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Emerging worldwide trends in substances diverted for personal non-medical use by anaesthetists

2020; Elsevier BV; Volume: 20; Issue: 4 Linguagem: Inglês

10.1016/j.bjae.2020.01.002

2058-5357

Garrett W. Burnett, R. A. Fry, Ethan O. Bryson,

Cardiac, Anesthesia and Surgical Outcomes

Learning objectivesBy reading this article, you should be able to:•Identify the risk of substance use disorder (SUD) in the anaesthetist.•Assess which anaesthetic agents have a high risk for diversion and use by anaesthetists with SUD.•Distinguish which non-opioid and unscheduled (not controlled) medications have diversion potential and should be considered a workplace hazard, in addition to existing controlled medications.•Recognise the warning signs of SUD in a colleague, and know what to do if you suspect a colleague has developed a problem.Key points• Anaesthetists are at high risk of substance use disorder (SUD) because of their access to extremely addictive pharmaceutical opioids.• Recent data from the USA suggest that the incidence of SUD is increasing both in the general population and in physicians.• Whilst the use of alcohol and opioid medications remains the most likely reason an anaesthetist with SUD would be referred to a facility for treatment, there are emerging trends involving the use of non-opioid anaesthetic agents, particularly propofol.• There is a paucity of reliable data regarding the worldwide prevalence of SUD in anaesthetists, but it appears that the incidence is not significantly different across geographical regions. By reading this article, you should be able to:•Identify the risk of substance use disorder (SUD) in the anaesthetist.•Assess which anaesthetic agents have a high risk for diversion and use by anaesthetists with SUD.•Distinguish which non-opioid and unscheduled (not controlled) medications have diversion potential and should be considered a workplace hazard, in addition to existing controlled medications.•Recognise the warning signs of SUD in a colleague, and know what to do if you suspect a colleague has developed a problem. • Anaesthetists are at high risk of substance use disorder (SUD) because of their access to extremely addictive pharmaceutical opioids.• Recent data from the USA suggest that the incidence of SUD is increasing both in the general population and in physicians.• Whilst the use of alcohol and opioid medications remains the most likely reason an anaesthetist with SUD would be referred to a facility for treatment, there are emerging trends involving the use of non-opioid anaesthetic agents, particularly propofol.• There is a paucity of reliable data regarding the worldwide prevalence of SUD in anaesthetists, but it appears that the incidence is not significantly different across geographical regions. Anaesthetists have a higher risk for developing substance use disorder (SUD) than other physicians.1Merlo L.J. Teitelbaum S.A. Thompson K. Substance use disorders in physicians: assessment and treatment.https://www.uptodate.com/contents/substance-use-disorders-in-physicians-assessment-and-treatmentDate: 2019Date accessed: December 9, 2019Google Scholar Whilst the potential for the use of any number of substances, including alcohol, exists, the use of opioids, typically pharmaceutical agents, such as fentanyl, sufentanil and other injectable drugs, remains the most likely reason for referral to treatment programmes.2Boulis S. Khanduja P.K. Downey K. Friedman Z. Substance abuse: a national survey of Canadian residency program directors and site chiefs at university-affiliated anesthesia departments.Can J Anaesth. 2015; 62: 964-971Crossref PubMed Scopus (13) Google Scholar However, more recently, non-opioid agents, such as propofol, ketamine, nitrous oxide and the potent volatile anaesthetics, have been reported as being diverted for personal use by professionals with access to and knowledge of these medications.3Wischmeyer P.E. Johnson B.R. Wilson J.E. et al.A survey of propofol abuse in academic anesthesia programmes.Anesth Analg. 2007; 105: 1066-1071Crossref PubMed Scopus (91) Google Scholar, 4Maier C. Iwunna J. Soukup J. Scherbaum N. Berufliche Belastungen in der Anästhesiologie—abhängigkeitssyndrome bei Anästhesisten.Anasthesiol Intensivmed Notfallmed Schmerzther. 2010; 45: 648-655Crossref PubMed Scopus (11) Google Scholar, 5Wilson J.E. Kiselanova N. Stevens Q. et al.A survey of inhalational anaesthetic abuse in anaesthesia training programmes.Anaesthesia. 2008; 63: 616-620Crossref PubMed Scopus (32) Google Scholar In this review, we provide an overview of current worldwide trends and patterns in substance use, including which substances are being used in different regions around the world. The recognition and treatment of SUD are also addressed, but these areas are beyond the scope of this review to provide a guide to interventions, and these areas should be directed to qualified personnel with the necessary training and skills. The prevalence of SUD varies by geographical region and may vary amongst countries within the same region. The factors underlying these differences include variability in cultural attitudes towards different intoxicating agents, and the ability of individuals to access and subsequently ingest substances with addictive potential. In regions with restrictions on the production, importation, sale and use of alcoholic beverages, the rate of alcohol use is considerably lower than in areas where alcohol consumption is legal and socially acceptable. The WHO estimates that the global prevalence rates of alcohol use disorders amongst adults range from 0% to 16%.6World Health Organization Global health observatory data repository.https://www.who.int/gho/database/en/Date accessed: October 1, 2019Google Scholar Within larger countries, such as the USA, the availability of drugs may vary by region, resulting in, for example, a greater prevalence of heroin use in the Pacific Northwest compared with a greater prevalence of methamphetamine use in the Southern USA.7Ritchie H. Roser M. Drug use.https://ourworldindata.org/drug-use 2019Date accessed: October 1, 2019Google Scholar With respect to SUD amongst anaesthetists, there is considerably less variability in this setting, even across different countries. Classical changes in behaviour reported by the colleagues, friends and family of the anaesthetist with SUD are consistent across different regions, but reflect the cultural norms and acceptable behaviour of the individual country. Often, colleagues in the workplace will notice behavioural changes, as the addict struggles to maintain some semblance of normality to remain close to the source of their drug of choice. In contrast, family members may become increasingly alarmed at the growing isolation, withdrawal and non-participation. The classical signs and symptoms are listed in Table 1.Table 1Classical signs and symptoms of substance use disorder. (Whilst none of the following behaviour patterns is, in and of itself, an indication that an individual has developed SUD, changes in behaviour over time coupled with two or more of the following are suggestive.)•Periods of irritability and anger (during which the individual is in withdrawal and experiencing craving)•Periods of euphoria (when the individual is 'high')•Mood swings (may be common for some individuals and are not suggestive of SUD in isolation, but in a formerly stable or 'even-keeled' anaesthetist these changes suggest some underlying aetiology)•Increased episodes of anger, irritability and hostility (especially in individuals for whom this is not a historical norm)•Withdrawal from family, friends and leisure activities•Isolation (to have the time to participate in the activity of using drugs alone and unobserved, and increases in intensity as dependence on the drug and tolerance to its effects increase)•Spending more time at the hospital (to be close to the source, even when off duty on the pretence of just wanting to help out)•Volunteering for extra on call•Refusing relief for lunch or coffee breaks, but requesting frequent toilet breaks•Attributing increasingly inappropriate amounts of opioids or quantities inappropriate for the given case•Unexplained weight loss and pale skin (a very late sign) Open table in a new tab The probability that any given anaesthetist will manifest SUD depends on multiple risk factors, including genetic predisposition, comorbid mental health and environmental factors. Attempts to develop frameworks to identify at-risk individuals have been largely based on retrospective and observational data collected from individuals already diagnosed with SUD. However, the greatest risk is the anaesthetists' unique access to the drugs in their working environment. The risk factors are listed in Table 2, but it is important to note that the majority of individuals with these risk factors will not develop SUD.8Calabrese G. Evaluation of anesthesiologists' occupational well-being around the world.in: Occupational well-being in anesthesiologists. 15–36. Brazilian Society of Anesthesiology/Federal Council of Medicine of Brazil, Rio de Janeiro2014Google ScholarTable 2Risk factors for the development of substance use disorder in anaesthetists.•Genetic predisposition [can be suggested by family history, but may require epigenetic changes (methylation of DNA bases) for these genes to be expressed]•Novelty-seeking behaviour traits•Disproportionately strong response to dopamine-releasing drugs (may be pre-existing, but can also be induced by exposure to drugs of abuse)•Male sex•Comorbid psychiatric illness (especially when untreated, and many studies have reported that self-medication of psychiatric symptoms is associated with an increased incidence of SUD)•Female sex in the presence of comorbid psychiatric illness Open table in a new tab As demonstrated by retrospective research, surveys, case reports and information available on registration authority websites, SUD in anaesthetists is a worldwide phenomenon.2Boulis S. Khanduja P.K. Downey K. Friedman Z. Substance abuse: a national survey of Canadian residency program directors and site chiefs at university-affiliated anesthesia departments.Can J Anaesth. 2015; 62: 964-971Crossref PubMed Scopus (13) Google Scholar,4Maier C. Iwunna J. Soukup J. Scherbaum N. Berufliche Belastungen in der Anästhesiologie—abhängigkeitssyndrome bei Anästhesisten.Anasthesiol Intensivmed Notfallmed Schmerzther. 2010; 45: 648-655Crossref PubMed Scopus (11) Google Scholar,8Calabrese G. Evaluation of anesthesiologists' occupational well-being around the world.in: Occupational well-being in anesthesiologists. 15–36. Brazilian Society of Anesthesiology/Federal Council of Medicine of Brazil, Rio de Janeiro2014Google Scholar, 9Warner D.O. Berge K. Sun H. Harman A. Hanson A. Schroeder D.R. Substance use disorder among anesthesiology residents, 1975-2009.JAMA. 2013; 310: 2289-2296Crossref PubMed Scopus (59) Google Scholar, 10Fry R.A. Fry L.E. Castanelli D.J. A retrospective survey of substance abuse in anaesthetists in Australia and New Zealand from 2004 to 2013.Anaesth Intensive Care. 2015; 43: 111-117Crossref PubMed Google Scholar, 11Berry C.B. Crome I.B. Plant M. Plant M. Substance misuse amongst anaesthetists in the United Kingdom and Ireland: the results of a study commissioned by the Association of Anaesthetists of Great Britain and Ireland.Anaesthesia. 2000; 55: 946-952Crossref PubMed Scopus (35) Google Scholar, 12Al-Maaz S. Abu-Dahab R. Shawagfeh M. Wazaify M. Prevalence and pattern of substance use and misuse among anesthesia health-care personnel in Jordan.J Subst Use. 2019; 24: 317-322Crossref Scopus (3) Google Scholar, 13Zhang H.F. Li F.X. Lei H.Y. Xu S.Y. Rising sudden death among anaesthesiologists in China.Br J Anaesth. 2017; 119: 167-169Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 14Beaujouan L. Czernichow S. Pourriat J.-L. Bonnet F. [Prevalence and risk factors for substance abuse and dependence among anaesthetists: a national survey].Ann Fr Anesth Reanim. 2005; 24: 471-479Crossref PubMed Scopus (39) Google Scholar Despite this, there is a great degree of variability in the level of reporting. A 2015 review suggests that the prevalence of SUD in North American physicians is roughly 15–16%, slightly higher than the 12–13% prevalence in the general population of this region during the past decade.15Oreskovich M.R. Shanafelt T. Dyrbye L.N. et al.The prevalence of substance use disorders in American physicians.Am J Addict. 2015; 24: 30-38Crossref PubMed Scopus (137) Google Scholar The overall incidence of SUD in the US anaesthetists in training during a 35 yr period from 1975 to 2009 was reported to be 2.16 per 1,000 resident years.9Warner D.O. Berge K. Sun H. Harman A. Hanson A. Schroeder D.R. Substance use disorder among anesthesiology residents, 1975-2009.JAMA. 2013; 310: 2289-2296Crossref PubMed Scopus (59) Google Scholar An analysis of these data over time suggests a rate increase of SUD in the USA for the period of 2003–2009 (2.87 per 1,000 resident years) when compared with the period of 1996–2002. This finding is consistent with the growing opioid epidemic in the USA, and may be speculated to reflect an impact on neophyte anaesthetists coming of age during this time. A 2015 report on substance use within Canadian residency training programmes found 1.6% of residents and 0.3% of clinical fellows to be abusing substances, with fentanyl accounting for the majority of cases (37.5%); 71% of the respondents reported changes in how controlled substances were handled to improve drug accountability over the previous 10 yrs.2Boulis S. Khanduja P.K. Downey K. Friedman Z. Substance abuse: a national survey of Canadian residency program directors and site chiefs at university-affiliated anesthesia departments.Can J Anaesth. 2015; 62: 964-971Crossref PubMed Scopus (13) Google Scholar Alam and colleagues evaluated the characteristics of Canadian physicians requiring disciplinary action, and found the rate of SUD in this group to be equal for anaesthetists and non-anaesthetists, but it should be noted that disciplinary action is often avoided in favour of treatment programmes, and this statistic may not be true for those physicians undergoing treatment for SUD.16Alam A. Khan J. Liu J. Klemensberg J. Griesman J. Bell C.M. Characteristics and rates of disciplinary findings amongst anesthesiologists by professional colleges in Canada.Can J Anaesth. 2013; 60: 1013-1019Crossref PubMed Scopus (14) Google Scholar Much of the literature regarding SUD in anaesthetists in South America has come from Brazil and Uruguay. Barreiro and colleagues demonstrated that anaesthetists in Uruguay had significantly higher rates of alcohol use compared with internists (see Appendix A). Opioids, tranquilisers and cocaine were associated with higher rates of use amongst anaesthetists, but the differences were not statistically significant.8Calabrese G. Evaluation of anesthesiologists' occupational well-being around the world.in: Occupational well-being in anesthesiologists. 15–36. Brazilian Society of Anesthesiology/Federal Council of Medicine of Brazil, Rio de Janeiro2014Google Scholar In a review of 57 Brazilian anaesthetists treated for SUD, the rate of opioid use was found to be higher (59.6%) than benzodiazepine (35.1%) and alcohol (35.1%).8Calabrese G. Evaluation of anesthesiologists' occupational well-being around the world.in: Occupational well-being in anesthesiologists. 15–36. Brazilian Society of Anesthesiology/Federal Council of Medicine of Brazil, Rio de Janeiro2014Google Scholar Although these data might imply that those anaesthetists abusing opioids were more likely to seek treatment, this pattern has been confirmed by other investigators, such as a 2013 report by Calabrese from the Confederation of Latin American Societies of Anaesthesiology (CLASA), which reviewed 156 cases of SUD reported over 10 yrs and found 121 (77.6%) cases related to opioids, 20 (12.8%) to sedatives and 15 (9.6%) to hypnotics.8Calabrese G. Evaluation of anesthesiologists' occupational well-being around the world.in: Occupational well-being in anesthesiologists. 15–36. Brazilian Society of Anesthesiology/Federal Council of Medicine of Brazil, Rio de Janeiro2014Google Scholar There were 141 drug-related deaths, including 94 cases of drug-related suicide and 47 cases of overdose.8Calabrese G. Evaluation of anesthesiologists' occupational well-being around the world.in: Occupational well-being in anesthesiologists. 15–36. Brazilian Society of Anesthesiology/Federal Council of Medicine of Brazil, Rio de Janeiro2014Google Scholar A trend towards increasing self-referral to treatment programmes for anaesthetists with a history of SUD was reported by a Brazilian support network created for physicians with SUD.8Calabrese G. Evaluation of anesthesiologists' occupational well-being around the world.in: Occupational well-being in anesthesiologists. 15–36. Brazilian Society of Anesthesiology/Federal Council of Medicine of Brazil, Rio de Janeiro2014Google Scholar Berry and colleagues reported on a total of 130 cases of alcohol and other SUD within the UK and Ireland over 10 yrs, with 34.6% relating to consultants and 43.2% relating to trainees.11Berry C.B. Crome I.B. Plant M. Plant M. Substance misuse amongst anaesthetists in the United Kingdom and Ireland: the results of a study commissioned by the Association of Anaesthetists of Great Britain and Ireland.Anaesthesia. 2000; 55: 946-952Crossref PubMed Scopus (35) Google Scholar Alcohol was the most commonly used substance (53.8%) followed by opioids (34.6%). In addition, this study showed that younger anaesthetists were more likely to use opioids and benzodiazepines when compared with older anaesthetists who were more likely to use alcohol. The evidence suggests that, on average, one anaesthetist in the UK and Ireland was affected by SUD per month.11Berry C.B. Crome I.B. Plant M. Plant M. Substance misuse amongst anaesthetists in the United Kingdom and Ireland: the results of a study commissioned by the Association of Anaesthetists of Great Britain and Ireland.Anaesthesia. 2000; 55: 946-952Crossref PubMed Scopus (35) Google Scholar A survey of French anaesthetists found that, overall, 10.9% had SUD (excluding tobacco), with alcohol being the most common (59.0%), followed by tranquilisers and hypnotics (41.0%). Interestingly, the rate of opioid use was lower (5.5%) than reported in other parts of the world.14Beaujouan L. Czernichow S. Pourriat J.-L. Bonnet F. [Prevalence and risk factors for substance abuse and dependence among anaesthetists: a national survey].Ann Fr Anesth Reanim. 2005; 24: 471-479Crossref PubMed Scopus (39) Google Scholar A survey evaluating the rate of SUD involving opioids in German anaesthetists found that 35% of respondents knew of a colleague who had a history of SUD. Of this group, 65% were anaesthetists, suggesting a high rate of substance use amongst German anaesthetists. Furthermore, 20% of those anaesthetists known to have SUD died as a result of this or from suicide.4Maier C. Iwunna J. Soukup J. Scherbaum N. Berufliche Belastungen in der Anästhesiologie—abhängigkeitssyndrome bei Anästhesisten.Anasthesiol Intensivmed Notfallmed Schmerzther. 2010; 45: 648-655Crossref PubMed Scopus (11) Google Scholar Minimal information regarding SUD in anaesthetists is available from Africa. A study of South African physicians with SUD described the typical profile as being aged between 40 and 70 yrs old, reporting high work-related stress, have a pattern of self-prescribing and are outstanding achievers in school. Thirty-five per cent of subjects interviewed had developed SUD during training, and 77% of them complained of a lack of support system within their specialty.17Bateman C. The drug-addicted doctor—who dares to care?.S Afr Med J. 2004; 94: 726-727PubMed Google Scholar A recent survey of anaesthetists in South Africa found that the most common substances used over an anaesthetist's lifetime were alcohol (92.8%), tobacco (42.3%), cannabis (34.7%) and sedatives (34.4%). The rate of opioid use was found to be 1.9%. The rates of SUD were not significantly different by gender or practice setting (e.g. private practice or state hospital).18Van Der Westhuizen J. Roodt F. Nejthardt M. et al.The prevalence of substance use in anaesthesia practitioners in South Africa.South Afr J Anaesth Analg. 2019; 25https://doi.org/10.36303/SAJAA.19.6.A2Crossref Google Scholar A report of substance use in all healthcare workers in Kenya found alcohol to be the most common substance used (35.8%) compared with cocaine (8.8%), amphetamines (6.4%), inhalants (3.4%) or opioids (3.9%). Although the rates of SUD in healthcare professionals were found to be higher than the general public of Kenya, the rate of SUD was lower when compared with healthcare workers globally.19Mokaya A.G. Mutiso V. Musau A. et al.Substance use among a sample of healthcare workers in Kenya: a cross-sectional study.J Psychoactive Drugs. 2016; 48: 310-319Crossref PubMed Scopus (6) Google Scholar Notably, this study was not limited to anaesthetists and did not state how many cases were anaesthetists. There have been a number of case reports of SUD in physicians and anaesthetists throughout Asia, but there are insufficient data to allow estimates of the incidence of SUD or the types of substances commonly used. Although no formal data are available regarding the overall incidence of SUD in South Korean anaesthetists, the National Forensic Service of Korea reported that the incidence of propofol use amongst anaesthetists is estimated to be 'similar to the USA'. Following a series of reports of propofol use in South Korea, the country became the first to classify propofol as a controlled substance.20Lee J. Propofol abuse in professionals.J Korean Med Sci. 2012; 27: 1451-1452Crossref PubMed Scopus (9) Google Scholar Zhang and colleagues surveyed 12,000 Chinese anaesthetists in response to an increasing rate of deaths amongst young Chinese anaesthetists regarding work-related stressors.13Zhang H.F. Li F.X. Lei H.Y. Xu S.Y. Rising sudden death among anaesthesiologists in China.Br J Anaesth. 2017; 119: 167-169Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Approximately 1.8% reported stress caused by drug addiction, but no further description was given.13Zhang H.F. Li F.X. Lei H.Y. Xu S.Y. Rising sudden death among anaesthesiologists in China.Br J Anaesth. 2017; 119: 167-169Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar In a study of suicide in physicians in Tokyo, Japan, depression, drug use and alcoholism were related to physician's suicide. It was reported that 80% of anaesthetists commiting suicide used anaesthetic drugs. Although this study evaluated suicide rather than drug use, it is not unreasonable to believe that SUD may have led to accidental death.21Hikiji W. Fukunaga T. Suicide of physicians in the special wards of Tokyo Metropolitan area.J Forensic Leg Med. 2014; 22: 37-40Crossref PubMed Scopus (9) Google Scholar A 2014 study from Singapore reported that 17% of anaesthetists were aware of at least one colleague who used a controlled drug.22Ong C. Seet E. Koh K.F. Kumar C.M. Knowledge and perception of a sample of Singapore anaesthetists towards controlled drug security and abuse.Anaesth Intensive Care. 2014; 42: 675-677PubMed Google Scholar One of the earliest reports of propofol misuse in the world was from Singapore in 1994. Very little information regarding substance use in anaesthetists in the Middle East exists beyond one study of SUD amongst anaesthetists in Jordan. Subjects using drugs for non-medical reasons (18.6%) were more likely to be residents (57.1%). Although many subjects reporting substance use did not state the drugs being used, the answers provided included opioids, such as fentanyl and pethidine, and benzodiazepines and propofol.12Al-Maaz S. Abu-Dahab R. Shawagfeh M. Wazaify M. Prevalence and pattern of substance use and misuse among anesthesia health-care personnel in Jordan.J Subst Use. 2019; 24: 317-322Crossref Scopus (3) Google Scholar The reported incidence of SUD by anaesthetists in Israel is said to be 'similar to those in other developed countries'.23Lev-Ran S. Adler L. Nitzan U. Fennig S. Attitudes towards nicotine, alcohol and drug dependence among physicians in Israel.J Subst Abuse Treat. 2013; 44: 84-89Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar A case report of propofol misuse by a Turkish emergency physician was reported in 2015 by Köroğlu (see Appendix A). No regional differences between New Zealand and various states within Australia have been identified. The overall incidence of SUD in anaesthetists appears not to have changed significantly over the past 20 yrs with an incidence of 1.2 per 1,000 anaesthetist years of observation, although the incidence in trainees is double that of consultant grade anaesthetists. Overall, females may have a slightly higher incidence of use than males, although the incidence in trainees was similar. Between 2004 and 2013, propofol became the most common substance used, followed by opioids and alcohol. The use of recreational drugs has generally been uncommon or unreported.10Fry R.A. Fry L.E. Castanelli D.J. A retrospective survey of substance abuse in anaesthetists in Australia and New Zealand from 2004 to 2013.Anaesth Intensive Care. 2015; 43: 111-117Crossref PubMed Google Scholar Common behaviours specific to the anaesthetist with SUD may be explained away by others as relating to workplace stress, a demanding operating theatre schedule, the common cold or even some undefined crises at home, and not the result of addiction. The anaesthetist in withdrawal may appear to have a cold or the flu, and may appear run-down or exhausted and dishevelled, but when offered relief will refuse in order to remain close to the source of drugs. He/she may become irritable, less flexible and frequently start arguments over trivial matters. Although there are some for whom these behaviours describe a baseline personality, in previously amiable individuals such changes in behaviour deserve investigation. If you suspect that your colleague may have a problem with SUD, do not confront him/her yourself. Instead, contact your department's wellness or physician health officer or equivalent, who will arrange for a properly conducted intervention, in which irrefutable evidence is presented in a setting of care and concern for the individual's health and well-being. Anaesthetists with a substance use problem have been known to attempt suicide once they find out they have been discovered. The stakes for these people are very high; they have the potential to lose everything and the means to end their own lives effectively. Once identified, good treatment options exist for the anaesthetists with SUD, although the levels of support may vary according to geographical location. Because anaesthetists have access to extremely high-risk addictive medications, regardless of the drug they have been using, the first course of action should be removal from clinical duties. The initial treatment should be intensive inpatient therapy coupled with medically monitored detoxification for a period sufficient to reduce the risk for relapse. This period is determined by many factors beyond the scope of this review, but may range from 60 days to 1 yr or more, and is followed by outpatient treatment and at least 5 yrs of monitoring, even if the physician has not yet returned to clinical practice. Results from Australia have indicated potentially improved outcomes with longer inpatient treatment.10Fry R.A. Fry L.E. Castanelli D.J. A retrospective survey of substance abuse in anaesthetists in Australia and New Zealand from 2004 to 2013.Anaesth Intensive Care. 2015; 43: 111-117Crossref PubMed Google Scholar Options for reducing the risk for relapse or the impact of relapse should it happen include enrolment in a monitoring programme, regular group therapy treatment, participation in mutual support groups and a graded return to clinical practice if indicated. Monitoring programmes typically last 5 or more years, and enrolled physicians are tested (urine, hair and breath) several times a month to ensure compliance with abstinence from all mood-altering chemicals, including alcohol. Facilitated group therapy once a week involves several physicians in recovery and a psychiatrist who reports directly to the monitoring programme. Mutual support groups, such as Alcoholics Anonymous, Narcotics Anonymous and Caduceus Club (physician-only mutual support groups), are anonymous and do not report directly to the monitoring entity, but they offer an additional layer of support. Once it has been determined that the physician can safely return to clinical practice, reintroduction should be on a graded basis with a gradual ramping up of duties from part-time with no call to full-time with call responsibilities. Data from the USA, Canada and Australia indicate a success rate of between 70% and 80% for physicians with SUD returning to work. The outcome rate for anaesthetists is similar to other physicians. However, the relapse rate for anaesthesia residents appears to be as high as 40% for those returning to the same specialty.1Merlo L.J. Teitelbaum S.A. Thompson K. Substance use disorders in physicians: assessment and treatment.https://www.uptodate.com/contents/substance-use-disorders-in-physicians-assessment-and-treatmentDate: 2019Date accessed: December 9, 2019Google Scholar Despite various cultures, ethnicities and social differences, SUD is a problem for anaesthetists around the world, and the risk of SUD exists in the operating theatre regardless of where it is located in the world. Although the issue of SUD in healthcare professionals is recognised as a global problem, there is no reliable information regarding the incidence or which substances are most likely to be misused by professionals in different regions throughout much of the world. We have therefore relied primarily on published case reports, commentaries, surveys and retrospective studies. Countries, such as the UK, USA, Canada, Australia and New Zealand, and organisations, such as the CLASA, have made attempts at more robust research into the topic of substance use in anaesthetists. In contrast, countries within Africa and to a lesser extent Asia have very minimal information, and there is a lack of quality data on the subject. The rates of SUD in anaesthetists are likely to be under-reported because of potential professional risks or a lack of transparency from monitoring organisations at local or national levels. As such, this is a limitation of all previous and future studies regarding SUD in anaesthetists. It is also important to recognise that the total number of anaesthetists per capita varies from region to region. It may therefore be difficult to characterise SUD in anaesthetists in regions with very few anaesthetists. Historically, anaesthetists admitted for SUD treatment overwhelmingly reported the use of one or more of the so-called major opioids, that is, injectables, including morphine, hydromorphone, fentanyl, sufentanil and meperidine. Over the past two decades, with the advent of new anaesthetic agents with addictive potential, there has been a notable increase in the reported use of non-opioid drugs. Concurrent with the observed increase in the use of opioids, the incidence of non-opioids appears to be increasing, although this may be the result of increased awareness and reporting. Chief amongst the non-opioids with addictive potential is propofol. Despite originally found to score high on 'likability' rating scales by human volunteers, propofol was not designated a 'controlled substance' in many regions. Since its appearance on the commercial market, propofol has been recognised in many jurisdictions as a drug with the potential to be diverted for non-medical use. Recent attempts to elevate its schedule in the USA have failed, though propofol was designated a controlled substance by Korea in 2011.20Lee J. Propofol abuse in professionals.J Korean Med Sci. 2012; 27: 1451-1452Crossref PubMed Scopus (9) Google Scholar Guidelines for control were established in by the Australian and New Zealand College of Anaesthetists in 2018.24Australian and New Zealand College of Anaesthetists Guidelines for the safe management and use of medications in anaesthesia.2018: 1-8http://www.anzca.edu.au/documents/ps51-2009-guidelines-for-the-safe-administration-oDate accessed: October 1, 2019Google Scholar Designating propofol as a Schedule II drug, defined as 'drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence', will not stop determined practitioners from accessing the drug, but the designation would increase awareness of the potential for harm. Australian and US survey data and numerous case reports have illustrated the potential for the non-medical use of propofol amongst anaesthetists worldwide.3Wischmeyer P.E. Johnson B.R. Wilson J.E. et al.A survey of propofol abuse in academic anesthesia programmes.Anesth Analg. 2007; 105: 1066-1071Crossref PubMed Scopus (91) Google Scholar,10Fry R.A. Fry L.E. Castanelli D.J. A retrospective survey of substance abuse in anaesthetists in Australia and New Zealand from 2004 to 2013.Anaesth Intensive Care. 2015; 43: 111-117Crossref PubMed Google Scholar It is unclear from the literature whether the perceived increase in propofol use amongst anaesthetists is a result of increased recognition and reporting, or represents a real increase. The incidence of inhaled anaesthetic agent misuse is much lower than opioid use, but it appears to be increasing. Nitrous oxide use has been historically more prevalent in dentists, but nitrous oxide is the most commonly used inhaled gas by anaesthetists. Sevoflurane and isoflurane are the most commonly used volatile hydrocarbon anaesthetic agents.5Wilson J.E. Kiselanova N. Stevens Q. et al.A survey of inhalational anaesthetic abuse in anaesthesia training programmes.Anaesthesia. 2008; 63: 616-620Crossref PubMed Scopus (32) Google Scholar One additional consideration is the changing legality of marijuana throughout the world. Marijuana has become legal in many states of the USA and is fully legalised in Canada. Although recreational marijuana is still illegal in many parts of the world, marijuana for medicinal purposes has become legal in several countries, including Argentina, Australia, Denmark, Germany, Italy, Mexico, Switzerland and more. At this time, the exact impact of marijuana legalisation on medical registration bodies or physicians remains unclear. Testing for marijuana use is controversial, and no formal method for screening physicians has been broadly accepted in medicine, although other industries, such as construction and mining, have adopted screening methods. Further evaluation will need to take place to determine a best practice for marijuana screening in anaesthetists. Substance use disorder is common amongst anaesthetists worldwide, but better-quality data are required to characterise its incidence accurately. Although opioids continue to be commonly used amongst anaesthetists, the use of non-opioid anaesthetic agents, such as propofol, is increasingly being reported. Multiple sources from different regions discuss stressful work conditions as contributing to the development of problems with substance use with factors contributing to stress, including training, clinical responsibilities, production pressures, research and professional responsibilities. Establishing more reasonable work hours and improving work–life balance may reduce stressors. Improved support systems to aid the anaesthetist with SUD are needed worldwide, as anaesthetists with SUD may encounter limited access to care because of the lack of a structured support system or because of perceived legal ramifications for those anaesthetists who seek support or treatment. National or local support systems, such as those systems created in Brazil, are fundamental to help improve treatment options for anaesthetists with SUD.