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(Editor’s note: In this second part of a two-part series on addictions among health care professionals, we discuss return-to-work issues, examine why anesthetists are more at risk, and list signs of addiction. In last month’s issue, we explored why same-day surgery professionals are particularly at risk and gave you suggestions for cutting that risk. We provided a warning list of signs of addiction and gave you additional resources. We also shared one nurse’s nightmare when she had one incident of misusing a drug.)
Warning: Clinicians who are impaired by the use of drugs or alcohol can invoke the Americans with Disabilities Act (ADA).
The ADA could be invoked if a facility decides not to permit a recovered health care provider to return to work, solely on the basis of the history of addiction, warns William P. Arnold III, MD, associate professor of anesthesiology at the University of Virginia Health System in Charlottesville and chair of the Task Force on Chemical Dependence of the Park Ridge, IL-based American Society of Anesthesiologists (ASA).
The ADA defines addiction as a disability, Arnold says. Thus, an employer may not refuse employment to a recovering individual solely on the basis of that disability. "One key for the entity is whether or not it has a real or imputed employer-employee relationship with the anesthesiologist," the ASA says. "If this relationship does not exist, then the law would not be applicable." In addition, the ADA doesn’t offer protection to addicts who are currently engaging in the illegal use of drugs, according to the association.
If your facility is accredited by the Joint Commission on Accreditation of Healthcare Organizations, you are required to have a policy for handling impairment.
There are four goals of substance abuse policies, according to the ASA’s brochure, Chemical Dependence in Anesthesiologists: What You Need to Know When You Need to Know It.1 (See "Sample policy/procedure for departments of anesthesia on chemical dependency," in this issue.) The goals are:
For example, the problem may need to be reported to the physician well-being committee of the state medical society, a peer assistance committee, the department’s chair, a direct supervisor, or another relevant individual, according to the ASA. This person or committee should confidentially investigate the information and seek corroborating documentation, the association says. "The investigation may involve interviews with associates, colleagues, family members, friends, and others acquainted with the person in question, as well as reviews of anesthetic and pharmacy records," the ASA says.
Don’t go directly to the police, the association suggests. "Anyone who has diverted controlled drugs for personal use has, by law, committed a felony and is subject to prosecution," the ASA says. "This individual is, at the same time, however, acutely ill and urgently in need of treatment. Prosecution may be in the individual’s future, but treatment should be the primary intent of the initial investigation."
Should a recovering health care provider return to work? The issue is controversial, and there are no easy answers, experts advise. (To see policy, click here. Also, see "Guidelines to help evaluate anesthesiologists who desire to continue their careers in anesthesia," in this issue.)
Consider these factors:
• Attitude of peers plays a significant role.
The attitudes of colleagues, surgeons, other members of the medical staff and the administrators play a major role, the ASA points out. "If these individuals are unwilling to accept the recovering physician and the stipulations outlined in the aftercare contract, then the likelihood of successful return will be slim," the association says. "On the other hand, if they have a basic understanding of the disease of addiction and are amenable to gradual return to work in keeping with the contract, then the outcome in most cases will be positive."
• The drug that was abused.
The preliminary analysis of data obtained in an ASA survey of anesthesia training programs, indicated that only about 50% of physicians with a history of fentanyl abuse returned to the specialty following treatment.2 "Of those who returned, nearly half were terminated either voluntarily or involuntarily," the ASA says. In that group, the apparent relapse rate was nearly 20% per year over a maximum period of 18 months. In contrast, for those who abused nonopioid drugs, the relapse rate was about 4% per year.
Regard these figures with caution because they don’t take into account the length and type of treatment, the willingness of the department to accept the individual, and other factors that are felt to be important to long-term recovery, the ASA says.
• Talk to the therapist.
"We usually ask for therapists to be involved in that decision, as would any release to work for any medical condition," says Nancy Kehiayan, RN, MS, CS, director of the Colorado Nurse Health Program, in Lakewood. Kehiayan’s program was developed by state board of nursing as an alternative to board’s disciplinary process. It provide nurses with opportunity and support for recovery and treatment.
• Consider another work setting.
Often, recovered health care providers should not return to the same work environment as the one in which they were addicted, particularly if the area is high stress such as the surgical area, Kehiayan says. "They should try to practice in areas where there’s less access [to drugs] and less stress," she adds.
Most recovered addicts aren’t allowed to have access in the first six to 12 months anyway, Kehiayan points out. The employer has to accommodate that practice restriction, she says. Also, recovered addicts are usually limited to a 40-hour workweek and are required to work on a shift where they can be well supervised. "We don’t want them floating from unit to unit," Kehiayan says.
Fentanyl, sufentanil, and their metabolites are challenging but not impossible to detect, the ASA says. If indicated by the drug of choice, these relatively expensive assays should be specifically requested, the association says. Many treatment programs insist that their patients sign an aftercare contract prior to discharge, the ASA says. According to the association, that contract may include the following:
— recommendations concerning returning to work in writing by the treating facility, state medical society, and/or other organization with expertise in managing aftercare in anesthesiologists;
— details such as whether the person should return to the practice of anesthesiology, the administration of controlled drugs, rate of resumption of responsibilities, and hours worked;
— regular monitoring of recovery by a physician who has been trained to perform this task;
— mandatory collection of random urine or blood screens for a period of five years or more, which is mandated by most programs;
— collection of specimens being witnessed to avoid the possibility of deception;
— management in the event of relapse, which usually will include re-evaluation by experts and return to treatment if indicated by the evaluation.
1. Excerpted from Chemical Dependence in Anesthesiologists: What You Need to Know When You Need to Know It, copyright 1999 of the American Society of Anesthesiologists. A copy of the full text can be obtained free on the web site (www.ASAhq.org/ProfInfo/chemical.html) or for $2 per copy from ASA, 520 N. Northwest Highway, Park Ridge, IL 60068-2573.
2. Survey of Chemical Dependence in Anesthesiology Training Programs in the United States: 1986-1995. (Analysis of data and preparation of report are in progress.)