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

To 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. (These are the same compounds most commonly associated with addiction and death in the fraction of ACPs who divert and abuse drugs.) Although a body of literature is developing that identifies the risks of addiction and relapse to physician ACPs, the risks to other ACPs remain poorly defined. However, the collective experience of the AANA Peer Assistance Advisors makes it clear that the risk of death from relapse is similar to, if not greater than, that posed to physicians, yet we believe falls well short of the “nearly 100% relapse rate” mentioned by Berge et al.²

Oreskovich and Caldiero¹ nicely summarize the current literature regarding the treatment and aftercare programs that appear to provide the best chance of long-term recovery and safe return to the workplace for physician ACPs.² Two topics of discussion missing from much of the literature that these authors use to support their stance concern the role that environmental cues play in relapse and the optimal time spent away from the operating room (OR) environment in early recovery. A survey that I conducted as a part of my PhD coursework (unpublished data) determined that environmental triggering cues found in the OR may be olfactory (eg, alcohol preparatory pads, fumes from electrocautery), tactile (eg, handling vials of opiates, needles, and tourniquets), or situational (eg, seeing a syringe with leftover fentanyl). Although such triggering cues have been linked with relapse to drug abuse,^3-6 the role of cues in relapse in health care professionals or in ACPs specifically has not been well documented.

Cue exposure therapy may have a useful role in extinguishing responses to cues to relapse,^3,7-13 but current literature might have limited generalizability for the ACP. For example, a person recovering from alcoholism (unless employed as a bartender or waitstaff) can legitimately avoid going to bars, pubs, or other places heavily laden with cues for relapse to alcohol consumption. A recovering ACP cannot, on reentry, avoid the OR and all its associated cues. Not all triggering cues are obvious: Several recovering Certified Registered Nurse Anesthetists (CRNAs) reported (in my aforementioned survey) that cues related to the “bathroom” (the smell of the bathroom cleaner, being offered a bathroom break) elicited a strong physiologic and psychological reactivity because the bathroom is where many addicted ACPs self-medicate in isolation.

The recovering ACP requires time away from the OR environment (1 year has been suggested)¹⁴ to build a solid foundation of recovery. This time may be critical for allowing the power of cues to extinguish by a process of “reprogramming” the addicted ACP's hippocampus and amydala.^15,16 The AANA Peer Assistance Advisors have undeniably seen over the years that returning to work in the OR environment too soon leads to a dramatic increase in the risk of relapse. The time away from the OR practice of anesthesia need not be entirely a gap in training or practice for the ACP. Indeed, Bryson and Levine¹⁷ advocate the use of an anesthesia simulator for 12 months before reentry. Although their study of 5 recovering opiate-addicted anesthesia residents at a large academic teaching hospital did not address cues, it did emphasize the many benefits of having reentrants use the anesthesia simulator to maintain their clinical skill level while actively teaching medical and other students. This work schedule also facilitated attendance at 12-step and other support group meetings. Of the 5 residents, 3 successfully completed their residencies and their 5-year monitoring contract, subsequently taking positions as attending anesthesiologists. Although the cost of simulator time is considerable, it would almost certainly be less than that of wasting the years of education and training that have been invested in becoming an anesthesiologist. Because much of the expense of running a simulator is related to personnel, some of that can be offset by offering the recovering ACP meaningful employment at the simulation center during a period when he or she is not eligible for an OR position. The OR simulator might prove to be a safe “virtual reality” for the reentering ACP to identify problematic cues and perhaps to extinguish the power of such cues by gradual reexposure in a more controlled setting than that represented by the OR environment.

Oreskovich and Caldeiro are to be applauded for their effort to further the standardization of what constitutes sufficient treatment and monitored aftercare. Hopefully, this will facilitate a safe reentry for the recovering ACP, without a prohibitive risk of relapse and death. Better understanding of the potent environmental cues to relapse and tailoring efforts to modify the response to these cues during the time before return to the workplace may be extremely important in ensuring sustained recovery from addiction and restoring professional productivity (and personal independence) in these individuals who have high value to society and the medical community.