Substance Use & Misuse, Early Online:1–7, 2011Copyright C© 2011 Informa Healthcare USA, Inc.ISSN: 1082-6084 print / 1532-2491 onlineDOI: 10.3109/10826084.2011.564705

ORIGINAL ARTICLE

The Misuse and Abuse of Propofol

Todd Monroe1, Heather Hamza2, Greg Stocks3, Paula Davies Scimeca4

and Ronald Cowan5

1School of Nursing, Vanderbilt University, Nashville, Tennessee, USA; 2Los Angeles County Medical Center Departmentof Anesthesiology, Los Angeles, California, USA; 3Massachusetts Association of Nurse Anesthestists, Boston,Massachusetts, USA; 4Wagner College, School of Nursing, Staten Island, New York, USA; 5Department of Psychiatry,Vanderbilt Addictions Center, Nashville, Tennessee, USA

Media attention on the misuse of propofol increasedsignificantly when the drug was implicated in thedeath of pop music superstar Michael Jackson in 2010.The misuse and abuse of propofol among healthcareproviders has been reported worldwide, with some mis-use resulting in death. Propofol policies guiding health-care worker re-entry into the workplace after misusingpropofol have received rare attention in the researchliterature. The paucity of information regardingpropofol-specific re-entry policies suggests that littleresearch has addressed this problem and the lack of re-search and policy guidance can contribute to unsafe re-entry and even death. This paper focuses on healthcareproviders because they have an easy access to propofoland therefore are vulnerable to misusing or abusing thedrug. To accomplish this, the pharmacology and mis-use/abuse potential of propofol and the influence of the12-step recovery paradigm in the re-entry literature arereviewed. In conclusion, existing research and policyare drawn upon to suggest employment re-entry guide-lines for healthcare workers.

Keywords propofol addiction, propofol misuse, propofol abuse,re-entry to work after propofol abuse, propofol re-entrypolicies, recovering health care providers

BRENDA: A FICTIONAL VIGNETTE

The following fictional scenario relays experiences com-monly reported among healthcare providers throughoutthe world. These experiences especially occur in locationswhere propofol is an unrestricted, unsecured, and unreg-ulated drug, which remains the case in the majority ofhealthcare institutions (Bonnet, Harkener, & Scherbaum,2008; Chao, Lo, Chui, & Koh, 1994; Cirimele, Kintz,

The authors gratefully acknowledge Arthur (Art) Zwerling, CRNA, DNP, DAAPM, for his input regarding re-entry recommendations.Address correspondence to Dr Todd Monroe, School of Nursing, Vanderbilt University, 461 21st Ave South, 600 A-GH, Nashville, TN 37240;E-mail: todd.b.monroe@vanderbilt.edu

Doray, & Ludes, 2002; Fritz & Niemczyk, 2002; Iwersen-Bergmann, Rosner, Kuhnau, Junge, & Schmoldt, 2001;Klausz, Rona, Kristov, & Toro, 2009; Kranioti, Mavro-forou, Mylonakis, & Michalodimitrakis, 2007; Roussinet al., 2006; Ward, 1992).

Brenda was an exceptional nursing student whose at-traction to excitement led her to procure a job in an in-tensive care unit (ICU) after graduation. After a few yearsof ICU work, she entered a nurse anesthesia school andthen joined a group practice as a certified registered anes-thetist (CRNA), where she was respected and trusted byher colleagues.

Brenda found her new job stressful and began to ex-periment with the drugs readily available to her at workto help her cope with working conditions. Although shehad access to a wide array of potent narcotics, injectablepropofol became her “drug of choice” because it was notaccounted for as a controlled substance and was there-fore easily accessible. Three weeks after she first startedinjecting propofol, Brenda was found in respiratory ar-rest on the operating room floor. Resuscitated success-fully by colleagues, she was brought to the emergency de-partment and released once she was medically stable. Themanager of her anesthesia group confronted Brenda withthe obvious evidence of her misuse of propofol. Brendawas given the option of receiving assistance for her sub-stance use disorder (SUD) or being terminated from herjob. Brenda reported to the Employee Assistance Program(EAP), which expedited her admission into an inpatientsubstance user treatment program the same day.

Brenda believed after 90 days of inpatient treatmentthat she was ready to return to work; however, the drug-monitoring program in her state and her employer insistedupon additional treatment in an outpatient treatment set-ting prior to her re-entry into the clinical workplace. Six

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months after her overdose and after 90 days of intensiveoutpatient follow-up, Brenda was cleared by the drug-monitoring program to return to a nonanesthesia positionwith no access to controlled substances. Her EAP collabo-rated with nursing administration and arranged for Brendato fill a part-time position in the ICU, allowing her to at-tend ongoing aftercare and 12-step meetings. The require-ment that Brenda had no access to controlled substanceswas accommodated by assigning other nurses to admin-ister controlled substances to Brenda ’s patients whileBrenda fulfilled skilled nursing functions on the unit. De-spite the careful orchestration of efforts to ensure Brenda’ssafe return to practice, her nurse manager found her in res-piratory arrest in the ICU staff bathroom four weeks afterher return to work. The cause of her second respiratory ar-rest was once again propofol. Brenda ’s colleagues wereunable to revive her.

BACKGROUND

Despite the spectacular media coverage that Michael Jack-son’s propofol-related death received and evidence ofpropofol misuse and deaths among healthcare providers(Fritz & Niemczyk, 2002), propofol largely remains anuncontrolled substance. Propofol, in use since 1986, iscurrently the most widely used anesthesia induction agent(Eger, 2004) and ICU sedative in the world (Wilson &Compton, 2009). Although warnings of propofol’s abusepotential appeared in 1992 (Follette & Farley, 1992), thedrug remains readily accessible in many hospitals. Nu-merous investigators have shown that propofol misuse andabuse is a problem among healthcare providers (Bell, Mc-Donough, Ellison, & Fitzhugh, 1999; Iwersen-Bergmannet al., 2001; Soyka & Schutz, 1997; Wischmeyer et al.,2007), and that the most common reason for choosing itas a drug of misuse is its ease of access (Stocks, 2009).Not surprisingly, abuse1 rates decrease when propofol isregulated and similary accounted for as other controlleddrugs (Wishcmeyer et al., 2007).

Re-entry of healthcare providers to the clinical work-place who are recovering from propofol abuse has re-ceived little attention in the literature. Workplace re-entryis defined as the employer-sanctioned return to work af-ter a period of abstinence from an active SUD. Wilsonand Compton (2009) reviewed the literature related tore-entry to work after recovering from any SUD amonganesthesia providers. Their review found no studiesspecifically related to propofol re-entry. Thus, this paper’soverall purpose is to increase awareness about the mis-use and abuse potential of propofol. To accomplish this,we discuss the pharmacology of propofol, re-entry policyconcerns, and the influence of the 12-step paradigm in there-entry literature. Suggestions for re-entry of healthcareproviders recovering from identified propofol misuse arepresented to help prevent Brenda’s story from becoming areality. This re-entry discussion centers mostly on health-

1The journal’s style utilizes the category Substance abuse as a diagnos-tic category. Substances are used or misused; living organisms are andcan be abused. Editor’s note.

care providers because of the largely unrestricted accessto propofol found in the clinical work environment; how-ever, the lay public is also misusing the drug.

Current estimates are that the percentage of healthcareproviders with substance dependency are from 2% to 10%(Bell et al., 1999; NCSBN, 2001; American Nurses As-sociation, 1984; Moore, Mead, & Pearson, 1990; Hugheset al., 1992; Trinkoff & Storr, 1994; Baldisseri, 2007;Helzer et al., 1990; Siegel & Fitzgerald, 1988; Trinkoff,Eaton, & Anthony, 1991; Trinkoff & Storr, 1998) whilemisuse and abuse rates are reported from 14% (Baldisseri,2007; Siegel & Fitzgerald, 1988) to over 20% (Trinkoffet al., 1991). The prevalence of propofol abuse amonganesthesia providers ranges from 3% (Stocks, 2011) to10% (Bell et al., 1999); however, the misuse of the drugappears to be much higher. Propofol is often one of thesubstances that healthcare providers manifesting an SUDhave used recreationally [Scimeca, 2010; Stocks (2011)].A recent survey utilizing a convenience sample of recov-ering anesthesia providers found high rates of propofolmisuse (Stocks, 2011). Propofol was named as the drugof choice for only four respondents (3.6%); however, therate of propofol misuse was greater and nearly 33% of re-spondents reported using propofol at least once.

PHARMACOLOGY AND MISUSE/ABUSE POTENTIALOF PROPOFOL

Propofol’s actions at multiple receptor subtypes accountfor its potential for misuse/abuse and its lethality in over-dose. Propofol alters ventral striatal dopamine, a phar-macologic characteristic shared with other commonlyabused medications (Roussin, Montastruc, & Lapeyre-Mestre, 2007; Zacny, Lichtor, Thompson, & Apfelbaum,1993a; Zacny, Lichtor, Zaragoza, et al., 1993b; Zacnyet al., 1996). Propofol’s actions on dopamine likely ac-count for its addictive properties, and human propofol ad-diction has been reported in the literature (Chao & Nestler,2004; Chao et al., 1994; Zacny, Lichtor, Thompson, et al.,1993a; Zacny, Lichtor, Zaragoza, et al., 1993b; Zacnyet al., 1996). Propofol acts at gamma-amino butyric acid(GABA) receptors and N-methyl-d-aspartate (NMDA)type glutamatergic receptors (reviewed in Roussin et al.,2007). Propofol’s actions on GABA and glutamate, neuro-transmitters that are critical for influencing level of arousaland consciousness, likely account for its anesthetic prop-erties and lethality in overdose.

Subanesthetic doses of propofol can elicit a euphoricresponse (Patel et al., 2003; Zacny, Lichtor, Thompson,et al., 1993a). Propofol rapidly redistributes from theplasma into highly perfused brain tissue, and rapid redis-tribution into adipose tissue accounts for its short dura-tion of action. Propofol has an extremely narrow thera-peutic index related to the small dosing window betweeneuphoria and apnea. Propofol is metabolized in the liverthrough glucuronidation and is renally excreted (Iwersen-Bergmann et al., 2001; Roussin et al., 2007).

Despite the strong recommendation to control propo-fol as a narcotic by the American Association of NurseAnesthetists (AANA, 2009a, 2009b), propofol is not yet

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PROPOFOL MISUSE, RE-ENTRY TO WORK AFTER PROPOFOL ABUSE 3

regulated as a controlled substance by the United StatesDrug Enforcement Agency (DEA) (Wilson, Canning, &Caravati, 2010). However, the DEA has recently requesteda public comment on a proposal to schedule propofol asa Schedule III controlled substance. Until this proposal isimplemented, regulating propofol access will depend onvoluntarily accounting by individual hospitals. Interest-ingly, fospropofol, a newly released prodrug of propofol(a prodrug is an inactive form of a drug that is converted toan active drug metabolite in vivo), is classified as a Sched-ule IV controlled substance [American Society of Anes-thesiologists (ASA), 2009a, 2009b].

CURRENT RE-ENTRY RECOMMENDATIONS FORHEALTHCARE PROVIDERS

Contracts between an affected healthcare provider andhis or her employee are commonly used to delineatethe circumstances and rules for a healthcare workers’re-entry into the workplace. The current literature onthe re-entry of healthcare providers has predominantlycentered on opioid misuse, with the result that mostre-entry contracts include opioid restrictions (Monroe,2009; Monroe, Pearson, & Kenaga, 2009; Roche, 2007).However, unlike opioid misuse, in which the opioid an-tagonist naltrexone can be used to aid in safer re-entry(Angres, 2001; Farley & Arnold, 1991; Roche, 2007), aneasily administered antagonist is not readily available forpropofol.

Many recommendations for re-entry contract guide-lines appear in the literature. These include one year awayfrom anesthesia practice (Bryson & Silverstein, 2008;Paris & Canavan, 1999), documented attendance at 12-step meetings (Monroe, 2009; Roche, 2007), mandatorydrug testing (AANA, 2009a, 2009b; Herrington, Ben-zer, Jacobson, & Hawkins, 1982; Monroe, 2009; Roche,2007), and limited work hours with five-year monitoringcontracts (Clark & Farnsworth, 2006). If necessary, re-entry may include redirection of the affected healthcareworker into another specialty (Collins, McAllister, Jensen,& Gooden, 2005; Fry, 2005; Menk, Baumgarten, Kings-ley, Culling, & Middaugh, 1990). Individuals who are un-able or unwilling to be rehabilitated may need redirectionout of the profession (Monroe, Pearson, & Kenaga, 2008).

RE-ENTRY OF HEALTHCARE PROVIDERS AND THE12-STEP RECOVERY PARADIGM

The use of a 12-step program to aid in a healthcareprovider’s recovery is required by most nursing and med-ical regulatory boards in the United States. For exam-ple, the National Council of State Boards of Nursing(NCSBN) conducted surveys of state-administered drug-monitoring programs and found that nearly 80% requirethat the nurses attend 12-step meetings and 61% requireparticipants to have a 12-step sponsor (NCSBN, 2009,2010a, 2010b). Nursing regulatory boards are not alone inusing the 12-step treatment approach. The Federation ofState Physicians’ Health Program guidelines recommendthat individual physician participants have a contract thatincludes the requirement to attend 12-step programs such

as Alcoholics Anonymous (AA) or Narcotics Anonymous(NA) (DuPont, McLellan, White, Merlo, & Gold, 2009).

The requirement that individuals participate in 12-stepprograms is supported by several studies showing thatthese programs augment an individual’s recovery. Forexample, Fiorentine and Hillhouse (2003) found thatextensive participation in 12-step program treatment wasassociated with the reduction of addictive behaviors. A re-cent study by McLellan, Skipper, Campbell, and DuPont(2008) demonstrated that 79% of 904 physicians in 16state physician-monitoring programs had no interruptionin their recovery from SUDs at an average follow-up of7.2 years. The authors concluded that participation in 12-step programs, when combined with additional intensivemonitoring, benefitted long-term recovery. Twelve-stepmeeting involvement appears beneficial to facilitate re-covery in nurses who were previously addicted (Scimeca,2010). Between January 2009 and April 2010, 29 nursesfrom 20 states shared personal stories for a book about re-covering nurses. All 29 nurses credited 12-step programparticipation with their ability to establish an initialfoundation in recovery. Six nurses reported re-initiationof substance use and each of them identified a lack of12-step involvement as the main precipitant of theirre-initiation of substance use (Scimeca, 2010). The exactmechanisms resulting in positive outcomes with 12-stepinvolvement are unknown. However, components, suchas cognitive restructuring (Steigerwald & Stone, 1999),helping others with recovery (Zemore, Kaskutas, &Ammon, 2004), and lifestyle change and social networkenhancement (Owen et al., 2003), appear to contribute tothe efficacy of these programs.

RE-ENTRY SUGGESTIONS FOR HEALTHCAREPROFESSIONALS RECOVERING FROM PROPOFOLMISUSE

Our suggestions, as follow, are based on evidence in theliterature and on the current requirements of nurse andphysician substance abuse monitoring programs in theUnited States:

1. Screening and evaluation for an SUD with specific rec-ommendations for treatment (inpatient or outpatient).

2. Five years of monitoring for substance use, includingrandom drug screening with appropriate tests to detectpropofol.

3. On the basis of enhanced treatment success and multi-ple mechanisms of efficacy for 12-step programs, someform of active participation in a recovery-based pro-gram such as AA or NA and documentation to corrobo-rate weekly attendance for the duration of the five-yearcontract is recommended.

4. Minimum of one year away from practice in any fa-cility that uses propofol. This means that the practicewill be restricted from any facility such as a hospital,an outpatient surgical center, an outpatient endoscopy,a dental office, etc., that stocks or uses propofol seda-tion anywhere within the organization. Preferable op-tions of re-entry to practice may include primary-care

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clinics, long-term care facilities, chronic or acute dial-ysis centers, etc.

DISCUSSION

The purpose of this paper was to discuss the abuseand misuse potential of propofol. The serious implica-tions of propofol misuse have received insufficient atten-tion in the drug policy literature. Re-entry of healthcareproviders with documented propofol misuse or abuse re-quires heightened scrutiny and careful planning becausethe drug is generally not regulated. Healthcare institutionsshould consider voluntary regulation of propofol accessuntil federal requirements are implemented.

LimitationsOur recommendations have limitations. First, our sug-gestions are based on the notion that an SUD is a diseasethat can be treated.2 This philosophy is often not easilyaccepted by everyone and options to re-enter work aftersubstance misuse may not be the cultural norm. Second,the majority of the research about re-entering healthcareproviders comes from North America. This presentsa clear bias of Western ideologies toward SUDs andtheir treatment. Third, the re-entry plan is influencedby the 12-step paradigm; however, as indicated, nearlyall nursing and medical boards in the United Statesmandate use of this paradigm. We understand that thereare many successful treatment programs and that no onephilosophy is best suited to any one individual. Moreempirical evidence about the quality and effectivenessof such programs, and the necessary internal as well asexternal critical conditions for their achievement andsustainability are urgently needed.

CONCLUSION

Current U.S. and international policy about propofol re-entry needs more attention. Basic re-entry suggestions forhealthcare providers with a history of propofol misuse orabuse are outlined. By raising awareness of this issue andby offering re-entry guidelines, we hope to help protect thepublic, save lives, and to assist healthcare administratorsand the professional treatment community.

Declaration of Interest

The authors claim no conflict of interest with thismanuscript.

RESUME

Mots cles: dependance au propofol; mauvaiseutilisation du propofol; abus du propofol; reinsertionprofessionnelle apres abus de propofol; regles de

2The reader is reminded that the medicalizing and associated diagnosisof types of psychoactive substance use and selected users is relativelyrecent and is a consensus-based taxonomy, which is not empirically in-formed. Editor’s note. American Psychiatric Association. (1994). Diag-nostic and Statistical Manual of Mental Disorders (DSM-IV) (4th ed.).Washington, DC: Author.

reinsertion liees au propofol; professionnels de santeœuvrant dans le domaine de la toxicomanie et/orreadaptation

L’attention mediatique portee a la mauvaise utilisation dupropofol a augmente de maniere significative lorsque cemedicament a ete mis en cause lors du deces en 2010 de lasuperstar de pop musique Michael Jackson. La mauvaiseutilisation et l’abus du propofol parmi les professionnelsde sante ont aussi ete constates a l’echelle mondiale, avecdes consequences telle que la mort. Les regles de conduiteencadrant la reinsertion dans le milieu de travail d’un em-ploye ayant un probleme d’abus du propofol a jusqu’icirecu peu d’attentions. La penurie d’informations concer-nant les regles specifiques de reinsertion de professionnelssuggere que peu d’etudes ont examine ce probleme et cemanque de donnees et de directions peuvent contribuera une reinsertion dangereuse pouvant meme entrainer lamort. Cette etude se concentre sur les professionnels desante parce qu’ils ont facilement acces au propofol et parconsequent peuvent etre davantage tentes de mal l’utiliserou meme d’en abuser. Pour se faire, la pharmacologie,la mauvaise utilisation/l’abus potentiel du propofol et lesresultats d’un programme de reprise en 12 etapes dansle domaine de recherche sur la reinsertion professionelle,sont en cours d’examen. En conclusion, la recherche ex-istante et ses avancees sont utilisees pour encourager lamise en place de regles regulant la reinsertion au travailpour ces employes dans le domaine medical.

RESUMEN

Palabras claves: adiccion al propofol; mal uso delpropofol; abuso del propofol; restablecimiento en eltrabajo posterior al abuso de propofol; reglas dereentrada vinculadas al propofol; proveedores decuidados de salud en estado de recuperacion

Ha habido una reciente atencion en los medios de comuni-cacion sobre el abuso del propofol. Su aumento se produjocuando la droga fue vinculada con la muerte en 2009, delartista y superestrella de musica pop, Michael Jackson. Lamalversacion y abuso del propofol entre los profesionalesde la salud se ha diseminado por todo el mundo, ademas decausar la muerte como resultado del abuso. Las reglas so-bre el propofol que guıan la reinsercion del personal al em-pleo, una vez que han abusado la droga, han recibido es-casa atencion en la literatura de investigacion. La falta deinformacion sobre la reentrada especıfica al propofol sug-iere que un mınimo de investigacion se ha concentrado eneste problema, y la carencia de investigacion, puede con-tribuir a un mal restablecimiento, el cual hasta puede re-sultar en fatalidades. Este informe se enfoca en los provee-dores de servicios de la salud, debido a su acceso facil alpropofol, y de acuerdo a su vulnerabilidad para la malver-sacion o abuso de la droga. Para lograr lo dicho, se consid-eran la farmacologıa y posibilidad de abuso y mal uso, y laparadigmatica del programa de rehabilitacion de 12 pasosen la literatura de reentrada. En suma, se examinan aquıla investigacion sobre el abuso y las reglas actuales para

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PROPOFOL MISUSE, RE-ENTRY TO WORK AFTER PROPOFOL ABUSE 5

sugerir protocolos que guıen la reentrada de proveedoresde servicios de la salud.

THE AUTHORSDr. Todd Monroe, Ph.D.,is a Research Associate andPostdoctoral Fellow at theVanderbilt University School ofNursing (VUSN). His fellowshipis jointly supervised betweenthe VUSN and the VanderbiltUniversity Institute of ImagingScience. Dr. Monroe received aBSN degree with honors fromthe University of SouthernMississippi, an MSN degreefrom the University of Alabama,

and his Ph.D. in Nursing from the University of Tennessee HealthScience Center. For more than a decade, Dr. Monroe has workedclinically in both acute and long-term care. Dr. Monroe has spentpast several years in researching substance misuse and abuseamong healthcare providers and students with an emphasis onpolicy development. Dr. Monroe’s current research is focused onthe neurobiology of pain and using functional magnetic resonanceimaging to study pain in older adults with cognitive impairments.

Heather Hamza, CRNA, isa Faculty Anesthetist/ClinicalInstructor at Los AngelesCounty Medical Center atthe University of SouthernCalifornia. She received herMaster of Science in NurseAnesthesia from the Universityof Buffalo. Mrs. Hamza has beeninterested in healthcare providersubstance abuse and re-entry towork policy for several years.She is a national Peer Assistance

Advisor with the AANA. Because of her expertise, Mrs. Hamzafrequently speaks to healthcare audiences about substance abuseissues among healthcare providers. Mrs. Hamza is also a third-year Ph.D. student at UCLA, where her dissertation research willinvolve CRNA re-entry, specifically focusing on cue reactivity.

Greg Stocks, J.D., has practicedas a Nurse Anesthetist overthe last 21 years in majoracademic institutions and privatepractice. He is a former PeerAssistance Advisor for theAANA and holds an ExecutiveJuris Doctor in Health Law.Currently, he provides medicallegal consulting services throughLaw Med Consulting, LLC,a company that he owns inBaltimore, Maryland.

Paula Davies Scimeca, RN,MS, obtained her baccalaureatedegree in Nursing from AdelphiUniversity and her master’sdegree in Psychiatric/MentalHealth Nursing from the StateUniversity of New York atStony Brook. Her career hasspanned over three decades,with the first 10 years spent inmedical, surgical, and criticalcare nursing. With over 20years’ experience in addiction

and psychiatric nursing, her focus has centered on addictionand recovery in nurses since 2003. The author of “UnbecomingA Nurse” and “From Unbecoming A Nurse to OvercomingAddiction,” she is an adjunct professor at Wagner College Schoolof Nursing in Staten Island, New York.

Dr. Ronald Cowan, Ph.D.,M.D., is an Associate Professorof Psychiatry, and an AssistantProfessor of Radiology andRadiological Sciences atVanderbilt University Schoolof Medicine. He is an AssistantProfessor of Psychology atVanderbilt University. Healso serves as the Directorof Vanderbilt’s PsychiatricNeuroimaging Program andas the Scientific Director of the

Vanderbilt Addiction Center. Dr. Cowan received his Ph.D. inNeuroscience from the University of Tennessee Health ScienceCenter and an MD from Weill Cornell University MedicalCollege. Dr. Cowan completed an internship in internal medicineat the Massachusetts General Hospital/Harvard Medical Schooland a residency in psychiatry at the McLean Hospital/HarvardMedical School. Dr. Cowan directs a research program onaddiction, with a focus on the neurobiology of motivated behavior.Clinical areas of interest include addiction, depression, andobesity.

GLOSSARY

GABA: Inhibitory neurotransmitter.Glutamatergic: Excititory type neurotransmitter.Glucuronidation: Process that makes substances more

water-soluble, and, in this way, allow for their subse-quent elimination from the body.

Uncontrolled drug: A drug not on the list of FDA con-trolled substances with misuse/abuse potential.

Ventral Striatum: Associtaed with limbic structures in thebrain consisting of the nucleus accumbens and the ol-factory tubercle.

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