Securing Propofol Position Statement

The American Association of Nurse Anesthesiology (AANA) supports the well-being and safety of Certified Registered Nurse Anesthetists (CRNAs) and student registered nurse anesthetists (SRNAs). The AANA recognizes that anesthesia professionals have an increased occupational risk of substance use disorder (SUD), as well as experience professional and personal consequences of SUD.1-6

Since the introduction of propofol, the incidence of healthcare professionals’ abuse of propofol continues to increase.5,7 Propofol is among the most commonly abused drugs by anesthesia professionals.8 Propofol accounts for 41% of reported substance abuse cases among anesthesia providers.9 Research has shown that at least 1 incident of propofol abuse or diversion occurred in 18% of anesthesia departments affiliated with an academic program in the United States.4,10,11 The 10-year incidence of propofol abuse was 0.1% (10 per 10,000 anesthesia providers), which is higher than previous reports indicating a propofol abuse incidence of 0.02%.4,10,11 Incidence of death among anesthesia professionals abusing propofol was 28%.4,10,11 This abuse is primarily due to ease of access, rapid onset of action, short duration of action, and feelings of elation and euphoria.2,5,6,12-24 Access to highly addictive drugs, including propofol, is a significant risk factor for SUD among anesthesia and other healthcare professionals.2,3,5,6,11,15-20,25,26 Research also suggests that exposure to propofol aerosolized in the operating room may sensitize personnel to later abuse.5,27-29 Unfortunately, the first sign of propofol abuse or addiction is often death.6,11,17,18,21-23

A lack of controls (e.g., pharmacy accounting, stricter dispensing control) is associated with an increased incidence of abuse.4,18,24,30 Propofol storage, dispensing, return, and disposal is not standardized across facilities.24 Because healthcare professionals who divert drugs, such as propofol, pose a risk to their patients, employers, coworkers, and themselves, the AANA takes a strong position on the need to secure propofol within facilities.5,24,31

Position

Recommendation for Classification by Federal Drug Enforcement Administration

• Since 2010, it has been the AANA’s position that, due to the risk of abuse, propofol warrants, at a minimum, Schedule IV controlled substance classification.12,17,25,32,33

Recommendations for Facilities

• AANA supports the development of facility policies, procedures, and clinician education that address signs and symptoms of diversion and SUD, prevention, reporting, and safe intervention.

• If propofol is controlled in a manner consistent with a scheduled drug, the incidence of propofol abuse and accidental fatal overdoses is decreased.9,18 The AANA strongly recommends that facilities with propofol on formulary develop and implement methods to reduce the likelihood of propofol diversion, such as placing propofol in a secure environment only accessible by those professionals identified in a medication management policy. Controlled substance diversion prevention programs that build in

tight control through process checks and balances, diligent surveillance, and prompt interventions are required to prevent, promptly identify, and investigate suspected diversion.34

• Establish a comprehensive workplace SUD policy, which includes propofol, and addresses drug storage, abuse and diversion, methods to prevent drug diversion, reporting mechanisms, and criteria for reentry to clinical practice.1,6,15,31,35

• Educate all healthcare professionals on drug diversion and impairment in the workplace, signs and behaviors of drug diversion and impairment, appropriate response, and proper ways to report drug diversion and impairment.1,26,31 Establish a communication pathway to safely and confidentially raise concerns in order to empower healthcare professionals to report suspected diversion or concerns of an individual with SUD.

• When propofol diversion and abuse are suspected, use an extended drug testing panel and protocols that identify anesthesia drugs.1,5,36

AANA Resources

• The AANA Helpline at (800) 654-5167 is available to all CRNAs, SRNAs, nurse anesthesia educational programs, and employers for drug and alcohol concerns, including appropriate steps for suspected diversion, intervention, and treatment for anesthesia professionals.

• For additional resources on this topic, please visit the AANA website at www.AANAPeerAssistance.com.

References

1. Addressing Substance Use Disorder for Anesthesia Professionals, Position Statement. Rosemont, IL: American Association of Nurse Anesthesiology; 2021.

2. Tezcan AH, Ornek DH, Ozlu O, et al. Abuse potential assessment of propofol by its subjective effects after sedation. Pak J Med Sci. Nov-Dec 2014;30(6):1247-52. doi:10.12669/pjms.306.5811

3. Bonnet U, Scherbaum N. Craving dominates propofol addiction of an affected physician. J Psychoactive Drugs. Apr-Jun 2012;44(2):186-90. doi:10.1080/02791072.2012.684635

4. Bozimowski G, Groh C, Rouen P, Dosch M. The prevalence and patterns of substance abuse among nurse anesthesia students. AANA J. Aug 2014;82(4):277-83.

5. Earley PH, Finver T. Addiction to propofol: a study of 22 treatment cases. J Addict Med May-Jun 2013;7(3):169-76. doi:10.1097/ADM.0b013e3182872901

6. Palabiyik-Yucelik SS, Yoladi FB, Yegenoglu S, Baydar T. The fine line between occupational exposure and addiction to propofol. Istanbul J Pharm. 2023;53(1):95-102. doi:10.26650/IstanbulJPharm.2023.1134975

7 Burnett GW, Taree A, Martin L, Bryson EO. Propofol misuse in medical professions: a scoping review. Can J Anaesth. Mar 2023;70(3):395-405. Utilisation abusive du propofol dans les professions medicales : une etude de portee. doi:10.1007/s12630-022-02382-2

8. Wright EL, McGuiness T, Moneyham LD, Schumacher JE, Zwerling A, Stullenbarger NE. Opioid abuse among nurse anesthetists and anesthesiologists. AANA J. Apr 2012;80(2):120-8.

9. Schneider D, Ponto J, Martin E. Propofol Disposal in the Anesthesia Setting: Overcoming Barriers. AANA J. Dec 2017;85(6):417-423.

10. Booth JV, Grossman D, Moore J, et al. Substance abuse among physicians: a survey of academic anesthesiology programs. Anesth Analg. Oct 2002;95(4):1024-30, table of contents. doi:10.1097/00000539-200210000-00043

11. Drug Enforcement Administration. Office of Diversion Control. Drug & Chemical Evaluation Section. Propofol. Accessed June 5, 2023, https://www.deadiversion.usdoj.gov/drug_chem_info/propofol.pdf

12. Schedules of Controlled Substances: Placement of Propofol Into Schedule IV, 75 Fed Reg. Oct 27, 2010: 66195-66199.

13. Koopmann A, von der Goltz C, Hermann D, Kiefer F. Propofol addiction initiated by anesthetic use. Case Reports Letter. Am J Psychiatry. Feb 2011;168(2):211-2. doi:10.1176/appi.ajp.2010.10091293

14. Roussin A, Montastruc JL, Lapeyre-Mestre M. Pharmacological and clinical evidences on the potential for abuse and dependence of propofol: a review of the literature. Research Support, Non-U.S. Gov't Review. Fundam Clin Pharmacol. Oct 2007;21(5):459-66. doi:10.1111/j.1472-8206.2007.00497.x

15. Lee J. Propofol abuse in professionals. J Korean Med Sci. Dec 2012;27(12):1451-2. doi:10.3346/jkms.2012.27.12.1451

16. Klausz G, Rona K, Kristof I, Toro K. Evaluation of a fatal propofol intoxication due to self administration. J Forensic Leg Med. Jul 2009;16(5):287-9. doi:10.1016/j.jflm.2008.12.010

17. Welliver M, Bertrand A, Garza J, Baker K. Two new case reports of propofol abuse and a pattern analysis of the literature. Int J Adv Nurs Studies. 2012;1(1):22-42.

18. Wischmeyer PE, Johnson BR, Wilson JE, et al. A survey of propofol abuse in academic anesthesia programs. Research Support, Non-U.S. Gov't. Anesth Analg. Oct 2007;105(4):1066-71, table of contents. doi:10.1213/01.ane.0000270215.86253.30

19. Jungerman FS, Palhares-Alves HN, Carmona MJ, Conti NB, Malbergier A. Anesthetic drug abuse by anesthesiologists. Rev Bras Anestesiol. May-Jun 2012;62(3):375-86. doi:10.1016/S0034-7094(12)70138-1

20. Kranioti EF, Mavroforou A, Mylonakis P, Michalodimitrakis M. Lethal self administration of propofol (Diprivan). A case report and review of the literature. Forensic Sci Int. Mar 22 2007;167(1):56-8. doi:10.1016/j.forsciint.2005.12.027

21. Kirby RR, Colaw JM, Douglas MM. Death from propofol: accident, suicide, or murder? Case Reports Research Support, Non-U.S. Gov't. Anesth Analg. Apr 2009;108(4):11824. doi:10.1213/ane.0b013e318198d45e

22. Riezzo I, Centini F, Neri M, et al. Brugada-like EKG pattern and myocardial effects in a chronic propofol abuser. Case Reports. Clin Toxicol (Phila). Apr 2009;47(4):358-63. doi:10.1080/15563650902887842

23. Colucci AP, Gagliano-Candela R, Aventaggiato L, et al. Suicide by self-administration of a drug mixture (propofol, midazolam, and zolpidem) in an anesthesiologist: the first case report in Italy. J Forensic Sci. May 2013;58(3):837-41. doi:10.1111/1556-4029.12053

24. Ring MT, Pfrimmer DM. Propofol as a Drug of Diversion: Changing Disposal Practices to Reduce Risk. Crit Care Nurse. Dec 1 2021;41(6):45-53. doi:10.4037/ccn2021123

25. Welliver M. Propofol alert! Gastroenterol Nurs. Sep-Oct 2011;34(5):398-9.

doi:10.1097/SGA.0b013e318229bbd6

26. Lee S. Guilty, or not guilty?: a short story of propofol abuse. Korean J Anesthesiol. Nov 2013;65(5):377-8. doi:10.4097/kjae.2013.65.5.377

27. Li KY, Xiao C, Xiong M, Delphin E, Ye JH. Nanomolar propofol stimulates glutamate transmission to dopamine neurons: a possible mechanism of abuse potential? J Pharmacol Exp Ther. Apr 2008;325(1):165-74. doi:10.1124/jpet.107.132472

28. Merlo LJ, Goldberger BA, Kolodner D, Fitzgerald K, Gold MS. Fentanyl and propofol exposure in the operating room: sensitization hypotheses and further data. J Addict Dis 2008;27(3):67-76. doi:10.1080/10550880802122661

29. McAuliffe PF, Gold MS, Bajpai L, et al. Second-hand exposure to aerosolized intravenous anesthetics propofol and fentanyl may cause sensitization and subsequent opiate addiction among anesthesiologists and surgeons. Med Hypotheses 2006;66(5):874-82. doi:10.1016/j.mehy.2005.10.030

30. Maier C, Iwunna J, Tsokos M, Musshoff F. [Deaths from propofol abuse : Survey of institutes of forensic medicine in Germany, Austria and Switzerland]. Anaesthesist. Feb 2017;66(2):109-114. Todesfalle durch Propofolmissbrauch : Befragung in rechtsmedizinischen Instituten in Deutschland, Osterreich und der Schweiz. doi:10.1007/s00101-016-0260-6

31. Berge KH, Dillon KR, Sikkink KM, Taylor TK, Lanier WL. Diversion of drugs within health care facilities, a multiple-victim crime: patterns of diversion, scope, consequences, detection, and prevention. Mayo Clin Proc. Jul 2012;87(7):674-82. doi:10.1016/j.mayocp.2012.03.013

32. U.S. Drug Enforcement Administration. Controlled Substances Act. 21 CFR 13 § 811 and § 812.

33. Kim DK. Propofol use for sedation or sedation for propofol use? J Anesth. Apr 2012;26(2):289-91. doi:10.1007/s00540-011-1275-4

34. Clark J, Fera T, Fortier C, et al. ASHP Guidelines on Preventing Diversion of Controlled Substances. Am J Health Syst Pharm. Dec 5 2022;79(24):2279-2306. doi:10.1093/ajhp/zxac246

35. Devine B, Gutierrez K, Rogers R. Drug diversion by anesthesiologists: identification through intensive auditing. Am J Health Syst Pharm. Apr 01 2012;69(7):552, 556. doi:10.2146/ajhp120010

36. Jones JT. Advances in Drug Testing for Substance Abuse Alternative Programs. J Nurs Regul. 2016;6(4):62-67.

Adopted by AANA Board of Directors June 2009

Revised by AANA Board of Directors September 2009

Revised by AANA Board of Directors November 2012

Revised by AANA Board of Directors April 2017

Revised by AANA Board of Directors August 2023

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