Perhaps no one understands the ongoing dilemma of substance abuse as well as Dr Naham “Jack” Warhaft. Having experienced his own issues with substance abuse in the past, Dr Warhast, who now practises as a specialist addiction physician, is well aware of the persistent dangers an addiction can hold over somebody, especially doctors and anesthetists.
“There’s not an anaesthetist born who doesn’t know drugs are dangerous,” he says. “But addiction is such a powerful driving force that all the knowledge in the world is not going to stop an addict from getting and using the drugs.”
Whereas a decade ago, those same individuals suffering from the scourge of addiction would have likely found relief in alcohol or readily available opioids, recent rescheduling and reclassification of drugs has resulted in the advent of a different kind of relief.
In the last few years, Dr Warhast says narcotic abuse among healthcare professionals has declined while abuse of the anaesthetic, propofol, has grown.
The name may not have the same bite as heroin or morphine, but Dr Warhast says propofol abuse is “extremely dangerous”. “That fact that you’re an anaesthetist does make these drugs easier to access,” he says, “and anaesthetists have extraordinary access to dangerous drugs.”
Propofol, also known theatrically as “the milk of anaesthesia” due to its pale, milky colour, is an anaesthetic used as the primary sleeping agent in most medical procedures. It induces sleep in under 60 seconds and only 100-200mg is needed to put a patient under for an average of 10-15 minutes.
It’s also extremely deadly. If a patient were given a slightly higher amount than the usual recommended cc’s, blood pressure would lower and respiratory arrest would follow with fatal results.
In the inner sanctums of the hospital, the drug is also widely known as the ‘Jacko Drug’, or simply ‘Jacko’. It was the sleeping agent haphazardly prescribed to Michael Jackson, which resulted in the King of Pop’s untimely death in 2009.
“We see doctors who come to us (all the time) for help,” says medical director of the Victorian Doctor’s Health Program, Kym Jenkins. “It’s really only in the past couple of years that I’ve seen people coming to help for propofol.”
As well as being used by some anaesthetists, propofol is also being abused by a number of exhausted health care professionals, who Jenkins believes are desperate to “self-medicate”.
Jenkins says propofol is not as highly regulated, nor is its monitoring as “rigorous”, as other anaesthetic agents. While similar drugs, such as morphine and fentanyl (which belong to the opioid family) are classified as schedule 8 drugs in Australia, meaning they can only be approved for use by certain permitted healthcare professionals, Propofol is only schedule 4, thus not requiring the same level of stringent restrictions.
This could be seen as one of the driving factors behind the increased misuse of the sleeping agent. Chloe Durukan, who works as an anaesthetic nurse and is currently studying to become a gynaecologist, has also noticed increased misuse of propofol in the “last year or so” which she attributes to the drug’s accessibility.
“We don’t hear about the other stuff (fentanyl, morphine) a lot because they’re tightly controlled,” she says. “So it’s not surprising people use propofol.”
Despite the number of recorded cases of propofol abuse in Australia being comparatively small, Durukan still believes the problem is not receiving enough attention, and that given propofol’s potency, cases of abuse by healthcare professionals are too often being ignored.
“It’s definitely kept on the hush hush,” she says. “When we see someone being given propofol they literally stop breathing; it’s really potent.”
The misuse of propofol by healthcare professionals is by no means a recent phenomenon, nor is it merely exclusive to the Australian healthcare industry. A study conducted by the American Journal of Addiction Medicine in 2013 found that the number of healthcare professionals treated for propofol abuse from 1990-2010 rose steadily. The study also found that many of those treated for abuse were doctors and nurses working in anaesthetic departments, who thus had ready access to the drug.
While no official studies on propofol abuse have been conducted in Australia, a retrospective questionnaire by the Anaesthetic and Intensive Care Journal of 185 anaesthetic colleges across Australia and New Zealand yielded some unexpected results. Of the questionnaires returned, the results found 61 cases of substance abuse from January 2004 to December 2013. The results also indicated that while opioid abuse had decreased, propofol abuse had risen steadily, with propofol abuse having a particularly high mortality rate of 45 percent.
Despite these recent numbers, anaesthetic surgeon of 15 years, Dr Linda Stephenson* says substance abuse in the profession has “always been a problem”, and that she has not noticed any increase in the misuse of propofol in her years as a doctor.
She also believes that tightening restrictions on propofol would have an adverse effect, in many ways hindering anaesthetists from being able to provide the sleeping agent at pivotal moments during a procedure.
“Say you have an anaesthetised patient, and they start waking up during an operation, and you need to give them more propofol,” she says. “If it’s locked away in a cupboard (like fentanyl and other schedule 8 drugs) then you can see how ridiculous that is.”
Stephenson is not the only doctor sceptical of changing the sleeping agent’s classification. Dr Warhast also agrees that tighter restrictions would be “impractical”. “This has been tried around various parts of the world,” he says. “But determined addicts would find ways around it anyhow.”
Nevertheless, Kym Jenkins remains vigilant to the dangers of propofol abuse. Despite the lack of solid data recorded in Australia, Jenkins understands that trends in America may have resounding effects. “(Propofol) is recognised as a problem in the US and now we’re on high alert that it could become a problem here,” she says. “We have to be very alert to the possibilities.”
While there may be cause for concern, cases of propofol abuse by healthcare professionals are slight. However those aware of the problem express concern that some individuals practising what is widely recognised as the most trusted profession in the world, are hazardly self-medicating to deal with their stressful jobs .
Kym Jenkins calls for more data and research to halt the problem in its infant stage, while Dr Warhast says education is the simplest form of prevention. “The answer to the drugs is education,” he says. “And good early identification of the problem, that’s what’s needed.”
If you are a doctor seeking help for substance abuse, contact the Victorian Doctor’s Health Program on 9495 6011. If you are a doctor living outside of Victoria and are seeking help with substance abuse, contact Australasian Doctor’s Health Network at 9437 6552.
If you are a nurse or midwife seeking help for substance abuse, contact the Nursing and Midwifery Health Program at 9415 7559.
*Subject’s name has been changed upon request
-Propofol is a short-acting medication used in most general anaesthetic procedures.
-It acts quickly and induces unconsciousness and memory loss. It also slows the activity of the brain and entire nervous system.
-It is given to patients via injection, and can only be administered by a doctor or anaesthetist in a medical setting.
-Side-effects include feelings of elation and euphoria, and sexual disinhibition.
-Has an extremely narrow therapeutic index with only a few more cc’s than the required amount resulting in the recipient experiencing apnoea.
-Since it lowers blood pressure and supresses breathing, the vital signs of the recipient are always monitored by an anaesthetist during surgery.