4.1 Addiction

Question 1

Tolerance

Answer 1

Pharmacological state
Exposure to drug

Produces ever decreasing effects

Continually higher level required to produce adequate effect

Question 2

Dependence

Answer 2

Physical Adaption
Continue use substance
Necessary prevent withdrawal symptoms

Manifested drug-class specific withdrawal syndrome
on cessation or reduction

Question 3

Addiction

Answer 3

Spectrum of substance misuse

Leading to continued abuse
despite actual and potential harm rendered

Various factors involved:
Placing increasing importance on substance and effect

Loss of control over its use

Presence mood swings

Potential relapse states

Question 4

Perioperative management of a patient with substance abuse

Answer 4

Pre-Operative

1) Full history incl. psychiatric
Elicit current and past substance misuse

• Include current medication history
  (safe prescribing - ie potential dd interaction)

2) I.D contributing Social factors
Alcohol / tobacco / recreation Drug use / Family circ

3) Clinical exam
recognise Sx + Sy relating to addiction / withdrawal

4) Initiation and Continuation of treatment
may affect timing surgery

Question 5

Preop Mx cont

Answer 5

5) Frank discussion -
Acceptable behaviour
Therapeutic goals
Rationale behind modality Rx

Aim to gain trust

6) Staff aware
regular daily intake of opioids
may increase patients perception pain

7) Appropriate analgesic regimen

Question 6

7) Appropriate analgesic regimen

Answer 6

7) Appropriate analgesic regimen
1. avoid opioid debt

2. Simple analgesics as adjuncts
   Paracetamol NSAID
3. Controlled reg distrib sustain release opioids
   Preferred to peaks and troughs of short acting
4. Opioid rotation
   if current Rx inadequate
5. Consider transdermal patches

Question 7

7) Appropriate analgesic regimen

Answer 7

6. Contact local drug advisory
   replace methadone if missed on admission
7. Back-up short acting opioids for break through
8. Prescription to treat potential withdrawal sy or complications
9. Adequate Rx of anxiety disorders where possible

10/ Ward aware hx abuse
potential drug seeking behaviours

Question 8

Intraoperative

Answer 8

May require premed w/ Opioids or Vzd

Polymodal analgesia
Simple analgesia + Opioid

Use regional as sole technique
using long acting LA

Consider adjuncts
Mag / Clon / Ket

Question 9

Postoperative

Answer 9

1. Do not underestimate analgesic regiments
   Supplementary opioid doses
   supranormal level may be required
2. PCA regimen may need to be altered
   - ie background / increase in bolus size
3. Communicate w/ acute pain service
   Regular Post op review
   med adjust according to progression