Substance abuse and anesthesia
Myron Yaster MD and Lynne G. Maxwell MD
More than 40 years ago, one of my most distinguished colleagues and friends began to act erratically at work. An investigation and intervention revealed that (s)he was addicted to alcohol and opioids and was abusing both at work. Fortunately, we had an enlightened department chair who sought to save my friend’s career and who facilitated the intervention which was successful. About 2-3 years into recovery, (s)he required elective surgery and (s)he asked me to provide the anesthesia. (At that time, many of the Hopkins pediatric anesthesiologists also routinely provided anesthesia to adult patients). In discussing the plan, (s)he was frightened that the drugs we routinely use in anesthesia would cause a substance abuse relapse postoperatively. (S)he was adamant that (s)he did not want benzodiazepines (alcohol), ketamine (psychostimulant), or opioids. We decided on a continuous spinal anesthetic because by varying the baricity of the local anesthetic we could isolate the area of surgery and we could continue the infusion postoperatively in the ICU and thereby forgo the use of both opioids and benzodiazepines during surgery and postoperatively.
This was a “one and done” and no systematic approach for other patients was available. We realized that there were no clear policies or guidelines on how to treat these patients perioperatively and their numbers were only increasing. We tried to figure out how to study this problem but ultimately failed in coming up with a usable study protocol or plan. The idea, like so many others, withered on the vine and how to study this disease prospectively in a randomized controlled trial remains unsolved even today.1
Thus, when I saw today’s editorial and associated articles, these memories came flooding back and I thought these would be great for the PAAD even though their focus concerns adult patients. In 2023, how to treat these patients in general, and adolescents in particular, perioperatively remains unclear to me. If you have interest in this issue and/or know of papers that directly relate to how to treat adolescents with substance abuse disorders perioperatively please contact me (myasterster@gmail.com) at your earliest convenience.
In today’s PAAD we’ll review the editorial by Goel and Lamba which is a terrific overview.1 Over the next few days we’ll discuss the associated papers discussed in this editorial. Myron Yaster MD
Original article/editorial
Goel A, Lamba W. Nothing About Us Without Us: A Solution to Iatrogenic Perioperative Morbidity and Mortality in People Who Use Drugs. Anesth Analg. 2023 Sep 1;137(3):470-473. doi: 10.1213/ANE.0000000000006571. Epub 2023 Aug 17. PMID: 37590792.
“Anesthesiologists as perioperative physicians, are now more than ever, faced with the need to discuss with patients and colleagues the question of if “to stop or continue” agents of misuse or their associated “craving controlling aids.”1 Three articles and the editorial by Goel and Lamba in the September issue of Anesthesia and Analgesia describe the fundamental philosophies that guide the disease management of substance abuse disorders.1-4
“The key goal …. is to ’help individuals reduce harmful substance use, improve their social function and health, and mitigate the risk for relapse.’”2 The perioperative period leaves patients with substance abuse disorders with a dilemma of how pain is to be managed and the “reemergence of substance cravings due to destabilization of ’craving control therapies.’”1, 2 “Barreveld et al.3 accept that the perioperative cessation of buprenorphine, designed to reduce cravings in patients with opioid use disorder, may, in fact, increase the risk of recurrence (ie, illicit use) and remove protection from potential overdose. In doing so, then, they acknowledge that interventions and “noninterventions” during the perioperative period have far-reaching consequences for patients who live with addiction. These authors support the notion that perioperative discontinuation of a “craving-controlling” medication in favor of more optimal acute pain management can be more detrimental to a patient’s health than any alternative.”1, 3 Indeed, “the perioperative period is but one tiny aspect of a patient’s lifelong battle with addiction, yet has lasting ramifications.”1
Identifying patients at risk preoperatively and getting assistance from colleagues in addiction medicine is the critical first step. Overcoming the resistance for the need for help and advice from addiction specialists is the first, and for many of us, the most difficult first step. For many decades I (MY) have been teaching residents, fellows, and young faculty on how to prepare for the oral board examinations. My mantra has always been “you are the consultant” and asking for advice from say a cardiologist on how to manage atherosclerotic heart disease is not a game winning strategy for passing the examination. In reading today’s article, this is wrong…the perioperative management of patients with substance abuse disorders demands collaboration and obtaining expert advice from colleagues in addiction medicine.
Over the next few days, we will review management in much greater detail. However, “well thought-out perioperative strategies should seek to incorporate approaches for patients who plan to continue using drugs and substances, especially in the immediate postoperative period. In much the same way that anesthesiologists anticipate and prepare for glycemic derangement in a diabetic patient, they should similarly anticipate and plan for perioperative recurrence of an SUD. In situations where patients express a choice to continue using a substance perioperatively, advocating for ideal medical care, incorporating harm reduction strategies such as naloxone kits and safe injection supplies, as well as the safe and monitored provision of these substances (ie, provision of alcohol or opioids) are worthy of consideration.5 In much the same way that inappropriate prescription of opioids may lead to the iatrogenic development of an SUD, withholding of opioids in the perioperative period may lead to subsequent withdrawal and loss of tolerance, thereby contributing to patients leaving against medical advice (AMA), and even accidental overdose on discharge.6 Optimal care in these cases may involve advocating for surgical rehabilitation facilities to care for patients who use drugs, thereby facilitating optimal recovery of their medical comorbidities. Certainly, some guidelines even advocate for initiation of medication for opioid use disorder (MOUD) in the perioperative period as an additional option.7 For those who want abstinence, supporting patients to connect with treatment posthospital discharge may also have value, and involving a hospital-based addiction consultation service can help. These teams usually include addiction medicine, case management, and peer support.8
Over the next few days we will review the article by Ruiz et al. a review of the physiology of pain and addiction and the current best thinking and a guide to caring for patients with substance abuse by Barreveld et al. We would love to hear from you on how you treat adolescent patients; if you have organized plans and protocols. Do you screen for opioids, psychostimulants (marijuana, amphetamines), and alcohol abuse? Do you see patients on buprenorphine, suboxone, naltrexone, or methadone? Send your responses to Myron who will post on the Friday Reader response.
References
1. Goel A, Lamba W. Nothing About Us Without Us: A Solution to Iatrogenic Perioperative Morbidity and Mortality in People Who Use Drugs. Anesthesia and analgesia. Sep 1 2023;137(3):470-473. doi:10.1213/ane.0000000000006571
2. Jimenez Ruiz F, Warner NS, Acampora G, Coleman JR, Kohan L. Substance Use Disorders: Basic Overview for the Anesthesiologist. Anesthesia and analgesia. Sep 1 2023;137(3):508-520. doi:10.1213/ane.0000000000006281
3. Barreveld AM, Mendelson A, Deiling B, Armstrong CA, Viscusi ER, Kohan LR. Caring for Our Patients With Opioid Use Disorder in the Perioperative Period: A Guide for the Anesthesiologist. Anesthesia and analgesia. Sep 1 2023;137(3):488-507. doi:10.1213/ane.0000000000006280
4. Emerick TD, Martin TJ, Ririe DG. Perioperative Considerations for Patients Exposed to Psychostimulants. Anesthesia and analgesia. Sep 1 2023;137(3):474-487. doi:10.1213/ane.0000000000006303
5. Sharma M, Lamba W, Cauderella A, Guimond TH, Bayoumi AM. Harm reduction in hospitals. Harm Reduct J. Jun 5 2017;14(1):32. doi:10.1186/s12954-017-0163-0
6. Thakrar AP. Short-Acting Opioids for Hospitalized Patients With Opioid Use Disorder. JAMA internal medicine. Mar 1 2022;182(3):247-248. doi:10.1001/jamainternmed.2021.8111
7. Kohan L, Potru S, Barreveld AM, et al. Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel. Regional anesthesia and pain medicine. Oct 2021;46(10):840-859. doi:10.1136/rapm-2021-103007
8. Englander H, Jones A, Krawczyk N, Patten A, Roberts T, Korthuis PT, McNeely J. A Taxonomy of Hospital-Based Addiction Care Models: a Scoping Review and Key Informant Interviews. Journal of general internal medicine. Aug 2022;37(11):2821-2833. doi:10.1007/s11606-022-07618-x