Chapter 24. Evaluation of the Patient with Alcohol or Drug Addiction

1. Addiction is a very common medical illness. It is characterized by loss of control over an abusable substance, including an inability to voluntarily self-regulate drug use, compulsive preoccupation with obtaining or using a drug, and continued use despite adverse consequences.

2. Addiction may be managed successfully as a chronic disease, and many patients respond positively to treatment with long periods of abstinence.

3. Consultation with an addiction medicine specialist is encouraged when providing care for active or recovering alcohol or drug abusers during the perioperative period.

4. Preoperative assessment of all patients presenting for surgery should include a routine evaluation for alcohol or drug abuse.

5. Establishing a supportive, nonjudgmental but firm approach to the patient with active alcoholism or drug addiction is vital for successful care.

6. Preoperative history, physical examination, and laboratory testing should be guided by the known medical consequences of alcohol and drug addiction.

7. A blood alcohol concentration and a urine drug screen should be obtained in all active and most recovering alcohol or drug abusers.

8. Polysubstance abuse is common among alcohol or drug users.

9. Infectious diseases are epidemic in injection drug users.

10. Alcohol abuse has extensive medical consequences that impact every major organ system and is a major risk factor for perioperative morbidity and mortality.

11. Abuse of sedative–hypnotics, opioids, cocaine, amphetamines, hallucinogens, and inhalants is associated with a wide variety of drug specific medical complications.

12. Withdrawal is commonly encountered during the perioperative period in alcohol or drug abusers, and prophylaxis against withdrawal should be instituted before surgery.

13. Recovery involves abstinence in combination with a series of personal changes to maintain sobriety.

Addiction is a major public health problem. The lifetime prevalence of alcohol or drug addiction in the United States is estimated to be approximately 14% and 7%, respectively.1 The literature describing the evaluation and treatment of patients with addiction is exhaustive. This chapter focuses on what the anesthesiologist needs to know to effectively manage the perioperative care of the addicted patient.

Addiction is defined by loss of control over a drug or substance of abuse. The inability to voluntarily self-regulate drug use, compulsive preoccupation with obtaining or using a drug, and continued use despite adverse consequences are central features of this multifaceted disease.2 Initial drug use is usually voluntary, and most users do not develop drug dependence, but repetitive drug exposure in a susceptible individual appears to cause fundamental changes in central nervous system function that produce the disease. Evidence suggests that genetic predisposition to addiction may be related to alterations in neurocircuitry that enhance sensitivity to the reinforcing effects of drugs of abuse, thereby overwhelming cognitive control of behavior.3 Thus addiction is a chronic disease; once present, it is regarded as permanent. However, it may be managed successfully, and many patients respond positively to treatment with long periods of abstinence.4

The neurobiology of addiction has been well documented and is not discussed in detail here.3,5 Three major concepts pertain to ...