Surgery and drug use

1
Surgery
2
Drug-related Problems and Hospitalisation

• In Australia, almost 18,000 deaths and 190,000
  hospital episodes are AOD-related 93 of these
  are attributable to alcohol and tobacco
• Of all hospital separations with principal
  diagnosis of alcohol dependence
• almost 70 were males
• predominantly aged 3554 years (both male and
  female)
• Of all hospital separations with principal
  diagnosis of illicit drug dependence
• almost 60 were males
• predominant age range of 1544 years (both males
  and females).

3
Surgery and Drug Use The Relationship

• AOD-related issues are very common on surgical
  wards
• intoxication may precipitate trauma
• undetected high-risk or dependent use may
  influence or complicate surgical outcomes
• Screening and assessment is essential
• ideally the GP screens before admission to
  hospital to prevent harm and costs associated
  with treating withdrawal in hospital settings
• if detected early, intervene or refer to a
  specialist for further AOD assessment prior to
  surgery
• delaying surgery until patient reduces or ceases
  AOD use may be the best option.

4
Importance of Pre-operative AOD Screening

• Up to 30 of hospitalised patients report
  high-risk or dependent use of alcohol
• Use of alcohol or illicit drugs has been found in
  history of up to 40 of trauma patients
• Alcohol-related problems are frequently missed
  among the elderly, women and people of high
  socioeconomic status (SES)
• AOD dependence influences amount of anaesthetic,
  opioid or other drugs used to achieve therapeutic
  effects
• Post-operative alcohol withdrawal may complicate
  recovery or precipitate delirium tremens, a
  medical emergency
• Pre-op screening has a sensitivity of 7080 for
  detecting alcohol problems (high-risk of
  dependent patterns of use).

5
Pre-operative Intervention

• High-risk AOD use should be addressed as soon as
  it is detected. Ideally, this should occur at the
  GPs surgery to minimise, detect or prevent
• anaesthetic risk and pain management issues
  (e.g., high tolerance to opioids, cross tolerance
  with other CNS depressants)
• onset of post-operative withdrawal
• peri-operative morbidity and mortality
• post-operative pain
• challenging or disruptive behaviours during the
  period of hospitalisation
• self-medication.

6
Effective Pre-op Screening (1)

• Emphasise need for accurate history
• I need to understand exactly how much you drink
  or what drugs you take as this may affect your
  anaesthetic and your recovery after surgery.

7
Effective Pre-op Screening (2)

• Taking an AOD history is the most effective
  approach.
• Obtain information about
• drug type (what, where, when)
• pattern of use (quantity, frequency, when last
  used / possibility of intoxication on admission
  assess breath / blood alcohol level )
• route of administration (how)
• use screening tools e.g., AUDIT, CAGE, SDS
• laboratory tools used in conjunction with history
  may confirm suspicion of problems or dependence.

8
Tobacco and Surgery (1)

• Surgery is an opportunity to intervene, as many
  patients
• will be motivated to cease smoking
  pre-operatively
• may be receptive to advice and treatment
  (including nicotine replacement if necessary)
• may wish to prevent post-operative withdrawal
  (nicotine withdrawal is often under-estimated and
  under-treated)
• are aware of links between smoking and post-op
  chest infections and will wish to avoid this
• are aware of no-smoking policies in hospitals.

9
Tobacco and Surgery (2)

• If patient wants to cease tobacco use before
  surgery, advise cessation at least 2 weeks prior
• Withdrawal may manifest in anxiety, irritability,
  cravings. Consider nicotine replacement therapies
  (NRT) while an in-patient (unfortunately a rare
  consideration)
• Drug seeking (for cigarettes) may warrant a
  response similar to those implemented for other
  drugs
• If policy allows, exercise discretion in cases of
  palliative care/comorbid mental health conditions.

10
Effective Pre-op Screening Alcohol

• Assess for previous withdrawal history (severity,
  any previous post-op complications)
• Screen for comorbid conditions which may affect
  outcome (COPD, CAD, diabetes mellitus)
• Haematological and metabolic assessment (CBC,
  liver function, electrolytes, magnesium,
  phosphate, bilirubin, albumin, INR)
• Other investigations (e.g., ECG, CXR for smokers,
  suspected cardiomyopathy etc.)
• Pre-operative anaesthetic assessment (and
  internal medicine if dependence with associated
  liver disease is suspected)
• If on naltrexone, cease at least 3 days pre-op
• Discuss concerns with patient, intervene or refer
  where necessary.

11
Alcohol and Surgery (1)

• Daily use of gt 6 standard drinks (60 g) can
  result in
• ? total morbidity and post-operative mortality
• poorer outcomes requiring increased / extended
  care (? costs)
• surgical complications (? risk of haemorrhage or
  infection, cardiopulmonary insufficiency)
• need for repeat procedures (? costs)
• adverse outcomes with some conditions (e.g.,
  colorectal surgery, hysterectomy, evacuation
  subdural haematoma, healing / setting of
  fractures).

12
Alcohol and Surgery (2)

• If alcohol-related problems are present,
  consider
• delaying surgery
• specialist referral if dependent and disease
  present
• offering (standard) interventions to reduce
  consumption and alcohol-related harm (to reduce
  post-op morbidity)
• prescribing thiamine.

13
Postponing Elective Surgery

• For patients who are alcohol-dependent, consider
  postponing surgery if patient
• is in active (alcohol) withdrawal
• has past history of severe minor withdrawal,
  intermediate withdrawal or delirium tremens
• is acutely intoxicated
• has massive ascites
• has acute alcoholic hepatitis / cirrhosis
• is severely malnourished
• requires review by gastroenterologist /
  hepatologist because liver disease, HIV, Hep B or
  C are present (? risk of complications).

14
Postponing Elective Surgery

• For patients who are alcohol-dependent, consider
  postponing surgery if patient
• is in active (alcohol) withdrawal
• has past history of severe minor withdrawal,
  intermediate withdrawal or delirium tremens
• is acutely intoxicated
• has massive ascites
• has acute alcoholic hepatitis/cirrhosis
• is severely malnourished
• requires review by gastroenterologist/hepatologist
  because liver disease, HIV, Hep B C are
  present (? risk of complications).

15
Opioids and Surgery (1)

• Consider that people who are opioid-dependent
• are likely to require greater analgesia
  post-operatively
• will require a pain management plan to manage
  existing tolerance and to ensure provision of
  adequate analgesia
• may reinstate opioid use on discharge
• may have best outcomes if commenced or stabilised
  on maintenance pharmacotherapies pre-operatively
• may require careful management not to reinstate
  opioid dependence if abstinence was achieved
  pre-operatively
• can be helped by methadone for pre-operative
  stabilisation.

16
Opioids and Surgery (2)

• In designing a management plan for opioid
  dependent patients, provide staff education to
• validate patients need for analgesia when opioid
  / drug-dependent
• explain principles of hypertolerance / cross
  tolerance and medical management
• ensure staff honour the drug-dependent patients
  rights to fair treatment (as with any other
  patient)
• ensure consistency in behavioural management
  strategies (e.g., for drug seeking behaviour,
  pain management)
• encourage compliance with management plan (e.g.,
  use fixed rather than p.r.n. doses to avoid
  staffpatient conflict).

17
Opioids and Surgery (3)

• Post-op analgesics used as required
• PCA can be used successfully, but the patient
  needs to understand that opioid analgesics will
  be withdrawn when no longer indicated or if used
  inappropriately
• If unable to tolerate oral medications, replace
  methadone with morphine and add analgesia on top
• Prescribe fixed doses to avoid patientstaff
  conflict over required dose
• Higher doses, and longer durations of therapy,
  may be required in tolerant patients.

18
Benzodiazepines and Surgery

• Benzodiazepine dependence
• is easily missed often only detected with
  thorough assessment
• may be first recognised post-operatively when
  patient exhibits withdrawal symptoms
• and withdrawal is managed using same principles
  as in other clinical settings (i.e. titrated
  reduction rather than sudden cessation)
• may require collaboration between hospital and GP
  to enable successful initial and ongoing
  management.

19
Amphetamines and Surgery

• Rarely a problem in general wards / elective
  surgery
• Psychostimulant intoxication and overdose an
  issue for Emergency Department staff and patients
  experiencing trauma requiring surgical
  intervention (e.g., cardiac effects, haemodynamic
  and temperature monitoring)
• Drug-induced psychosis may require medication to
  reduce / manage psychosis
• Psychiatric consultation may be indicated to
  ensure safety of patient and staff, and assist
  with resolution of psychotic symptoms.
  Drug-induced psychosis rarely requires ongoing,
  long-term medication or psychiatric care.

20
Cannabis and Surgery

• High prevalence rates suggest need for accurate
  screening pre-operatively may be missed
• Possibility of cannabis withdrawal syndrome may
  be underestimated
• Observe and plan for respiratory problems (as per
  tobacco).

21
Suspected Drug Use on the Wards

• Examine reasons for ongoing use
• e.g., anxiety, unrelieved pain, continued
  dependence
• Management strategies
• plan for and ensure consistency between all staff
• examine cause and responses to continued anxiety
• increase analgesia / methadone
• consult with AOD worker
• intervene (using motivational interviewing
  principles)
• premature discharge may be a necessary option
• discourage visitors from bringing in drugs.

22
Discharge Planning

• Consult AOD specialists p.r.n., include referral
  in discharge plan
• Involve patient
• e.g., discuss treatment goals, relapse prevention
  strategies, future pain management, non-medicated
  methods for achieving pain relief (massage,
  physiotherapy, activities etc.)
• encourage contact with AOD services
• Ideally, cease opioid use before discharge from
  hospital
• in both dependent and non-dependent patients
• maintain methadone / buprenorphine in
  consultation with the usual prescriber
• refrain from withdrawing analgesics prematurely
  when persistent pain is present.