Environmental Cues and Relapse: An Old Idea That Is New for Reentry of Recovering Anesthesia Care Professionals–Reply–I

Abstract

We appreciate the excellent observations and suggestions made by Ms Wilson in response to our editorial. As a member of the American Association of Nurse Anesthetists (AANA) Peer Assistance Advisors Committee, Wilson emphasizes that the occupational risk of substance abuse and dependency more commonly discussed in relationship to anesthesiologists also extends to nurse anesthetists and other anesthesia care professionals (ACPs) who have access to potent sedative, analgesic, and anesthetic drugs. Not only do we concur with that observation but we also believe it extends to other operating room (OR) personnel who do not provide anesthesia services but may have access to unused drugs. We have observed a wide variation in the quality of accountability in hospital policies for controlled substances in the OR and also have seen instances of diversion by OR nurses, surgical residents, and medical students. Ms Wilson shares the results of a survey she conducted as a part of her PhD course work (unpublished), which demonstrated that environmental OR cues can involve many different senses: “olfactory (eg, alcohol preparatory pads, fumes from electrocautery), tactile (eg, handling vials of opiates, needles, and tourniquets), or situational (eg, seeing a syringe with left-over fentanyl).” Wilson suggests that OR anesthesia simulation laboratories can be used as a site for cue exposure therapy1Childress AR Hole AV Ehrman RN Robbins SJ McLellan AT O'Brien CP Cue reactivity and cue reactivity interventions in drug dependence.NIDA Res Monogr. 1993; 137: 73-95PubMed Google Scholar, 2McLellan AT Childress AR Ehrman R O'Brien CP Pashko S Extinguishing conditioned responses during opiate dependence treatment: turning laboratory findings into clinical procedures.J Subst Abuse Treat. 1986; 3: 33-40Abstract Full Text PDF PubMed Scopus (82) Google Scholar, 3O'Brien CP Childress AR McLellan AT Ehrman R Ternes JW Types of conditioning found in drug-dependent humans.NIDA Res Monogr. 1988; 84: 44-61PubMed Google Scholar to desensitize the ACPs before allowing them to return to the OR after treatment for their chemical dependency. In fact, we are incorporating this approach into our “back-to-work” evaluations and recommendations for anesthesiologists who have completed treatment. One of my colleagues (Paul Earley, MD, unpublished data, September 2009) has proposed that addiction memory invokes the same neural circuits as the abnormal memory experiences associated with posttraumatic stress disorder and that some of the treatment modalities for this disorder can be equally effective in preventing cue-induced relapse. In addition to the cue exposure therapy referenced by Wilson,4O'Brien CP Childress AR McLellan AT Conditioning factors may help to understand and prevent relapse in patients who are recovering from drug dependence.NIDA Res Monogr. 1991; 106: 293-312PubMed Google Scholar, 5Reid MS Flammino F Starosta A Palamar J Franck J Physiological and subjective responding to alcohol cue exposure in alcoholics and control subjects: evidence for appetitive responding.Neural Transm. 2006 Oct; 113 (Epub 2006 Apr 11.): 1519-1535Crossref PubMed Scopus (28) Google Scholar Earley and I suggest that both eye movement desensitization and reprocessing therapy and meditation may have useful roles in the extinction of cue-induced craving caused by smells, sights, and touches in the OR anesthesia simulation laboratories. In most circumstances, the anesthesiology staff members, residents, and fellows that we monitor after treatment for chemical dependency do not return immediately to the OR. Several issues are considered in their return to work evaluation and recommendations, including, but not limited to, the following: drug use history, 12-step progression, sponsor, recovery integration, duration of proven abstinence, relapse history, tobacco and nicotine use, behavioral addictions, genetic predilection, gratitude vs resentment and blame, use of opioid antagonists, quality of multimodal monitoring, advanced drug screening, high-risk co-occurring medical disorders, co-occurring mood disorders or other Diagnostic and Statistical Manual of Mental Disorders Axis I and Axis II disorders,6American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. Revised 4th ed. American Psychiatric Association, Washington, DC2000Google Scholar risk-taking behavior, history of boundary violations, family history and family stability, quality of psychosocial support systems, quality of diversion-prevention protocols, attitude of the work environment toward the recovering anesthesiologist, and the quantity and quality of cue-induced craving and euphoric recall. On the basis of the recommendations by Wilson, we propose that the same vigorous approach be applied to all ACPs. Environmental Cues and Relapse: An Old Idea That Is New for Reentry of Recovering Anesthesia Care ProfessionalsMayo Clinic ProceedingsVol. 84Issue 11PreviewTo the Editor: The recent editorial by Oreskovich and Caldeiro1 points out the dangers posed to anesthesiologists who attempt to return to the workplace after treatment for drug addiction. As a member of the American Association of Nurse Anesthetists (AANA) Peer Assistance Advisors Committee, I am well aware that the dangers of addiction and relapse extend not only to anesthesiologists but also to all anesthesia care professionals (ACPs) who have access to potent sedative, analgesic, and anesthetic drugs used daily in their clinical practices. Full-Text PDF