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Anaesthetist Substance-Use Disorder (SUD)
Definitions
| Term | Working definition |
|---|---|
| Substance abuse / harmful use | Repeated, excessive or inappropriate use of a mood-altering substance causing social, occupational or health harm, without meeting full criteria for addiction. |
| Addiction / SUD | A chronic, relapsing brain disorder characterised by loss of control, compulsive use, craving and continued use despite harm. |
Epidemiology & Mortality
- Lifetime incidence among anaesthetists ≈ 1–2 % (higher than most specialties).
- Intravenous opioid misuse dominates (fentanyl, sufentanil); propofol and midazolam next; alcohol remains the most prevalent legal drug.
- Case-fatality after relapse 10–19 %–death is often the first presenting sign in trainees.
Risk Factors
| Personal | Professional (anaesthesia specific) |
|---|---|
| Family history of SUD, childhood trauma, co-existing mood / anxiety disorder, male sex, early experimentation. | Ready access to potent IV drugs, ability to divert small volumes unnoticed, culture of lone working out of hours, high stress & fatigue, knowledge of pharmacology enabling self-titration. |
Red-flag Behaviours & Workplace Clues
- Frequent unexplained absences, volunteering for extra call / ‘opioid-heavy’ lists.
- Discrepancies in drug records, broken ampoules, excessive wastage.
- Pupillary changes, excessive nasal rubbing, tremor, sweating, needle marks.
- Poor handwriting, missing charts, unexplained performance decline.
Immediate Response (duty of care)
| 5-step SPiES action | Key tasks |
|---|---|
| Seek information | Gather objective concerns; check drug logs. |
| Patient safety first | Remove clinician from patient care; arrange cover. |
| Initiative | Offer occupational-health triage and toxicology screen. |
| Escalate | Inform head of department; activate HPCSA Impaired Practitioner Programme. |
| Support | Provide transport home, peer mentor; schedule review within 24 h. |
- Document facts; use neutral language; maintain confidentiality.
Management Pathway (HPCSA & SASA 2022)
- Confidential assessment by addiction specialist & occupational physician.
- Written Fitness-to-Practise contract: treatment plan, random hair / urine testing, 12-step or CBT programme, weekly group.
- Minimum 3-month abstinence before considering return.
- Notify malpractice insurer; liaise with SA Medical Association for medico-legal advice.
Return-to-work–Angres Criteria Snapshot
| Category | Likelihood of safe return | Typical features |
|---|---|---|
| I Certain | ≥ 90 % success | First episode, opioid diversion < 6 months, full insight, strong family & employer support. |
| II Possible | 50–70 % | Single relapse, partial insight, mood disorder controlled, supportive programme. |
| III Redirect | < 30 % | Multiple relapses, IV fentanyl > 2 yrs, co-existing severe psychiatric illness, non-compliance. |
- (Simulation and graduated duties recommended in all categories before unsupervised practice.)
Relapse Monitoring
- Hair testing every 3 months for opiates, propofol & cocaine; random urine on demand.
- Contracted period ≥ 5 years; any positive = immediate removal and reassessment.
- Success rates for doctors in structured programmes: 74–90 % 5-year abstinence.
Prevention & Departmental Duties
- Secure drug cupboards; hash-mark opioid vials; mandate witnessed disposal.
- Two-person sign-out for Schedule 6 drugs; electronic dispensing logs reviewed weekly.
- Fatigue-risk-management and wellbeing culture (access to counselling, rostered breaks).
- Designate a wellbeing lead consultant as per SASA Practice Guidelines.
Stake Holders Rights Involved in Theatre Environment
| No. | Individual / group | Key needs & rights you must balance |
|---|---|---|
| 1 | Patients on today’s list | Safe care, competent supervision, informed if delay/cancellation occurs. |
| 2 | Trainee who raised the concern | To be listened to without retribution, protected from practising unsupervised, supported if list is disrupted. |
| 3 | Possibly-impaired specialist | Fair, confidential assessment; just-culture approach; immediate support (occup-health, transport home) and due-process under HPCSA. |
| 4 | Theatre team / other staff | Clear instruction about list changes, safe staffing levels, freedom to speak-up. |
| 5 | Organisation & public (hospital exec, regulators, patients waiting) | Continuity of essential services, compliance with policy & law, incident documentation for governance. |
Links
Past Exam Questions
Managing Suspected Impairment of a Supervising Specialist
A junior trainee reports to you just before the operating lists are about to start, that she thinks that the specialist allocated to supervise her is under the influence of alcohol or drugs.
a) List the individuals, and their potential needs and rights you need to take into account when considering how you would approach this issue. (5)
b) Briefly describe how you would approach this problem, balancing all the needs and the need to keep clinical services going. (5)
References:
- Mayall, R. (2016). Substance abuse in anaesthetists. BJA Education, 16(7), 236-241. https://doi.org/10.1093/bjaed/mkv054
- Association of Anaesthetists. Substance use disorder in the anaesthetist. Anaesthesia 2022;77:1001-09. associationofanaesthetists-publications.onlinelibrary.wiley.com
- South African Society of Anaesthesiologists. Practice Guidelines 2022–Impaired Practitioner & Welfare (Ch. 10). sasaweb.com
- Health Professions Council of South Africa. Management of Impaired Practitioners and Students (2023). hpcsa.co.za
- Collins GB et al. Outcomes of substance-abusing anaesthesiology residents. Anesth Analg 2005;101:1451-7. pmc.ncbi.nlm.nih.gov
- Warner D et al. Mortality and relapse patterns in anaesthetists with SUD. Anaesthesia 2021;76:1243-52. pmc.ncbi.nlm.nih.gov
- Angres DH, Talbott GD. Return-to-practice criteria after chemical dependency. BJA Educ 2017;17:315-20. bjaed.org
Summaries:
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