The story of a wayward anesthesia trainee who took a near fatal dose of fentanyl hit the news this week. Of particular interest is that he overdosed (and lived) just hours after a nurse in the same large university medical center hospital overdosed and died from a combination of fentanyl and midazolam (Versed™). The tragic coincidence points out the problem unique to health care workers: easy access to feel-good, rapidly and intensely addictive drugs, as well as the clean needles and syringes to inject them.
The situation is not at all rare. I have known two anesthesiologists who died young after inadvertently overdosing on similar drugs to which they were secretly addicted. Each died with the needle in his arm, apparently miscalculating a dose. One had a new wife and a newer baby; the other a girlfriend liked by all of us. Neither was particularly depressed or lonely; rather, each was an upbeat, personable guy whose addiction escaped everyone’s suspicion. I wrote a condolence note to the parents of one and received a brutally pained comment back months later from his mother: “We still can’t understand what happened!”
The number of drug- and alcohol-addicted physicians and nurses is estimated at 10% to 14%, similar to the general population. The subset comprised by drug addicts alone is not known, but the composition of those with a drug (not alcohol) problem is well characterized. In the medical world, three specialists account for a substantially higher proportion than other specialties: anesthesiologists, emergency room specialists, and psychiatrists.
Dr. Jeffrey Silverstein, an anesthesiologist in New York, has written several important papers on the topic of addiction among those in his field (here and here). He points out that it is difficult—if not impossible—to derive accurate estimates but that it is likely that the drug use problem among anesthesiologists is worsening. Others have warned that alcohol addiction, often swept under the carpet as socially “normal,” may pose the larger risk to both patients and health care workers.
A great deal of ink has gone to speculating whether people who go into these specialties are corrupted somehow from regular human-ness to addict, or whether a certain type of person—one with an intense interest in drugs and drug addiction and danger—is the very sort who might favor these specialties. I suspect it is the latter—people of a certain stripe are drawn to these specialties, rather than a systematic perversion of John Q. Physician-Doctor into junkies.
But it matters little what the reason is—the problem is the same. Thousands of doctors each year become impaired. Some are sufficiently compromised to harm patients most dramatically by diverting drugs, such as fentanyl, from the patient to themselves. The trick is simple enough—a syringe with an addictive drug is handed to a health care worker; he gives a little to the patient, a little to himself, and perhaps a little more to the patient.
Over time, he can transmit a bloodborne disease such as hepatitis C to the patients he is “sharing” narcotics with. Two recent cases of this have made large headlines: that of Kristen Dane Parker in Colorado and a much larger, eight-state, multihospital problem with David M. Kwiatkowski, who recently was sentenced to 39 years in prison for infecting at least 45 patients with his own hepatitis C infection. One newly infected patient died of the disease. The diversion problem is of such sufficient scope and threat that major drug companies, worried about more regulation, are getting into the anti-diversion game, paying to develop a hapless mascot named Dougie the Drug Dog.
The public health implications of diversion have probably only begun to be elucidated. Meanwhile, the crisis of the addicted health care worker is carried into the public imagination by Showtime’s Nurse Jackie (which I never have watched). As an Edie Falco fan, I feared enjoying the show, which seems to be a total Hollywood-ification of a grave problem—addicted health care staff. By report, Nurse Jackie is a fun and loveable nurse who just likes the drugs a bit too much. Everyone is just an inch from some sort of cataclysmic downfall on Showtime, where they can skirt consequences for 60 minutes weekly (and sometimes a little less often when contracts are under renegotiation).
But just as the true life of Jersey mob bosses and city girls without real jobs is in fact much more of a chaotic dead end than HBO would have it, so too is the true life of a drug-addicted nurse or doctor. Rather, as with my two late colleagues, the life is smaller, sadder, and without clear remedy. I suspect their day-to-day existence was dark and frightened and panicky, as small amounts of drugs must be syphoned off for use; locked cabinets opened; quick decisions in closets and far-away lounges made sometimes with catastrophic consequences.
Given all the lives lost and harmed by this problem, perhaps the doctor-nurse same-day overdose will at least help demonstrate the ubiquity of addiction and the fact that it doesn’t conform along socioeconomic lines. Drug addiction is a disease—an infuriating one that allows a great deal of self-pity and mischief around the edges, but a disease all the same. Programs for addicted health care workers can be effective, but backsliding and relapse are every bit as common as with any other group.
Only by accepting just how complex a disease drug addiction truly is can we begin to control this endless epidemic.