I read with interest the article by Bryson and Silverstein1and the accompanying editorial by Berge, Seppala, and Lanier.2The problem of addiction among all anesthesia providers is a problem that requires continued study and attention to try and lessen the potentially devastating impact this disease continues to have among our colleagues.

While I welcomed the exposure to this issue the article brought, I am disturbed by the editorial by Berge et al.  and the attention it may receive as representing current opinion regarding their recommended approach to this problem.

Coming from a background of 29 yr of private practice as an anesthesiologist and 14 yr of active recovery, I have worked with physician health programs in 2 states as well as remaining involved with well-being activities in my local hospital, my state medical association, and our state component society of the American Society of Anesthesiologists. I have been aware of and witnessed both the successes and tragedies of the disease in anesthesiology with my involvement in recovery in these capacities.

I do not agree with the proposed approach of Berge et al.  of “one strike, you’re out.” I think that this is exactly opposite to the approach that should be taken to individuals who find themselves addicted to or are abusing drugs used in the work environment. I also disagree that the current default position is one of assuming a return to the workplace, a policy that I equally take issue with.

I am in agreement that there are data lacking to fully support any specific position on this issue, and also agree with Berge et al.  that such data would be impossible or inappropriate to obtain using the usual scientific approach. Further, the idea that a pragmatic approach should therefore be taken is also difficult to argue with. Where these concepts diverge from what I feel needs to be done is in how to apply this to the individual physician caught up in the disease process.

Anyone who has been active in physician well-being and addiction recovery has seen that there is a great deal of ignorance about this issue by even otherwise well-educated and well-intentioned people, often in the position to either support the idea of an appropriately conducted recovery of an individual or not. My concern with “one strike, you’re out” is that you will give these individuals the easy option of dismissing every  addicted anesthesia health care worker as too dangerous to return to work. That is draconian and also inappropriate. Evaluating each case individually involves a lot of work. Creating an appropriate aftercare environment of support, accountability and monitoring does also, but we as physicians need to do this for our colleagues.

Further, I believe that “one strike, you’re out” will discourage individuals who might otherwise seek help from doing so because of the concern that this action will end their career. Rather than disclose the need for help, even after years of successful practice, the individual will choose to remain out there rather than suffer the inevitable consequence of career loss. This has a strong potential for keeping the individual isolated, disease progressing, until he injures a patient or himself and then is discovered. For some individuals career redirection needs to happen and is the right approach, but it shouldn’t be applied to everyone any more than the idea that everyone should get a chance to return to the same work environment in the same capacity.

I am also disappointed in the editorial policy of Anesthesiology that allowed this editorial to be published without so much as a counterpoint view. For the uneducated and inexperienced in this area this editorial may well be adopted as the standard approach by some departments and treatment centers dealing with these personnel, simply because it appeared as it did in this journal. That would be very unfortunate and a tragedy for some in its own right.

I think this editorial, unlike the article by Bryson and Silverstein,1have helped foster the idea that we need a “one size fits all” approach where what we should be doing is to evaluate each case individually, applying data where they it exist (like family history, personal history, length of time using, comorbidities, family and hospital/department support, and environment, among others) and individually making a decision to return to the same work or not, employing appropriate monitoring, aftercare and safeguards for the individual and to protect his or her patients.

I agree that it is time we revisit the issue of addiction among our anesthesia caregiver peers. We should continually revisit the handling of this problem, given the potentially tragic consequences to our peers and their patients. I would propose continuing to develop an individualized care plan, based on the best data and judgment available, for each of them much as we do for all our other patients.

Tahoe Forest Hospital, Truckee, California. tcspecht@usamedia.tv

Bryson EO, Silverstein JH: Addiction and substance abuse in anesthesiology. Anesthesiology 2008; 109:905–17
Berge KH, Seppala MD, Lanier WL: The anesthesiology community’s approach to opioid- and anesthetic-abusing personnel: Time to change course. Anesthesiology 2008; 109:762–4