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Anesthesia for the Patient with Substance Use Disorder
TEXTCoexisting Disease · 8 min read
Active intox, chronic dependence, MAT (buprenorphine/methadone), withdrawal management. NBCRNA SEE-tested heavily; clinical reality even more.
After this lesson you can
2 min read7 sections- Identify opioid tolerance/dependence.
- Plan multimodal regimens for SUD patients.
- Manage acute withdrawal intraop/post-op.
- Support recovery during the perioperative period.
Alcohol use disorder
Chronic use induction enzymes (CYP2E1) higher anesthetic requirements when sober, hepatic dysfunction (see hepatic section), thrombocytopenia, esophageal varices.
6-12 hrtremor/anxiety12-48 hrhallucinations + seizures48-96 hrDTs (hyperadrenergic + delirium, 5% mortality untreated)
CIWA score-driven benzodiazepines (lorazepam IV q1h prn), thiamine 100 mg BEFORE glucose (prevent Wernicke), folate, multivitamin.
Consider phenobarbital protocols for refractory.
Opioid use disorder
Postop pain management: continue baseline opioid equivalence + add multimodal (regional, dex, ketamine, lidocaine, acetaminophen, NSAIDs) + escalate breakthrough opioid above usual.
Document opioid contract and pain plan with patient awake.
Buprenorphine — the perennial controversy
Two approaches: (1) continue buprenorphine perioperatively (current guideline trend) — multimodal + higher-dose full agonists for breakthrough; (2) hold 48-72 hr preop (older approach) — risk of return to use.
ASRA/ASAM 2021 guidelines favor continuation for most surgeries.
For major procedures with anticipated severe pain, hold or reduce based on shared decision-making.
Postop: regional + multimodal + bridge with hydromorphone/fentanyl if needed.
Methadone
QT prolongation — check ECG, avoid concurrent QT-prolonging agents (ondansetron, haloperidol), correct K + Mg.
Adds to postop opioid requirement on top of baseline.
Stimulants (cocaine, methamphetamine)
- hypertension
- tachycardia
- hyperthermia
- arrhythmia
- ischemia risk (coronary vasospasm)
- seizures
Elective surgery postpone if acute use suspected (urine screen + symptoms).
Emergent: avoid ephedrine + ketamine (additive sympathomimetic), avoid beta-blocker alone (unopposed alpha); use mixed agents (labetalol) or phentolamine for HTN.
Chronic use: cardiomyopathy, vasospasm risk persists weeks after last use.
Cannabis
- increased anesthetic requirement
- airway hyperreactivity if smoked
- postop nausea higher
Question all patients in screening (legalization → underreporting).
No definitive cessation guidelines; some recommend 24-72 hr abstinence pre-op when feasible.
Benzodiazepine + sedative dependence
Withdrawal is dangerous (seizures, autonomic instability) — protocol-driven taper if cessation needed.
Flumazenil rescue contraindicated in chronic users (precipitates withdrawal/seizures).
Plan postop disposition carefully — escalating doses for tolerance.
⚠ Common pitfalls
- Standard opioid dosing in tolerant patient — inadequate analgesia + risk of return-to-use.
- Stopping buprenorphine peri-op routinely — modern guidance is to continue and adjust.
- Naloxone + buprenorphine — precipitated withdrawal; avoid full antagonists.
- Discharging without recovery plan — opioids can trigger relapse.
💎 Clinical pearls
- Continue buprenorphine through surgery; add full agonist on top for breakthrough analgesia.
- Methadone: continue regular dose; supplement for surgical pain.
- Multimodal opioid-sparing essential: regional, ketamine, acetaminophen, NSAIDs.
- Engage addiction medicine peri-op when available; outpatient follow-up critical.
Recap
- Continue buprenorphine through surgery; add full agonist on top for breakthrough analgesia.
- Methadone: continue regular dose; supplement for surgical pain.
- Multimodal opioid-sparing essential: regional, ketamine, acetaminophen, NSAIDs.
- Engage addiction medicine peri-op when available; outpatient follow-up critical.
Mark each section done to complete the module.