Anesthesia for Drug Abusers

Published on 07/02/2015 by admin

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Last modified 07/02/2015

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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

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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

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