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Drug-related Problems and
• 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 35–54 years (both male and female)
• Of all hospital separations with principal diagnosis of
illicit drug dependence:
– almost 60% were males
– predominant age range of 15–44 years (both males and
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.
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 70–80% for detecting
alcohol problems (high-risk of dependent patterns of use).
Pre-operative Intervention
High-risk AOD use should be addressed as soon as
it is detected. Ideally, this should occur at the GP’s
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.
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.’
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.
Tobacco and Surgery (1)
Surgery is an opportunity to intervene, as many
• 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
• 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.
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
• Drug seeking (for cigarettes) may warrant a
response similar to those implemented for other
• If policy allows, exercise discretion in cases of
palliative care/comorbid mental health conditions.
Effective Pre-op Screening
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.
Alcohol and Surgery (1)
Daily use of > 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).
Alcohol and Surgery (2)
If alcohol-related problems are present,
– delaying surgery
– specialist referral if dependent and disease
– offering (standard) interventions to reduce
consumption and alcohol-related harm (to
reduce post-op morbidity)
– prescribing thiamine.
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).
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
Opioids and Surgery (2)
In designing a management plan for opioid
dependent patients, provide staff education to:
• validate patient’s need for analgesia when opioid / drugdependent
• explain principles of hypertolerance / cross tolerance and
medical management
• ensure staff honour the drug-dependent patient’s 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 staff–patient conflict).
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
• If unable to tolerate oral medications, replace
methadone with morphine and add analgesia on top
• Prescribe fixed doses to avoid patient–staff conflict
over required dose
• Higher doses, and longer durations of therapy, may
be required in tolerant patients.
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
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.
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).
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.
Discharge Planning
• Consult AOD specialists p.r.n., include referral in discharge
• 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.