The Patient Recovering from Alcohol or Drug Addiction: Special Issues for the Anesthesiologist

Acute Pain Management of Chronic Pain Patients in Ambulatory Surgery Centers

PURPOSE OF REVIEW

With the widespread growth of ambulatory surgery centers (ASCs), the number and diversity of operations performed in the outpatient setting continue to increase. In parallel, there is an increase in the proportion of patients with a history of chronic opioid use and misuse undergoing elective surgery. Patients with such opioid tolerance present a unique challenge in the ambulatory setting, given their increased requirement for postoperative opioids. Guidelines for managing perioperative pain, anticipating postoperative opioid requirements and a discharge plan to wean off of opioids, are therefore needed.

RECENT FINDINGS

Expert guidelines suggest using multimodal analgesia including non-opioid analgesics and regional/neuraxial anesthesia whenever possible. However, there exists variability in care, resulting in challenges in perioperative pain management. In a recent study of same-day admission patients, anesthesiologists correctly identified most opioid-tolerant patients, but used non-opioid analgesics only half the time. The concept of a focused ambulatory pain specialist on site at each ASC has been suggested, who in addition to providing safe anesthesia, could intervene early once problematic pain issues are recognized. This review focuses on perioperative pain management in three subsets of patients who exhibit opioid tolerance: those on large doses of opioids (including abuse-deterrent formulations) for chronic non-malignant or malignant pain; those who have ongoing opioid misuse; and those who were prior addicts and are now on methadone/suboxone maintenance. We also discuss perioperative pain management for patients who have implanted devices such as spinal cord stimulators and intrathecal pain pumps.

Perioperative Management of Patients on Buprenorphine and Methadone: A Narrative Review

The opioid epidemic has emerged as a major health and social problem over the last few decades. An increasing number of patients with opioid use disorder are presenting for perioperative management. These patients are either on buprenorphine or methadone for the maintenance and treatment of opioid addiction or chronic pain. In the settings of acute pain, the optimal management of patients with opioid use disorder is challenging, and recovery can be jeopardized secondary to the unique pharmacology of these agents. The purpose of this narrative review is to summarize the existing studies on the perioperative management of patients who are using buprenorphine and methadone and provide guidance for the management of patients with opioid use disorder during the perioperative period.

Morphine in Plasma and Cerebrospinal Fluid of Patients Addicted to Opiates Undergoing Surgery: High-performance Liquid Chromatography Method

Background

The prevalence of opium addiction among Iranians is considerable. Since endogenous opioid systems may be altered as a consequence of addiction, it is very important to determine the plasma and cerebrospinal fluid (CSF) levels of morphine in Iranian patients addicted to opiates who will undergo surgery.

Methods

We obtained CSF and plasma samples from 50 volunteers with an established opioid addiction pattern. Samples were analyzed using high-performance liquid chromatography (HPLC). Additionally, frequency of nausea and vomiting, baseline heart rate (BHR), and systolic blood pressure (SBP) were recorded within the surgery and postoperatively during a 10-min interval.

Findings

84% of participants were men with a median age of 39.08 years. Mean score of body mass index (BMI) was 23.30 and most of the participants (46%) used opium in its traditional inhaled form. A higher concentration of morphine in blood was found in comparison with CSF (P < 0.001) in relation to the way of use. However, no statistically significant differences were found in relation to the type of addictive substance. No other association was found between the levels of morphine and the clinical characteristics of the patients. Moreover, results revealed no difference between hemodynamic-related data with blood and CSF level in opium-dependent patients.

Conclusion

Quantification of plasma and CSF morphine, both immediately before initiation of surgery and subsequently on recovery room, showed that although clinical efficacy of systemic morphine was poor in addicted patients, it had no effect on patients' hemodynamic variable and following complications after surgery.

Severe Uncontrolled Pain in Buttock in a Patient on Naltrexone: A Diagnostic Challenge

A 26-year-old woman with a history of intravenous drug use was admitted to hospital with worsening pain in the right buttock radiating to the lateral part of the thigh and to the calf with no suspicion of cauda equina compression. Eventually, a diagnosis of sacroiliitis was made and appropriate antibiotics were administered. Provision of analgesia for this patient was difficult. On admission her medications included naltrexone, venlafaxine and tramadol. Initially naltrexone was continued and analgesia provided by epidural local anaesthetic and clonidine, intravenous ketamine and oral agents. After several days, naltrexone was ceased and opioids were used in addition to the other analgesics. The epidural analgesia was only partially effective, perhaps because of inadequate blockade of the L4-S1 nerve roots, which carry sensation from the sacroiliac joint.

Naltrexone is a long-acting opioid antagonist. If opioid analgesia is planned, it is necessary to cease naltrexone for 24 to 72 hours. In an emergency, if non-opioid techniques prove ineffective, short-acting opioids can be titrated to effect in a monitored environment.

No. 349-Substance Use in Pregnancy

OBJECTIVES

To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers.

OPTIONS

This guideline reviews the use of screening tools, general approach to care, and recommendations for the clinical management of problematic substance use in pregnancy.

OUTCOMES

Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation.

EVIDENCE

Updates in the literature were retrieved through searches of Medline, PubMed, and The Cochrane Library published from 1996 to 2016 using the following key words: pregnancy, electronic cigarettes, tobacco use cessation products, buprenorphine, and methadone. Results were initially restricted to systematic reviews and RCTs/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report.

BENEFITS, HARMS, AND COSTS

This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care lead to reduced health care costs and decreased maternal and neonatal morbidity and mortality.

RECOMMENDATIONS

To Stop or Not, That Is the Question: Acute Pain Management for the Patient on Chronic Buprenorphine

Perioperative pain management suggestions for patients taking buprenorphine and presenting for elective and urgent/emergent surgery have been developed and are described here.

No 349 - Consommation de substances psychoactives pendant la grossesse

OBJECTIFS

Accroître la sensibilisation à la consommation problématique de substances psychoactives pendant la grossesse et les connaissances à ce sujet, et formuler des recommandations factuelles relatives à la prise en charge de cet épineux problème clinique à l'intention de l'ensemble des fournisseurs de soins.

OPTIONS

La présente directive clinique analyse l'utilisation d'outils de dépistage, l'approche générale de soins et les recommandations pour la prise en charge clinique de la consommation problématique de substances psychoactives pendant la grossesse.

ISSUES

Recommandations factuelles pour le dépistage et la prise en charge de la consommation problématique de substances psychoactives pendant la grossesse et l'allaitement.

RECHERCHE DOCUMENTAIRE

La littérature à jour a été obtenue au moyen de recherches dans Medline, PubMed et la Bibliothèque Cochrane visant les articles publiés entre 1996 et 2016, avec les mots clés suivants : « pregnancy », « electronic cigarettes », « tobacco use cessation products », « buprenorphine » et « methadone ». Les résultats ont d'abord été restreints aux analyses systématiques, aux ECR et aux essais cliniques contrôlés. Ensuite, en raison de la rareté des ECR sur le sujet, des recherches d'études observationnelles ont également été menées. Les articles sélectionnés ont été limités aux études chez l'humain publiées en anglais, puis d'autres articles ont été trouvés manuellement, par l'analyse des listes de références.

VALEURS

La qualité des données a été évaluée au moyen des critères énoncés dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs. Les recommandations visant la pratique ont été classées conformément à la méthode décrite dans ce rapport. AVANTAGES, DéSAVANTAGES ET COûTS: La présente directive clinique a pour but d'améliorer les connaissances et le degré d'aisance des fournisseurs qui dispensent des soins aux femmes enceintes ayant un trouble de l'usage d'une substance. L'amélioration de l'accès aux soins de santé et de l'aide pour obtenir un traitement adéquat de la dépendance fait diminuer les coûts de santé et les taux de morbidité et de mortalité chez la mère et l'enfant. RECOMMANDATIONS.

Do injection drug users have more adverse events during procedural sedation and analgesia for incision and drainage of cutaneous abscesses?

OBJECTIVE

Injection drug users (IDUs) often undergo procedural sedation and analgesia (PSA) in the emergency department (ED). We compared adverse events (AEs) for IDUs to those for non-IDUs receiving PSA for incision and drainage of cutaneous abscesses.

METHODS

This was a retrospective analysis of a PSA safety audit. IDU status was prospectively documented among consecutive patients undergoing PSA at two urban EDs. Structured data describing comorbidities, vital signs, sedation regimens, and adverse events were collected. Primary outcome was the proportion of patients in each group experiencing an AE, whereas the secondary outcomes included recovery times.

RESULTS

Of 525 consecutive patients receiving PSA for incision and drainage of an abscess, 244 were deemed IDUs and 281 non-IDUs. IDUs received higher doses of sedatives and analgesics, and 14 experienced AEs (5.7%), whereas 10 non-IDUs had AEs (3.6%), for a risk difference of 2.1% (95% CI -1.8, 6.5). Median recovery times were 18 minutes (interquartile range [IQR] 10-36) for IDUs and 12 minutes (IQR 7-19) for non-IDUs, for a difference of 6 minutes (95% CI 2-9 minutes). Median sedation times were also longer in IDUs, for a difference of 6 minutes (95% CI 5-10 minutes). Of 20 IDU patients and 1 non-IDU patient admitted to hospital, none had experienced an AE related to PSA.

CONCLUSIONS

For ED patients requiring PSA for incision and drainage, IDUs had an AE rate similar to that of non-IDUs but longer sedation and recovery times. In experienced hands, PSA may be as safe in IDUs as in patients who do not use injection drugs.

Does the sedation regimen affect adverse events during procedural sedation and analgesia in injection drug users?

OBJECTIVES

Injection drug users (IDUs) often undergo procedural sedation and analgesia (PSA) as part of emergency department (ED) treatment. We compared adverse events (AEs) using a variety of sedation regimens.

METHODS

This was a retrospective analysis of a PSA safety audit in two urban EDs. Consecutive self-reported IDUs were identified, and structured data describing comorbidities, vital signs, sedation regimens (propofol [P], propofol-fentanyl [PF], fentanyl-midazolam [FM], ketofol [1:1 ketamine:propofol, KF], and ketamine-propofol [KP]) and AEs were collected. The primary outcome was the proportion of patients in each sedation group having an AE; the secondary outcome was the proportion of patients having a cardiovascular or respiratory AE.

RESULTS

Data were collected on 276 IDUs (78 P, 82 PF, 65 FM, 25 KF, and 26 KP), and 18 patients had AEs (6.5%, 95% CI 4.0-10.3). The AE rates were 0.0%, 8.5%, 9.2%, 12.0%, and 7.6%, respectively, with propofol having a significantly lower rate (Pearson coefficient 14.9, p  =  0.007). The cardiovascular/respiratory AE rates were significantly different as well, with P, KP, and KF having the lowest rates (Pearson coefficient 13.3, p  =  0.01).

CONCLUSIONS

For IDU PSA, the overall AE rate was 6.5%, and propofol appeared to have a significantly lower rate.

Perioperative management of the child on long-term opioids

The strategies used to manage children exposed to long-term opioids are extrapolated from adult literature. Opioid consumption during the perioperative period is more than three times that observed in patients not taking chronic opioids. A sparing use of opioids in the perioperative period results in both poor pain management and withdrawal phenomena. The child's pre-existing opioid requirement should be maintained, and acute pain associated with operative procedures should be managed with additional analgesia. This usually comprises short-acting opioids, regional or local anesthesia, and adjuvant therapies. Long-acting opioids, transdermal opioid patches, and implantable pumps can be used to maintain the regular opioid requirement. Intravenous infusion, nurse controlled analgesia, patient-controlled analgesia, or oral formulations are invaluable for supplemental requirements postoperatively. Effective management requires more than simply increasing opioid dose during this time. Collaboration of the child, family, and all teams involved is necessary. While chronic pain or palliative care teams and other staff experienced with the care of children suffering chronic pain may have helpful input, many pediatric hospitals do not have chronic pain teams, and many patients receiving long-term opioids are not palliative. Acute pain services are appropriate to deal with those on long-term opioids in the perioperative setting and do so successfully in many centers. Staff caring for such children in the perioperative period should be aware of the challenges these children face and be educated before surgery about strategies for postoperative management and discharge planning.

SOGC clinical practice guidelines: Substance use in pregnancy: no. 256, April 2011

OBJECTIVE

To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers.

OPTIONS

This guideline reviews the use of screening tools, general approach to care, and recommendations for clinical management of problematic substance use in pregnancy.

OUTCOMES

Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation.

EVIDENCE

Medline, PubMed, CINAHL, and The Cochrane Library were searched for articles published from 1950 using the following key words: substance-related disorders, mass screening, pregnancy complications, pregnancy, prenatal care, cocaine, cannabis, methadone, opioid, tobacco, nicotine, solvents, hallucinogens, and amphetamines. Results were initially restricted to systematic reviews and randomized control trials/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists. Searches were updated on a regular basis and incorporated in the guideline up to December 2009. Grey (unpublished) literature was also identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table 1).

BENEFITS, HARMS, AND COSTS

This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care leads to reduced health care costs and decreased maternal and neonatal morbidity and mortality.

Acute Pain Management in Opioid-Tolerant Patients: A Growing Challenge

In Australia and New Zealand, in parallel with other developed countries, the number of patients prescribed opioids on a long-term basis has grown rapidly over the last decade. The burden of chronic pain is more widely recognised and there has been an increase in the use of opioids for both cancer and non-cancer indications. While the prevalence of illicit opioid use has remained relatively stable, the diversion and abuse of prescription opioids has escalated, as has the number of individuals receiving methadone or buprenorphine pharmacotherapy for opioid addiction. As a result, the proportion of opioid-tolerant patients requiring acute pain management has increased, often presenting clinicians with greater challenges than those faced when treating the opioid-naïve.

Treatment aims include effective relief of acute pain, prevention of drug withdrawal, assistance with any related social, psychiatric and behavioural issues, and ensuring continuity of long-term care. Pharmacological approaches incorporate the continuation of usual medications (or equivalent), short-term use of sometimes much higher than average doses of additional opioid, and prescription of non-opioid and adjuvant drugs, aiming to improve pain relief and attenuate opioid tolerance and/or opioid-induced hyperalgesia. Discharge planning should commence at an early stage and may involve the use of a ‘Reverse Pain Ladder’ aiming to limit duration of additional opioid use. Legislative requirements may restrict which drugs can be prescribed at the time of hospital discharge. At all stages, there should be appropriate and regular consultation and liaison with the patient, other treating teams and specialist services.

Substance use in pregnancy

OBJECTIVE

To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers.

OPTIONS

This guideline reviews the use of screening tools, general approach to care, and recommendations for clinical management of problematic substance use in pregnancy.

OUTCOMES

Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation.

EVIDENCE

Medline, PubMed, CINAHL, and The Cochrane Library were searched for articles published from 1950 using the following key words: substance-related disorders, mass screening, pregnancy complications, pregnancy, prenatal care, cocaine, cannabis, methadone, opioid, tobacco, nicotine, solvents, hallucinogens, and amphetamines. Results were initially restricted to systematic reviews and randomized control trials/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists. Searches were updated on a regular basis and incorporated in the guideline up to December 2009. Grey (unpublished) literature was also identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table 1).

BENEFITS, HARMS, AND COSTS

This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care leads to reduced health care costs and decreased maternal and neonatal morbidity and mortality.

RECOMMENDATIONS

1. All pregnant women and women of childbearing age should be screened periodically for alcohol, tobacco, and prescription and illicit drug use. (III-A) 2. When testing for substance use is clinically indicated, urine drug screening is the preferred method. (II-2A) Informed consent should be obtained from the woman before maternal drug toxicology testing is ordered. (III-B) 3. Policies and legal requirements with respect to drug testing of newborns may vary by jurisdiction, and caregivers should be familiar with the regulations in their region. (III-A) 4. Health care providers should employ a flexible approach to the care of women who have substance use problems, and they should encourage the use of all available community resources. (II-2B) 5. Women should be counselled about the risks of periconception, antepartum, and postpartum drug use. (III-B) 6. Smoking cessation counselling should be considered as a first-line intervention for pregnant smokers. (I-A) Nicotine replacement therapy and/or pharmacotherapy can be considered if counselling is not successful. (I-A) 7. Methadone maintenance treatment should be standard of care for opioid-dependent women during pregnancy. (II-IA) Other slow-release opioid preparations may be considered if methadone is not available. (II-2B) 8. Opioid detoxification should be reserved for selected women because of the high risk of relapse to opioids. (II-2B) 9. Opiate-dependent women should be informed that neonates exposed to heroin, prescription opioids, methadone, or buprenorphine during pregnancy are monitored closely for symptoms and signs of neonatal withdrawal (neonatal abstinence syndrome). (II-2B) Hospitals providing obstetric care should develop a protocol for assessment and management of neonates exposed to opiates during pregnancy. (III-B) 10. Antenatal planning for intrapartum and postpartum analgesia may be offered for all women in consultation with appropriate health care providers. (III-B) 11. The risks and benefits of breastfeeding should be weighed on an individual basis because methadone maintenance therapy is not a contraindication to breastfeeding. (II-3B).

[Anesthesia in drug addiction]

The growing social problem of drug abuse has increased the likelihood that anesthesiologists will find acute or chronic drug users among patients requiring anesthesia for elective or emergency surgery. We must therefore be aware of the effects drugs have on the organism and their possible pharmacokinetic and pharmacodynamic interactions with anesthetic agents in order to prevent complications during surgery and postoperative recovery. Such knowledge is required for the management of abstinence syndrome or overdose, which pose the greatest potential dangers for the hospitalized drug addict.

Drug abuse and dependency during pregnancy: anaesthetic issues

Drug abuse is a significant social problem that can lead to serious obstetric complications, some of which may be confused with pregnancy-related disease states. Substance abuse poses a number of challenges with respect to the management of pain and the conduct of anaesthesia in the peripartum period. This review was based on information from a literature search of epidemiological, research and review papers on substance abuse during pregnancy, obtained for the purpose of preparing a background paper for the Ministerial Council on Drug Strategy, Commonwealth Government of Australia. Given that almost 80% of substance-abusing parturients require anaesthetic services in the perinatal period, early antenatal referral for anaesthetic review is recommended. To optimise the care of these vulnerable patients, obstetricians, general practitioners and midwives should attempt to identify substance-abusing parturients and refer them to an anaesthetist. A careful anaesthetic evaluation with non-judgemental questioning is essential, with management tailored to individual patient needs and the urgency of obstetric intervention for vaginal delivery or caesarean section. Opioid-dependent women, in particular, benefit from antenatal pain management planning. Patients recovering from drug addiction should also have a well-documented analgesic strategy. A multidisciplinary approach will involve obstetricians, anaesthetists and staff of the Drug and Alcohol Service. In acute admissions of women by whom antenatal care was not accessed, a high index of suspicion for illicit drug use should arise. Because illicit substance use is so prevalent, if untoward reactions occur during an otherwise uneventful anaesthetic, the possibility of drug abuse should be considered.

Anästhesie und Analgesie bei Suchtpatienten

Addicts have an exaggerated organic and psychological comorbidity and in cases of major operations or polytrauma they are classified as high-risk patients. Additional perioperative problems are a higher analgetics requirement, craving, physical and/or psychological withdrawal symptoms, hyperalgesia and tolerance. However, the clinical expression depends on the substance abused. For a better understanding of the necessary perioperative measures, it is helpful to classify the substances into central nervous system depressors (e.g. heroin, alcohol, sedatives, hypnotics), stimulants (e.g. cocaine, amphetamines, designer drugs) and other psychotropic substances (e.g. cannabis, hallucinogens, inhalants). The perioperative therapy should not be a therapy for the addiction, as this is senseless. On the contrary, the characteristics of this chronic disease must be accepted. Anesthesia and analgesia must be generously stress protective and sufficiently analgesically effective. Equally important perioperative treatment principles are stabilization of physical dependence by substitution with methadone (for heroin addicts) or benzodiazepines/clonidine (for alcohol, sedatives and hypnotics addiction), avoidance of stress and craving, thorough intraoperative and postoperative stress relief by using regional techniques or systematically higher than normal dosages of anesthetics and opioids, strict avoidance of inadequate dosage of analgetics, postoperative optimization of regional or systemic analgesia by non-opioids and coanalgetics and consideration of the complex physical and psychological characteristics and comorbidities. Even in cases of abstinence (clean) an inadequate dosage must be avoided as this, and not an adequate pain therapy sometimes even with strong opioids, can potentially activate addiction. A protracted abstinence syndrome after withdrawal of opioids can lead to increased response to administered opioids (e.g. analgesia, side-effects).

Trikuspidalklappenersatz bei einer heroinabhängigen Patientin

A 24-year-old female with a history of former heroin addiction underwent open heart surgery for a mechanical tricuspid valve replacement. Anaesthesiological management included a thoracic epidural catheter at the Th(2)/Th(3) segments and balanced general anaesthesia (remifentanil, desflurane/propofol). Additionally, clonidine (2 microg*kg(-1)*h(-1)) was continuously administered. Pain therapy was achieved using 0.375% ropivacaine via a thoracic epidural catheter (4 ml*h(-1)) and metamizole (4 x 1 g/day) intravenously. With this concept we were able to achieve an appropriate anaesthesia and analgesia and the operation was carried out without complications.

Review article: Perioperative pain management of patients on methadone therapy

PURPOSE

Methadone, an opioid traditionally associated with the management of opioid addictive disorders, has been prescribed increasingly as an analgesic for the management of various chronic pain conditions. Despite the increasing popularity of methadone, most anesthesiologists are not familiar with its complex pharmacology. The purpose of this article is to review the pharmacology of methadone and to suggest a management algorithm for the perioperative care of methadone patients.

SOURCE

A Medline search was performed to obtain the published literature on the pharmacology of methadone and its use perioperatively.

PRINCIPAL FINDINGS

The complexity of methadone's pharmacology is characterized by a high inter-individual variability, a potential for interaction with other medications, and a long elimination half-life. The postoperative management of methadone patients may be difficult as they are often 'opioid-tolerant' but may be 'pain-intolerant'. For those patients who are taking part in methadone-maintenance programs, there is a potential for the problematic use of opioids or other substances. The management plan for patients taking methadone may differ depending on the type of surgery and the associated perioperative differences in fasting status and gastrointestinal function. In consideration of all the factors listed above, a management algorithm is outlined for the perioperative care of methadone patients.

CONCLUSION

Methadone is an opioid with complex properties, and a patient that is taking methadone can represent a unique challenge to the anesthesiologist. A good understanding of the pharmacology of methadone and of the type of patients on this medication will help to improve their perioperative care.

Challenges that opioid-dependent women present to the obstetric anaesthetist

A retrospective casenote review was performed to identify anaesthetic challenges relevant to the opioid-dependent obstetric population. Medical records showed that of the 7,449 deliveries during a 24 month period, 85 women (1.1%) were taking regular opioids such as methadone and/or heroin. Of these 67 (79%) received anaesthetic services, ten of whom (11.7%) were referred antenatally. Forty opioid-dependent women (47%) received epidural analgesia in labour compared with the overall hospital rate of 38%. Twenty-three women (27%) delivered by caesarean section: five received general anaesthesia, five combined spinal anaesthesia, five spinal anaesthesia and eight epidural anaesthesia. Twenty opioid-dependent women (23.5%) had documented problems related to labour analgesia and 17 (74%) had problems with analgesia after caesarean section. A variety of postoperative analgesia methods were administered in addition to maintenance methadone. Fourteen patients (16.5%) had difficult intravenous access and seven "arrest" calls were documented. One anaesthetist was exposed to hepatitis C. This review demonstrates the demands placed on obstetric anaesthetic services by opioid-dependent women. Early antenatal referral for anaesthetic review is recommended.

Severe intraoperative hypertension and opioid-resistant postoperative pain in a methadone-treated patient

Patients who are treated with methadone present challenges for the anesthesiologist. We report the untoward effects of rapid preoperative methadone tapering on the operative and perioperative course of a patient who required emergency surgery. The patient's exaggerated stress response to surgery and severe intractable postoperative pain might have resulted from unrecognized methadone withdrawal. Continuation of methadone treatment in patients who have surgery may prevent exaggerated intraoperative hemodynamic responses to surgical stimuli and unnecessary postoperative suffering.

Patients on party drugs undergoing anesthesia

PURPOSE OF REVIEW

Drug abuse, especially with designer drugs, continues to grow, involving a wide demographic range. Consequently, anesthesiologists may be involved in the care of patients under the acute and chronic influence of a myriad of substances. In addition to the usual physiological damage to vital organs (heart, lungs, kidneys, and immune system) new evidence of permanent damage in regions of the brain responsible for memory and pain mediation is emerging. As drug use continues to increase, anesthesiologists must learn to detect drug abusing patients and avoid known interactions. This article will attempt to review the recent literature on this subject.

RECENT FINDINGS

Cocaine, marijuana, ethanol, and heroin top the list of abused drugs, alone and in combination. The combined effects of these drugs can be synergistic in creating cardiovascular instability and toxicity. Because combinations create synergy in dopamine and serotonin transmission, addiction is possibly faster, more entrenched, and more difficult to treat. Anesthesiologists are now becoming involved in many of the rapid detoxification procedures to combat/treat addiction. Only limited research has addressed the newer designer drugs, but case reports regarding hyperthermia, cerebral edema, cerebral vasospasm, and lethal interactions with commonly used medications such as beta-blockers implicate the need for awareness in anesthesia personnel.

SUMMARY

Drug abuse continues to be a major problem facing our society. Anesthesiologists encounter emergency cases in which 'party drugs' have clearly been used, and may also be anesthetizing patients in whom abuse is present but unrecognized. Understanding how illicit drugs interact with anesthetic agents is of paramount importance.

The management of acute dental pain in the recovering alcoholic

Although there have been many advances in our understanding of the neurophysiology of pain, the management of acute pain continues to be a challenge. When the need arises to provide adequate and effective pain management for the recovering alcoholic, the problem becomes much more complex. The clinician must provide the patient with adequate analgesia without causing a relapse. In the US, 6% to 10% of the population has attended Alcoholics Anonymous at some point, increasing the likelihood of the clinician being faced with the need to manage acute pain in a recovering alcoholic. The purpose of this article is to suggest guidelines for the management of acute dental pain in the recovering alcoholic based on current principles of acute pain management and for the treatment of pain in addicted patients.

Attitudes of anesthesiologists about addiction and its treatment: a survey of Illinois and Wisconsin members of the American Society of Anesthesiologists

STUDY OBJECTIVE

To survey practicing anesthesiologists about their attitudes about addiction and its treatment by means of a previously validated instrument.

DESIGN

Anonymous mail survey.

SETTING

Metropolitan medical college.

PARTICIPANTS

Active members of the American Society of Anesthesiologists in Illinois and Wisconsin.

MAIN RESULTS

The survey consisted of 50 statements presented in a five item Likert (agreement-disagreement) format that evaluated five attitude factors: permissiveness, nonstereotypes, treatment interventions, treatment optimism, and nonmoralism. Five hundred twelve completed and 21 undeliverable surveys were returned from 1,656 surveys mailed (response rate = 31%). The raw scores for the five attitude factors were permissiveness 25 +/- 6, nonstereotypes 34 +/- 6, treatment interventions 32 +/- 4, treatment optimism 19 +/- 3, and nonmoralism 31 +/- 5 (means +/- SD). Anesthesiologists with a personal history of addiction recorded attitude scores that were significantly (p < 0.05) higher than those of their colleagues. Formal training in substance abuse management, attendance at a Twelve Step meeting as either a participant or an observer, and experience with a friend, relative, or colleague with addiction were also associated with significantly higher attitude scores. The attitude scores of anesthesiologists were consistently below those previously reported for clinicians who regularly care for patients with addiction.

CONCLUSIONS

Personal experience with, or education about, addiction contributes to a more positive attitude about addiction. Anesthesiologists have less positive attitudes about addiction than do physicians who regularly manage the disease.