feel stressed as the inciting cause, turning to fentanyl, an easily accessable drug, thinking they can control their use. But rapid escalation is the rule, and within a few weeks to a few months, most have escalated their doses to massive amounts, sometimes up to 20-50cc per day IV.
You can help...take note of those that are dissheveled, frequently late or unreliable, frequently early (when the obtain the drugs), staying late, seem preoccupied, pinpoint pupils, withdraw from social groups or engagements, and are less conversant than previously. Their charting may become sloppy or abbreviated. Their patients arrive in the PACU screaming in pain and require much higher doses of narcotics in the PACU than do those of other providers. If you notice these signs, don't just chalk it up to too much hard work or study...by notifying your program director, you may save their life. We lost two lives over the past 10 years by not noticing soon enough....don't make the same mistake or think someone else will file a report...everyone else is thinking the same thing and nothing gets reported.

This is good to know. Thanks, paindoc.

jackstem · Mar 8, 2009

I'm not sure that the addiction rate is higher for CRNA's. I've worked for many years in many OR's and have heard of a many anesthesiologists, OR RN's & Techs, PACU RN's, EMT's and med/surg/re-hab/LTC RN's but NEVER a CRNA. Perhaps the numbers are so small that it doesn't take many to skew the percentage rate.

The rate of addiction in society and specific groups (nurses, anesthesia providers, pharmacists, attorneys, pilots, etc.) is difficult to determine accuratley. The stigma (they did this to themselves, they deserve whatever happens to them) associated with this disease means most people are unwilling to disclose they are addicted or have received treatment and are now in recovery.

The rate of addiction in anesthesia providers (anesthesiologist or CRNA) is indeed higher than in other health care professionals. I'm a recovering addict, former CRNA, and now chair and senior advisor for the Ohio State Association of Nurse Anesthetists Peer Advocacy for Practitioner Wellness Committee. Substance abuse and addiction is the number one health risk associated with the practice of anesthesia. According to the American Association of Nurse Anesthetists past president Terry Wicks, CRNA, MHS,

Every anesthesia provider, irrespective of credentials, experience, or responsibilities, can become a victim of chemical dependency when they experience unmanageable physical or emotional pain, unrelenting stress, or other life experiences that increase their vulnerability.

The Farley Center and The Talbott Treatment Campus have treatment programs spefically for health care professionals. Multiple risk factors for addictive behavior have been identified for the anesthesia provider.

Farley and Talbott commented on certain similarities among the anesthesiologists and nurse anesthetists treated in the Medical Association of Georgia's Impaired Physician Program which they labeled "anesthesiology trigger mechanisms. The 5 most common triggers are:
Ease of drug availability
Prior experimentation with mood-altering drugs
Job-related stress of highly specialized vocation
Respect not equivalent to responsibility
Intimate knowledge of the power of drugs
More specific stress-related risk factors include life and death decision making, long working hours, and altered sleep patterns associated with call. Depression may also manifest itself in the professional due to fatigue, stress, the death of a patient, and the juggling of a family/social life with a demanding career.

Similar risk factors exist for the nurse anesthesia student, the most predominant being stress. Students have high expectations of their own performance in both the classroom and the clinical arena. Perception of poor performance, be it accurate or not may put them at risk because of decreased self-esteem. Other factors for students may be related to increasing financial problems, decreasing time for self/family, lack of coping skills, and depression from being overwhelmed by the association demands.

Statistics are gathered from a variety sources including hospital admissions, ER visits, addiction treatment facilities, police records, and death certificates. But addiction and substance abuse aren't always included in these records for a variety of reasons (another topic for another thread).

The AANA has chosen to face this issue in their membership head on. They formed an ad hoc committe in 1983 which has evolved into the Peer Assistance and Wellness Committee. They have endorsed and encourage state associations to form their own committees and employ peer assistance advisors. The following are suggested functions for the state peer assistance advisor position:

Attend an orientation training program, where available.
Serve as a resource and support for nurse anesthetists and students with impairment issues.
Regularly communicate and network with state peer assistance programs, the board of nursing peer assistance programs, and professional alternative discipline programs.
Monitor state legislative and regulatory activities regarding chemical dependency in nursing and other health professional groups.
Familiarity with treatment programs located in the state, particularly those with a focus on health professional programs.
Act as a resource for the state nurse anesthetists association and other entities in developing or providing educational programs
Advocate for funding by your state association and other appropriate sources for support of peer assistance activities.
Request to be part of the business agenda at state association meetings to update the Board of Directors and members on state peer assistance activities
Collaborate with other groups in developing or supporting initiatives in the state that advance improvements in the area of professional well-being, substance misuse and chemical dependency.
Submit items for the state newsletter and request that the AANA Hotline, the AANA Web site information, and the Anesthetists in Recovery Hotline (AIR) be published. State peer assistance contact numbers should be listed in each issue.
Share information as appropriate with the Peer Assistance Advisors Group. Such information may include:

o Reports of state activities and/or state newsletter articles
o Suggested content for the focus sessions during the AANA Annual Meetings
o Suggested areas for student research
o Suggested postings on website.
Developed by the AANA Peer Assistance Advisors Committee, October 2006

Addiction is a chronic, progressive, unnecessarily fatal disease and must be treated in the same manner as other chronic diseases (diabetes, CAD, asthma, emphysema, etc.). With the significant increase in knowledge about the epidemiology, pathophysiology, psychology, and relapse triggers, evidence based treatment protocols are being developed which significantly increase the success of treatment and long term recovery. We can't expect society to change it's views about addiction if the health care community won't change theirs.

Addiction isn't a moral weakness or a lack of willpower. It's a chronic brain disease that destroys a person mentally, emotionally, physically, and spiritual while disrupting families, businesses, and society at large.

The impaired anesthesia provider: The manager's role

Frequently Asked Questions About AANA Peer Assistance

Key Concepts

Peer Assistance, An Historical Perspective

American Nurses Association (ANA) Resolution 2002

AANA State Peer Assistance Advisors Locator

ANA Impaired Nurse Resource Center

National Council of State Boards of Nursing Alternative Programs

Jack

tfleuter, BSN, RN · Mar 11, 2009

All very interesting and so sad at the same time. I am actually quite surprised to hear about this. I used to work as a vet tech and was handling many of these same drugs (Ketamine, Propofal, Fentanyl) I knew these drugs could be dangerous/addicitive, but never really saw anything tempting about them. I guess it was more difficult to relate to the effects they had on animals then it would on a fellow human being. At the same time, I've heard of vet techs and veterinarians abusing these drugs too.

jackstem · Mar 11, 2009

All very interesting and so sad at the same time. I am actually quite surprised to hear about this. I used to work as a vet tech and was handling many of these same drugs (Ketamine, Propofal, Fentanyl) I knew these drugs could be dangerous/addicitive, but never really saw anything tempting about them. I guess it was more difficult to relate to the effects they had on animals then it would on a fellow human being. At the same time, I've heard of vet techs and veterinarians abusing these drugs too.

Addiction is a disease that affects smart people, dumb people and every one in between. It's a bio-psycho-social disease with strong evidence of a genetic basis. Exposure to the right substance, in the right amount, for the right amount of time, in the right person, leads to addiction. No one ever drinks or uses mood altering substances intending to become an addict. In 10 - 20% of the population who "use", the disease will become active. In 80 - 90% it won't. Unfortunately, a majority of the 80 - 90% think if they can decide when enough is enough, then anyone should be able to do the same. Sadly, that's not accurate. There is a wealth of information available explaining the pathophysiology of this disease process. The problem is, very few health care providers read it. And the information that is taught in many nursing programs isn't up to date. If the health care system managed other chronic, progressive, potentially fatal diseases the way substance abuse and addiction are managed, there would be a huge outcry and something would actually be done to change the system. But since people don't understand the disease, they find it very easy to ignore the folks who have the disease. Education is a major component of the American Association of Nurse Anesthetists Peer Assistance/Wellness program. They have accepted the reality that this is the #1 health risk associated with the profession and are taking the steps necessary to bring awareness to the profession. I feel blessed that I am able to be a small part of that effort.

Jack

loveanesthesia · Mar 14, 2009

In 10 - 20% of the population who "use", the disease will become active. In 80 - 90% it won't.

These numbers may be accurate for substances such as alcohol, but I don't think so for the drugs that anesthesia providers have access to. I don't think that 80-90% of CRNAs who "use" anesthetic agents such as fentanyl or propofol can avoid addiction, my impression is that almost all will become addicted and very quickly. Or am I wrong in this? I imagine that everyone thinks before that first time they take a little fentanyl that it won't be a problem, that they won't become an addict.

jackstem · Mar 14, 2009

These numbers may be accurate for substances such as alcohol, but I don't think so for the drugs that anesthesia providers have access to. I don't think that 80-90% of CRNAs who "use" anesthetic agents such as fentanyl or propofol can avoid addiction, my impression is that almost all will become addicted and very quickly. Or am I wrong in this? I imagine that everyone thinks before that first time they take a little fentanyl that it won't be a problem, that they won't become an addict.

We have no truly accurate numbers for the rate of dependency in any population. Not all incidences of abuse and dependency are accurately recorded due to stigma and fear of backlash by colleagues and society in general. The most common sign there may be a problem is finding the provider unconscious or dead. The numbers that are available are generally considered to be lower than the actual rate. The addiction rate for ALL anesthesia providers is listed as 10 - 20%. We're talking all providers, not just CRNAs. Also, that rate isn't just those who have "tried" the drugs...it's for the entire profession (MDA, CRNA, AA). I'd agree that of those who choose to "experiment" or use it for pain control, sleep, etc., the rate of addiction is well over 20%. There are those who think it's lower, but in my experience over the past 18 years, it's well over 10%...closer to 17+%.

Read "Substance Abuse Policies for Anesthesia". It's the most current and complete source of information available.

loveanesthesia · Mar 15, 2009

I guess my point is that the rate of addiction-often quoted at 10-20% of anesthesia providers- is different than saying that only 10-20% of those that try it will become addicted. Most anesthesia providers never try fentanyl or propofol, so do not become addicted. But of those that do divert the drugs I think the evidence shows that the vast majority will develop an addiction. It is dangerous to think that you only have a 10-20% chance of getting into trouble if you take some fentanyl. Taking the drug the first time is a choice, after that it may not be, but you do have control that first time. I believe education can help prevent experimentation and/or self medication.

jackstem · Mar 15, 2009

I guess my point is that the rate of addiction-often quoted at 10-20% of anesthesia providers- is different than saying that only 10-20% of those that try it will become addicted. Most anesthesia providers never try fentanyl or propofol, so do not become addicted. But of those that do divert the drugs I think the evidence shows that the vast majority will develop an addiction. It is dangerous to think that you only have a 10-20% chance of getting into trouble if you take some fentanyl. Taking the drug the first time is a choice, after that it may not be, but you do have control that first time. I believe education can help prevent experimentation and/or self medication.

You're correct...the rate of 10 - 20% is for ALL anesthesia providers, not of those who "try" fentanyl, sufentanil, propofol, etc. If my original post wasn't clear I apologize. You would be surprised at the number of individuals who don't believe the number is as high as 10%.

Unfortunately we live in a society that enjoys the use of mood altering substances, activities, etc. The age for first use of alcohol is getting lower (11 -12). For the person who has the genetic predisposition for chemical dependence (around 10 - 12% of the population), avoiding the use of alcohol and other substances can prevent the disease from ocurring. Many anesthesia providers have substance abuse and chemical dependence before they enter the profession. A large number of people (in and out of the profession) don't believe chemical dependence is a disease, they believe it's a lack of willpower or moral weakness. Pretty tough to get people to avoid exposure to ETOH, marijuana, etc. if they don't believe dependence will happen to them. That's why a major focus of the Peer Assistance Advisors Committee and the State Peer Advisors is on recognizing the signs and symptoms in a colleague and having polices and procedures in place to help get that colleague into treatment at the earliest possible moment. The lack of education and the stigma associated with the disease make it difficult to get the profession to change the way they deal with this issue. We're doing our best to get things changed.

alterego33 · Mar 20, 2009

I would highly recommend that you go to http://www.aana.com, and look for the link called AIR (anesthetists in recovery). You will get some valuable information there and maybe meet people who have personal knowledge about the topic.

Home Health Columnist / Guide · Mar 22, 2009

aana links:

peer assistance homepage

anesthetists in recovery (air)

anesthetists in recovery, chemical dependency in the profession