Alcohol consumption is highly prevalent in the United States. National surveys indicate that approximately 52% of persons aged 12 and older are current drinkers. Heavy drinking, defined as having five or more drinks per day on at least 5 days in the past 30 days, was reported in 6.8% of the population or 17.1 million people.¹ Approximately 6% of the population, or 15.4 million people, were classified as being dependent on or abusing alcohol according to DSM-IV criteria.² People who are dependent on alcohol have developed tolerance and will experience withdrawal symptoms if they abruptly stop drinking. These individuals drink more than they intend, are unable to cut down or stop their drinking, and continue to drink despite known medical problems.

Associated Medical/Surgical Problems

Heavy alcohol consumption is also associated with several types of cancer. Alcohol use disorders have been reported in over 50% of patients with upper GI tumors.^3,4 Heavy alcohol users have also been shown to be at higher risk for head and neck cancers,^5,6 hepatocellular cancers,⁷ high-grade prostate cancer,⁸ and, to a lesser extent, breast cancer⁹ and colorectal cancers.¹⁰ In addition, alcohol use is associated with numerous medical problems including gastritis, pancreatitis, cirrhosis, hepatic failure, cardiomyopathy, anemia, peripheral neuropathy, malnutrition, and dementia. Relevant to surgical outcomes, heavy alcohol use is also associated with impaired hemostasis, immunosuppression, and increased stress response.

One study that compared the postoperative course for misusers of alcohol to nonusers in patients admitted for elective colorectal surgery demonstrated that misusers experienced more postoperative complications (eg, bleeding, wound infection, pneumonia, intra-abdominal abscess, and myocardial infarction), had longer hospital stays, and required more nursing care.¹¹ Another study looking at postoperative outcomes in patients with head and neck cancer found that 40% of these patients suffered minor and major medical complications due to heavy alcohol and/or tobacco use; 11% suffered from alcohol withdrawal.¹² The cost for patients with medical complications in this study was 71% higher than those without and was mostly attributed to ICU stays as well as an overall longer length of stay.

Surgical Alcohol Withdrawal Guidelines

In order to address the postoperative complications associated with long-term alcohol use and alcohol dependence we have developed a set of guidelines at Memorial Sloan-Kettering Cancer Center (MSKCC) to identify preoperatively the patients most at risk for alcohol withdrawal postoperatively. Those at increased risk for alcohol withdrawal include men who consume 60 or more grams of alcohol per day (12 oz of beer, 5 oz of wine, and 1.5 oz of spirits each contain about 15 g of alcohol), patients who have a past history of alcohol withdrawal seizures or delirium tremens, patients over 65, and patients with comorbid medical conditions. The amount of daily alcohol consumption that puts women at risk is less clear but, due to pharmacokinetic differences, is probably much less than in men.

Our screening consists of asking patients the number of drinks or alcohol equivalents (15 g of alcohol, as defined above) they consume on a daily basis. In addition, each patient is administered the CAGE questionnaire, an instrument that was developed to identify clinical alcoholism in patients (see Table 1).^13,14 This screening is done at two time points: during the first presurgical office visit and again when the patient comes in for presurgical testing. All patients are also given information cards educating them about the surgical risks of alcohol and advised to cut down or stop drinking prior to their surgery.

Patients are screened positive if they report that they consume four or more drinks per day or have two or more positive answers on the CAGE questionnaire. These patients are then referred for a medical consultation to further evaluate their risk for postoperative alcohol withdrawal. The consultant will work with patients who are determined to be most at risk for alcohol withdrawal, to help them cut down or possibly detoxify, if time permits and adequate home support is available. Further psychiatric consultation may also be advised for patients with severe alcohol dependence or coexisting psychiatric disorders.

For patients with cancer who are found to be alcohol dependent, however, preoperative detoxification is not usually possible or practical. For many of these patients, we recommend an alcohol withdrawal prevention regimen (see Table 2). This regimen was developed from evidence-based guidelines for the treatment of alcohol withdrawal,¹⁵ but because this is a prophylactic regimen, we begin with lower dosing. Although alcohol withdrawal usually begins approximately 24 hours after the last drink, symptoms may sometimes appear within 6 to 12 hours. The prophylactic regimen is therefore begun in the recovery room as soon as the patient reaches a specified level of consciousness. The prophylactic regimen is not used for patients undergoing outpatient surgery.

When the patient is discharged from the recovery room, the medical or psychiatric consultant continues to work with the team to continue the taper and discontinuation of lorazepam. The consultant may also recommend modifications of the regimen as clinically indicated, ie, lower or discontinue lorazepam if the patient appears oversedated, or increase the dosing if the patient has signs and symptoms of withdrawal.

Effectiveness of Guidelines

The most important part of these guidelines has been to do a better, more focused job of identifying patients at risk for alcohol withdrawal presurgically so that appropriate multidisciplinary measures can be implemented when the patient comes in for a procedure. Such identification may have prevented the severe withdrawal and prolonged hospitalization of the patient in the case example (see sidebar). While we chose to use the CAGE questionnaire as part of our screening, other instruments such as the Alcohol Use Disorders Identification Test (AUDIT-C) have also been found to be very useful for identifying patients with alcohol dependence.^16,17

Once patients at risk have been identified, the implementation of the prophylactic regimen is intended to prevent the onset of alcohol withdrawal and accompanying postoperative morbidity. We are currently evaluating the effectiveness of our guidelines through a quality assurance project, but preliminary observations indicate that fewer cases of postsurgical alcohol withdrawal have been seen since these guidelines went into effect. ■

Dr. Bialer is Attending Psychiatrist at Memorial Sloan-Kettering Cancer Center, New York.

References

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