Cocaine-Positive Patients Undergoing Elective Surgery: From Avoiding Case Cancellations to Treating Substance Use Disorders.

Abstract

See Article, p 308 The impact of substance use disorders (SUDs) on the management of anesthesia for patients undergoing surgical procedures covers a broad spectrum, from the acute effects of intoxication to chronic effects such as altered anesthetic drug metabolism or a predisposition to perioperative organ injury.1 SUDs, which are characterized by the persistent use of a substance despite adverse consequences, including health problems, are extremely common. For example, in the United States, the 12-month prevalence of alcohol use disorder is 13.9%.2 For the less common substances encompassed by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) SUD definition (amphetamines, cannabis, club drugs, cocaine, hallucinogens, heroin, nonheroin opioids, sedative/tranquilizers, and/or solvent/inhalant use disorders), the 12-month prevalence is still 3.9%.3 The immediate dilemma for the anesthesiologist presented with a urine toxicology result that is positive for cocaine, or any of the substances included in the DSM-5 SUD definition, is then whether to (1) postpone the elective surgery or (2) proceed with the anesthetic while anticipating potential problems associated with the urine toxicology result. While option (1) may seem the “safest” from a provider’s point of view, unanticipated cancellations of surgery come at steep costs. In addition to the financial implications of unused operating room time, prolonged patient suffering, worsened patient experience, and treatment delays resulting in worsened clinical outcomes due to disease progression represent potential consequences to case cancellations.4 The higher prevalence of SUDs in socioeconomically disadvantaged populations5 with limited access to care makes a decision to postpone an elective procedure even more consequential. The acutely cocaine-intoxicated patient may display hypertension, tachyarrhythmias, myocardial ischemia, and convulsions, and management of anesthesia in such patients has been described for parturients, fetuses, and neonates.6 Cocaine-using patients presenting in a clinically nontoxic (asymptomatic) state, defined as normal blood pressure, heart rate, temperature, and normal or unchanged electrocardiogram, have been shown to receive general anesthesia safely for scheduled elective surgery in a prospective cohort study including 40 cocaine-positive patients.7 In the current issue of the Journal, Moon et al8 report on a single-center prospective cohort study evaluating the association of a positive preoperative urine test for cocaine and intraoperative hemodynamic events in a cohort of 327 asymptomatic patients with a history of cocaine use. Hemodynamic events were defined as a mean arterial blood pressure of <65 or >105 mm Hg, or a heart rate of <50 or >100 beats per minute. They found that the 173 asymptomatic cocaine-positive patients undergoing elective noncardiac surgery under general anesthesia had similar percentages of intraoperative hemodynamic events when compared to 154 cocaine-negative patients. Moon et al’s8 current study adds to a growing body of literature suggesting that urine toxicology results positive for cocaine, per se, may not reflect an absolute contraindication to proceeding with a surgical procedure.7,9,10 While this is undoubtedly a critical conclusion, we would like to contextualize these results with respect to (1) the prevalence of polysubstance use, particularly multiple stimulants, and (2) the effectiveness of in-hospital interventions on SUD trajectories in general. POLYSUBSTANCE USE A complicating factor for patients with cocaine use disorder is the concomitant use of other substances. Accordingly, patients with polysubstance use (except marijuana) were excluded from Moon et al’s8 study. However, a patient presenting with a urine toxicology result positive for cocaine plus an additional substance may be quite common. For example, in a sample of 706 rural methamphetamine users in the United States, 35% reported using both methamphetamines and cocaine.11 The example of concurrent cocaine and amphetamine use (which could also be present among cocaine users who use prescription stimulants) illustrates why surgical patients with polysubstance use may demand a more conservative approach. Since both substances can lead to a hypermetabolic state, including tachycardia, hypertension, and hyperthermia, the risk for adverse perioperative outcomes is amplified in these patients. Specific conditions such as serotonin syndrome may further be triggered by preoperatively administered medications and pose a unique risk to polysubstance users. An isolated positive urine toxicology result for cocaine in an otherwise asymptomatic patient may lead to alterations in the anesthetic care plan, but not necessarily postponement of the surgical procedure. However, the detection of other substances in addition to cocaine may still merit delaying an elective procedure, even if the patient appears asymptomatic. Obtaining urine toxicology results as a part of the preoperative assessment in patients at risk for SUD is a requirement to make an informed decision on whether or not to proceed with surgery. IN-HOSPITAL INTERVENTIONS ON SUDS SUDs may have contributed to the presenting complaint that necessitated a surgical procedure and pose challenges to the recovery process after anesthesia and surgery. Hospitalizations, in general, offer the opportunity to administer interventions beyond the primary admission diagnosis, especially in populations that are otherwise unlikely to seek regular primary care. The standard of care in this setting is screening, brief intervention, and referral to treatment (SBIRT), which quickly assesses the severity of a patient’s substance use, identifies the appropriate level of treatment, and attempts to increase insight regarding substance use and motivation for behavioral change. SBIRT can be implemented by a wide range of health care personnel with varied backgrounds. The efficacy of SBIRT has been well described for common SUDs. A Cochrane review on the effectiveness of interventions for smoking cessation in hospitalized patients found that only high-intensity behavioral interventions that began during a hospital stay and lasted a minimum of 1 month after discharge were effective.12 Interestingly, interventions of low intensity or shorter duration were not successful in this study. Yet, brief interventions administered in the preadmission clinic before elective surgery have shown success in reducing smoking rates at 1 year with a number needed to treat of 5.9.13 Similarly, for perioperative alcohol use, a recent Cochrane review summarized the results of 3 clinical studies.14 The authors found that alcohol cessation interventions significantly increased the number of participants who quit drinking alcohol during the intervention period and likely reduced the number of postoperative complications.14 SBIRT approaches have been successfully implemented across a variety of different health care sites, including emergency departments and urgent care centers, inpatient hospital settings, and outpatient and community-based clinics, and have shown success in regard to reducing cocaine use specifically.15 SBIRT has also been shown to improve functioning in other domains that may have been associated with the initial complaint that brought the patient to medical attention, including general health, mental health, employment, housing status, and criminal behavior.15 Thus, postoperative hospital-based intervention for SUDs following a positive urine toxicology result for cocaine or another substance may decrease future substance use and increase the likelihood that patients adhere to postoperative care recommendations and do not require subsequent readmission. FUTURE DIRECTIONS The study by Moon et al8 may help anesthesiologists who must make a challenging decision when faced with the dilemma of canceling versus proceeding with a scheduled case in a patient with cocaine use disorder and an isolated positive urine toxicology result. In addition to safely shepherding our patients through the intraoperative course, opportunities for expansion of our practice exist. Future study may focus on how to best manage patients presenting with polysubstance use, as well as hospitalization-based interventions geared at the long-term reduction of illicit drug use in these patients. DISCLOSURES Name: Karsten Bartels, MD, PhD. Contribution: This author helped write and revise the manuscript. Name: Joseph P. Schacht, PhD. Contribution: This author helped write and revise the manuscript. This manuscript was handled by: Richard C. Prielipp, MD, MBA.