The role of intoxicants in perioperative care: A focus on Methamphetamine, GHB, and Cannabis.- ATOTW 559

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The role of intoxicants in perioperative care: A focus on Methamphetamine, GHB, and Cannabis.- ATOTW 559

11 February 2026

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1) Preoperative urine drug screening tests are essential.

True False

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False: Preoperative drug testing is not routine and should only be performed if the result changes patient management.

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2) All methamphetamine users presenting to the theatre will have significant cardiovascular instability.

True False

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False: In the absence of acute intoxication, most patients do not experience serious adverse events, including cardiovascular instability. Studies have not shown an increase in perioperative complication rate compared to non-using counterparts. Although it is essential to be aware of the risks and side effects associated with methamphetamine use so that, as a healthcare provider, you can manage potential complications, each patient should be managed and assessed individually.

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3) Methamphetamine’s primary mechanism of action is monoaminergic.

True False

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True: Methamphetamine exerts its effects by triggering the release of endogenous monoamines, including dopamine, noradrenaline, and serotonin, which then act as agonists at their respective receptors, resulting in the effects of intoxication.

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4) GHB acts primarily on serotonin receptors.

True False

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False: GHB acts primarily to potentiate GABA receptor activity. GHB is an endogenous substance that exerts typical physiological effects pre- and post-synaptically at the GABAA receptor. These effects include the regulation of neurotransmitter release, sympathetic tone, sleep cycle regulation, learning, and thermoregulation. After ingestion of GHB, high levels result from agonist action at the GABAB receptor. Some studies have shown that GHB affects the dopaminergic, serotonergic, opioid, and glutaminergic systems. However, these are not the primary sites of action.

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5) Cannabis use is rare in the perioperative population and, therefore, not of importance.

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False: The decriminalisation of cannabis has led to a surge in use, with an estimated 2.5% of the global population reporting use.

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6) The primary treatment of hypertensive crisis secondary to methamphetamine intoxication is Beta-blockers.

True False

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False: Benzodiazepines are the first-line treatment for a hypertensive crisis caused by methamphetamine intoxication. Beta-blockers are controversial as they may result in unopposed alpha receptor agonism and worsening hypertension and, therefore, are not recommended.

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7) Chronic cannabis users have been shown to have increased propofol requirements.

True False

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True: Chronic cannabis users require increased propofol dosages compared to patients who are not chronic cannabis users. However, this may not be true for every patient, and care should be taken in titration and careful administration of every drug.

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8) Recent methamphetamine use increases the risk of intraoperative hypotension.

True False

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True: These patients are at risk of developing intraoperative hypotension for up to 7 days, with the most significant risk in the first 48 hours after use. As such, close monitoring and support of blood pressure may be necessary.

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9) Acute intoxication with cannabis increases the risk of perioperative myocardial infarction.

True False

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True: Acute intoxication with cannabis increases the risk of perioperative myocardial infarction, especially within 2 hours of use. This is due to the increased myocardial work secondary to the drug-induced tachycardia and peripheral vasodilation. If possible, postponing surgery for at least 2 hours after use is recommended.

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10) GHB has a slow onset and offset with adequate time to manage developing coma and respiratory depression.

True False

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False: GHB has a rapid onset and offset, often leading to inadequate time to manage developing coma and respiratory depression if not anticipated. As a result, sudden onset coma in a patient who is not closely monitored may result in hypoxic arrest, which may not be recognised in a timely fashion.

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11) Assuring patients that their confidentiality with doctors is protected may encourage them to disclose their drug use more openly.

True False

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True: Assuring patients about doctor-patient confidentiality and taking history away from friends and family may improve the disclosure of drug use. Assuring patients that the history they provide guides safe perioperative care, establishing rapport, ensuring confidentiality, and being non-judgmental are crucial.

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12) Chronic management of substance abuse is not our problem, and therefore, anaesthetists don't need to advocate for multidisciplinary intervention.

True False

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False: Patient care is everyone’s responsibility, and hospital presentation offers an opportunity to intervene and assist with treating underlying risk factors as well as the substance use disorder itself.

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13) GHB users may present with Wernicke-Korsakoff syndrome.

True False

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True: GHB users may present with Wernicke-Korsakoff syndrome, especially since concomitant alcohol use is common, further increasing the risk. As with any drug, but especially with GHB, there may be multiple substances used simultaneously. Adverse effects and complications can result from exposure to and interactions between multiple substances.

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14) Cannabis use causes acute tachycardia and postural hypotension due to increased sympathetic tone.

True False

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True: Acute cannabis intoxication causes acute tachycardia and postural hypotension. This is due to increased sympathetic tone to the heart, myocardial work, and peripheral vasodilation.

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15) Synthetic cannabinoids are safer, with fewer side effects and complications compared to cannabis.

True False

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False: Synthetic cannabinoids have greater sympathomimetic effects, with an increased incidence of seizures, aggression, agitation, dystonia, and unexplained bleeding refractory to conventional medical therapy.

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16) Smoked substances may lead to chronic lung disease and reactive airways, posing a potential airway risk.

True False

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True: Smoked substances lead to airway and lung changes, which increase the risk of bronchospasm, laryngospasm, and other airway issues, as well as ventilatory challenges.

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17) Underlying psychological and social stressors don’t play a significant role in determining drug abuse.

True False

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False: Underlying psychological and social stressors play a significant role in drug abuse. Presentation to the hospital, therefore, offers an opportunity to intervene and assist with treating underlying risk factors as well as the substance use disorder itself. Consult with a psychologist and psychiatrist, or drug and alcohol services, if available perioperatively, for assessment and treatment of underlying comorbid psychiatric conditions and ongoing management of or enrolment into local drug management programmes.

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18) Adequate multimodal and regional analgesic techniques are fundamental in substance users, especially as they may have tolerance and increased requirements for systemic analgesia.

True False

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True. The addition of regional techniques may be more advantageous in optimising analgesia. Systemic analgesics, when relied upon alone, may be required in larger doses, increasing the risk of side effects.

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19) There is no need to postpone non-urgent surgery in cases of cannabis hyperemesis syndrome.

True False

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False: Cannabis hyperemesis syndrome is a rare condition in chronic users that presents as nausea, vomiting, and abdominal pain, which can be complicated by significant electrolyte abnormalities, typically resolving with abstinence. This condition usually resolves with abstinence, and a delay in elective surgery is recommended until symptoms resolve (usually within 24 hours). Treatment focuses on fluid replacement, correcting electrolyte imbalances, and preventing aspiration.

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20) All substance users present in the same way.

True False

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False: Substance users may present in a variety of ways, including acute intoxication and withdrawal. Symptoms may range from asymptomatic to presenting with severe haemodynamic instability and substance use-associated complications.

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