Addiction. Julia E. Linton York College/ Wellspan Health Nurse Anesthesia Program

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2 Addiction Julia E. Linton York College/ Wellspan Health Nurse Anesthesia Program

3 Objectives Identify patient populations at risk for drug abuse Identify several common drugs of abuse and the MOA Identify common pharmacologic cessation therapies and the MOA Discuss anesthetic management of patients with drug addiction Discuss anesthetic management of patients undergoing drug cessation therapy

4 Disclosures None All brand names used in this presentation are presented for ease of understanding and not endorsement of any specific product

6 DRUG ADDICTION DEMOGRAPHICS

7 Heroin Highways

8 ADDICTION RISKS

9 THE NEURAL CIRCUITS OF PLEASURE PLEASURE CENTERS

10 Drugs we will discuss Marijuana Stimulants cocaine, amphetamines, ADHD MDMA Hallucinogens Opiates Heroin New, scary, designer drugs Methadone Buprenorphine

Marijuana Most widely used, most widely available, safest illegal drug MOA: non-ionized THC molecules bind to the CB1 receptor in the brain and spinal cord

11 Marijuana Most widely used, most widely available, safest illegal drug MOA: non-ionized THC molecules bind to the CB1 receptor in the brain and spinal cord 97% protein-bound Anesthetic implication: THC modulates neurons in a similar fashion of our drugs. Potential for synergistic effect is currently intoxicated.

12 Gateway Drug?

13 Stimulants Cocaine, amphetamines, methamphetamines Includes common ADHD medical therapies Increase the amount of the monoamine neurotransmitters Norepi, epi, dopamine, serotonin

14 Stimulants - Cocaine Methods of ingestion oral, mucosal absorption, smoking, IV MOA: Blocks the dopamine transporter in nerve terminals Remember it s also a LA = seizures are very common

15 Cocaine CV Concerns Summary: There is no greater risk for the cocainepositive patient than any other patient

16 Amphetamines & Meth Pills, powders, chunks = ice Precursor is pseudoephedrine Meth ingredients Battery acid, drain cleaner, antifreeze, engine starter, lantern fuel MOA: Indirect sympathomimetic

17 Stimulants Ritalin & Adderall 30% of college students Methylphenidate (Ritalin) most prescribed ADHD drug, now abused by college students to gain an edge

18 MDMA 3,4-methylenedioxy-methamphetamine AKA: Ecstasy MOA: Increases levels of norepi, serotonin, and dopamine in the synapse. Most effective at increasing serotonin levels.

19 Hallucinogenics Population: white teenage males, Native Americans for religious ceremonies Schedule I with some exceptions (ketamine, dextromethorphan) Encompasses a wide variety of substances natural herbs to synthesized chemicals MOA: variable

20 Opiates Numbers most abused substance after ETOH and marijuana 2014 pills most abused (90%), but heroin still a significant problem

21 Heroin Purity varies 10 to 70% - avg 30% Cut with talc, quinine, baking powder MOA: Its just extra-lipid-soluble morphine

22 Other Drugs of Interest K2/Spice synthetic cannabis Bath salts MDOV or mephedrone stimulant Krokodile desomorphine

23 K2/ Spice Generally a mixture of dried herbs and plants that are then sprayed with synthetic cannabinoids Second in use among high-schoolers only to marijuana

24 Bath Salts MDOV or mephedrone stimulants Amphetamine derivatives Chemical alterations make effects unpredictable

25 Krokodil Codeine mixed with paint thinner, gasoline, red phosphorus, iodine, and hydrochloric acid Flesh-eating Drug

26 Cessation Medication

27 Methadone MOA NMDA antagonist, mu and delta opioid receptor agonist DOS protocol Take morning dose and resume ASAP. Additional analgesia as required. Patients on >200mg may have prolonged QT get baseline EKG

28 Buprenorphine Indications opioid addiction Subutex just buprenorphine Suboxone buprenorphine/ naloxone No effect from naloxone, included to prevent IV injection MOA partial mu agonist, kappa antagonist DOS protocol Two protocols Wean with stopping 72 hours prior to surgery Continue therapy as part of pain management

29 Naloxone Pure opioid agonist at mu, kappa, and delta receptors Duration shorter than heroin..

32 References Bryson, E. (2014). The perioperative management of patients maintained on medications used to manage opioid addiction. Current Opinions in Anesthesiology, 27, Cook, H. (2015). Role overload and prescription stimulant use among college students. Butler Journal of Undergraduate Research, 1 (3). Culver, J., Walker, J. (1999). Anesthetic implications of illicit drug use. Journal of PeriAnesthesia Nursing, 14 (2), Hill, G., Ogunnaike, B., Johnson, E. (2006). General anesthesia for the cocaine abusing patient. Is it safe? British Journal of Anesthesia, 97 (5), Kim, D., Irwin, K., Khoshnood, K. (2009). Expanded access to naloxone: Options for critical response to the epidemic of opioid overdose mortality. American Journal of Public Health, 99 (3), Kuhn, C. Swartzwelder, S., Wilson, W. (2014). Buzzed: The straight facts about the most used and abused drugs from alcohol to ecstasy. W.W Norton & Company, Inc: New York, NY. Peng, P. Tumber, P. Gourlay, D. (2005). Review article: Perioperative pain management of patients on methadone therapy. Canadian Journal of Anesthesia, 52 (5), Perrine, D. (1996). The chemistry of mind-altering drugs: History, pharmacology, and cultural context. American Chemical Society: Washington, D.C. May, J., White, H., Leonard-White, A., Wartlier, D., & Pagel, P. (2001). The patient recovering from alcohol or drug addiction: Special issues for the anesthesiologist. Anesthesia and Analgesia, 92, Winger, G. Woods, J., Hofmann, F. (2004). A handbook on drug and alcohol abuse: The biomedical aspects. Oxford University Press: New York, NY. Wright. E. (2012). How do addicted brains differ from nonaddicted brains? AANA News Bulletin.

California Department of Justice Bureau of Investigation. Special Agent Supervisor Tim Haskill Special Agent Supervisor Andre Hernandez

California Department of Justice Bureau of Investigation Special Agent Supervisor Tim Haskill Special Agent Supervisor Andre Hernandez Drugs Trends Drug trends are constantly changing Influenced by: Socio-economics