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Perioperative analgesia and challenges in the drug-addicted and drug-dependent patient

https://doi.org/10.1016/j.bpa.2014.02.003Get rights and content

The epidemic use of illicit drugs has led to an increasing number of patients with drug addiction and dependence presenting for perioperative care. There are a wide variety of drugs commonly abused including opioids, such as heroin and prescription drugs; stimulants, such as amphetamine and cocaine; depressant drugs, such as alprazolam and diazepam; and hallucinogens, such as lysergic acid diethylamide, phencyclidine, and marijuana. Treatment of opioid dependence by office-based buprenorphine and methadone maintenance programs has expanded opportunities for therapy. Treatment of these patients in the perioperative period is challenging. In addition to pain control, management of anxiety, psychological states, and hemodynamic control are the factors to be considered to provide optimum treatment. Although opioids are the mainstay for the control of acute pain, other therapeutic options include alternative routes of administration of local anesthetic, ketamine infusion, and the use of regional anesthesia. We discuss optimum perioperative management, the role of perioperative urine testing, and special considerations in patients on methadone and buprenorphine.

Introduction

The main dangers of a drug addiction during the perioperative period are drug overdose and withdrawal [1], ∗[2]. It is thus important for the anesthesiologist to understand which substances are commonly abused and the frequency of their preoperative use. Additionally, appreciation of the pharmacodynamics and pharmacokinetics as well as drug interactions are critical to ensure perioperative safety of drug-dependent and drug-tolerant patients.

Section snippets

Cocaine

Cocaine is a natural alkaloid extracted from the leaves of the shrub Erythroxylon coca which is an indigenous plant in South America, Mexico, the West Indies, and Indonesia. Over the past 20 years, the abuse of cocaine has grown enormously because of the ease of availability and dramatic reduction in cost. The alkaloid is dissolved to form a water-soluble salt cocaine hydrochloride. The bioavailability of cocaine is 30–40% by the oral route and about 80–90% by inhalation or via the intranasal

Hallucinogens

The most common drugs in the class of hallucinogens are phencyclidine (PCP) and lysergic acid diethylamide (LSD). PCP produces a dissociative state with associated agitation, delirium, and hallucinations. Its mechanism of action includes agonist, partial agonist, and antagonist at dopaminergic, adrenergic, and serotonergic receptors, respectively. Severe sympathetic activation, delirium, and respiratory depression can occur. Ketamine is a PCP derivative and should be avoided for perioperative

Lysergic acid diethylamide

LSD is a semisynthetic drug derived from ergot, a rye fungus, and from morning glory seeds. It is tasteless, colorless, and odorless. Its physical effects include increase in heart rate, blood pressure, blood sugar, temperature, dilatation of pupils, dry mouth, sleeplessness, salivation, perspiration, and nausea. Serotonin reuptake inhibitors and marijuana may exacerbate LSD flashbacks and effects.

Marijuana

Marijuana is derived from a plant called Cannabis sativa. The extract from dried leaves yields marijuana, and the concentrated resin yields hashish. The psychoactive agent is delta-9-tetrahydrocannabinol, which is an inhibitor of the muscarinic receptor of the parasympathetic system and results in the increase in the turnover of acetylcholine. Common symptoms include feelings of euphoria and drunkenness. Cannabis is also an antidepressant and an antiemetic agent. Insomnia, troubled mood, and

Methadone

Methadone (Dolophine®, Roxane Laboratories, Columbus, OH, USA; Mylan Inc., Canonsburg, PA, USA) is a synthetic opioid that was developed in Germany during World War II. Methadone was not placed into widespread use until after the war due to the difficulty in understanding proper dosing [6]. It has several unique properties that make it useful for two extremely important uses: treatment of opioid dependence and the treatment of pain, particularly chronic pain. It has been estimated by the

Mechanism of action of methadone

Methadone has a primary action of binding to the mu receptor, as well as having an N-methyl-D-aspartate (NMDA) receptor antagonist action making it more useful for the treatment of chronic pain than pure mu agonists. Specifically, methadone produces analgesia and sedation by stimulating a number of opioid receptors via the l-isomer, in addition to blocking the NMDA receptor via the d-isomer. Methadone is also a norepinephrine and a serotonin reuptake inhibitor [8]. Methadone is about three

Metabolism of methadone

Methadone does not have metabolites that are neurotoxic. Cytochrome P450 enzymes CYP3A4 and 2D6, and possibly 2B6, metabolize methadone in the liver. Methadone is primarily metabolized in the liver using CYP3A4 by N-demethylation to 2-ethylidene-1, 5-dimethyl-3, and 3-diphenylpyrrolidine (EDDP), which is a nontoxic and inactive metabolite [9]. Methadone compliance can be gauged by serum EDDP levels and methadone metabolism can be gauged by the methadone-to-EDDP ratio [10]. However, it has a

Methadone for the treatment of pain

Though the prescription of methadone for addiction treatment is restricted to those with a special license, all physicians able to prescribe Schedule II medications can issue prescriptions of methadone for analgesia. It can be used for the treatment of acute postoperative pain as well as chronic pain. For the treatment of pain, methadone is usually used two to three times a day. It is an NMDA antagonist, and this property along with its long half-life could make it particularly useful in the

Methadone for the treatment of opioid dependence

It must be remembered that treatment of opioid dependence and addiction by methadone should only be done as part of a dedicated methadone maintenance program requiring a special license. If buprenorphine is being used, the prescriber must be registered to prescribe Suboxone (buprenorphine and naloxone).

Buprenorphine

Buprenorphine is a derivative of an alkaloid of morphine called thebaine [33]. Buprenorphine is a partial agonist with a high affinity for mu receptors and is a kappa antagonist. The high affinity for the mu receptor leads to slow dissociation from the receptor. Though it binds tightly to the mu receptor, it only partially activates it, being a partial agonist, leading to intermediate or reduced efficacy. Its affinity for the mu receptor is greater than that of the antagonist naloxone as well

Conclusion

In addition to pain control, management of anxiety, psychological states, and hemodynamic control are the factors to be considered in providing optimum treatment for the drug-dependent and drug-addicted patient in the perioperative setting.

Management of acute pain in patients with drug-addicted and drug-dependent patients is truly a challenge. Opioids are the mainstay for the control of acute pain. In the drug-addicted and drug-dependent patients, other therapeutic options include alternative

Conflict of interest

None.

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