A cry for help: Developing a culture of kindness in substance abuse intervention

Anaesthesia and Intensive Care has published more than 60 articles concerning the welfare of anaesthetists and has been committed to this for over 30 years. The article by Baird in this edition is unique as it openly explores and addresses his personal encounter with substance use disorder. While summarising the international literature the most valuable part of this article is his personal experience and his expressions of commitment to the rehabilitation process, especially the invasive ongoing surveillance involved. He describes this as one of the key pillars necessary for those overcoming this affliction. This article is also unique in the way it outlines many of the steps following the confrontation required on the path, which must be travelled, to allow a return to work as an anaesthetist under these circumstances. His cry for help is succinctly echoed by Elton John: ‘The moment the words “I need help” came out of my mouth I felt different. It was like something had been switched back on inside me.’ ¹

Roberts succinctly stated in her 2005 editorial that the discovery of substance misuse in a colleague, or even its suspicion, provokes strong emotional responses (particularly when death is the sentinel event). ² For the person reporting a colleague, the emotional discomfort and courage involved is rarely mentioned but it is often the essential initiating event for a return to health. Knowing the potential consequences for the person with substance use disorder, the reporter must strongly oppose their doubts and proceed with the correct life-saving action. The misgivings of making a potential honest error or perhaps the disquiet of being labelled a pariah by others, must rest heavily on their conscience. This concern is best allayed well before any report is necessary, by developing a culture within every department or operating suite that a non-punitive approach will be taken in these circumstances. This safeguard should remove the natural innate inhibition to report someone early, with the knowledge that the culture is to look out for the person exhibiting substance use disorder. It is equally important to support the reporter carefully and to reassure them throughout the ongoing process that they have done the correct thing, as they too will suffer.

Shrivastava and Zuccherelli in their editorial ‘Can we survive propofol?’ reiterated Roberts’ assertion that most of our knowledge of substance misuse comes from teaching departments, and despite the advances we have made in welfare for the anaesthetist, that full-time private practices still do not have access to welfare strategies or the capacity to deal with such a problem within their ranks. ³ It is an area that still needs to be addressed some 15 years later.

For the welfare officer and managers involved, obtaining all the necessary colluding evidence while protecting the individual and their patients is an unenviable and often immensely time-consuming activity. Due diligence to avoid inappropriate sanction is, however, vital, and a small supportive, circumspect team approach is mandatory. For this group there are a number of equally important prerequisites during the intervention which open the road to recovery, the foremost being total honesty from the suspect. Excuses, lies and denial of carefully gathered evidence make future negotiation regarding return to work extremely difficult. This again is facilitated by an exculpatory culture. At the same time a fair, empathetic and non-punitive intervention is equally important. Allowing the victim to remain on full pay or sick leave for a period, and a genuine commitment to assisting them through their subsequent interventions, with a stated aim ultimately to try and help them return to work, reduces the sense of doom the situation invokes in the subject. Often a second meeting of the group after a few weeks, once the dust has settled, will show support, engender trust and allow some of the necessary ongoing planning to occur under more reciprocal circumstances. This includes planning for appropriate collegial notification, which can also set an appropriate tone for acceptance and an eventual supported return to work. This may also start the process of rehabilitation for the practitioner such as an open letter to workmates simply acknowledging the problem and commitment to undergoing therapy.

Suicide following an intervention is always a risk no manager wants on their watch. Obtaining permission, when appropriate, to involve the practitioner’s significant other (who may not have been the support person) at the conclusion of the interview may help. Allowing them access to the meeting may in some instances enable the practitioner to commence their therapy safely as an outpatient from home after due deliberation. It can also start the honest dialogue required in a relationship which has usually had a dark, unacknowledged secret within it. Others deemed more at risk, in denial or with no safe home to return to may need to be admitted initially to inpatient care under the direct supervision of psychiatry. A psychiatric assessment is always advisable when there is any doubt about safety.

Nearly one in five deaths among working age anaesthesiologists have recently been attributed to substance use disorder in the United States, with a high lifetime risk of relapse. ⁴ Access to powerful opiates and other anaesthetic agents such as propofol will always exist despite the careful and increasing regulation of these substances. Ward, in his editorial, commented that ‘rules rarely ever stop the “truly motivated” but they can at times deter the “simply inquisitive” ’. ⁵ The recognition of this by the College and the recent joint statement on the storage of propofol is to be lauded.^6,7