This article originally appeared on VICE Canada
If the opiate crisis has taught us anything, it's that addiction affects everyone. An unprecedented surge in fentanyl-implicated death – across all incomes and backgrounds, obviously – has sparked public health emergencies across the country. With each fentanyl overdose reported, from British Columbia's rural suburbs to the streets of Calgary and Toronto, we're seeing assumptions about who uses drugs and why finally put to rest.
But there was a time when fentanyl was almost exclusively used by a very small group, and it had nothing to do with a conservative columnist's idea of a "typical drug addict" or poverty or organized crime. What the general public is oblivious to – but the medical community knows – is how fentanyl addiction took its roots in anesthesiology before it made its way into the mainstream.
Dr Ethan Bryson, associate professor in the anesthesia and psychiatry departments at the Icahn School of Medicine at Mount Sinai, New York, believes it was anesthesiologists who, familiar with fentanyl's pharmacology and abuse potential, first began misusing the opioid.
"If you look at the history of morphine, cocaine, and heroin, these were all drugs which were initially developed for legitimate medical purposes, but subsequently became recreational pharmaceuticals," Bryson told VICE. "They were all experimented on by people with that access. That's well documented in history."
While relatively new as an illicit drug on the streets of Canada, fentanyl's origins date back to 1959, when it was synthesized by Belgian chemist Paul Janssen. Fentanyl was developed for palliative care, but was soon adopted as an anesthetic agent. In the 1990s, transdermal drug delivery for fentanyl was introduced, and patients were prescribed patches that release fentanyl through the skin into the bloodstream over a couple of days.
Through the 90s and early 2000s, physicians and health workers were the only people with easy access to fentanyl. Addiction experts say during this period they encountered fentanyl dependence in anesthesiologists and nowhere else in the community – not even among other physicians.
Roughly 10 to 14 percent of all physicians will be substance-dependent over their lifetime, and the incidence in anesthesia providers is 2.5 times higher than other physicians, according to a five-year outcome study from 16 physician health programs in the US.
The substances available to anesthesia providers in their workplace can become a deadly occupational hazard. No other medical specialty has easier access to potent opioids and equipment (needles, syringes), as well as a greater expertise of IV insertion.
Bryson has written extensively on the subject of the addicted health care provider, and even published his book, Addicted Healers, in 2012. He was inspired to write about opioid addiction because someone close to him was affected, and has since met and interviewed hundreds of opioid-dependent healthcare professionals. During his residency in 2002, Bryson attended a mandatory meeting where he and his peers heard from anesthesiologists recovering from fentanyl addiction. They talked about the desperate actions their addiction drove them to take.
"They spoke of diverting medications intended for their patients, injecting these medications into themselves instead, rummaging around in sharps containers looking for a drop of the liquid drug, and not caring if it was tainted with hepatitis or HIV," Bryson said. "And then, having found something in a discarded syringe, injecting the contents into their veins in a desperate attempt to get high… even if it was not the fentanyl they were looking for."
The actions of substance-dependent anesthesia providers can have potentially life-threatening consequences for patients, too. If an anesthesiologist siphons off painkillers meant for a patient, it would appear the patient has developed a tolerance to the drugs.
"If subsequent doses are then increased because of suspected tolerance, and the patient actually receives the medication this time, it can cause an unintentional overdose," Bryson said. Patients under anesthesia could also wake up in extreme pain after surgery, if some of their medication was diverted.
Fentanyl's move to the mainstream began 20 years ago, when physicians began prescribing opioids to manage all kinds of pain, an idea promoted by pharmaceutical companies. "This led to a lot of addiction, and a great deal of diversion," Dr. Andrew Clarke, executive director of the Physician Health Program of BC, told VICE.
When the risk of addiction was discovered and over-prescription practices were tightened, diversion went down, but it opened the door for illicitly manufactured drugs to fill the void.
Although fentanyl addiction in the general Canadian population is growing, the incidence among anesthesiologists remains unchanged, according to Dr. Clarke. "Yes, it's a problem, but it always has been," he said. "We think we have it under reasonable control so that it doesn't constitute a danger to the public."
A 2015 report on substance abuse in Canadian residency programs published in the Canadian Journal of Anesthesia states that despite attempts to tighten practices around liability and disposal of controlled substances in the OR, opioids continue to be the drugs most often abused by anesthesia providers.
Fentanyl in particular is suited to the needs of the high-functioning user. It delivers an intense but short-acting effect in a patient. It provides analgesia and euphoria for about an hour, and is then quickly eliminated from the body. This allows the user a short period of euphoria without hours of impairment, unlike morphine, heroin, methadone, and other longer-acting opiates. However, the short half-life of the drug also results in the rapid experience of withdrawal, and the drive to continually use more of the drug.
Anesthesiologists are particularly stigmatised for opioid addiction because stealing or diverting drugs meant for patients is considered unethical and unlawful. They face overwhelming psychological and spiritual turmoil, which results in further substance use, continuing the downward cycle.
Clarke believes stigma around mental health and substance use is what holds physicians back from seeking help. It also makes it difficult for researchers to measure how many physicians are addicted. Canadian health authorities rely mainly on data from the United States, although studies show the incidence of substance abuse among Canadian anesthesiologists appears to be consistent with anesthesiologists south of the border.
Physician health programs in provinces across Canada offer support to healthcare providers dealing with substance abuse disorder and/or mental illness, and manage and monitor them after treatment. Research shows early recognition and treatment of substance use disorder among anesthesiologists remains largely flawed. When anesthesia providers do seek help for opioid addiction, it's often too late.
"You don't want to be only asking for help at the time when you might be a danger to your patients or to yourself," Clarke said. "You want to be asking for help long before that."
Follow Rumana on Twitter.