Download Surgery and drug use

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