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Re-entry into Anesthesia Practice
Stephen M. Dorman, M.D.
The issue of allowing physicians with Substance Use Disorder (SUD) to return to clinical practice—particularly in anesthesia—is complex. Safe re-entry depends on multiple factors, including the specific substance involved, the quality of the recovery program, and the use of appropriate medication-assisted treatments.
Today, the preferred term is Substance Use Disorder (SUD), which reduces stigma and frames addiction as a medical condition rather than a moral failing.
Several key considerations guide decisions about re-entry:
• The specific substance of abuse
• The effectiveness of the treatment program
• The provider’s willingness to undergo routine drug or alcohol testing
• Compliance with recommended medication-assisted therapy
SUD affects both the provider and the patient. For that reason, patient safety must remain the top priority, and shortcuts in evaluating readiness to return to practice are unacceptable. Policies vary significantly among states and hospitals. Some institutions are more progressive, while others still classify drug diversion as “theft” and pursue legal action.
Alcohol use disorder is generally the most straightforward to manage. Alcohol has no role in anesthesia practice, and intoxication can be quickly identified with breath-testing devices.
Disulfiram is an inexpensive and effective adjunct in recovery, though it requires complete abstinence from alcohol—including trace amounts found in certain foods. If impairment at work is suspected, immediate breath testing is appropriate, and many hospitals require a zero blood-alcohol level for on-duty providers. Distinguishing a single glass of wine consumed while on call from a deeper alcohol problem can be difficult; however, confirmed alcohol addiction warrants a 12-step program, a strong long-term recovery plan, and random breath testing. When these measures are followed, return to practice can occur relatively quickly.
Opioid addiction, however, presents far greater challenges. Opioids are used routinely in anesthesia, and anesthesia carts are often referred to within the addiction field as the “candy store.” Many professional organizations recommend that opioid-dependent anesthesia providers either never return to anesthesia or achieve a minimum of two years of sobriety, participate
in ongoing treatment, and remain on naltrexone. The extended-release monthly injection has improved compliance compared to the former daily pill. However, naltrexone blocks opioid analgesia—problematic if the provider later requires opioids for legitimate pain—and it also suppresses endorphins, sometimes resulting in prolonged depression.
Although propofol is not classified as a controlled substance in most states because it lacks traditional physical addiction, it is nevertheless a high-risk drug of abuse and can be lethal. As a result, many hospitals are implementing stricter controls. A provider who has abused propofol—if they survive—requires intensive psychiatric care and should not return to clinical practice.
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