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Chapter 7
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Elective Surgery forPatients
withSubstance Use Disorder or Recent
Substance Misuse
TaliaScott andEthanO.Bryson
Abbreviations
AUD Alcohol use disorder
AUDIT Alcohol use disorders identication test
COPD Chronic obstructive pulmonary disease
CUD Cannabis use disorder
MI Myocardial infarction
NIDA National institute on drug abuse
NMDA N-methyl-D-aspartate
NSDUH National survey on drug use and health
OUD Opioid use disorder
PCA Patient-controlled analgesia
SAMHSA Substance abuse and mental health services administration
SUD Substance use disorder
THC tetrahydrocannabinol
US United States
TSA Total shoulder arthroplasty
WHO World Health Organization
T. Scott
Department of Anesthesiology, Perioperative and Pain medicine, Icahn School of Medicine at
Mount Sinai, New York, NY, USA
e-mail: talia.scott@mountsinai.org
E. O. Bryson (
Department of Anesthesiology and Psychiatry, Icahn School of Medicine at Mount Sinai,
New York, NY, USA
e-mail: ethan.bryson@mountsinai.org
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_7
*)
103© The Author(s), under exclusive license to Springer Nature
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T. Scott and E. O. Bryson
Introduction
Substance use disorder (SUD), including alcohol use disorder (AUD), affects a signicant percentage of the population worldwide, and up to 16.5% of the United
States (U.S.) population alone, which includes persons above the age of 12, are
affected [1]. So prevalent is the issue of recreational substance use that one recent
study suggests that up to 40% of patients undergoing elective surgery present with
a history of recent substance use preoperatively [2]. Substance use is an independent
risk factor for increased complications, cost, and length of stay, and should therefore be taken into consideration when planning for elective surgery [3]. These complications can include higher risk of hemorrhage, sepsis, stroke, respiratory issues,
renal failure, and issues with wound or graft healing [3]. Patients with a history of
substance use are also more likely to have other serious medical conditions, such as
liver disease, chronic obstructive pulmonary disease (COPD), and human immunodeciency virus (HIV) infection [3].
Detecting a substance use disorder perioperatively can be a challenging task.
These diagnoses are commonly missed, whether as a result of absent inquiry or an
unwillingness on the part of the patient to admit use, either due to the stigma
attached to substance use or ignorance of its potential effects during the perioperative period [4]. Patients may not understand the implications of recent substance use on perioperative outcomes, thinking it is only a concern if they are
acutely intoxicated. Because of this, it is essential to explain to patients that disclosing substance use prior to elective surgery will not be reported to authorities,
is protected by the doctor-patient relationship, is essential for safe administration
of anesthesia, and has signicant implications for the success of and recovery
from surgery. It should be emphasized that asking these types of questions does
not imply judgment but are only asked to gain knowledge that is essential to keep
the patient safe during the perioperative period and do not necessarily preclude
proceeding with the procedure. Clearly, if, on the day of surgery, the patient
appears acutely intoxicated, concerns about the ability to fully understand the
informed consent process should be evaluated and the elective surgery should be
rescheduled.
There is considerable evidence that patients with a current or recent history of
drug use or misuse are at a signicantly higher risk for experiencing any number
of perioperative complications associated with elective surgery. When it comes to
patients with underlying medical conditions, the risk for complications increases
substantially, often leading to increased morbidity, longer hospital stays and
higher risk for perioperative mortality [3]. According to this recent report, current or recent drug misuse also has the potential to increase the length of hospital
stay resulting in higher costs, regardless of the patient’s age or medical comorbidities [3].
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105
Consumption Screening
It can be very challenging to identify these patients in the perioperative period as
recreational substance misuse if often not disclosed, reported or previously diagnosed when they present for elective surgery [4]. Despite this, it is estimated that up
to 40% of patients presenting for elective surgery do so with a history of recent or
current substance misuse which has the potential to increase their risks for perioperative complications [2]. In the following sections we will discuss the identication, implications, and management of the patient who presents for elective surgery
with recent or current substance use.
Commonly Misused Substances
Alcohol
Alcohol is ubiquitous and in many countries social drinking is considered acceptable substance use. That being said, there is a ne line between alcohol use and
misuse, with the denition of alcohol misuse varying between cultures, religions
and geographical areas. In general, alcohol misuse includes heavy or binge drinking
which is beyond the accepted norms for the population, but even regular acceptable
consumption has implications for patients presenting for elective surgery. Alcohol
use disorder (AUD) encompasses both alcohol misuse and dependence, and involves
negative consequences related to use [5]. AUD is a highly prevalent disorder which
affects 237 million men and 46 million women worldwide [6]. In the United States
alone, AUD affects 13.2% of adult men and 9.5% of adult women [7]. Patients who
present for elective surgery should be questioned regarding their specic daily
intake as this has signicant implications for anesthesia and post-surgical recovery
success.
Identication
While many patients will occasionally drink alcohol, the stigma attached with perceived excessive alcohol consumption varies from culture to culture. From the
standpoint of the anesthesiologist or surgeon, no judgment is made regarding individual use, but the quantity and frequency of use must be identied. The Alcohol
Use Disorders Identication Test (AUDIT-C) tool consists of three questions that
can be used to screen for AUD [8]. The AUDIT-C is scored on a scale of 0–12 (a
score of 0 reects no alcohol use).
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Implications forSurgery
Intraoperatively, chronic alcohol use can create tolerance, leading to higher anesthetic requirements, while on the other hand, acute intoxication lowers the anesthetic requirement [9]. Obviously the patient who presents for elective surgery
either acutely intoxicated or who reports same day alcohol use should be rescheduled and encouraged not to drink prior to surgery, but it is more often that the
patient who regularly uses or misuses alcohol will under-report their actual
consumption.
There appears to be a dose-dependent relationship between alcohol consumption
and surgical complications, with one study nding that the complication rate was
50% higher with consumption of three to four drinks daily but climbed to 200–400%
higher in those who consumed ve or more drinks a day. These complications
included postoperative infection, cardiopulmonary events, and increased bleeding [10].
Alcohol Use Disorder is associated with increased length of hospital stay and
cost across surgical elds [11–13]. These risks are particularly notable in colectomy
patients. Colectomies are already one of the most expensive surgeries, costing up to
$25,000 [14]. Patients undergoing colectomy with a history of AUD have increased
hospital cost from an already high baseline. Even more concerning is that, patients
with AUD who undergo this procedure are at increased risk for in-hospital mortality [11].
A history of AUD is also signicant in patients undergoing orthopedic surgery.
An association has been demonstrated between alcohol use and decreased bone
remodeling in animal models, so it follows that poor post-orthopedic surgery recovery in this population [15]. In arthroplasty patients, those with AUD had higher risks
of dislocation and readmission [12]. According to the Hospital Readmissions
Reduction Program (HRRP), a value-based purchasing program run by the Center
for Medicare and Medicaid services (U.S.) designed to reduce avoidable readmissions, increases in readmission could lead to nancial repercussions for the hospital [12].
Management Strategies
Preoperative abstinence can have benecial effects. One study found that patients
who were abstinent from alcohol for 1month preoperatively had less postoperative
arrhythmia, hypoxemia, and myocardial ischemia than those who continued drinking [16]. A meta-analysis agreed that 1–2months of abstinence preoperatively was
associated with fewer complications, although the effect on mortality was unclear
[17]. Cessation of alcohol use should be guided by specialists who will be able to
wean the patient from alcohol while limiting risk of withdrawal and also providing
psychosocial support.
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Tobacco
According to the World Health Organization (WHO), as of 2022, 22.3% of the
global population used tobacco (36.7% men and 7.8% women) [18]. While cigarette
smoking is the most common form of tobacco use worldwide, tobacco products also
include waterpipe tobacco, commonly referred to as hookahs, which have cultural
signicance in many populations and are symbolic of friendship, trust, and respect,
as the pipes are shared with physically connected inhalation tubes. The tobacco
smoked in this manner is inhaled unltered and regular users are often exposed to
increased levels of nicotine and other products of combustion which have signicant implications for patients during the perioperative period.
Smokeless tobacco products, such as “vapes,” “e-cigarettes,” or other electronic
nicotine delivery devices, chewing tobacco, nicotine gum and patches reduce exposure to many of the toxic chemicals associated with the inhalation of cigarette
smoke but still provide the user with nicotine, which also has signicant implications for the perioperative patient. Although designed as a replacement for cigarettes, the popularity of e-cigarette use has risen dramatically among young people,
and by 2022 4.5% of middle school students and 16% of high school students in the
U.S. had used an e-cigarette in the past 30days compared to approximately 3.7% of
adults [19, 20]. In one survey of preoperative patients it was found that 13.9% of
those who used e-cigarettes had used them in the last week [21].
Identication
The easiest way to identify patients who use tobacco products is to ask direct questions during the preoperative interview. Unlike alcohol, which patients may minimize their actual use, or illicit drugs, which they may deny using altogether, patients
who smoke are usually forthcoming when asked. Preoperatively, patients should be
screened for both tobacco and nicotine-containing e-cigarette use. Of note, those
who use e-cigarettes commonly do not believe the term “smoking” includes
e- cigarette use [21]. Patients can then be counseled on smoking cessation and given
the appropriate tools, support, and resources to quit successfully.
Implications forSurgery
Individuals who smoke heavily for several years are more prone to developing complications in their lungs after surgery, but even those who smoke occasionally or in
small quantities may face an elevated risk. Smoking causes airway hyper-reactivity,
contributing to pulmonary complications during anesthesia such as laryngospasm,
bronchospasm, reintubation, and hypoxemia even in the absence of reactive airway
disease. Age and body habitus are also important, with a 6.3x increased risk of pulmonary complications in obese young smokers compared to 2.3x in young smokers
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T. Scott and E. O. Bryson
and 1.8x in all smokers [22]. Given these pulmonary risks, it follows that smokers
are more likely to be admitted to the ICU postoperatively [23]. In one study the relative risk for any of these pulmonary complications was 1.8 for all smokers but signicantly higher in patients aged 16–39 years (2.3) and jumped to 6.3 if these
patients were also obese [22]. In the same study, young smokers with chronic bronchitis were 25.7 times more likely to experience bronchospasm in the perioperative
setting.
In colorectal surgery, current smokers had increased risk of major complications
such as infection, cardiac events, and sepsis as well as increased mortality risk.
Overall, within 30days of surgery, smokers had a 30% increased risk of sustaining
either a major complication or mortality [24]. In total hip arthroplasties, there was a
higher rate of revision in patients who smoke [25].
Wound healing is well-known to be impaired in cigarette smokers [26]. Nicotine
is thought to directly cause injury to the vascular intima, leading to atherosclerosis.
This can be especially detrimental in plastic surgery and surgery involving grafts, as
cutaneous tissue beds are most susceptible to decreased blood ow. Particularly in
the case of elective surgery, poor wound healing can detrimentally impact the
desired outcome [27].
Although e-cigarettes avoid inhalation of combustible material, their use is still
associated with pulmonary toxicity including airway hyperreactivity [28]. The nicotine contained in e-cigarettes stimulates catecholamine release affecting the cardiovascular system, which in turn can make the effects of anesthetics less predictable
[29]. E-cigarette use in total joint arthroplasty patients was associated with longer
operative time, hospital length of stay, and readmission [30]. In plastic surgery,
those who used e-cigarettes had similar rates of ap necrosis to cigarette smokers,
implying that nicotine is the substance toxic to ap survival [31]. E-cigarettes may
be a helpful tool in smoking cessation, but their use should be considered when
proceeding with elective surgery.
Management Strategies
Smokers who stop at least 6–8weeks prior to elective surgery have been shown to
reduce their risk for intraoperative and postoperative complications [32]. Surgery
may provide good incentive to quit smoking and may be a good time to quit. One
review found that 8% of those who quit do so because of surgery [33]. Additionally,
in one study, 28 subjects (46.7%) who were able to stop smoking prior to surgery
remained abstinent at follow-up 1year after intervention [34].
The detrimental effects of smoking on surgical outcomes decrease the longer the
period between smoking cessation and surgery and each week of cessation can
increase the magnitude of this effect by up to 19% [35]. Cessation of greater than
4weeks was associated with a 20% decreased risk of complications compared to
cessation of less than 4weeks [36]. The benets of a longer time frame are explained
by the weeks to months it can take for the pulmonary cilia to heal and pulmonary
function to return, making 8weeks of abstinence before elective surgery ideal [37].
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At a minimum, from an anesthesia standpoint, the patient should not smoke for
at least 12h preoperatively so that levels of nicotine and carboxyhemoglobin can
decline. Carboxyhemoglobin can signicantly decrease the bioavailability of oxygen, which can be catastrophic in patients with a history of coronary artery disease.
If a patient with coronary history reports smoking the day of elective surgery, it may
be reasonable to postpone the case [38].
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Marijuana
According to the United States Substance Abuse and Mental Health Services
Administration (SAMHSA) National Survey on Drug Use and Health (NSDUH),
52.5 million people aged 12 or older (18.8% of the population) reportedly used
marijuana in 2020 [1]. With an increasing move toward decriminalization and legalization in many areas, these numbers will undoubtedly increase, either to come in
line with true numbers as the stigma of marijuana use is lessened by the elimination
of legal consequences or as new users begin to adopt the habit.
Identication
Signs of acute marijuana intoxication include anxiety, tachycardia, decreased shortterm memory (the individual may not be able to adequately participate in the preoperative interview), Dry mouth, conjunctival injection, impaired perception, and
motor skills. In chronic users who have not recently used and are not currently
under the inuence these ndings are not common. Simply asking about regular
marijuana use, however, usually elicits an honest response. In patients who are hesitant it is important to emphasize that questions about regular use are not intended to
judge but to obtain information important to keep the patient safe during the
procedure.
Signs such as a “green tinge” on the tongue (related to inhaling chlorophyll, or
articial green dye which is sometimes added to vaping preparations) has been
reported, though these signs are non-specic and rare [39].
Screening tests for marijuana use are, as of this writing, only reliable in chronic
users and require regular use over a period of 30 or more days to produce a consistently positive result. After the initial use, one-third of the major psychoactive component of marijuana which is tested for, tetrahydrocannabinol (THC), is excreted in
the urine. After a single use, THC may be detected on a urine drug screen for
2–3days, though this is not consistently reliable. With chronic use, however, and
depending on the test used, the length of time after the last ingestion during which
THC can be detected in the urine increases to 1– 4 weeks [40]. False positive drug
screen results have been reported in patients who have been taking over the counter
medications such as ibuprofen and naproxen [41].
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Implications forSurgery
In 2020 a retrospective cohort analysis published by Goel etal. provided signicant
evidence that patients with active cannabis use disorder (CUD) who underwent
elective surgery were at increased perioperative risk of myocardial infarction (MI)
[42]. In this cohort of 27,206 patients the odds of postoperative MI was 1.88 times
higher for patients with a reported active cannabis use disorder, as dened by the
International Classication of Diseases, Ninth Edition, Clinical Modication
(ICD-9-CM) diagnostic codes for cannabis dependence and cannabis abuse. Prior to
this, most evidence in the literature regarding recent or chronic marijuana use as
related to surgical implications were, in part, extrapolated from studies performed
on patients who reported tobacco smoking, and focused on wound healing [43].
While the route of ingestion of cannabis products is important to consider when
looking at outcomes such as wound healing related to decreased vascular perfusion
related to vasoconstriction and tissue ischemia, the potential for physiological withdrawal symptoms during the perioperative period, when access to cannabis may be
limited, is important to consider as a potential etiology for postoperative MI, especially in the chronic user who presents for elective surgery.
Similar to patients who are chronic tobacco smokers, patients who regularly
smoke marijuana are subject to the same pulmonary risks outlined above [38].
Additionally, case reports of uvulitis or uvular edema leading to airway obstruction,
laryngospasm and bronchospasm while under anesthesia in patients who regularly
smoke marijuana highlight the increased risk for these patients who present for elective surgery [44–46]. Anecdotal evidence suggests that, much in the same way
patients with AUD present with increased tolerance for anesthetic agents, patients
with CUD also have increased intraoperative anesthetic requirements and are, as a
result, at increased risk for complications related to a lighter plane of anesthesia,
including awareness.
The route of ingestion preferred by the user is important to consider. Much like
the hookah, commercially available marijuana is not, as of this writing, produced in
the form of ltered cigarettes. Due to the absence of lters signicantly more products of combustion such as tar and other carcinogens are inhaled than with commercially available ltered tobacco cigarettes [47]. The carboxyhemoglobin level in
the blood of a marijuana smoker can be up to ve times higher than that of a tobacco
smoker, primarily due to the practice of deep inhalation, holding the smoke in lungs
longer [48]. Patients who use marijuana in different forms, other than smoking, are
still subject to the effects of the drug. Edibles, tinctures, and other forms of noninhaled cannabis will still increase in heart rate, produce ectopy, and in patients with
underlying coronary vascular disease, can result in reversible ST or T segment
abnormalities visible on the perioperative electrocardiogram (ECG). These factors
alone can make the safe induction of anesthesia challenging, increase the risk for
perioperative MI, and require higher doses of anesthesia to achieve a depth adequate
for elective surgery [38, 49].
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