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EVALUATION/RISK FACTORS

Introduction

“Substance use” and “substance use disorder” (SUD) are broad terms that encompass a spectrum of patterns of use and results to overall health. Multiple substances fall under the umbrella of SUD, including illicit/illegal agents such as non prescription opioids or stimulants (Table 33-1). The potential for misuse also occurs with legally regulated agents such as alcohol, prescription opioids, prescription stimulants, and cannabis (recreational or medical legalization varies by state). Rates of illicit substance use are increasing, with over 28 million Americans over 12 years old reporting use in the prior month, increasing the potential that patients who use substances will present for surgery.1 Perioperative risk and considerations vary by agent.

TABLE 33-1Representative Examples of Complications of Chronic and/or Long-Term Use of Illicit Substances, which can Increase the Risk of Perioperative Respiratory, Cardiac, Infectious, or Neuropsychiatric Postoperative Complications2,4,6,8,14

Substance use disorders are best viewed as medical conditions with available treatments rather than choice, poor willpower, or moral failure. The term “substance use disorder” rather than “substance abuse” or “substance dependence” reflects a shift toward more scientifically based, patient-centered language.2 Discriminatory language like “addict” or “intravenous drug user” should also be avoided in favor of more medical descriptions.

Appropriately assessing and managing substance use disorder in the perioperative period is an opportunity for high value, patient-centered care that also draws attention to preoperative optimization of modifiable risk factors and harm reduction. Preoperative management may also facilitate the chance to initiate sustained recovery or prevent perioperative relapse.

Medical Complications of Substance Use Disorder

Substance use disorder can increase perioperative risk due to the medical sequelae of current or former use. Some of these risks may include interactions between the agent used and anesthetic agents and risk of perioperative medical complications such as myocardial infarction. In addition to complications of intoxication or chronic use, withdrawal syndromes may add to perioperative risk.

Medical complications of use vary by agent as well as route and duration of use (Tables 33-1 and 33-2). Complications relevant to the ...

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