Anesthesia, Opioids, and Anxiety: Your Pre-Surgery Questions Answered

If you’re anticipating surgery, you’re not alone—15 million people undergo a surgical procedure each year in the United States. The days before it can be intimidating and anxiety-provoking, so it’s important to prepare—both physically and mentally.

One way is to ask questions—and lots of them. Each person’s experience is different, and accurate information can help ease any anxiety and give you an understanding of what to expect.

But that doesn’t mean you have to expose yourself to more information than you want; it’s an individual decision. “Not every patient wants all the details about their surgery,” says Yale Medicine thoracic surgeon Justin Blasberg, MD, MPH. “Some people find it overwhelming; for others, however, there can never be too much information.”

We spoke more with Dr. Blasberg and other Yale experts to get answers to some of the most common questions and concerns people have about an upcoming surgery.

Experts recommend having your surgery in a place that performs a high volume of that particular surgery; it can make a significant difference in the safety and success of the operation. It’s also best to choose a surgeon who is board-certified in the field and has done the particular surgery many times.

A good surgeon should be happy to answer any questions about how many times they have performed an operation and how commonly it’s performed in the center where you will be having the surgery.

“The higher those volumes, the more likely you are to have an optimal outcome,” says Dr. Blasberg, adding that studies back this up in a variety of surgical specialties. “The volume-outcome relationship is well-established.”

You need to be upfront with your surgeon and anesthesiologist about all medicines or supplements you take, including over-the-counter ones. One idea is to make a list of all your medications and notes on dosages, including times of day you take them, when you took your last dose, and whether you have missed any. Then, bring that list to the hospital on the day of your surgery.

For example, if you take a blood thinner, such as warfarin, or aspirin (or another non-steroidal anti-inflammatory drug [NSAID]) for a heart condition, you may need to stop taking it for a few days before surgery. This is because blood thinners reduce the body’s ability to clot, raising the risk of internal bleeding during surgery. (Always talk to your doctor first before stopping any medication.)

Likewise, you should make sure the surgeons are aware of any medical conditions you have, since they can affect your anesthesia and/or surgery. For example, acid reflux needs to be monitored because it raises the risk of aspirating (drawing fluid in by suction) anything that may be in your stomach into the lungs during the procedure.

“Similarly, sleep apnea can affect your respiratory rate, making you more sensitive to the effects of anesthesia and raising your risk for cardiopulmonary complications after surgery,” says anesthesiologist Jill Zafar, MD, medical director of pre-surgical evaluation for Yale New Haven Health.

“Every specialty has different thresholds for what is important,” says Dr. Blasberg, who is also the director of the Patient Experience program for the Yale Department of Surgery. “But the principle is the same—in each operation, certain patients may be at risk for particular surgical complications, and we need to calculate that risk to give them the best opportunity to recover from surgery.”

Alcohol, cannabis, and tobacco can all interfere with anesthetics, so you should be upfront about any use. It’s important to remember that sharing this information affects your comfort during and after your surgery—it’s not about a health care professional’s approval or disapproval of your lifestyle.

“This conversation will be had in a nonjudgmental fashion,” says Britt Tonnessen, MD, a Yale Medicine vascular surgeon and an associate director of the Patient Experience program. “These things are important to know because they can impact both the anesthesia and the surgery.”

For example, regular alcohol or marijuana use can result in a person needing more anesthesia to get the same effect as they would if they didn’t have those substances in their system, she explains. “If we know about it beforehand, we may need to adjust the level of anesthesia. But if we don’t know, we might need to figure out why you need more anesthesia while you’re in surgery, which is not ideal,” she says.

Smoking decreases blood flow, making surgical wounds less likely to close (or heal properly) and more likely to become infected. Smoking tobacco also causes your body to produce mucus that can plug up secretions in the lungs, leading to breathing problems while you are under anesthesia. Patients who smoke are also more likely to need a ventilator after surgery and have a greater chance of having a heart attack during surgery.

It’s best to quit smoking as soon as possible, preferably at least a month prior to surgery and more in advance if possible. But even if it’s close to surgery, Dr. Zafar says quitting smoking is one of the best things a person can do for the success of their procedure.

Yes. At most hospitals—and in most situations—patients will meet their anesthesiologist just prior to their surgery, Dr. Zafar explains.

However, anesthesiology teams screen patients beforehand by reviewing their electronic medical records and sometimes calling patients ahead of time on the phone, she adds. Patients who will be undergoing a major procedure may have an in-person evaluation.

But you can always initiate a conversation with the anesthesiologist in the days before the operation—if you’re not sure how to reach them, ask your surgeon for contact information. (Who you will talk to varies by state. Patients can ask to speak to an anesthesiologist in Connecticut, while in other states, they may meet with a nurse anesthetist).

“Every hospital has an anesthesia department, and patients should feel empowered to reach out with questions and concerns,” says Dr. Zafar. "On the day of surgery, you will be evaluated by your anesthesiologist. They formulate the anesthesia plan, introduce themselves to you, and will go over any risks, benefits, or concerns. If there is a choice of anesthetics, they will ask you about your preference.”

We make a plan for anesthesia working as part of a collaborative team with the surgeon and the patient, she adds.

“It’s normal to be anxious before surgery—having an operation is not something people do every day, and many don’t like the loss of control,” says Dr. Zafar.

If the anxiety is intense, she suggests contacting the hospital’s anesthesiology team before the day of surgery to discuss it. “Knowing your anesthesia plan beforehand can reduce your anxiety on the day of surgery,” she says.

In some cases, the anesthesiologist can add a medication to the anesthesia—typically midazolam (brand name: Versed), which decreases anxiety along with memory of the procedure.

But midazolam may not be appropriate for everyone—for instance, doctors avoid giving it to older patients because it can put them at higher risk for side effects like delirium, Dr. Zafar explains.

But much of the anxiety lies in the anticipation, Dr. Zafar says. “A common thing I see in the recovery room is when the patient says, 'I was so nervous, but that was so much easier than I thought it would be.'”

“One of the biggest changes in anesthesia in the last decade has been the rising use of multimodal—or multiple methods for—pain control, which has resulted in less opioid use,” says Dr. Zafar. “This includes simple approaches such as giving patients Tylenol as part of their pre-operative care.”

There also are different types of anesthetics, including non-narcotic medicines, Dr. Zafar explains. Some patients can have NSAIDs for pain, partly depending on the surgery—if it’s a hip or knee surgery, for example, this may work for them.

Some studies have shown that regional block anesthetics can be as effective as opioids, Dr. Zafar adds. A nerve block is delivered to the surgical site by injection or infusion through a catheter. It can block the initial pain of surgery in a limb or even numb the body from the waist down during childbirth.

However, the block’s effectiveness decreases each hour after the surgery, and some patients may need more pain medication as the block wears off. For instance, those who undergo orthopaedic surgeries may be given a multimodal prescription (that could include some opioid medicine) to help with pain as the nerve block starts to wear off.

At one time, some patients went home with prescriptions of opioid medicine that were beyond what they needed (a 30-day prescription for pills, for instance), which put some of them at risk for addiction; now, patients typically get just enough pills for a day or two, depending on their needs. “In general, for everything short of major procedures, opioids are not usually needed for more than a few days—if at all,” Dr. Tonnessen says.

“Combined with minimally invasive approaches and getting patients active after some operations, multimodal pain control has contributed to quicker recoveries,” Dr. Zafar says. “We're getting to the point where we're able to provide surgery for patients with much less pain and fewer side effects, and this gets people back to their baseline functional status much more quickly.”

Post-operative nausea and vomiting (PONV) is common, and it can occur for a number of reasons, including dehydration (sometimes a result of not eating and drinking before surgery). Some patients are also at higher risk for nausea, including women, nonsmokers, and people with a history of motion sickness.

“Almost every patient gets some sort of anti-nausea medication when they are under anesthesia,” Dr. Zafar says. “We also screen for this before surgery, and if you are at higher risk, we tend to give you more medications to prevent nausea.” Some medications, such as opioids, increase the risk of nausea, so decreasing those medications can lower the risk, she adds.

Preventing the likelihood of a surgical-site infection—one that occurs after surgery in the part of the body where the surgery took place—is a major priority in hospitals, Dr. Tonnessen explains.

“Depending on the type of surgery that you’re having, there are some specific things your surgeon and their staff will do to prevent infection,” she says. That may include performing a nasal swab before surgery to check for the presence of methicillin-resistant Staphylococcus aureus (MRSA). Patients who test positive for MRSA, a type of bacteria that commonly affects surgical wounds and is resistant to antibiotics, may need a different antibiotic with surgery than they would get otherwise.

No matter the type of surgery you’re having—or where it’s taking place—it might give you peace of mind to know that both inpatient and ambulatory surgical centers have protocols in place to ensure a safe experience for all patients.

“At the very least, it’s reassuring to know that, in surgery, there are protocols for best practices,” says Dr. Blasberg. “There also are things patients can do ahead of time. The more complex the surgery, the more complicated the pre-operative checklist. It’s important to tick off all of the boxes.”

Yale New Haven Health has a list of general directions and advice for patients anticipating surgery.