Providing Anesthesia for Patients with Substance Use Disorder

The burgeoning opioid crisis presents a series of critical challenges to CRNAs who provide anesthesia care to patients who are suffering from or in recovery from the disease of addiction. In response, during the 2017 Jan Stewart Memorial Wellness Lecture, Sunday, Sept. 10, a panel of CRNA experts offered a timely overview of “Safe Anesthesia Care of the Patient with Substance Use Disorder.”

The topic of this year’s lecture was particularly poignant and significant given the fact that its namesake, former AANA President Jan Stewart, CRNA, ARNP, died of a self-administered overdose of sufentanil. Linda Stone, DNP, CRNA, the moderator of the panel discussion, noted that Stewart’s passing in 2002 brought home the realization that “no one is immune to the risk” of opioid addiction and that “when the risk is ignored, our whole profession is in danger.”

The AANA Wellness Program was formed as a way to continue Stewart’s legacy. After being introduced to the audience, Stewart’s daughter, Sara Stewart Gomes, told the audience that it is “humbling to see how these programs have grown up” since her mother passed and that she is truly honored to hear the stories about the impact the program has had on the lives of members and their families.

The Science of Addiction

The panel discussion began with an overview by Olin (Brad) Hutto, MHS, CRNA, of the science behind substance use disorder (SUD). Substance use disorder is defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders as the “recurrent use of alcohol or other drugs that causes clinically and functionally significant impairment such as health problems, disability, and failure to meet major responsibilities at home.” Addiction is the most severe, chronic stage of SUD, with substantial loss of self-control and compulsive drug-taking despite the desire to stop.

Hutto explained that addiction “is an actual disease of the brain” with physiologic changes that eventually result in compulsive drug-taking. He demonstrated the concept to the audience with a slide showing a scan of the brain of a patient addicted to cocaine next to a normal brain. On the same slide, a scan of a diseased heart was next to that of a normal heart. Both the diseased heart and the brain of the patient with SUD showed visible, profound damage.

Medication Assisted Treatment

Jessica Switzman, MSN, CRNA, continued the panel discussion with an overview of medication-assisted treatment, defined as a whole-patient treatment approach using medications in combination with counseling and behavioral therapies. Types of medications used by such patients include agonists such as methadone, partial agonists such as buprenorphine, and antagonists such as vivotrol.

Anesthesia Planning and Care

Brian Selai, MSN, CRNA, concluded the panel with a presentation on assessing and planning the anesthetic care of patients with SUD. Selai stressed the importance of building a relationship with the patient even though “you only have a few minutes” before the procedure. During the preanesthesia assessment, the provider has to obtain sensitive information from the patient, including whether the patient is in the acute phase or the recovery phase of SUD, medication history, and medications currently used. Discussing the patient’s needs and fears is important, Selai said, and the provider can consult with an addictionologist if necessary.

Selai touched on the value of Enhanced Recovery after Surgery (ERAS) protocols and non-opioid pain management options and urged patients to become familiar with AANA’s online resources.

Before the lecture concluded with a question-and-answer session, Selai urged the audience to consider the positive impact they can have on patients with SUD. “Give yourself more credit than you do,” he said. “What we do and the choices we make has a large impact on a patient’s life beyond the few hours we spend with them.”