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Surgery Surgery 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 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 females). Surgery 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 Surgery 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). Surgery 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. Surgery 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.’ 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. Surgery 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. Surgery 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. Surgery 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. Surgery 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). Surgery 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. Surgery 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). Surgery 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. Surgery 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). Surgery 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 patient–staff conflict over required dose • Higher doses, and longer durations of therapy, may be required in tolerant patients. Surgery 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. Surgery 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. Surgery 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). Surgery 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. Surgery 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. Surgery