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Substance Use
Disorders in Adult
Critically Ill Patients
KunalKaramchandani
JonE.Grant
Editors
Substance Use Disorders in Adult
Critically Ill Patients
Kunal Karamchandani • Jon E. Grant
Editors
Substance Use Disorders
in Adult Critically Ill Patients
ISBN 978-3-031-67068-8 ISBN 978-3-031-67069-5 (eBook)
https://doi.org/10.1007/978-3-031-67069-5
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland
AG 2024
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specic statement, that such names are exempt from the relevant
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The publisher, the authors and the editors are safe to assume that the advice and information in this book
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If disposing of this product, please recycle the paper.
Editors
Kunal Karamchandani
Department of Anesthesiology and
Pain Management
The University of Texas Southwestern Med
Dallas, TX, USA
Jon E. Grant
Department of Psychiatry and
Behavioral Neurosciences
University of Chicago
Chicago, IL, USA
v
1 Epidemiology and Impact of Substance Use Disorders
on the Intensive Care Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Jon E. Grant
2 Alcohol Abuse Disorder: Alcohol Withdrawal Syndrome . . . . . . . . . . 11
Deepali Dixit, Marissa Grillo, Jessica Hu, and Maria Cardinale-King
3 Alcohol Use Disorder and Critical Illness . . . . . . . . . . . . . . . . . . . . . . . 27
Akhil Patel
4 Managing an Opioid-Dependent Patient, Including Acute
Opioid Toxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Jasper Han and Kunal Karamchandani
5 The Critical Conundrum: Balancing Pain and Opioid
Use in Critical Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Mary L. Jarzebowski and Morgan Laney
6 Nicotine Use Disorders: Impact on Critical Illness
and Therapeutic Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Victoria Mroz and Zdravka Zarova
7 The Impact of Cannabis Use Disorder on Critical Illness . . . . . . . . . . 95
Zyad J. Carr and Eric Strand
8 Stimulant Use Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Kristin Reinaker and Jami Johnson
9 Psychoactive Medications in the ICU . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Sean P. Curran, Kenneth John, and Somnath Bose
10 Treatment of Substance Use Disorders in Post-ICU Settings . . . . . . . 143
Stephen V. Marcoux
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Contents
1© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
K. Karamchandani, J. E. Grant (eds.), Substance Use Disorders in Adult
Critically Ill Patients, https://doi.org/10.1007/978-3-031-67069-5_1
Chapter 1
Epidemiology andImpact ofSubstance
Use Disorders ontheIntensive Care Unit
JonE.Grant
Prevalence ofSubstance Use Disorders
intheGeneral Population
Both alcohol and drug use disorders are common and associated with signicant
morbidity and mortality [1–3]. In fact, the current prevalence rates of alcohol use
disorder and drug use disorders in the general population of the United States are
approximately 13.9% and 3.9%, respectively, based on the National Epidemiologic
Survey on Alcohol and Related Conditions [4, 5]. The lifetime prevalence rates of
alcohol use disorder and drug use disorders in the general population of the United
States are approximately 29.1% and 9.9%, respectively [4, 5]. This roughly trans-
lates to one out of every ten adults in America having a current substance use disor-
der and one out of every three people having a substance use disorder in their
lifetime. Past-year rates of nicotine dependence are found in 14.0% of the adult US
population as well [6].
Diagnosing aSubstance Use Disorder
Clinically, we make the diagnosis of a substance use disorder based on the follow-
ing criteria set forth by the American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders (DSM-5). To meet the criteria for substance
use disorder, the person must meet at least two criteria within the same 12-month
period [7]. The DSM-5 further allows clinicians to specify how severe or how much
J. E. Grant (*)
Department of Psychiatry and Behavioral Neurosciences, University of Chicago,
Chicago, IL, USA
e-mail: jongrant@uchicago.edu
2
of a problem the substance use disorder is, depending on how many symptoms are
identied. Two or three symptoms indicate a mild substance use disorder, four or
ve symptoms indicate a moderate substance use disorder, and six or more symp-
toms indicate a severe substance use disorder.
Substance Use Disorder Criteria (Adapted fromtheDSM-5) [7]
The clinician using these criteria should rst make sure a specic time period is
being referenced. That is, does the patient endorse these symptoms within the past
12 months (i.e., a current problem) or ever during their lifetime? These criteria
should be used separately for each substance that the person reports using. For
example, all 11 symptoms should be examined for alcohol and then separately for
cocaine, etc. The result of this assessment is that a person could have several sub-
stance use disorders, such as alcohol use disorder, cocaine use disorder, etc. As each
substance necessitates different interventions, it is important to diagnose which sub-
stance use disorders the person has.
1. The person takes the substance in larger amounts or for longer than intended.
2. They try unsuccessfully to cut down on or stop using the substance.
3. They spend a lot of time trying to acquire, use, or recover from the substance.
4. The person reports cravings and urges to use the substance.
5. They fail to fulll obligations at work, home, or school because of substance use.
6. Even when substance use results in relationship problems, they continue
to use it.
7. They abandon important social, occupational, or recreational activities because
of substance use.
8. They use the substance even when it puts them in danger.
9. Even when you know you have a physical or psychological problem that could
have been caused or made worse by the substance, they continue to use it.
10. The amount of the substance increases over time to get the desired effect.
11. They experience withdrawal symptoms.
The DSM-5 criteria for substance use disorders is the gold standard, but many
research reports and clinical settings may prefer to screen for alcohol and drug use
disorders with shorter measures and then have mental health professionals do a
follow-up assessment for any patient with a positive substance use disorder screen.
Prevalence ofSubstance Use Disorders inMedical Settings
As common as these problems are in the general population, data show that the rates
of substance use disorders are even more frequently found in medical populations.
In primary care settings, 20–30% of patients can be expected to have some current
J. E. Grant
3
level of problem use of alcohol, and approximately 5–10% of patients have a current
substance use disorder [8–10]. In hospital settings, the problems with substances are
generally higher, with rates of current alcohol use disorder ranging as high as
19–50% and rates of current drug use disorders ranging from 12% to 15% [11–14].
Screening forSubstance Use Disorders inMedical Settings
Because rates of substance use disorders are higher in medical settings compared to
the overall population, screening for use problems should be considered in all hos-
pital settings, including the emergency department and the intensive care units.
Emergency room screening is recommended by the American College of Emergency
Physicians, and as this may be the point of contact before the patient is admitted to
an intensive care unit (ICU), the screening in the emergency department may assist
with more appropriate treatment planning in the ICU. Ideally, a positive screen
should be followed by a more detailed diagnostic assessment by trained mental
health staff.
On a practical level, there are several measures that could be used in hospital
settings, including the ICU, to screen for substance use problems. A couple of the
most commonly reported instruments that are easy to use in an ICU to screen for
alcohol and drug use in adults are the AUDIT and the DSAT-10. The Alcohol Use
Disorders Identication Test (AUDIT) [15] is perhaps the most widely used screen-
ing tool for alcohol use. Instead of only screening for a formal alcohol use disorder,
the measure screens for unhealthy use and provides a level of risk that the person
meets (a score of ≥8 also suggests an alcohol use disorder). The most-used version
has ten items and takes a couple of minutes to administer. In terms of screening for
unhealthy drug use (or a substance use disorder), the most widely used measure is
the Drug Abuse Screening Test (DSAT-10) [16]. It also consists of ten questions and
takes only a few minutes to administer (a score of ≥3 also suggests a substance use
disorder).
Screening in a hospital setting, such as an emergency department or ICU, is
likely to result in a higher proportion of patients who screen positive, identify more
severe substance use, and be associated with complex psychiatric and medical
comorbidities compared to outpatient settings. Of course, screens are not the same
as diagnostic measures, and they are intended to over-identify problems. Clinicians
need to be aware of the limitations of these instruments and follow-up positive
screens with more detailed assessments.
The goals of screening in the ICU, for example, will also differ from those in
outpatient settings. At minimum, ICUs should screen to identify patients at high risk
for acute withdrawal or for procedural complications related to their substance use.
Screening in the ICU can also identify patients with substance use disorders who
need medications or ongoing treatment post-discharge. When substance use disor-
ders are identied by screening, ICUs may also afford themselves, where available,
of addiction consult services, which typically involve a team-based approach to
1 Epidemiology andImpact ofSubstance Use Disorders ontheIntensive Care Unit
4
managing patients in the hospital and engaging them in post-discharge treatment
and harm reduction services. Controlling the substance use disorder post-discharge
is more likely to ensure the patient will also follow up with post-discharge medical
care for whatever complex health problem was the reason for the ICU admission.
This in turn should reduce readmission for the same problem or for complications.
Substance Use Disorders intheIntensive Care Unit
The epidemiology of substance use disorders in ICUs is largely unknown. As emer-
gency departments tend to have higher rates of substance use disorders than in the
general population, we might expect rates to be higher in ICUs as well, and some
data support this heuristic. Using 2016–2017 emergency department data from the
National Hospital Ambulatory Medical Care Survey, Zhang and colleagues exam-
ined adults with and without a substance use disorder and found that people seen in
emergency departments who had substance use disorders were more likely to be
hospitalized and admitted to the ICU (they were also more likely to experience
homelessness, suffer from mental illness, and require ambulance services) [17].
One study reported that approximately 16–31% of patients in ICUs have an alcohol
use disorder [18], which is higher than the current rate of 13.9% in the general popu-
lation [4]. Estimates from one community hospital, however, reported that 14% of
ICU admissions were non-tobacco substance-related [19], a rate similar to the gen-
eral population [4]. Another study found that 19% of ICU admissions in NewYork
City were due to alcohol and drug intoxication [20]. This study did not report rates
of substance use disorders but instead examined any level of unhealthy alcohol or
drug use. Another study found that of their mechanically ventilated patients in the
ICU, 39% had a substance use disorder [21].
Based on the available research, ICUs constitute a setting where clinicians will
have to be aware of and willing to manage a range of problems associated with
substance use disorders as well as misuse of alcohol and drugs (i.e., use that may not
be at the level of a substance use disorder but necessitates medical attention due to
the health consequences of the substance use).
Not All Substance Use Is aSubstance Use Disorder
Of course, not all alcohol and drug use meets the diagnostic criteria for a substance
use disorder, and yet it can still impact patient care and outcomes. In fact, the screens
mentioned above were created to also examine levels of use that might be below the
severity of a substance use disorder but may still necessitate interventions as this
can cause some problems for the person. Thus, there are gradients of use from no
use to non-harmful recreational use, to misuse of drugs or alcohol (this might mean
meeting a single criterion for a substance use disorder such as in the case of
J. E. Grant
5
hazardous alcohol use), and nally to meeting DSM-5 diagnostic criteria for a sub-
stance use disorder (see above). In an ICU setting, this lower level of substance
misuse will often result in the same acute interventions. The difference between
misuse and a substance use disorder is generally more important for post-discharge
treatment planning.
Even at lower levels of use (often referred to as misuse or hazardous use), how-
ever, alcohol and drugs can lead to ICU admissions and resultant health problems.
Research suggests that prevalence rates of alcohol and drug misuse are actually
higher than the rates of substance use disorders, but oftentimes only come to the
attention of medical professionals when severe health problems occur [22–24]. For
example, hazardous drinking is common among college students in the United
States, with studies documenting prevalence estimates ranging from 33% to 57%
[25]. A Finnish study of 2045 patients admitted to the ICU found that 21% screened
positive for hazardous alcohol use [26]. Similarly, a trend worldwide has seen an
increase in opiate misuse among people who in turn need ICU admissions [27],
often leading to high mortality rates (up to 10%) [28].
Medical Problems Associated withSubstance Use
intheIntensive Care Unit
Beyond the range of long-term health issues associated with substance use disorders
[29, 30], doctor and nurses in the ICU will often be called upon to manage substance
intoxication and potential withdrawal in many people, even those who do not meet
criteria for a use disorder. Additionally, as each substance results in different clinical
manifestations of intoxication and withdrawal, staff in an ICU need to understand
the clinical presentation of intoxication and withdrawal across a range of substances
(the various chapters of this volume will present the unique issues related to each
substance and management strategies).
One study suggested that approximately 16–31% of patients in an ICU are at risk
for developing alcohol withdrawal syndrome, and this is likely the most common
substance seen in ICU admissions [18]. Patients admitted to the ICU with alcohol
withdrawal tend to have longer ICU stays, a longer duration of mechanical ventila-
tion, higher costs, and increased mortality compared with those admitted who do
not go through alcohol withdrawal [18].
Medical management of substance use disorders is not conned to the intoxica-
tion or withdrawal from the misused substance. There are substantial health comor-
bidities related to chronic drug and alcohol misuse that often need to be managed in
the ICU, such as gastrointestinal bleeding due to alcohol misuse. Available data
demonstrate that substance use problems are major risk factors associated with poor
ICU outcomes. Patients in the ICU are more likely to experience delirium, which in
turn complicates the management of comorbid health conditions [31]. In a large
(n=11,651) study of adult admissions to two urban ICUs, the researchers found
that 12.2% had a diagnosis consistent with alcohol dependence, and those patients
1 Epidemiology andImpact ofSubstance Use Disorders ontheIntensive Care Unit