General Surgery Rotation

General Surgery: Substance abuse

Patient will present as →  a 26-year-old man is seen in the emergency department for abdominal pain that began after returning home from a party where he consumed pizza and eight beers. The pain is constant, located in the upper part of his abdomen, and radiates to his back. Approximately 3 to 4 hours after onset of the pain, the patient vomited a large amount of undigested food, but the emesis did not resolve his pain. His past medical history is unremarkable, and he consumes alcohol daily and on the weekends when he attends parties with his friends. On examination, the patient appears uncomfortable. His temperature is 38.8°C (101.8°F), heart rate 110 beats/min, blood pressure 110/60 mm Hg, and respiratory rate 28 breaths/min. The abdomen is distended and tender to palpation in the epigastric and periumbilical areas. Laboratory studies reveal a WBC count of 18,000/mm3, hemoglobin 17 g/dL, hematocrit 47%, glucose 210 mg/dL, total bilirubin 3.2 mg/dL, aspartate aminotransferase (AST) 380 U/L, alanine aminotransferase (ALT) 435 U/L, lactose dehydrogenase (LDH) 300 U/L, and serum amylase 6800 IU/L. Arterial blood gas studies (room air) reveal pH 7.38, Paco2 33 mm Hg, Pao2 68 mm Hg, and HCO3 21 mEq/L. Chest radiography reveals the presence of a small pleural effusion

Key Features of Substance Abuse

  • The substance is often taken in larger amounts over a longer period than intended
  • Unsuccessful efforts to cut down
  • A great deal of time spent obtaining the substance or recovering from its effects
  • Craving
  • Social, occupational, or recreational
  • Recurrent despite hazards
  • Tolerance or withdrawal

Alcohol or drug dependence: 5% to 10% of population

  • Approximately 15% of patients in primary care practice have an at-risk pattern of drug and/or alcohol use; lifetime prevalence of any alcohol use disorder: 30%; prescription drug misuse is on the rise with 5% past-year prevalence.
  • Males > females

Surgical problems due to drug misuse

  • Venous access: Repeated use of veins for intravenous self-administration of drugs leads to major damage to superficial veins, which are very likely to become thrombosed.
  • Arterial injury: Attempted deep venous access brings with it the risk of arterial damage. This is a particular risk in the femoral region where critical ischaemia of the entire leg may result from arterial damage or thrombosis. This may require urgent vascular surgical intervention, repair and/or embolectomy.
  • Deep venous thrombosis (DVT)
  • Abscess formation and gas gangrene
  • Tissue compression, crush injury and ischaemia: Other complications of prolonged immobility following illicit drug administration include compartment syndrome and neuropraxia.

The clinician should screen for alcohol and drug use in all patients

  • Ask about quantity and frequency of alcohol or drug use.
    • The National Institute on Alcohol Abuse and Alcoholism (NIAAA) declares that problem drinking is defined as more than 2 drinks per day for men and more than 1 drink per day for women or anyone > 65 yr.
  • CAGE questionnaire (“1. Have you ever felt you need to Cut down on your alcohol or drug use? 2. Have people Annoyed you by criticizing your alcohol or drug use? 3. Have you ever felt Guilty about alcohol or drug use? 4. Have you ever felt you need to drink first thing in the morning [Eye opener] to stop shakiness?”).

Because self-report of substance use and its consequences can be unreliable, obtaining corroborating information, such as from family members, past detoxifications, or drug rehabilitations, is often helpful.

Obtain serum or urine tests on those who are likely by history, physical examination, or circumstances to be intoxicated.

  • Blood alcohol content (BAC) measured on the breath is practical to define intoxication and provides a rough measure of impairment. In general, two standard drinks may cause BAC 0.08% or higher, which is considered legally impaired.
  • Obtain toxicology screen in urine or blood samples.
  • Biologic markers such as elevated mean corpuscular volume (MCV), γ-glutamyltransferase (GGT), liver function tests (AST and ALT), and carbohydrate deficient transferrin (CDT) may also be used to diagnose and monitor.

 

Tracks secondary to intravenous heroin abuse.

Tracks secondary to intravenous heroin abuse.

A history of drug abuse could be considered a contraindication to day-case surgery.

  • Operations on acutely intoxicated patients should be delayed if possible.
  • Local, regional or axial (spinal and epidural) anaesthetic techniques may be particularly useful.

Those caring for substance user postoperatively should be wary of the potential for hemodynamic compromise, poor wound healing, altered consciousness and difficulty with pain management

Anesthesia: Information regarding a patient's drug habit may be very important in planning their anaesthetic care.

  • Opioid users may display both tolerance and physical dependence, making prediction of their analgesic needs difficult.
  • Patients that smoke or inhale illicit substances may have considerable airway damage and significant chronic obstructive pulmonary disease
  • The use of sympathomimetic drugs such as cocaine, amphetamines and related compounds may be associated with greater pressor responses to stimuli such as oro-tracheal intubation and surgical incision, a greater amount of anaesthetic agent may be required including a higher concentration of volatile anaesthetic.
  • The abuse of volatile solvents can mimic alcohol intoxication and is most commonly seen in school-age males. Chronic use can lead to cardiomyopathy and dysrhythmia, a sensitivity to sympathomimetic agents and myocardial depression with volatile anaesthetic agents.
  • Patient controlled analgesia (PCA) usually involves morphine and is a commonly used mode of post-operative pain management. However, in opioid-abusing patients there is a risk of increased use for chemical gratification.
  • Re-exposure to opioids in ‘recovered’ addicts risks re-establishment of drug-craving. Intravenous boluses of opioids in an unanaesthetised drug user patient should be avoided.

Treatment options

  • Naltrexone helps reduce craving for alcohol. Naltrexone 50 mg once daily for 12 wk can be a useful adjunct to substance abuse counseling or rehabilitation programs. Randomized treatment studies are equivocal for long-term outcomes. Naltrexone reduces relapse and the intensity or frequency of any drinking that does occur. It can be hepatotoxic and is contraindicated in opiate users. Intramuscular naltrexone (380 mg monthly) may be considered if adherence is an issue.
  • Acamprosate also helps reduce craving for alcohol. Acamprosate 666 mg three times daily may be an effective adjunct to counseling. A recent meta-analysis showed overall benefit with increase in the number of abstinent days.
  • Disulfiram provokes acetaldehyde accumulation after alcohol ingestion, producing a toxic state manifested by nausea, headache, flushing, and respiratory distress. Studies have shown limited efficacy mostly due to noncompliance.
  • Topiramate may be an alternative treatment for alcoholism. In a 12-wk randomized trial topiramate up to 300 mg daily significantly reduced the number of heavy drinking days
  • Methadone maintenance for opiate addiction is effective and involves once-daily dosing of methadone in a controlled setting via methadone clinics.
  • Buprenorphine is as effective as low-dose methadone and may be prescribed by physicians who have completed approved training. For induction, initiate 12 to 24 hr after short-acting opioid use and 24 to 48 hr after long-acting opioid use. Use buprenorphine/naloxone tablets in most patients, since buprenorphine-only tablets have risk of abuse. Maximum first-day dosage is 4 to 8 mg of buprenorphine. Titrate buprenorphine dose up to 12 mg on day 2 for signs of withdrawal. Then adjust dosage in frequent outpatient visits (weekly) to minimum needed for maintenance (up to 32 mg daily).
  • Naltrexone (oral or injectable) may also be used for maintenance in opioid dependence treatment, though evidence of effectiveness is limited.
  • Always combine pharmacotherapy with counseling.
  • Treatment of comorbid psychiatric disorders improves outcomes.
  • Intervention may be used to break through denial of a person with a serious addictive disorder to help the person acknowledge that he or she suffers from a disorder and agree to treatment.
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