It is the shorthand that makes us shiver: ETOH. IVDA. Seeing these acronyms in a patient's chart — ETOH, short for ethanol, indicates chronic alcoholism; IVDA stands for intravenous drug abuse — gives us pause. Patients with a history of addiction have special requirements for surgical care. We must consider their current physical health, medication reactions, recovery room behavior and social issues. Several of our surgeons are affiliated with rehabilitation facilities and specialists here in the Los Angeles area, so our surgery center sees many addicted patients. Here are some practical tips for working with these patients and your physicians to achieve optimal surgical outcomes and a positive patient experience.

Create a compassionate culture
Our clinical staff includes several members who have personal experience with addiction within their families. Through our personal and professional histories, we've seen mistreatment of these fragile patients by hospital staff in the form of withholding of pain medications, neglect and verbal abuse. Rather than casting judgment and letting personal feelings affect our patient care like so many of our peers had done in the past, we decided to put a strategic plan in place to make sure we treat these patients, like all of our patients, with dignity and respect. Our staff is able to put aside any negative feelings and understand these patients can be complicated, both medically and psychosocially.

Through formal in-services and staff meetings, staff are now comfortable both addressing aspects of the patients' care and taking a proactive approach in patient communications to ensure we're doing everything we can to alleviate stress and minimize pain. Addressing patients' needs is important in every step of their experience at our center. From the pre-op call to discharge, we approach every patient with an attitude of respect and empowerment. We think our census of surgical patients in addiction recovery has grown because we've created a culture of compassionate care for this patient population.

How to handle pre-op calls and registration
Our team has become adept at identifying patients coming to surgery from recovery facilities by their demographic or insurance information, which you can glean from a History & Physical report. When we identify one of these patients, we make a note on our pre-op call checklist to discuss that patient's needs for transportation and an accompanying adult to sign discharge orders. If we're unable to reach patients who are residing in a treatment facility to give pre-op instructions, we'll give instructions to a caregiver at the patient's treatment facility; we're sure to document that fact in the chart. Some treatment facilities can provide supplementary lab work or physical assessment information that may be helpful.

When we are able to reach the patient, our pre-op team discusses the involvement of the patient's sponsor and a strategy for management of post-op pain. "Patients are very worried about reigniting their addiction process and, at the same time, are worried about adequate pain control due to previous drug use," says Damon Raskin, MD, a recovery specialist in our area. "They deserve adequate pain control and reassurance that opiates are okay after surgery." We encourage patients to take pain medications as prescribed for the first 24 to 48 hours to stay ahead of the pain cycle. When patients try to wean themselves off of pain meds too early because of anxiety related to their addiction, they can inadvertently create a recovery crisis that is even more difficult to manage and can extend their surgical recovery.

We also discuss privacy both at the pre-op call and at registration. Careful to observe HIPAA regulations, we ask patients to designate with whom we can speak about their care — their caregiver, a relative or friend — in the event someone else needs to call on their behalf. We want to address any post-operative questions patients may have when they might not be able to communicate with us directly. Sometimes the accompanying adult on the day of surgery is a caregiver, sometimes a driver from the treatment facility. Document the escort's role and whether the patient has given you permission to speak with the escort about post-op conditions.

Reassure patients upon pre-op admission
Our surgical team is adept at communicating with patients in a way that preserves their dignity and privacy. Although we don't want to solely focus on their addiction history, a direct conversation is the best way to approach patients in addiction recovery. Our pre-op nurse will discuss the patient's recovery process and concerns related to her surgical recovery. We're particularly interested in the patient's anxiety level and her ability — or willingness — to give an accurate medical history and follow post-op instructions.

DON'T CONDEMN When treating addicted patients, staff must put aside personal judgments.

Upon admission, our pre-op staff also discusses a plan for pain management and reassures the patient we'll listen to and address her pain needs during her stay. Many patients are nervous about receiving pain medications and prefer to abstain completely. However, we remind them that not treating their pain proactively can lead to further complications with their recovery. Their sponsors will typically have spoken with them about a "free day" in which they temporarily suspend their recovery program to receive medical care. We encourage them to contact their sponsors after surgery and to stay in touch with their surgeon regarding post-operative pain management.

Finally, our pre-operative nurses ask the patient about the best place for starting their intravenous lines. Those with a history of intravenous drug abuse may be able to provide first-hand knowledge of vessels that are permanently compromised and direct the nurse to start the IV in a more acceptable location. Involving patients with their care at this level shows them we respect them as individuals and lets them feel some sense of control in a potentially chaotic time of their lives. This is another opportunity for our nurses to put personal judgments aside to connect with the patient to provide a superior surgical experience.

Add-ons to the surgical time out
Besides the routine items, during the surgical time out we also discuss the patient's addiction history, and any related conditions or concerns. During the time out, we again review labs and document that we discussed potential complications such as anticipated blood loss, medication interactions and pain management. We also discuss with whom the surgeon should or should not speak after the procedure and who'll be responsible for filling prescriptions before the patient leaves the center. Dr. Raskin advises writing prescriptions for limited quantities of 10 to 20 pills with no refills rather than a typical prescription of 30 pills. This requires the patient to check in with his physician before obtaining a new prescription.

Once in the recovery room
In the PACU, our staff observes patients for signs of discomfort and encourages them to report pain accurately, as delaying intervention may cause symptoms to increase and subsequently increase the need for medication intervention and prolong recovery room time. Our nurses and anesthesiologist consider the use of adjunct medication therapies such as Benadryl and Demerol to help with pain management. Dr. Raskin also recommends discussing at-home adjunct medications such as anti-inflammatories and topical treatments to help them discontinue prescription meds. While giving discharge instructions, we'll review pain medication prescriptions and discuss who'll be helping them manage their pain after discharge. We'll document if patients request that we give their caregiver or family member their filled scripts for handling.

At the patient's request, we allow supportive visitors in the recovery room. This stems from our pre-op discussion with the patient regarding with whom we should speak and let visit. Staff should be aware of visitors with whom the patient may negatively interact and avoid bringing them into the recovery room. This may include accompanying friends, parents or even spouses.

For overly concerned patients, Dr. Raskin advises discussing home health options, short-term recovery facilities or even the return to a treatment facility for short-term in-patient monitoring after surgery. These facilities are well-equipped to manage the patient's addiction recovery process, as well as their post-op pain regimen.

Culture of dignity, respect
Our clinical team has worked to create a culture of dignity and respect for our addiction recovery patients. We've found that it's best to have open communication about patients' recovery process, and frank discussions regarding pain management and emotional support. Reassuring patients that we'll listen to them and address their concerns lets them maintain some element of control during an anxious time. Ensuring patients have access to support services such as their surgeon, their sponsor, their caregiver or a pain management specialist, encourages patients to reach out for additional help if needed during their surgical recovery.