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Time to Change Course IN this issue of ANESTHESIOLOGY, Bryson and Silverstein provide an excellent detailed summary of addiction and substance abuse among anesthesiologists, and a review of “state-of-the-art” theories on the mechanisms of addiction, as well as recognition, intervention, treatment, and aftercare of addicted caregivers. Their thoughtful review once again reminds us that anesthesiology, as a specialty, has made a sincere and earnest effort to diminish substance abuse and addiction within its ranks through education and the creation of ever more intrusive and cumbersome drug-dispensing and -control mechanisms. While new information is continually emerging on these issues, it is apparent from the authors’ analysis that despite multiple programatic efforts, there has been little, if any, positive impact on the specialty-wide incidence of substance abuse and addiction. Deaths from opioid abuse continue, and additional reports of deaths from nonopioid anesthesia-related drugs (such as propofol or inhalational anesthetic abuse) periodically appear. Although the drugs most commonly abused by the general population are nicotine and alcohol, multiple studies have shown that the drugs of abuse for which most anesthesia providers enter chemical dependency treatment are the potent opioids, with alcohol following far behind. The rate of abuse of other anesthesia-related drugs is largely unknown. Anesthesiologists clearly present a skewed subset of the general population, and there is no question that they get in trouble with very dangerous and often rapidly lethal drugs. Further, anesthesiologists abuse these highly potent drugs more than other physicians. In the United States, considerable efforts have been made to reduce the incidence of drug diversion by anesthesia practitioners through the implementation of systems such as those mentioned in the Bryson and Silverstein discussion. However, at Mayo Clinic, Rochester, Minnesota, the Department of Anesthesiology has carried these systems a step further. While Bryson and Silverstein use a qualitative random assay of returned waste in their own practice, Mayo Clinic uses a more expensive quantitative assay of randomly selected returned narcotic samples in conjunction with the other methods the authors describe (e.g., computer charting and Pyxis machine [Cardinal Health, Dublin, OR] drugdispensing records). Division of Pharmacy personnel rigorously review all available data and, in concert with a representative of the Department of Anesthesiology Chemical Abuse Committee, relentlessly investigate any apparent discrepancies in charting or variations from typical practice patterns. For such a system to be effective, there must be excellent cooperation between the Division of Pharmacy and Department of Anesthesiology to support the auditors in order to avoid “us-againstthem” conflicts. In every instance of suspected narcotic diversion, all waste narcotic returned by the individual in question is assayed until diversion is either confirmed or disproved. With this system in place, Mayo Clinic has seen its rate of recognized diversion of narcotics—in a department that has a combined population of some 475 staff anesthesiologists, residents and fellows, nurse anesthetists, and nurse anesthesia students—decrease from approximately one incident per year for many years to one incident in the past 7 yr. Having said that, we understand that there will continue to be practitioners who divert anesthesia-related drugs for their personal use, and we suspect that at Mayo Clinic Rochester, the problem is simply in remission, not cured. We are hesitant to suggest that this system change is solely responsible for the apparent decrease in diversion, although we are cautiously optimistic that the trend will continue. One issue not addressed by Bryson and Silverstein is that other anesthesia care providers (e.g., nurse anesthetists, sedation nurses) are at similar, if not increased, risk of addiction simply because their practices are often in remote settings, and they may not fully appreciate the risks of a first-time experiment with diverted anesthetic drugs. Unfortunately, there is very limited comment in the literature on this topic. However, one of us (K.H.B.) frequently lectures to large nurse anesthesia groups on this problem, and in response to the question, “Who here has lost a friend or colleague to narcotic addiction?” nearly every hand in the audience will go up. The American Association of Nurse Anesthetists has an active support line in an effort to help with the recognition and appropriate handling of drug diversion, and the death of a former American Association of Nurse Anesthetists president to a fentanyl overdose in 2002 makes the point vividly clear that abuse of diverted anesthetic drugs does not choose its victims by the letters after their names. This Editorial View accompanies the following article: Bryson EO, Silverstein JH: Addiction and substance abuse in anesthesiology. ANESTHESIOLOGY 2008; 109:905–17.

The Anesthesiology Community's Approach to Opioid- and Anesthetic-abusing Personnel