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Post by Kristen Horsman on Jan 2, 2019 8:54:03 GMT -5
This month’s journal club is presented by Lu Lin. She chose a great article that anesthesia management for the substance abuse patient.
Here is a link to the article.
The questions to encompass within your response:
1. Can you share your experience with substance abuse patients?
2. What is your medication choice when you have a patient with history of substance abuse?
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Post by Moishe Mayer on Jan 2, 2019 13:01:37 GMT -5
Great article summarizing some key points for substance abuse patients. Most the patients that I have dealt with have refrained from drug use for a week or more, thus mitigating some of the potential side/adverse effects. Otherwise, if surgery must proceed, symptoms need to be managed. It is a hard balance, and may result in a hemodynamic roller coaster. Of course, for any elective surgery, I would cancel a case should the patient have had recent cocaine use.
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Post by Jennifer Hannon on Jan 2, 2019 14:41:30 GMT -5
Good article with nice organization for a quick reference again. Thanks Lu!
As we all know, heroin usage in Baltimore is high and so I've had my fair share of current and ex-heroin users, methadone treatment users and abusers, as well as other illicit users. We also see a fair amount of chronic pain and pain medication dependent patients and so I've utilized Regional techniques and ketamine/Propofol/gabapentin combos, some precedex and also dosing methadone in the morning. I have used suboxone on a few rare occasions but that was not here at Hopkins. I like to use Ketamine mostly.
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Post by Ben Waldbaum on Jan 2, 2019 16:59:54 GMT -5
1.) With patients with a history of substance abuse I try to rely on objective data such as toxicology screens. Many times I've had patients claim to be sober that test positive for cocaine, amphetamines, etc. I routinely order these tests in preop. Positive tests are common.
2.) The question is vague as it all depends what substance of abuse they've been using and if they are currently under the influence. With heroine, ketamine is good with background methadone. Alcohol, volatile anesthetic and opioid. Not really concerned about marijuana use. Cocaine patient's tend to have a lot of cardiac dysrhythmia so I tend to look for cardiac studies and plan around those findings.
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Post by kel on Jan 3, 2019 8:25:08 GMT -5
I provided anesthesia for a patient that had a history of substance abuse who was taking methadone and also going to the methadone clinic. The patient requested that no or minimal opioids should be giving during the anesthetic . This patient was concerned about " getting addicted" and having opioids in the blood stream that could show up on future blood tests. After discussing the concerns and anesthesia plan the one drug that I thought was the most important to continue was the Methadone. Methadone can work very well for many people and I do think continuing this drug during the periop period is beneficial especially for those patients that are already on this medication .
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Post by Jocelyn Datud on Jan 3, 2019 13:44:17 GMT -5
This is a great article and reference. With the increasing number of addiction, this is a handy tool that can guide us with our anesthetic management. As a student, I had a patient who was opioid dependent. My preceptor at that time wanted to know how much can he tolerate analgesics so we started inducing by giving Fentanyl. It was shocking for me because after giving 700 mg of Fentanyl, the patient is still talking!
For patients who have history of substance abuse, regional anesthesia had been a good adjunct to our anesthetic. Also I try to utilize other adjuncts such as ketamine, clonidine, magnesium, lidocaine infusion. Tylenol, and gabapentin.
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nanci
Junior Member
Posts: 57
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Post by nanci on Jan 3, 2019 14:02:02 GMT -5
1)At Hopkins main campus it is common to deliver care to patients with substance abuse and their history of drug intake is often found to be unreliable. Every patient you are universally screening and looking out for indications of impairment. Some are more obvious- example arriving for I&D of injection site abscesses and cellulitis that is documented on their history. Others are ICU patients added on that can not describe their drug use history, but that have been so bad to lead to systemic infection requiring increased hospital stays and advanced care. Knowing their labs, liver function, and clotting status among other things to round out their care is important. Thinking ahead to their postoperative course is also important by being prepared for potential withdrawal symptoms and other complications during their recovery time. Peripheral venous access may be more difficult as well.
2) Do not have a medication of choice as each patient and their circumstances are different. If they are on a methadone regimen try to make sure they have had their normal dose. Regional techniques may provide postoperative pain control however may be difficult to provide if skin infections at area surgically providing care to. Cocaine causing increased myocardial oxygen demand with possible ischemia and subsequent infarction that can occur so generous premedication might be good to help decrease major hemodynamic changes during surgical stimulation. For other stimulants, benzodiazepines can be used to help control cerebral excitation. Yes this question is difficult to answer because there are so many variables that may present- would have to formulate a plan based on specific patient presentation and go from there.
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Post by aileenm4 on Jan 4, 2019 8:41:57 GMT -5
Good Morning all A very important subject in this day especially with all the news surrounding the epidemic of opiod addiction etc. It makes me sad that the article addressed children ages 12-17 as part of the group because we all want to assume children are innocent and not on the path to drug addiction. In peds, we often deal with our drug tolerant patients from NICU or PICU who are in the hospital for weeks or even months and have become super tolerant to not only narcotics but, Ketamine, Dexmedetomidine and Benzos as well as Propofol. Our Oncology patients need unbelievable doses of Propofol up to 10mg/kg to go to sleep. Recently I had a teen who had gone through rehab and wanted a No opiod surgery, we had discussed with the surgeon and patient and created a plan for a multimodal pain plan including blocks and all the non opiod meds you can think of.
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Post by jkim54 on Jan 4, 2019 15:15:55 GMT -5
1. The opportunities to treat patients with a history of substance abuse are plentiful and challenging at best. They require a good amount of empathy and flexibility in being able to treat their pain effectively both intra- and postoperatively. You also have to try and anticipate any physiological changes caused by their abuse history that may need to be addressed under anesthesia.
2.Ketamine has definitely become an important part of my treatment regimen in caring for these patients. Overall, medication options should be tailored to the patient and their specific history, utilizing other options such as regional and nonopioid adjuncts.
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Post by Jessica Switzman on Jan 7, 2019 9:44:20 GMT -5
I have cared for many patients on Methadone and/ or have untreated SUD. Working with patients with SUD requires patience, flexibility and sympathy. I tend to use Ketamine when appropriate. I make sure the patient receives their scheduled dose of Methadone and any antidepressants and/or prescribed anti anxiety medications. Regional Anesthesia and non opioid options are excellent when appropriate.
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Post by CVelarde on Jan 14, 2019 17:49:20 GMT -5
I have had patients with positive drug screens in the past. I requested to wait 24 hrs for clearance unless the surgeon thinks it is a true emergency. When faced with patients on chronic methadone maintenance I think following their regimen is quite important. Regional, multimodal anesthesia is the best approach to decrease the necessary narcotic for the post op pain management of the patient. If a patient had recent cocaine use I would use propofol. I would also discuss risk of coronary artery spasm etc and encourage the patient to wait unless it is a true emergency.
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Post by Jessica Hadley on Jan 15, 2019 11:12:52 GMT -5
I have experienced quite a few patients who either were current substance abusers or in recovery from substance abuse. The more challenging patients have been the ones who are recovering from addiction and prefer not to have narcotics. In these cases multimodal analgesia is very helpful. Agents include acetaminophen po or iv, ketorolac if appropriate, gabapentin, ketamine and regional anesthesia if feasible. The only cases I have had cancellations for have been + cocaine on tox screen or reported cocaine use within 24 hours. My experience with patients on methadone has been that it is ideal to continue the methadone up until surgery, however with the long half life patients tend to do okay even if one dose is missed. Some of the patients I have taken care of on larger doses of methadone actually require a good deal less anesthesia.
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Post by Sarah Rollison on Jan 15, 2019 13:36:25 GMT -5
I've had varied experiences with substance abuse patients, including those who have abstained from drug use prior to surgery, as well as those who were acutely intoxicated. Unless the case was a true emergency, it was usually cancelled for clearance of the drug. However, the major issue I've seen with this population is pain control. Like many others have mentioned, I also like to use a multimodal approach with preoperative Tylenol and Gabapentin if possible. I've also used precedex a lot for these patients, along with Ketamine, lidocaine infusions, and occasionally magnesium infusions. I agree also with continuing the Methadone treatment perioperatively for patients who are on it - I find it helps to smooth out the anesthetic.
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kty67
New Member
Posts: 22
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Post by kty67 on Jan 28, 2019 13:46:24 GMT -5
1. Great article for reference. I have canceled number of times the patients who had recent cocaine use. 2. with increasing of use multimodal pain therapy and use of blocks as much as possible for pain control, opioid addicted patients do much better. I like to use Ketamine, Lidocaine infusions also for opioid addicted patients.
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Post by LMeginnis on Jan 28, 2019 23:45:13 GMT -5
Like most of us I have had many patients with a history of or current drug use. Heroin, cocaine and prescription pain meds being very common. I agree that methadone should be continued and that we should utilize all the drugs in our arsenal (ketamine, gabapentin, acetaminophen, regional techniques, etc)
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