Anesthesia for Drug Abusers

Published on 07/02/2015 by admin

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Last modified 22/04/2025

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Anesthesia for Drug Abusers

Daniel J. Janik, MD

Illicit drug use is a major problem in the United States. Patients often abuse more than one substance simultaneously (polydrug abuse) and can present to the hospital requiring care because of the consequences of either acute intoxication (such as vehicular trauma) or chronic abuse (because of deterioration of major organ systems). Chronic illicit drug use can cause physical dependence (a condition in which withdrawal symptoms occur when the abused drug is withheld) and tolerance (the need for progressively larger doses to achieve the desired effect). Abuse potential correlates closely with euphoric potential. It is generally accepted that the perioperative period is not an appropriate time to attempt withdrawal. Rather, the clinician should prescribe or administer appropriate medication to substitute for the patient’s maintenance dosing preoperatively and delay withdrawal until the stress of surgery has abated.

Illicit drugs that are frequently abused, as well as drugs to which a patient may become addicted after chronic prescribed use, and information pertinent to anesthesia providers are described in Table 110-1. General principles should be considered when dealing with a patient who is acutely intoxicated, has chronic tolerance, is going through withdrawal, or is “recovering.”

Table 110-1

Common Illicit Drugs – Physiologic Effects and Anesthetic Considerations

Table 110-1

Drug	Class	Route	Mechanism of Action	Psychic Effects	Physical Effects	Anesthetic Effects	Anesthetic Concerns	Dependence	Abstinence Syndrome	Anesthetic Choice	Recommendations
Heroin Morphine Meperidine	Opioid	PO IV IM SQ	Activates opioid receptors throughout the nervous system Receptor μ2 modulates euphoria and physical dependence	Stupor/coma Euphoria Hallucinations	Respiratory depression Endocarditis Pulmonary infarcts Adrenal suppression Glomerulonephritis Tetanus Myelitis	Analgesia Euphoria	Stupor/coma Respiratory depression Depressed reflexes Seizures or tremor Sudden death	Psychic Physical	Diaphoresis Mydriasis Tremor Lacrimation Seizures	GTA Regional Local	Avoid opioid antagonists Avoid opioid premedication Avoid halothane Continue opioids perioperatively Tendency toward hypotension
Secobarbital Pentobarbital Phenobarbital	Depressant	PO IV IM PR	Potentiates GABA inhibition of neurotransmitter release throughout CNS, including RAS Hepatic microsomal enzyme induction	Stupor Coma	Phlebitis/sclerosis of veins Slurred speech Ataxia Loss of gag reflex Depressed ventilation Myocardial depression	Sedation	Increased fluoride metabolism Prolonged excitement phase Hypotension from central vasomotor or myocardial depression Altered metabolic profile of medications (warfarin, phenytoin, digitalis)	Psychic Physical	Anxiety Hypotension Tachycardia Cramping/nausea Hyperreflexia Tremor Fever Seizures	GTA Regional Local	Watch for hypovolemia Premedicate with barbiturate to prevent abstinence syndrome Chronic abusers require higher doses of sedatives and hypnotics Acute intoxication will reduce need for sedatives, hypnotics, and maintenance agents
Cocaine	Stimulant	Nasal Inhaled IV	Stimulates dopaminergic neurons in CNS Inhibits presynaptic reuptake of norepinephrine	Euphoria Excitement Hallucinations Aggression Tactile hallucinations	Hyperpyrexia Tachycardia Hypertension Arrhythmias Intracerebral hemorrhage Subarachnoid hemorrhage Cerebral infarction Seizures	Local Anesthetic	Sympathetic hyperactivity Increased myocardial O2 demand Coronary spasm/thrombus Myocardial depression Psychosis May increase MAC	Mild physical	Craving Occasional seizures	GTA (usually)	Control anxiety/psychosis Avoid using pancuronium Control cardiovascular effects Control seizures with barbiturate or benzodiazepine
LSD Psilocybin Mescaline	Hallucinogen	PO IV Inhaled	Binds to dopamine and serotonin (5-HT_2A) receptors in CNS	CNS excitation Delusions Sensory distortion Depersonalization Hallucinations Euphoria	Mild tachycardia Mild hypertension Fever Salivation/lacrimation Mydriasis Rare bronchoconstriction Occasional seizures	Analgesia Anticholinergic	May last 6-12 hStress may initiate flashback Use succinylcholine cautiously Avoid ester local anesthetic agents LSD prolongs analgesic and respiratory effects of opioids	Psychic	None	GTA Regional Local	Control anxiety Little need for opioids Avoid atropine/scopolamine
d-Amphetamine Methamphetamine	Stimulant	IV PO	Stimulate α- and β-adrenergic receptors in CNS and periphery Release catecholamines from storage sites Inhibit reuptake of catecholamines	Euphoria Hallucinations “Rush” Increased performance and power Increased interest in sex	Tachycardia Hypertension Palpitation Ketosis Increased reflexes Seizures Arrhythmias Angina/cardiomyopathy	Augments opioid analgesia Acute intoxication increases MAC Chronic use decreases MAC	Toxic delirium Chronic depletion of norepinephrine and dopamine Metabolized to false transmitter which accumulates	Physical Psychic	Apathy Depression	GTA	Treat hypotension with direct-acting vasopressors Treat toxicity May present with hypovolemia
Phencyclidine	Stimulant	IV Inhaled Nasal	NMDA receptor antagonist Inhibits reuptake of norepinephrine and serotonin	Euphoria Amnesia Paresthesia Distorted body image Psychosis/agitated delirium Cataleptic state Numbness of limbs	Tachycardia Hypertension Cerebral hemorrhage Rhabdomyolysis Renal failure Seizures Tremor/posturing	May inhibit pseudocholinesteraseCatalepsy Cross tolerance to ketamine	Laryngeal and gag reflexes intact but may have laryngospasm	Psychic	None	GTA	Control seizures Cataleptic state may obviate need for anesthesia, but patient will need airway control Propensity for violent behavior Avoid ketamine
Mephedrone 3,4-Methylenedioxypyrovalerone (MDPV), (“Bath Salts; Ivory Wave; Bliss”)	Stimulant (4x potency of methylphenidate)	IV Inhaled Rectal	Norepinephrine-dopamine reuptake inhibitor	Euphoria Arousal Agitation Psychosis Prolonged panic attacks Hallucinations	Tachycardia Hypertension Diaphoresis Vasoconstriction Trismus Bruxism	Similar to amphetamines, but limited data	Similar to amphetamines, but limited data	Psychic	Limited data	GTA (due to propensity for agitation)	Control cardiovascular effects as necessary Control psychosis and agitation with benzodiazepines Limited data available
Glue/paint (solvents/propellants including Freon, toluene, benzene, xylene, carbon tetrachloride, other fluorocarbons) Lighter fluid	Depressant	Inhaled	Variety of theories, including NMDA antagonism and GABA agonist	Excitation Euphoria Vertigo Hallucinations	Stupor/coma Seizures Hepatic necrosis Renal failure/RTA Hematopoietic changes Rhabdomyolysis Pulmonary edema Encephalopathy	None	Hyperchloremia Hypokalemia Hypophosphatemia Arrhythmia Peripheral neuropathy Sensitize myocardium to effects of catecholamines	Psychic	None	Regional (if patient is cooperative) GTA (isoflurane, desflurane, balanced)	Choose anesthetic agent that avoids renal or hepatic toxicity Use reduced doses of sedatives, hypnotics, opioids, and NMBAs Avoid halothane, cocaine, ketamine, and hypercarbia especially if using epinephrine Monitor ECG
Marijuana	Euphoriant	PO Inhaled	Active ingredient THC binds to cannabinoid receptors in CNS (CB₁) and immune system (CB₂)	Tranquility Altered visual perception Loose association Memory impairment Hallucinations Depersonalization	Tachycardia Hypertension Xerostomia Tachypnea (mild) Hyperthermia (mild) Bronchitis	Mild anticholinesterase activity Decreases MAC Prolongs sleep time of intermediate-acting barbiturates Analgesia	THC may increase narcotic respiratory depression Tachycardia may persist postoperatively Intermediate barbiturates may intensify hallucinations	Psychic	None	GTA (inhalation or balanced)	Avoid atropine Treat hallucinations with benzodiazepine Treat bronchospasm with inhalation anesthetic agent or bronchodilators
Spice; K21-pentyl-3-(1-naphthoyl)indole	Euphoriant	PO Inhaled	Synthetic cannabinoid 10x more active at CB₁ receptors than THC	Psychosis Anxiety Agitation Hallucinations Catalepsy Hypomotility	Tachycardia Hypertension Vomiting Tremors Pallor Hypokalemia Analgesia Hypothermia	Analgesia	Similar to marijuana but with addition of hypokalemia	Psychic	None documented	GTA	Treat hallucinations and agitation with benzodiazepines Control cardiovascular effects Watch for hypokalemia
Diazepam Lorazepam Midazolam Chlordiazepoxide Clorazepate Oxazepam	Tranquilizer	PO IV	Potentiates GABA inhibition of neurotransmitter release in cerebral cortex, cerebellum, and limbic system	Sedation Amnesia Anxiolysis Produces “high” when combined with other drugs	Decreased ventilation Decreased peripheral vascular resistance Skeletal muscle relaxation Depressed swallowing reflex	Sedation Amnesia	Moderate ventilatory depression Potentiate opioids Additive with volatile agents	Psychic Physical	Seizures Tremor Cramping/nausea Anxiety Insomnia (generally later than with barbiturates due to long half-life)	GTA Regional Local	Acute intoxication may obviate need for preoperative sedation or will reduce dose of sedatives and hypnotics Chronic abusers require higher doses of sedatives and hypnotics
3,4- Methylenedioxy-N-methamphetamine (MDMA) (“ecstasy”)	Empathogen; substituted amphetamine	PO	Stimulates release of serotonin, dopamine, and norepinephrine in CNS Inhibits reuptake of neurotransmitters	Energy Empathy Euphoria Elevated mood Hypersexuality (the “love drug”) Panic disorder Confusion	Tachycardia Hypertension Mydriasis Sweating Hyperthermia Hyponatremia Rhabdomyolysis Dysrhythmias and sudden death Increased ADH secretion	Euphoria Mild analgesia Effects last 4-6 h	Exertional hyperpyrexia with rhabdomyolysis and multiorgan system failure Serotonin syndrome Cerebral edema (from hyponatremia) Liver failure Sympathetic nervous system hyperactivity Trismus Stroke Dehydration (possible)	Psychic	Anxiety Irritability/anger Agitation Dizziness Headache Insomnia Panic attacks Residual feelings of empathy	GTA Regional Local (Depending on patient physiologic or psychological condition)	Control anxiety Correct hyponatremia if present Control hypertension (mixed α- and β-blocker such as labetalol) Correct metabolic acidosis Treat hyperthermia with cooling, or dantrolene if temperature >39°C) Replace fluids to enable normal thermoregulation Promote diuresis if rhabdomyolysis suspected

ADH, antidiuretic hormone; CNS, central nervous system; ECG, electrocardiogram; GABA, γ-aminobutyric acid; GTA, general tracheal anesthesia; HT, hydroxytryptamine; IM, intramuscular; IV, intravenous; LSD, lysergic acid diethylamide; MAC, minimum anesthetic concentration; NMBAs, neuromuscular blocking agents; NMDA, N-methyl-D-aspartate; PO, per os (by mouth); PR, per rectum; RAS, reticular activating system; RTA, renal tubular acidosis; SQ, subcutaneous; THC, tetrahydrocannabinol.

• Tolerance is extremely common, especially to drugs that are within the same chemical class that the patient has been using.

• Patients with acute intoxication, those with chronic abuse (but not intoxicated), and the recovering addict present with different issues that can have significantly different anesthetic implications.

• Withdrawal from central nervous system depressants can be dangerous, so care should be taken to minimize the potential for withdrawal to occur during the perioperative period.

The decision on type of anesthetic agent for an acutely intoxicated individual will often depend on both the physiologic and psychological or emotional state of the patient at the time of surgery.

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