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Nurse Anesthetists Address Propofol Abuse

Monday September 14, 2009
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Michael Jackson’s suspected death from propofol (Diprivan) on June 25 came just three days after the American Association of Nurse Anesthetists called on hospitals to more closely control the sedative/anesthetic because of an increase of abuse and diversion among healthcare professionals.

The AANA chose to issue the statement in June because of the increased numbers of calls to its hotline from members regarding their abuse of propofol in the past five to six years, says Art Zwerling, CRNA, DNP, DAAPM, chairman of the AANA’s peer assistance advisors committee. The AANA has also seen an increase of reported deaths among anesthesia providers from propofol, he says.

One of the reported deaths was a nurse anesthetist who died in January from self-administering propofol, says Lisa Thiemann, CRNA, senior director of professional practice for the AANA. Although the total number of healthcare professionals who abuse propofol is small, the deaths and the increased calls to the hotline prompted the association to develop a policy specific to the drug, she says.

According to AANA’s warning statement, “At subanesthetic doses, feelings of elation and euphoria have been reported. Unfortunately, too often the first sign of propofol misuse or addiction is the practitioner’s death.”

Readily Available
Propofol is not a controlled substance. In most hospitals, the supply of propofol is not closely monitored and is readily available in operating rooms, endoscopy suites, and physicians’ offices, where it is used for surgical and diagnostic procedures.

Propofol is a particularly dangerous drug to abuse because the “margin between the effective dose and lethal dose is so narrow,” says Zwerling. There is no antidote for propofol, which suppresses respirations.

Propofol is not physically addicting, but can be psychologically addicting. Medical professionals don’t usually take the drug to get high because it puts them instantly to sleep. Instead, it is taken to relieve stress because users wake up feeling refreshed, says Robert R. Kirby, MD, professor emeritus in the department of anesthesiology, University of Florida, College of Medicine, Gainesville. The drug also is popular because it has a rapid onset and short duration of action, he says.

“It’s addictive in the sense that the people who use it gradually increase the number of times they inject,” Kirby says.

The results of a survey of propofol abuse in academic medical centers concluded that the use of the drug by medical residents had increased over a period of 10 years and that most programs had no control of propofol inventory. “This may be of concern, given that all programs reporting deaths from propofol abuse were centers in which there were no pharmacy accounting for the drug,” according to the results of the study published in a 2007 article in the journal Anesthesia & Analgesia by Paul Wischmeyer, MD, an anesthetist at the University of Colorado, and colleagues.

A similar survey has not been done of nurse anesthetists but the AANA is collating the information it receives from its hotline, says Zwerling.

Not all medical professionals agree that propofol should be controlled. Kirby says nurses and doctors intent on abusing propofol still would be able to obtain it.
“The AANA supports measures that would lead to closer accountability for and decreased indiscriminate access to propofol,” Zwering says. It will be up to the DEA and FDA to decide whether the drug meets their criteria for being classified as a controlled substance.”

Requests to speak with someone from the American Hospital Association regarding propofol were unanswered.

The DEA already had started an inquiry into whether propofol should be controlled two years ago because of a petition made to the agency, says Rusty Payne, a DEA spokesman. The process to designate a drug as a controlled substance is complex, and the agency must gather various types of data before asking the FDA to make a recommendation about whether it thinks a drug to be controlled.

A New Danger
However, a new form of propofol not yet on the market is much closer to being classifed as a controlled substance and is in the public comments phase, says Payne. The drug, fospropofol (Lusedra), metabolizes into propofol once in the body. Fospropofol is water soluble and can be taken as a liquid, making it much easier to abuse than regular propofol, which must be administered intravenously. This is why the FDA recommended fospropofol be classified as a controlled substance, it says.

When propofol was introduced 20 years ago, “its potential for abuse was apparently not recognized from studies performed during development prior to its approval,” the FDA said in a written statement. “Also, propofol is an injectable drug, not generally available to the public and used only for administration by anesthesiolgists and other healthcare providers in hospitals and clinics in carrying out surgical procedures.”

“Before 1992, clinicians and the manufacturer (of propofol) were convinced that such abuse was rare to nonexsistent,” Kirby, wrote in an article in the April 2009 issue of the Anesthesia & Analgesia about the use of propofol in homicide. “Since 1992, however, reports have been published [largely in forensic medical journals] concerning abuse, accidental overdose, and suicide.”

Zwerling says the warning signs for propofol abuse were there early on. Studies of propofol resulted in lab animals self-administering the medication because the drug had such a profound effect on the reward section of the brain, he says. “We went in knowing it had some addiction potential,” Zwerling says.

Patients who received the drug for surgical or endoscopic procedures also quickly realized the feel-good effects of propofol. “It was obvious this drug makes you feel really good,” he says.

A fact sheet about propofol from the DEA notes, “Studies investigating the recovery profile of propofol have reported that patients anesthetized with propofol wake up ‘elated,’ ‘euphoric,’ and ‘talkative.’”

Propofol is an effective anesthetic/sedative when administered by certified nurse anesthetists and anesthesiologists who have the appropriate resuscitative equipment nearby, Zwerling says. Even physicians and nurses, except for ED doctors and ICU nurses, should not be administering propofol, says the AANA. “This is a drug that is extraordinarly dangerous in the wrong hands,” he says.

Despite an apparent increase of propofol abuse, the DEA may still “decide not to schedule the drug because of its lesser potential for abuse,” Payne says.
It is unusual for a nonmedical person, such as Michael Jackson, to abuse propofol, say the anesthesia personnel interviewed. But the practice is beginning to infiltrate the population outside the medical community, say Zwerling and Kirby.

Oxygen tanks and propofol were found in Jackson’s home by police after his death and the drug was allegedly administred by his personal physician Conrad Murray, MD. Police believe Murray gave Jackson the propofol to help him sleep, although that is not a recognized use for the drug.

Jackson most likely became exposed to propofol during his cosmetic procedures and for surgery following a severe burn he received while filming a Pepsi commercial in the 1980s, says Zwerling.

Janet Boivin, RN, is a senior writer at Gannett Healthcare Group.
To comment, e-mail editorNTL@gannetthg.com.


To comment, e-mail editorNTL@gannetthg.com.