While there is extensive literature regarding anesthesia for the actively addicted patient, there remains very little to guide the perioperative management of the patient in recovery. Developing a ...better understanding of the unique needs of the patient presenting for surgery who is in recovery from chemical dependency is essential for those involved in the perioperative care of such patients. Some of the issues that arise in this population are similar to those that confound the management of the chronic pain patient, such as tolerance, opioid-induced hyperalgesia, and withdrawal. In addition, many patients in recovery are maintained on methadone and buprenorphine, which can further complicate their perioperative management. This chapter will discuss pain management strategies involving alternatives to opiates, recommendations for safe use of opiates and other “triggering” agents, and relapse prevention. For the purpose of this discussion, the term “addict” will include persons addicted to alcohol.
There is mounting evidence that the spread of the human immunodeficiency virus (HIV) is associated with heroin trafficking routes. The relationship between the two is best illustrated by the routes ...leading from the two primary regions for the illicit opium poppy cultivation and heroin manufacture: the Golden Triangle of South-East Asia and the Golden Crescent of Central Asia. The producers in the Golden Triangle are the Lao People’s Democratic Republic and Myanmar, and those in the Golden Crescent are Afghanistan and Pakistan. Together, those States accounted for perhaps 80–90 percent of the world heroin supplies in 2007. HIV outbreaks resulting from unsafe injection practices among injecting drug users (IDU) in trafficking zones have been documented in Myanmar itself, in Belarus, China, India, Indonesia, the Islamic Republic of Iran, Malaysia, Pakistan, the Russian Federation, Tajikistan, Thailand, Ukraine, Uzbekistan, Vietnam, and in several States in Eastern Europe. Heroin trafficking in those States has led to serial epidemics: first of heroin use, then of injection, then of blood-borne pathogens, including hepatitis C and HIV. Ethnic and trade relationships in heroin trafficking zones appear to facilitate such epidemics, as does drug testing by petty traders in market nodes. Policy responses, or the lack thereof, have increased the vulnerability of users and their communities, as have the limited drug treatment options available in those zones. While “supplyside” approaches, including interdiction and policing, are likely to continue, those HIV epidemics will require improved drug treatment, access to HIV prevention services, including harm reduction, and new approaches to the prevention of HIV in areas where heroin trafficking occurs.
Deuterated methadone (M-d3) and GCMS were used to study the pharmacokinetics of methadone (M) during the induction stage of methadone maintenance treatment (MMT). A pulse dose of M-d3 was given on ...Days 1 and 25 of two dosage regimens, one with a continuous 30 mg dose (n = 6), and the other with 30 mg for 10 days, followed by 60 mg as the maintenance dose (n = 6). Plasma and urinary levels of M and M-d3 were measured throughout and plasma half-lives, oral bioavailabilities and volumes of distribution were calculated from the data of Days 1-2 and 24-26. The oral bioavailability of a methadone solution was found to be between 81 and 95%: elimination half-life in the beta-phase varied between 19 and 58 h; the volume of distribution was 4.1 +/- 0.65 l/kg; and total body clearance of M was 54-195 ml/min and its renal clearance 3.4-34 ml/min. A consistent finding was a lower urinary pH and increased renal clearance during the first month of treatment. The shorter elimination half-lives in those patients probably caused unacceptably high fluctuation in the body content of M during the 24 h dosage interval, and may have interfered therefore, with its therapeutic effectiveness.
Addictions Oslin, David W.
Psychiatry for Neurologists
Book Chapter
Alcohol and drug dependence are two of the leading causes of disability and mortality worldwide; however, these problems are often not appreciated and are often unrecognized in primary and specialty ...medical settings (1). Past drug or alcohol use has also been recognized as important in the care of patients, as past periods of abuse or dependence can increase vulnerability to subsequent medical and neuropsychiatric problems. Perhaps more importantly, recent research has demonstrated the efficacy of both psychosocial and pharmacological treatments for substance dependence and there is evidence that treatment can lead, not only to reductions in substance use and associated social problems, but also to substantial improvements in the physical and mental health of patients. This chapter highlights some of the recent advances in understanding and treating substance use and abuse, with a particular emphasis on the identification of patients, consequences of use, and methods for motivating patients to engage in treatment.
Liver transplantation is a complex surgical procedure requiring comprehensive and intensive multidisciplinary involvement in the perioperative period. Over the years there has been significant ...evolution of the surgical technique and the perioperative management that resulted in improved outcomes. The anesthesiologist and intensivist play a crucial role throughout the perioperative period and adequate analgesic delivery is of outmost importance during this period. Providing adequate pain control may prove to be challenging and there are unique considerations in patients undergoing liver transplantations. In addition to relieving mental suffering associated with pain, appropriate pain control is essential to prevent the profound physiologic consequences of inadequate analgesia. This chapter aims to address and discuss in detail the analgesic issues in liver transplantation and liver resection.
To study the pharmacokinetics of dextromoramide in long-term opiate addicts on methadone maintenance therapy (MMT) a reverse-phase HPLC technique was developed to monitor dextromoramide and methadone ...concentrations in plasma simultaneously. After liquid-liquid extraction from plasma, dextromoramide and methadone were determined using a Supelcosil LC-ABZ column and a mobile phase of KH2 phosphate buffer (25 mM, pH 2.5) mixed with acetonitrile (80:20, v/v) and UV detection at 206 nm. The method was found to be sufficiently sensitive, specific and reproducible to apply in six subjects on MMT for many years, receiving orally administered dextromoramide as adjuvant. Pharmacokinetic data sets for dextromoramide in each subject were conducted and analysed further, indicating short elimination half-life values (71 min, range 31-152 min). Contrary to previous studies, in all subjects tested the pharmacokinetics of dextromoramide are best described using an one-compartment model.
