Environmental cues and relapse: an old idea that is new for reentry of recovering anesthesia care professionals.

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 Ms Wilson shares the results of a survey she conducted as a part of her PhD course work (unpublished), which demonstrated that environmental OR cues can involve many different senses: “olfactory (eg, alcohol preparatory pads, fumes from electrocautery),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 therapy1-3 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 One of my colleagues (Paul Earley, MD, unpublished data, September 2009) has proposed that addiction memory invokes the same neural circuits as the abnormal memory experiences associated with posttraumatic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,4,5 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,6 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.