7 Perioperative analgesia and challenges in the drug-addicted and drug-dependent patient Nalini Vadivelu, MD, Associate Professor a,1 , Sukanya Mitra, MD, MAMS, Professor b, 2 , Alan David Kaye, MD, PhD, Professor and Chairman c , Richard D. Urman, MD, MBA, CPE, Assistant Professor d, * , 3 a Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3, New Haven, CT 06520, USA b Department of Anesthesia and Intensive Care, Government Medical College & Hospital, Sector 32, Chandigarh 160030, India c Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, LA, USA d Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham & Women’s Hospital, 75 Francis St, Boston, MA 02115, USA Keywords: drug addiction drug dependence methadone maintenance buprenorphine perioperative analgesia opioid dependence sub-anesthetic ketamine infusion The epidemic use of illicit drugs has led to an increasing number of patients with drug addiction and dependence presenting for perioperative care. There are a wide variety of drugs commonly abused including opioids, such as heroin and prescription drugs; stimulants, such as amphetamine and cocaine; depressant drugs, such as alprazolam and diazepam; and hallucinogens, such as lysergic acid diethylamide, phencyclidine, and marijuana. Treat- ment of opioid dependence by office-based buprenorphine and methadone maintenance programs has expanded opportunities for therapy. Treatment of these patients in the perioperative period is challenging. In addition to pain control, management of anxiety, psychological states, and hemodynamic control are the factors to be considered to provide optimum treatment. Although opioids are the mainstay for the control of acute pain, other therapeutic options include alternative routes of administration of local anesthetic, ketamine infusion, and the use of regional anesthesia. * Corresponding author. Tel.: þ1 617 732 8222. E-mail addresses: Nalini.vadivelu@yale.edu (N. Vadivelu), drsmitra12@yahoo.com, drsmitra123@gmail.com (S. Mitra), alankaye44@hotmail.com (A.D. Kaye), rurman@partners.org (R.D. Urman). 1 Tel.: þ1 2037852802; Fax: þ1 2037856664. 2 Tel.: þ91 172 2665253, þ91 172 2665260x1219, þ91 9646121521 (mobile); Fax: þ91 172 2609360, þ91 172 2608488. 3 Tel.: þ1 (617) 732 8222 (office). Contents lists available at ScienceDirect Best Practice & Research Clinical Anaesthesiology journal homepage: www.elsevier.com/locate/bean http://dx.doi.org/10.1016/j.bpa.2014.02.003 1521-6896/Ó 2014 Elsevier Ltd. All rights reserved. Best Practice & Research Clinical Anaesthesiology 28 (2014) 91–101