There are no reliable data on the incidence or prevalence of substance abuse or misuse among anesthesia practitioners. However, there are reasonable data on the incidence of chemical dependence among anesthesia residents and practicing registered nurse anesthetists (SRNAs): there is a clear incidence of 1% to 2% during the 2-3 years of anesthesia residency, when alcohol and marijuana are included.7 The most recent survey of 169 anesthesiology residency training programs was conducted in 2001, and 111 programs responded. 80% of programs reported at least one case of chemical dependence in their program between 1991 and 2001. In this study spanning 10 years, an average of 2.1 residents per program had chemical abuse. Mortality prior to intervention was 19% of reported cases. In the analysis of data from PHPs, the sample size of anesthesiologists always exceeded the proportion.9 In the previously cited Florida survey, the proportion of anesthesiologists in treatment (12%) exceeded their proportion of the total number of physicians (4.7%). There are four obvious explanations for this finding. (1) Substance abusers are looking for opportunities. Medical students and medical professionals with substance abuse problems seek opportunities to participate in anesthesia practice to facilitate access to opioids and other narcotics available for abuse. (2) This opportunity creates substance abusers. Anesthesia practitioners are at higher risk for addiction than other physicians because they have easy access to these drugs, whether they are treating patients or abusing them themselves. (3) The stress of anesthesia management can become overwhelming. Emotionally vulnerable anesthesia practitioners seek relief from the stress that comes from being in charge of drugs that can kill or injure patients every day. (4) The environment creates abusers. Chronic inhalation of residual doses of narcotics in the operating room increases susceptibility to abuse. Even though all of these hypotheses face validity issues, no experiments have been specifically designed to address the first three hypotheses.10 Gold et al.10 explored the fourth environmental hypothesis, suggesting that “secondhand” exposure may lead to brain alterations that make anesthesia practitioners vulnerable to chemical dependence. They have examined the concentrations of propofol and fentanyl in air samples from cardiac surgery rooms. The air samples with the highest concentrations came from near the patient’s head. Many have hastily concluded that anesthesia practitioners’ substance dependence is more severe than other practitioners because of the relatively high enrollment of anesthesia practitioners in PHPs. There are several strong reasons not to make such a conclusion at this point in time. First, addiction physicians do not examine the percentage of PHPs enrolled as a valid and representative sample. The percentage of individuals enrolled in treatment programs is smaller than the percentage of individuals in need of treatment. The cumulative probability of survival for patients treated for substance dependence was 52.7-76.9%. Second, the effect of substance abuse on PHP enrollment has not been well studied. The prevalence of survival for substance misuse disorders among anesthesiologists and other medical practitioners should be the same, but the time span from diagnosis to treatment should be shorter for anesthesiologists. This may occur because anesthesiologists are more likely to abuse drugs with high potential for addiction (e.g., abuse of fentanyl rather than alcohol). Third, the impact of the drug of choice for substance abuse (e.g., abuse of opiates rather than alcohol) on enrollment in treatment programs has not been well studied in the context of colleague relief and legal pressure. Alcohol is a legal substance, and its consumption is socially acceptable if it does not cause intoxication. Blood alcohol levels are legally permissible if driven below a specific threshold. People who abuse alcohol may seek counseling, but only if they develop alcohol dependence are they enrolled in the treatment programs investigated. “About 8 million people in the United States are alcohol dependent, and only a minority of these people ever receive treatment for the disorder, even when the scope of treatment is expanded to include attendance at Alcoholics Anonymous meetings.” Fourth, most of these analyses do not consider the impact of a diagnosis of abuse compared to dependence (according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, published by the American Psychiatric Association in 2000). Colleagues who are substance dependent may not exhibit behaviors associated with substance abuse, such as risky behavior or irresponsibility when playing social or work roles, or when faced with legal problems. In the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), which had 42,393 responses, 22% of patients who met the DSM-IV-TR diagnosis of drug dependence did not meet the DSM-IV-TR diagnosis of substance abuse (Table 96-1).13,14 It may be that people with a high prevalence of drug dependence who avoid behaviors that are associated with substance abuse may escape detection and not be enrolled in PHPs. and not be enrolled in PHPs. fifth, the effectiveness of substance abuse awareness education for professional dependence has not been established. Active education over the past 30 years has not reduced the incidence of such events in practice programs, probably because most trainees with chemical dependence during internship eventually develop addictive behaviors earlier than residency training. However, cognitive education programs may increase the detection and intervention rates of substance misuse disorders among anesthesiologists above other physicians.