With all the recent media attention on Diprivan abuse (Propofol), we asked Dr. Manejwala to share some of his experience and understanding about this rare disorder. Dr. Manejwala is one of a very small number of physicians in the nation who has treated a significant number of patients with Diprivan abuse or Diprivan addiction. Below is his response to our request.
What is Diprivan, or Propofol?
Propofol is a widely used intravenous sedative medication that is used both for procedures (such as in surgeries or colonoscopies) and for non-procedural sedation, for example for an ICU patient who is extremely agitated. It has been around since the 1980’s and is very widely used. It is often described as "milk of amnesia" or "milk of the ICU." I’ve worked with many practitioners who prefer to use it because of its rapid onset and the ability to carefully titrate doses and the rapid recovery afterwards. It has more than a couple of decades of safe, effective use when used appropriately.
What is Diprivan abuse? What is Diprivan addiction?
When Diprivan was first being used, practitioners generally did not consider it to be an abusable medication. In fact, it isn’t really controlled or regulated in the same way that powerful IV narcotics such as fentanyl and sufentanil are. That’s not to say that anyone can access it, but the strict monitoring present for IV narcotics is not generally done for Diprivan.
My ample clinical experience and that of some of my colleagues now readily confirms that Diprivan is reinforcing for some people. What that means is that people can abuse it, and people can develop the brain disease of addiction to Diprivan. Animal research shows that Diprivan increases brain concentrations of dopamine in the nucleus accumbens. This is a finding that is present in all other addictions. Additionally, some interesting human volunteer research conducted by Jim Zacny, PhD back in 1993 showed that people with a history of illicit drug use did tend to prefer Diprivan over a control. A few isolated case reports also appeared of Diprivan abuse in the medical literature.
We have been treating Diprivan abuse for several years, but aside from occasional interviews about this, I haven’t published on this disorder. In 2007, Dr. Paul Wischmeyer, an extremely well-regarded anesthesiologist published his survey of academic anesthesia programs and found that 18% of departments had experienced at least one case of Diprivan abuse or diversion in the past 10 years, and that of the 25 individuals reported to have been abusing propofol, 7 died as a result of the abuse, 6 of whom were residents. In the treatment field, we were very pleased that Dr. Wischmeyer and colleagues were willing to ask the tough questions about this disorder, and the treatment of Diprivan addiction owes much to his work. It is, however, important to note that the mortality data for Diprivan refers primarily to untreated addiction. Wischmeyer also noted that programs that didn’t regulate Diprivan use had all the mortality, and that there was a statistically significant correlation between Diprivan abuse and reduced pharmacy accounting for this medication. Remember, however, that correlation does not equal causality.
Who tends to abuse Diprivan? Who develops addiction to Diprivan?
Firstly, it is important to note that Diprivan abuse is extremely rare. Taking the available evidence in its entirety, it does seem that physicians, anesthesiologists and nurse anesthetists are not more likely to develop addiction than the general public. There was much sensationalism a few years ago when Men’s Health published an article entitled "Junkie in the OR," which was replete with factual inaccuracy and, unfortunately, propagated much more myth than reality about the incidence and treatability of these disorders.
In my clinical experience, most individuals who abuse Diprivan are health care practitioners, often anesthesiologists, nurse anesthetists and OR technicians. Most commonly, they are using it initially to treat refractory, persistent insomnia. This insomnia can be due to any number of causes including depression, PTSD, alcoholism or addiction to other agents, or just primary insomnia. Some of our cases were practitioners who had developed the brain disease of addiction to alcohol or to opiate medications, and then developed addiction-induced insomnia. Our patients with a history of Diprivan abuse often self-administered the medication dozens of times in a single day (owing to the short halflife).
Most, not all, of our patients with Diprivan addiction (rather than abuse) have a history of significant trauma, and this is usually (but not always) sexual trauma or molestation. This is an observation I made few years ago and shared with other colleagues who do concur. For more on this, see here:
http://www.anesthesiologynews.com/index.asp?ses=ogst§ion_id=1&show=d...
Thus, it is important to screen for trauma in this population and to treat traumatic disorders accordingly alongside the addiction treatment. There are a variety of specialized techniques for this which are beyond the scope of this article, but which seem to be quite effective such as pharmacotherapy, EMDR and experiential approaches.
Some have suggested that if you controlled or regulated Diprivan more strictly, you would have less of a problem. I’m avoiding discussing this controversy, but I will point out that even the most strictly regulated intoxicants are abused. One thing is absolutely clear: regulation alone will not solve the problem. Advocacy, awareness, education, prevention and treatment must be the mainstays of the public health approach to these disorders.
Do Diprivan abuse treatment and Diprivan addiction treatment work?
In a word, yes. Blueprint project data for 908 physicians with alcoholism and addiction show extraordinary success rates (approximately 80% abstinence at a mean of 7.2 years) for addiction treatment when it is of sufficient duration and coupled with advocacy, support and monitoring such as is found in addiction treatment programs. Our unpublished experience working with Diprivan addicted patients appears to be falling in line with this data. One confounding variable is the extremely high incidence of PTSD in this cohort. Of course, the numbers are so small that we would need to collaborate with other centers to get a clearer picture of outcomes, but so far, the adverse outcomes we have seen have been in patients who either left treatment prematurely or didn’t follow through with recommended treatment. This supports the general observation in our field that retention is tied to outcomes.
How does Diprivan get folks "high" if it lasts such a short time and it causes amnesia?
This is a really good question. When I discuss Diprivan abuse with colleagues who are not aware of it, their first reaction is usually "you are kidding me…Diprivan? Why would anyone want to do that?" As I mentioned above, Diprivan does increase nucleus accumbens dopamine concentration in animal models, and is preferentially self-administered by volunteers with a history of illicit drug use.
Firstly it is important to remember that, with addiction, people are using much more often to avoid a feeling state than to achieve one. This is an important observation…many addicts describe their own compulsive use as "just trying to feel normal." Nevertheless, the patients with Diprivan abuse that I have treated often describe a sense of euphoria on emergence from the drug.
Another interesting observation was made by Avery Tung, M.D. a few years ago, when he discovered that some EEG evidence of sleep deprivation recovery occurs after exposure to Diprivan. His conclusion (I’m paraphrasing here) was that there is at least something sleep-like about Diprivan coma. Or to put it more accurately, that recovery from sleep deprivation occurs both with sleep and, to some extent, with Diprivan exposure. Our clinical experience is that patients describe a short-lived sense of relief that is so reinforcing that, when it wears off, they try again and again.
It is also worth mentioning that Diprivan abuse in the traumatized patient is fundamentally avoidant in nature. That is to say, that avoiding hyperarousal and the affective intensity of life is a powerful drive that is accomplished immediately and, in the words of one of my patients, "magically" with Diprivan. This probably explains some of the connection between PTSD and Diprivan. Also, over half of the patients with PTSD suffer from severe insomnia.
Any final takeaways?
The bottom line takeaways are that addiction to Diprivan is possible, but addiction to alcohol and other intoxicants is far more common, and that addiction treatment of the highest quality and of appropriate duration, when followed by advocacy and aftercare is very effective. Treating addiction saves lives.
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