The Junkie in the O.R.
Some doctors are addicted to the very drugs they prescribe. Find out why going under the knife could be more dangerous than you think
By: Christopher McDougall, Photographs by: Julia Fullerton-Batten
Diarrhea was Jeffrey Junig's alarm clock. Boiling in his guts at 3 in the morning, it would send him staggering to the bathroom, panting and coughing, his sweat-soaked hand shaking on the knob. He had to be quiet, fiercely quiet, because good God -- what if his wife found out?
The secrecy was almost as awful as the sickness. He hated those moments when he had to look his wife in the eye and lie, "Nah, just a little tired," or, "Probably caught that flu going around the hospital," or whatever other b.s. he could muster just to get away from her long enough to slip into the bathroom and slide a needle into his ankle.
At least this wasn't his day off, Dr. Junig told himself as he slumped miserably on the toilet. It's tough being an addicted anesthesiologist, but it does have its perks: You get your fix on the job, the drugs are free, and if one of your patients dies on the table, well . . . that's just another tragedy chalked up to "unforeseen complications."
One of the most dangerous and best-kept secrets of the medical profession is the epidemic of anesthesiologists who are addicted to their own drugs. More than 400 drug-addicted anesthesiologists and residents may be working in operating rooms at this moment, based on the findings of separate studies by John Booth, M.D., a former Duke University anesthesiologist, and Mark S. Gold, M.D., a psychiatry professor at the University of Florida's McKnight Brain Institute.
That means the next time you lie on an operating table and close your eyes, your odds of ever opening them again could be in the hands of someone who's injecting himself every 6 hours with fentanyl, a painkiller that's 100 times more potent than morphine. He'll be suspending you in a near-death state -- slowing your heart, numbing your nerves, loosening your grip on consciousness -- while simultaneously siphoning off drugs for himself and, at times, shooting up right in the middle of the operation. One mistake and you could end up dead, or in a never-ending coma.
Dr. Gold became aware of how many anesthesiologists were diverting drugs into their own veins while he was assessing 20 years' worth of confidential records at the Physicians Recovery Network, an intervention and rehabilitation organization. He was struck by how often "anesthesiology" turned up as an addicted doctor's specialty, so he began tabulating. Dr. Gold has been an addiction expert for more than 30 years, but even that didn't prepare him for the total: Anesthesiologists are overrepresented by a staggering 500 percent.
"We ran the numbers in a variety of permutations," Dr. Gold says, "and each way you look at it -- year by year, consecutive cases, age group -- it's clear that anesthesiologists are by far the most likely to have chemical-dependency problems."
Dr. Booth came up with slightly lower but equally alarming figures. When he surveyed the anesthesiology chiefs at 133 teaching hospitals in 2002, he found that the faculty anesthesiologists and their anesthesiology residents were four times more likely to have had substance-abuse problems than other physicians. And that includes only the addicts who had been caught.
"I lost 12 top residents to addiction in 12 years, and I don't know how many others I've missed," concedes James Arens, M.D., chairman of the anesthesiology department at the University of Texas Health Science Center at Houston. "I never confronted a resident who didn't have narcotic addiction, which tells me I didn't confront enough." Translation: If he'd been wrong a few times, Dr. Arens would be more confident he was erring on the side of caution.
"I was stunned when I discovered not only the prevalence, but the institutional acceptance," says Dr. Gold of the reaction to his own findings. "When I brought the numbers to our chief of anesthesiology, I was surprised that he wasn'tsurprised. 'In fact,' he told me, 'I just had a call from a fellow chairperson who had an addiction-related death.' " Dr. Gold canvassed other department heads and kept getting the same response. "I was told that every anesthesiology department has some narcotic-addiction problem."
On a typical day, Dr. Junig would arrive at the hospital and get enough fentanyl for his first patient and, surreptitiously, a little extra for himself. After he finished shooting up in the O.R. toilet, his sweating and coughing would stop, and the aching in his head would ease. Soon, the tall, thin doc, whose boyish smile belied his bald head and 42 years, would be his usual self again -- joshing, focused, caring.
But not for long.Most of the narcotic analgesics used in O.R.'s are very short- term, so an addicted anesthesiologist can be going through the agonies of withdrawal every 6 hours. Of course, Dr. Junig knew that if anyone discovered his secret, they wouldn't care how much he was suffering.
"It's so awful, and so often, you just run around frantically, trying to find something to get you through the day," he would have liked to tell them. "Then you try to find something to bring home and set aside so you have some in the middle of the night, but it's gone by 8 p.m. You go to work the next day feeling terrible -- exhausted, sick, coughing, anxious, ashamed -- but you have to pretend you're totally calm and sunny."
Dr. Junig would be caught quickly if he stole too much fentanyl at once, but ironically, his stellar touch with patients gave him many chances to siphon off a little at a time. He was one of the most popular doctors in the hospital, and consequently, one of the most requested for intricate procedures requiring lots of anesthesia.
He'd always loved the intimacy of the job; that was the word he used when describing his specialty to friends. "In anesthesia, all you do is care for the patient," he'd explain. "You smell their flesh, hear their hearts. You breathe for them, and that is a wonderfully gratifying feeling." In fact, if it weren't for his lying, stealing, and furtive addiction, he'd be the perfect doctor.
Dr. Junig was already a star when he arrived at the University of Rochester medical school in 1982. While a freshman at Carroll College, he'd become a statewide media sensation for risking his life to swim out to a drowning woman in a flooded, rampaging river and pull her back to shore. At Rochester, he rocketed to the top of his class and graduated with both an M.D. and a Ph.D. in neuroscience, winning an armful of awards for outstanding achievement in anatomy, physiology, and clinical teaching.
He married, had the first of three children, and landed a coveted residency at the Hospital of the University of Pennsylvania before becoming a full anesthesiologist in Wisconsin in the early '90s. He was so dedicated to the job that one winter, rather than take time off with a cold, he dosed up with codeine and kept on working. Eventually, he shook off the bug, but not the drug.
"It felt like the answer to all life's problems, problems I didn't even know I had," Dr. Junig would later say. "It can be extraordinarily stressful when you're holding a person's life in your hands and things suddenly go wrong. You have a little kid and can't ventilate and you're thinking, Oh my God, this kid came in for ear surgery and isn't going to make it out of here!" A little jolt of codeine, though, and the anxiety melted away.
Once Dr. Junig realized he was hooked, he secretly checked himself into a nighttime outpatient rehab program, and within 13 weeks, he was detoxed. For 7 years, he was fine. But when his son needed a codeine pain reliever after injuring his neck during a family vacation, Dr. Junig decided he could handle a little taste and dipped into the medicine.
He was soon to discover an awful truth about addiction: When an addict relapses, he doesn't pick up where he left off. Instead, he finds himself with the same craving and dependence he'd have if he'd kept using the whole time. Little wonder, then, that in a matter of months, Dr. Junig found himself spiraling from a little codeine by mouth to a needleful of narcotics in his arm.
Control Over the Addiction
Contrary to the shabby, shuffling junkie stereotype, the anesthesiologists most at risk of addiction are the best in the business. They tend to be young, ambitious, highly talented physicians who graduated at the top of their medical-school classes and are ranked among the most popular and requested at their hospitals.
"My experience has been that the substance abusers are almost always male," says the University of Texas's Dr. Arens. "The all-American kid who's outgoing, very pleasant, well liked, very good technically -- the ideal resident."
In most occupations, two warning signs of an on-the-job addict are chronic absenteeism and crumbling job performance. But in a perverse twist, the opposite is true of hooked anesthesiologists: A study by the Association of Anesthetists of Great Britain and Ireland found that addicted anesthesiologists are extreme go-getters, always volunteering for extra shifts and holiday rotations. They're never seen heading off to Starbucks on coffee breaks, and even though they're predominantly 30 to 39 years old, they're never hanging with the gang at happy hour.
"The ability to consume large doses of drugs and still perform his job lends the impaired anesthesiologist the feeling of being in control of his addiction," says Susan Polk, M.D., an anesthesiologist at the University of Chicago who has been involved in antiaddiction training. Plus, unlike other junkies who have to hit the streets to score, anesthesiologists procure their drugs at work, so they know they have to look sharp while on the clock.
And when the symptoms of addiction can no longer be hidden, they can still be explained away. Mood swings, irritability, coughing, diarrhea -- all can be chalked up to the normal collateral damage of working in a high-stress, germ-rich environment. Consequently, an anesthesiologist can abuse his drug supply for years before causing a tragedy that leads to his exposure.
On July 15, 1998, Herman Cole brought his healthy, 36-year-old wife, Sadie, to Connecticut's Norwalk Hospital for a straightforward tubal ligation. Sadie's doctor knew that Cole,a 41-year-old client-care worker with the Connecticut Department of Mental Retardation, was also moonlighting nights as an office cleaner, so she told him to head home and get some sleep. She promised to call as soon as Sadie was ready to be picked up.
About 3 hours later, Cole was awoken by a phone call from the hospital, urging him to come right away. When he arrived, Sadie's doctor met him in the lobby. Sadie had mysteriously gone into cardiac arrest and stopped breathing, Cole was told. They'd managed to get her heart started, but . . . that was about it. She had suffered a devastating brain injury from oxygen loss.
"Wh-what happened?" a stunned Cole stammered.
"Unforeseen circumstances," Sadie's doctor replied.
But one of Sadie's nurses later pulled Cole aside for a confidential chat. She didn't know what had happened to Sadie, but she suspected it was more than the hospital was saying. "You ought to get a lawyer," she whispered, "and get some answers."
A Second Chance to Ruin Lives
Cole called attorney Richard Silver and was soon plunged into a dark side of medical care that he'd never dreamed existed. Silver began digging and learned that Sadie's anesthesiologist -- Dr. Jay Angeluzzi -- had behaved bizarrely during the procedure. First, he'd failed to recognize that Sadie had stopped breathing, even after the electronic monitor's alarms sounded. Then, instead of examining her, he'd turned off the alarms and left the room. It would be 9 critical minutes before anyone noticed Sadie was not responsive. By the time she was revived, her brain had been oxygen starved and ruined.
Dr. Angeluzzi, Silver discovered, had a history of drug abuse, psychiatric treatment, and failed institutional rehabilitations. He'd left Connecticut's Hospital of St. Raphael in 1985 after abusing tranquilizers while on duty, and had moved to Massachusetts, where his license was put on probation and he had to submit to special monitoring. But after a few years, Dr. Angeluzzi applied for a job at Norwalk Hospital, never mentioning his drug problems. One of his old bosses even made it easy for him, saying that Dr. Angeluzzi had moved to Massachusetts because of "family problems."
Cole sued, and after nearly 5 years of litigation, agreed to settle the case for more than $13 million. However, Dr. Angeluzzi still retained his medical license and continued to work at Norwalk Hospital.
It would be painful enough if the story ended there, but it has an epilogue. Five years later, Cole was visiting Sadie at Norwalk Hospital when he ran into an old friend. The friend's sister, a healthy, 34-year-old mom-to-be, had gone into Norwalk on July 8, 2003, to deliver her baby by cesarean and had suddenly stopped breathing. "The hospital told us these things sometimes happen," Cole's friend said.
Cole froze. "Do you know the name of the anesthesiologist?"
"No," his friend replied.
"Could it have been Jay Angeluzzi?"
"Yes!" his friend said. "How'd you know?"
As he had with Sadie, Dr. Angeluzzi had failed to notice that Mia House's oxygen levels had become dangerously low. And drugs were missing: Dr. Angeluzzi claimed he'd had leftover morphine from the operation and had poured it down a drain.
Mia House's case settled for nearly $17 million, and Dr. Angeluzzi lost his hospital privileges. But he dodged formal censure by surrendering his medical license.
"Drug-addicted doctors are passed around the country much like pedophile priests," says Ron Perey, a Seattle attorney who recently won an $8.5 million settlement for a patient who was doomed to a lifelong coma by an addicted anesthesiologist. "Doctors aren't employees of the hospital, so the administration has no real control over them, and their colleagues are dangerously willing to give them second chances."
When There's No Drug Test
Any addict with a degree in anesthesiology is an expert at, literally, covering his tracks.Some implant a plastic port under the skin in their ankle so they can shoot up during an operation. Because they're behind a drape next to the patient's head, no one can see. Some are even more creative. One psychiatrist who treats addicted doctors had an anesthesiologist client who administered fentanyl anally. "It's cumbersome," the psychiatrist says, "but ingenious. No syringes, no needle marks."
So why not just have docs step up to the cup, same as pilots and pro cyclists? One big problem: There's no test for fentanyl, the drug of choice for most addicted anesthesia providers. "We had Abbott Laboratories working on a fentanyl test for more than a year," says Dr. Arens, who had commissioned the project on behalf of the American Society of Anesthesiologists. "But they failed. Every variation showed false positives with antihistamines. So it's easy to call for randomized drug tests, but what do you do if you have no test?"
Short of wildly erratic behavior, often the only early warning sign that an anesthesiologist is stealing drugs is the suffering of his patients. "Excessive postoperative pain is one clue that something is fishy," says Dr. Arens. "The anesthesiologist signs out drugs for his patient but keeps them for himself, and nobody understands why the patient wakes up in excruciating pain."
Writhing agony on the operating table is what finally trapped Dr. Frank Ruhl Peterson, a 45-year-old Pennsylvania anesthesiologist who was sentenced to 10 to 23 months in prison in 1997. "He had more than 200 patients in the couple of months he was there. When I asked him how many of his patients he shortchanged on the drugs, he said, 'Everybody,' " the investigating detective told the Associated Press. "Since the patients were under no anesthetic, they could actually feel the scalpel cutting them, and the operations had to be stopped."
Those patients were the lucky ones; at least they were able to speak up. A far more horrifying effect is "awake paralysis," a living nightmare during which you can feel everything but can do nothing. Karen Domino, M.D., chairwoman of the American Society of Anesthesiologists' Committee on Professional Liability, offers this account from one victim:
"I remember feeling the cold plastic tube being inserted down the back of my throat. I remember trying to cough, talk, open my eyes and do anything to signal that I was still awake. At that point, I began to panic, and I could feel my heart racing. I was crying inside, but no one noticed my tears. The sensation and memory were similar to what I have read about people being buried alive."
The Need for a Fix
Unlike Dr. Angeluzzi, Dr. Junig was caught before his addiction ruined any lives except his own.
Many addicted anesthesiologists kill themselves, either on purpose or by accidental overdose. According to one study by the University of Washington, anesthesiologists are nearly 1.5 times as likely to commit suicide as internists -- themselves with a higher rate than the general population -- and more than twice as likely to OD.
Sadly, suicide has been a tragic tradition of the painkilling trade since its beginning, when Horace Wells, the Connecticut dentist who pioneered the medical use of anesthesia in the mid-1800s, became deranged under the influence of his own drugs and began attacking prostitutes with sulfuric acid. In prison, he took one last gasp of chloroform, then slashed his groin and bled to death.
Likewise, Dr. Junig found his own mental and physical health quickly deteriorating after he started mainlining narcotics, and it was all he could do to keep the hollow smile on his face. "I'd wake up in the middle of the night with diarrhea, not able to breathe, my brain just aching," he'd later say. "I'd be exhausted after a full day of work and know I had to be at my best in a few hours, but I couldn't rest if I didn't have any drugs. You're like a rat, pushing the lever, needing it all the time."
Someone else must have noticed that need, because 3 months after he started injecting fentanyl, security met him at the door when he showed up for work one morning. No one ever confronted or counseled him; he was just barred from the hospital.
Dr. Junig went home and locked himself in his bedroom, as waves of nausea and fever doubled him up in pain. With his wife banging frantically on the door, he lay in a ruined stupor, wondering what the hell had happened to the all-American kid who'd set out to help people.
Looking for an Explanation
To those who know his work, Dr. Gold is one of the world's top addiction specialists. To those who know the man, he's "the guy who never yawns," a relentless thinker who can't stop attacking a problem until he's found a solution. As soon as Dr. Gold learned about the addiction epidemic among anesthesiologists, he was troubled by the explanation: They can't handle the stress of 12-hour surgeries, and they hold the key to tremendously powerful narcotics.
Dr. Gold was doubtful. Yes, anesthesiologists are under terrible pressure, and sure, bliss is just a needle prick away, but that's just as true for other medical professionals. Oncologists trying to save dying patients are far more stressed and carry painkillers in their pockets all day, but don't have nearly the addiction rate. Nor does stress account for anesthesiologists' terrible relapse rate."Even after successful treatment, they have the highest relapse rate among all doctors," says Dr. Gold.
So he wondered, was there a weird character flaw that preselects for anesthesiologists, or could there be another explanation, something hidden in plain sight?
Avoiding Addiction Triggers
Dr. Junig was startled to learn of Dr. Gold's findings, and felt a shock of recognition. It explained so many things he'd never understood about his own behavior: why he'd never been a drug user, or even a partyer, until he became a resident, and why the cravings resumed when he was working the hardest.
Yet, he is still too guilt-stricken to accept the revelations as an indirect absolution for his addiction. At best, he hopes it will save other doctors -- not to mention their patients.
"I don't deny my own stupid mistakes," says Dr. Junig, "but it can be very helpful for other addicts to know that, yeah, maybe they came by this honestly. Maybe that will remove the shame and self-inflicted isolation, and let them seek help before it gets out of control."
After he was caught stealing drugs in 2001, Dr. Junig realized he could never trust himself around narcotics again. He checked himself in for intensive, in-patient rehab treatment and abandoned anesthesiology for good.
Since then, he's gone back to school and been retrained in psychiatry, a healing profession that will allow him to draw upon his own struggles without giving him direct access to the drug cabinet. He was recently hired by a small psychiatric practice in Wisconsin and was up front from the start about his past drug problems. Knowing that he's being watched, Dr. Junig figures, can only help him keep an eye on himself.
Something's in the Air
Dr. Gold decided to take a close look at O.R. procedures and was immediately struck by the anesthesiologists' posture. They weren't standing upright or moving around, like everyone else involved in the operation, but spent the entire time crouched right next to the patient's head. Dr. Gold watched a heart operation and noticed that during the 10-hour procedure, the anesthesiologist never budged from his post, not even for a bathroom break.
Wait, he thought. What if the drugs are escaping from the patients' breath? The system for delivering drugs may be airtight, but how about the ventilation? Dr. Gold enlisted the University of Florida's nanotechnology group to use its mass spectronomy equipment to test for the presence of drugs above a patient's mouth. They scanned an O.R., and . . . jackpot! Sure enough, narcotics were detected not only in the air, but also on metal trays and tables -- exactly the way vaporized gas would settle. "Fentanyl is extremely potent and active in the air -- that's why the Russians used it to put everyone in the theater to sleep during the Chechen hostage crisis," Dr. Gold explains. "It's also easily absorbed through the skin."
This would explain why the best, most requested anesthesiologists are the most prone to addiction: They handle more cases and more of the long, multihour procedures, so they're more exposed to airborne drugs. It also explains why addicts tend to be in their early 30s and suffer such rampant recidivism: Fresh out of medical school and internships, they're inhaling narcotics for the first time, and when they return to work after rehab, they're unwittingly using again.
After reporting his findings at the annual conference of the Association for Medical Education and Research in Substance Abuse, Dr. Gold is now collecting blood samples from nonaddicted anesthesiologists to test for trace levels of narcotics.
As for why every anesthesiologist isn't hooked, you have to figure in genetic predisposition, says Paul Earley, M.D., medical director of the Impaired Professionals Program at the Ridgeview Institute, in Atlanta. Addicts are five to seven times more likely to have a sibling or parent who is chemically dependent. This inherited vulnerability would explain why some, but not all, anesthesiologists react to the narcotized air; the fumes may affect only those pre-equipped with a genetic flip switch.
"Finally," says Dr. Earley, who has helped hundreds of physicians battle back from addiction, "this may give us an avenue to prevention, instead of chasing the horses after they're out of the barn."
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