Psychiatric and anesthetic implications of substance abuse: Present scenario.

Substance abuse has crossed all social, economic, and geographic borders and is spreading its fangs in each and every sphere of society irrespective of age, gender, caste, creed, and religion. These days, we encounter several patients of substance dependence who visit different hospitals for elective surgical procedures or in emergency (e.g., roadside accidents and with various complications associated with substance abuse). These patients at that time may be either addicted to them or are intoxicated by them or on de addiction treatment. Acute or chronic use of these drugs affect the respiratory, cardiovascular, central nervous, renal, hematological, and hepatic system variably in individuals thus due to diverse clinical presentations a complete understanding of the path physiology and anesthetic implications of drug abuse is essential to tailor a safe anesthetic plan for these high-risk group of patients.

INTRODUCTION

The population of India has reached over 1 billion and is rising at an incredible pace. This has brought with it, rapidly changing pattern in the country's social and cultural values, demographics and economy. Loss of traditional moorings, social taboos, emphasis on self-restraint, pervasive control, and discipline of the joint family and community has led to the increased prevalence of drug addiction. The epidemic of drug abuse continues to painstakingly seep into the country's social and cultural aspects and has assumed alarming dimensions. Today no part of the world is free from the curse of drug addiction and millions of drug addicts are leading a miserable life. India also is caught in this curse of drug addiction, and the number of drug addicts is increasing day by day. One-fifth of the population of India is in the age group of 15–24 years and drug abuse is now trickling in this younger generation - a generation refusing to be left out.[1] It is estimated that, in India, by the time most boys reach ninth grade, 50% of them have tried at least one of the substance of the abuse nature.[2] Our country's potential rests in the hands of our youth and the epidemic of drug abuse continue to rage on the sidelines and this will thwart the success of India's future. Substance abuse is a complex problem having medical and social ramifications which impact every social strata. It affects not only users and their family but all the sections of the society. It causes immense human distress, financial losses and leads to crime and violence worldwide. The risk for motor vehicle accidents increases in drivers using alcohol, cocaine, benzodiazepines, amphetamines, and opiates.[3] One of the foremost essential steps to combat this situation is to study the various aspects of drug addiction and how to curb this menace. These patients present to anesthesiologists in emergency, trauma, and elective surgeries as well as for Intensive Care Unit (ICU) care. As anesthesiologists, we need to be aware of the use of illicit drugs because of the long-term negative consequences that they may have on health and how it would impact the anesthetic care.[4] Injected drugs and high-risk sexual behaviors leads to increased risk of HIV/AIDS and hepatitis C. Because of HIV, there may be concomitant tuberculosis, which if disseminated can involve vertebral bodies, backache, and caused permanent neurological signs.[5] They may also be under medicated for pain since most of them have cross-tolerance to opioid analgesics. The present article highlights the predisposing factors leading to addiction, various ill-effects of drug abuse, how to tackle the menace of drug addiction, how an anesthesiologist can deal with such patients and future recommendations to deal with this situation.

DRUG ABUSE AND ADDICTION

Drug abuse is the use of a legal drug for a nonmedical reasons or the use of an illegally produced substance for the purpose for which it was not intended, such as with the aim of producing some type of mind altering effect likely to produce pleasure, alleviate stress or to avoid reality. Whereas addiction is defined as “compulsively seeking to use a substance, regardless of the potentially negative social, psychological, and physical consequences.” Addiction is a state where a person develops physical and psychological dependence on a substance. It includes the development of tolerance, dependence, and withdrawal symptoms. Dependence can be physical or psychological or both. Physical dependence produces withdrawals such as vomiting or tremors, and psychological dependence produces withdrawal symptoms, the intensity of which will depend on the physical condition of the user and the type, amount and duration of drug abused.[6] Use of drug leads to a feeling of self-confidence, relaxation, and enjoyment and the user again tries the drug to repeat the effect and at some point of time person becomes dependent on them.[7]

PREDISPOSING FACTORS LEADING TO DRUG ABUSE AND ADDICTION

Drug abuse is a complex phenomenon, which has various social, cultural, biological, geographical, and economic aspects. The disintegration of the old joint family system, the absence of parental love and care in modern families and decline in the moral values has led to the rise in the problem of substance abuse. The processes of industrialization, urbanization, and migration has led to the loosening of traditional ties and rendering an individual vulnerable to the stresses and strains of modern life. Various factors[89] in changing society predispose to drug abuse:

Demographic factors: Drug abuse is more commonly observed in males, these days even females are not being spared. 15–24 years age group is the most vulnerable age group for starting substance abuse. Genetic predisposition also plays a vital role as first-degree family members of alcoholics are more prone to start alcohol abuse at younger age

Unemployment is a major factor in predisposing a person to addiction as it leads to low self-esteem, frustration, laziness and ultimately leading to emotional distress

Peer pressure is one of the most powerful tools to sway youngsters to addiction. As children grow old, the parent's influence slowly diminishes and as a part of life's natural progression they are influenced more and more by their peers

Changing roles, increasing stress and alteration in the lifestyle and society has brought with it, the problem of drug abuse in women also

Personality of the person, family environment, children of drug abusers, and certain social segments like commercial sex workers, transportation workers, and street children are more exposed to the menace of substance abuse

Last but not the least factor in aggravating the situation is the easy availability and easy access to the drugs. The introduction of synthetic drugs has added a new dimension to the problem.

Commonly used drugs to which one can become addicted

Many different drugs are abused which can be illegal drugs like heroin, cannabis, or prescription drugs like analgesics, tranquilizers, cough syrups, or alcohol.[10] Given below are seven categories of commonly abused drugs with their street names:

Cannabiniods: Hashish, marijuana, charas, bhang

Stimulants: Amphetamine, cocaine

Depressants: Barbiturates, benzodiazepines, alcohol

Narcotics: Opium, morphine, heroin, codeine, buprenorphine

Hallucinogens: Lysergic acid diethylamide, phencyclidine, mescaline, psilocybin

Volatile solvents: Varnish, eraser fluids, petroleum

Others: Muscle relaxants, painkillers, anti-histamine, anti-emetic, anti-depressants.

These drugs are taken by different routes like oral, inhalation, injection, smoking and snorting, and all drugs pose a high potential for addiction. Alcohol, cannabis, and opiates are the commonly abused drugs in India.[11]

Various effects of drug abuse

Irrespective of the drug abused all drugs leads to physical, emotional, psychological, and financial losses.

Physical problems: Short-term and long-term health hazards produced by substance abuse are respiratory impairment, irregular heart rate, loss of appetite, constipation, diarrhea, fatigue, sleep disorders, bodily pains, tremors, loss of libido, etc., Sometimes these drug abusers land in emergency after drug overdoses or with withdrawal symptoms. Life-threatening injuries most commonly head injury, convulsions, coma, and even death due to drug overdose can occur. There is also increased risk of HIV, hepatitis C virus, hepatitis B surface antigen, and tuberculosis in drug abusers[12]

Psychiatric problems: Euphoria, mood instability, irritability, withdrawal from society, negative attitude, depression, and psychosis are the common psychiatric problems seen in drug abusers. Delusional jealousy, fighting behavior, and sometimes suicidal tendencies are also observed[13]

Intellectual impairment: Decreased interest, negative attitude, poor judgment, memory impairment lead to poor intellectual growth

Personality deterioration: Deterioration of physical appearance and grooming, lack of interest in day to day activities, always preoccupied about seeking drugs and stealing habits leads to deterioration of personality

High-risk behavior and legal complications: Addicts resort to crime to procure drugs. Drugs remove inhibition and impair judgment further leading to teasing, clashes, and even murders. Driving under the influence of drugs or alcohol can lead to accidents and loss of life. They may get involved in unsafe sex, thus exposing themselves to sexually transmitted diseases (STD). Wives of drug abuse are at an increased risk of domestic violence, emotional pain, and infection with HIV or other STD's[14]

Financial losses: With most drug users in the productive age group of 18–35 years, there is incalculable loss to the human potential apart from financial losses due to addiction.

According to the official data of the ministry of social justice and empowerment, India has an estimated 3.4 million drug abuse victims which excludes alcoholics, which figures around 11 million in the country. Controlling substance abuse by way of demand reduction, provision of treatment services, etc., has been a matter of priority for the Ministry of Health and Family Welfare. The government has opened ICRA that provides counseling, treatment, and rehabilitation services to drug abuse victims. Concerned over the wider ramifications of the spurt in drug abuse, government has also formed a multipronged strategy that involves motivational counseling, social integration, and building awareness about the ill-effects of drugs by educating the general public and through appropriate inputs in the school curricula about the ill-effects of drug abuse.[151617]

ANESTHETIC IMPLICATIONS OF COMMONLY USED DRUGS

Most commonly used abused drugs and their anesthetic implications are mentioned below:

Opioids

There analgesic, euphoric effects attract people to start abusing them orally, intravenously and subcutaneously leading to rapid development of tolerance, physical addiction, psychological dependence, and narcotic abstinence syndrome. Heroin abuse leads to peptic ulcer disease, tetanus, botulism, multiple skin infections, hepatitis B, hepatitis C, HIV/AIDS, pneumonia, thrombophlebitis, and endocarditis. Its overdose leads to respiratory depression, pulmonary edema, and miotic pupils. In parturients, it can cause fetal intrauterine growth restriction (IUGR), fetal distress, and neonatal opioid withdrawal. Opioids withdrawal seen after 4–6 h after last dose and peak seen after 48–72 h leading to increase sympathetic system activity resulting in restlessness, insomnia, mydriasis, tachycardia, tachypnea, and hypertension. Opioid agonists and antagonists can precipitate withdrawal symptoms thus should better be avoided. These addicts have difficult peripheral and central venous access. They are prone to sepsis, coagulopathies, hemodynamic instability, liver dysfunction, malnutrition, and reduced intravascular fluid volume thus posing a challenge to both regional as well as general anesthesia. Regional anesthesia is relatively contraindicated in patients having HIV induced progressive demyelination and neurological deficits. Acute opioid use decreases minimum alveolar concentration (MAC) of inhaled anesthetics whereas chronic use leads to cross-tolerance to central nervous system depressants. Postoperatively these patients experience exaggerated pain due to decrease endogenous opioid production leading to decrease pain tolerance.[41819]

Cocaine

Extracted from the leaves of Erythroxylon coca; its abuse potential especially in the form of crack (smoked) cocaine has become a serious health concern. It produces euphoria by prolongation of dopamine activity in limbic system and cerebral cortex. It stimulates sympathoadrenal axis leading to intense vasoconstriction thus compromising the blood supply to the vital organs leading to irreversible brain damage, myocardial infarction, renal failure, etc. It can also cause nasal mucosa ulceration, anxiety, restlessness, tachycardia, hypertension, ventricular arrhythmias, asthma, pulmonary hemorrhage, thrombocytopenia, and decrease in plasma cholinesterase enzyme levels. Pregnancy enhances the cardiovascular toxicity of cocaine, decreases uteroplacental insufficiency leading to hypoxia, acidosis, fetal distress, placental abruption, preterm delivery, and intra-uterine death. Serious complications are associated with both regional as well as general anesthesia. Under regional anesthesia, cocaine can cause hypertension as well as ephedrine resistant hypotension, combative behavior, altered pain perception. Cocaine abusing patients under general anesthesia can exhibit hypertension (during intubation), cardiac arrhythmia, and myocardial infarction. Drugs to be avoided during surgery include nonselective Beta blockers, labetalol, ketamine, succinylcholine, halothane, etomidate, etc. Potent volatile anesthetics may also produce cardiac arrhythmias and increase in systemic vascular resistance. If there is chronic cocaine abuse cocaine, free interval of at least 1 week before elective surgery is recommended.[41820]

Marijuana (Cannabis)

Smoked as a cigarette is one of the most popular recreational drugs giving an intense feeling of relaxation and euphoria. Its high fat solubility leads to its prolonged effects, and complete elimination of the drug requires around 30 days after a single dose. It can lead to anxiety, confusion, fear, depression, shortened memory span, delusions, violent behavior, dulled reflexes and hallucinations, and even seizures. In pregnant women, it may lead to decrease in uteroplacental blood flow, IUGR, low neonatal birth weight. Cannabis increase in sympathetic system and decrease in parasympathetic system leading to tachycardia and increase cardiac output. Cross-tolerance has been seen with alcohol, barbiturates, benzodiazepines, and phenothiazines. It adds to the effect of inhalational agents leading to profound myocardial depression. It also increases the effects of opioid leading to respiratory depression. In acute abuse drugs increasing the heart rate, so drugs like ketamine, pancuronium, atropine, and epinephrine should be avoided. Adverse autonomic reactions and psychiatric effects interfere with postoperative recovery.[41821]

Hallucinogens

Psychedelic agents ingested orally cause auditory, visual hallucinations, distortion of body image, surroundings and reality, anxiety, panic attacks, and fear of going crazy. Hallucinogens activates sympathetic nervous system activity resulting in tachycardia, hypertension, increased body temperature, dilated pupils developing in 1–2 h lasting for approximately 12 h. Overdose of these drugs can lead to respiratory depression, seizures, coma, and even death. Parturients have a higher risk of IUGR, premature labor, meconium stained fluid, neonatal withdrawal symptoms, fetal heat induced neurological damage, and increased incidence of congenital anomalies. Fluids and electrolytes should be monitored as ecstasy users are prone to water intoxication leading to pulmonary and cerebral edema. Anesthesia should be avoided until the acute effects of the drug settles. Caution should be used while using opioids (enhances its ventilator depressant effects), scoline (decrease in plasma cholinesterase activity), sympathomimetics, and ketamine. Metabolism and clearance of the drugs through liver and renal systems is decreased due to fatty liver and acute renal failure seen in the abusers.[41822]

Volatile substances

Young adolescents abuse them by “huffing.” There increased abuse potential is due to easy availability and low cost; these include household cleaning agents, paint thinner, glue, etc. Sniffing leads to relaxation, euphoria, and pleasant hallucinations. Solvents can impair multiple systems resulting in autonomic cardiac dysfunction, ventricular fibrillation, myocardial infarction, tachycardia, methemoglobinemia, increased bronchial irritation, pulmonary hypertension, restrictive lung disease, reduced diffusing capacity, acute respiratory distress syndrome, peripheral neuropathy, acute rhabdomyolysis, hematuria, cerebral and cerebellar atrophy and proximal and distal renal tubular acidosis, and liver toxicity. Multi organ involvement can thus effect anesthetic drug dosing as well as their effects. Solvent abusers are more prone to arrhythmias and increased incidence of airway resistance. In cases of acute intoxication, general anesthesia is considered the best whereas if regional anesthesia is used patients altered perception and combative behavior should be kept in mind.[41823]

Alcohol

Alcohol use has drastically increased these days especially in children of alcoholic patients leading to increase incidence of liver cirrhosis, malnutrition, pancreatitis, cardiomyopathy, and altered drug metabolism, and above all increased incidence of traumatic injuries seen regularly in abusers presenting as patients. A heavy dose of alcohol increases gastric fluid acidity and volume and also impaired laryngeal reflexes thus decreasing the ability to protect the airway. It can lead to physiological dependence and withdrawal symptoms include generalized tremor, tachycardia, cardiac arrhythmias, hypertension, nausea, vomiting, confusion, agitation, and hallucinations. These can be treated with benzodiazepines and alpha 2 adrenergic agonists. Alcohol abuse is generally associated with resistance to the actions of central nervous system depressants. Regional anesthesia can be safely given but while giving general anesthesia, it is necessary to take into consideration of hepatic dysfunction, hypoalbuminemia, and cardiac failure.[182425]

Tobacco

Nicotine is the primary ingredient present in cigarettes producing the dependence and majority of the side effects. It primarily affects the pulmonary functions decreasing the ciliary motility, increasing sputum production, and impairment of gas exchange. Smokers have a higher incidence of peripheral vascular disease and atherosclerosis and myocardial infarction. Minimum 48 h of abstinence is required to decrease the carboxyhemoglobin levels to normal values but at least 4–6 weeks are needed to bring back the mucociliary function to normal. Regional anesthesia is more judicious to use as airway manipulation is avoided leading to decrease chances of bronchospasm and postoperative respiratory dysfunction. While giving general anesthesia, effects of cigarette smoke on hepatic enzyme function must be considered.[182627]

Smokeless tobacco

These are abused in the form of snuff or chewable betel “paan supari.” Chronic use leads to the development of oral submucosal fibrosis resulting in progressive inability to open the mouth, burning sensation, and dysphagia and finally causing malignancy. Airway assessment is of particular importance in these patients. Mallampati and Cormack grading and indirect laryngoscopy should be used as these patients are worthwhile to categorize in unanticipated difficult airways.[182829]

Amphetamines

Most frequently abused stimulant drug via snorting, smoking and ingestion leading to euphoria, decreased fatigue, increased cortical alertness, and appetite suppression. Symptoms of acute intoxication include hypertension, tachycardia, arrhythmias, dilated pupils, hyperreflexia, proteinuria, and confusion. Chronic use can lead to decrease catecholamine levels resulting in somnolence and psychotic state. Acute intoxication decreases the MAC whereas chronic use increases the MAC of inhalational agents. Halothane potentiates arrhythmogenic effects thus better avoided. While giving regional anesthesia, severe refractory hypotension due to sympathectomy may be precipitated in amphetamine abusers.[183031]

CONCLUSION

Substance abuse has to be addressed at the individual, society national and at international level. Always be aware of the latest trends of the newer substance abuse appearing on the horizon, before it covers the sky. Whenever, a patient lands in emergency, routine operation theater or in ICU, take explained history from the patient or his/her attendants so that better and safer anesthesia can be planned.

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Conflicts of interest

There are no conflicts of interest.