Month: February 2021

Substance abuse disorders can reduce one’s quality of life, threaten relationships, increase risk of comorbid mental illness, and impair one’s ability to perform work-related tasks. Unfortunately, physicians can be at heightened risk for developing substance abuse disorders. One 20-year longitudinal study found that practicing physicians were more likely to take tranquilizers, sedatives, and stimulants than their counterparts.^[1] Another study found that 73 percent of doctors had taken some form of non-prescribed psychoactive drug.^[2] A shocking report from the Medical College of Wisconsin identified that 15.8 percent of their anesthesiologists had diagnosable substance abuse problems.¹

Research has also shown that susceptibility to substance abuse and substance of choice vary with specialty. Overall, around 10 percent of physicians will suffer from substance abuse at some point during their careers.^[3] Hughes et al. performed a comprehensive self-report study of over 600,000 physicians and broke down rates of drug abuse by specialty.^[4] Here were their findings:

Anesthesiologists: Overall, approximately 7.8 percent of anesthesiologists struggled with substance abuse. However, these physicians were much more likely to abuse opioids specifically, possibly as a result of their increased access to these substances.

Psychiatrists: This specialty had the highest proportion of physicians with substance abuse problems, at almost 15 percent. Psychiatrists also had a threefold preference for benzodiazepines as compared to other doctors. It is not clear why psychiatrists were significantly more susceptible than other specialties, but Hughes et al. postulated that it was the result of their ease of access to prescriptions and normalized relationship with medication.

Pediatrics: Around 6.8 percent of pediatric doctors self-reported substance abuse issues, one of the lowest percentages of all specialties.

Surgeons: Along with pediatrics, surgery had an extremely low rate of substance abuse; only 5.5 percent of surgeons had fallen victim to addiction and/or dependency. 

Emergency medicine: Physicians working in emergency medicine had a relatively high rate of substance abuse, totaling 12.4 percent. They were also significantly more likely to take illicit drugs, such as marijuana or cocaine. Hughes et al. suggested that the reason for this may have been the inherently stressful and demanding nature of their day-to-day work.

These findings point towards the need for interventional support systems and preventative programs for physicians with substance abuse problems, particularly ones tailored to certain specialties. Physician health programs have had notable success in fighting addiction, with over 78 percent of enrolled physicians remaining substance free at a five-year follow-up.^[5] These resources should therefore be considered an integral part of any clinical setting.

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References

^[1] Valliant GE, Brighton JR, McArthur C: Physicians use of mood-altering drugs: A 20-year follow-up report. N Engl J Med 282:365-370, 1970. doi:10.1056/NEJM197002122820705

^[2] Lutsky I, Hopwood M, Abram SE, et al: Psychoactive substance abuse among American anesthesiologists: A 30-year retrospective study. Can J Anesth 40:915-921, 1993

^[3] Baldisseri, M.R. Impaired healthcare professional. Critical Care Medicine, 35(2 Suppl), S106-S116, 2013

^[4] Patrick H. Hughes MD, Carla L. Storr ScD, Nancy A. Brandenburg PhD, Dewitt C. Baldwin Jr. MD, James C. Anthony PhD & David V. Sheehan MD. Physician Substance Use by Medical Specialty, Journal of Addictive Diseases, 18:2, 23-37, 1999

^[5] Reading EG: Nine years’ experience with chemically dependent physicians: The New Jersey experience. MD Med J 41:325-329, 1992

Anesthesia for cardiac surgery has traditionally relied on high-dose opioids to mitigate the body’s sympathetic response to surgery [1]. However, recent studies have suggested that opioids extend postoperative intubation, resulting in increased morbidity [1]. Moreover, in-hospital exposure to opioids have been linked to increased dependency [1]. Regional cardiac analgesia techniques, also known as fast-track cardiac anesthesia (FTCA), have emerged as a promising alternative to traditional IV opioids for controlling perioperative pain [2]. 

The use of FTCA techniques in cardiac surgery dates back to 1954 when one of the first heart surgeries was performed under thoracic epidural analgesia (TEA) [3]. Advantages of TEA include decreased incidence of adverse cardiovascular events (e.g. stroke and myocardial ischemia), fewer respiratory complications, decreased risk of renal failure, lower infection rates, and earlier hospital discharge [3]. Additionally, TEA can continuously provide analgesia throughout the perioperative period [3]. Several clinical trials have confirmed the safety of TEA, but concerns remain over potential complications, such as spinal cord compression caused by a hematoma or abscess [3,4].  A meta-analysis examining the difference in rates of mortality and myocardial infarction after cardiac surgery for patients receiving TEA with general anesthesia, intrathecal analgesia with general anesthesia, or general anesthesia alone was published in 2004 [5]. The study examined 1,178 patients and concluded that there was no difference in rates of mortality or myocardial infarction in those who receive TEA versus general anesthesia only [5]. However, patients who received TEA were found to have decreased pulmonary complications, fewer cardiac dysrhythmias, and reduced pain scores [5]. A follow-up meta-analysis completed in 2011 yielded results consistent with the previous study [4]. 

Another well-studied FTCA technique is the paravertebral block [6]. Paravertebral block of the spinal nerve roots provides similar analgesia to TEA without the risk of hypotension or hematoma [6]. Additional benefits of paravertebral blocks include reduced opioid exposure and risk of perioperative myocardial infarction [1]. Other FTCA techniques that have been studied include parasternal, pectoral, and erector spinae plane blocks [1]. These techniques require further investigation but show a potential to further reduce the risk of adverse complications [1]. 

Pain following cardiac surgery may be intense, typically peaking on the first postoperative day [2]. Inadequate analgesia during the postoperative period can result in many adverse hemodynamic, metabolic, immunologic, and hemostatic alterations [2]. Techniques available for postoperative analgesia include local anesthetic infiltration via catheters placed at the incision site, nerve blocks, IV opioids, nonsteroidal anti-inflammatory drugs, cyclooxygenase inhibitors, and alpha-adrenergic agonists [2]. The American Society of Anesthesiologists Task Force on Acute Pain Management in the Perioperative Setting recommends a multimodal analgesia approach to provide superior analgesic efficacy with fewer adverse effects [2]. 

In an attempt to reduce postsurgical pain, researchers have also investigated the effect of remifentanil infusion during cardiac surgery on postoperative pain scores [7]. Remifentanil infusion has been associated with reduced postoperative pain, allowing patients to avoid the need for a nerve block [7]. Buprenorphine infusion has also been shown to reduce pain immediately following cardiac surgery [7]. 

References 

1. Caruso, T., Lawrence, K., & Tsui, B. (2019). Regional anesthesia for cardiac surgery. Current Opinion in Anaesthesiology, 32(5), 674-682. doi:10.1097/aco.0000000000000769 

2. Chaney, M. (2006). Intrathecal and Epidural Anesthesia and Analgesia for Cardiac Surgery. Anesthesia & Analgesia, 102(1), 45-64. doi:10.1213/01.ane.0000183650.16038.f6 

3. Liu, H., Emelife, P., Prabhakar, A. et al. (2019). Regional anesthesia considerations for cardiac surgery. Best Practice & Research Clinical Anaesthesiology, 33(4), 387-406. doi:10.1016/j.bpa.2019.07.008 

4. Svircevic, V., Nierich, A., Moons, K. et al. (2009). Fast-Track Anesthesia and Cardiac Surgery: A Retrospective Cohort Study of 7989 Patients. Anesthesia & Analgesia, 108(3), 727-733. doi:10.1213/ane.0b013e318193c423 

5. Liu, S., Block, B., & Wu, C. (2004). Effects of Perioperative Central Neuraxial Analgesia on Outcome after Coronary Artery Bypass Surgery. Anesthesiology, 101(1), 153-161. doi:10.1097/00000542-200407000-00024 

6. Bigeleisen, P., & Goehner, N. (2015). Novel approaches in pain management in cardiac surgery. Current Opinion in Anaesthesiology, 28(1), 89-94. doi:10.1097/aco.0000000000000147 

7. Anwar, S., & O’ Brien, B. (2021). The Impact of Remifentanil Infusion During Cardiac Surgery on the Prevalence of Persistent Postsurgical Pain. Journal of Cardiothoracic and Vascular Anesthesia, 35(2), 467-469. doi:10.1053/j.jvca.2020.09.131