Hospital Care of Patients with Substance Use Disorder
Heather Bell, MD
Originally posted in October 2020 Newsletter
It is important to remember that patients with substance use disorders can have additional complications during hospitalizations for non-related addiction issues (i.e. COVID-19). Excessive alcohol use impacts 1/5-1/3 of all patients admitted to an intensive care unit (ICU), 20-40% of inpatients have alcohol-related conditions, and up to 40% of hospitalized patients have alcohol use disorder (AUD). Patients that fit these categories have a high potential for withdrawal, and if they do not accurately disclose this information at admission, this can significantly complicate their hospital course. Five percent of patients with AUD admitted develop severe withdrawal or DTs, and many of those symptoms/signs overlap those found in patients with sepsis. Thinking of severe cases of COVID-19 with prolonged ventilation specifically, patients with AUD have a significantly higher need for mechanical ventilation and AUD serves as an independent risk factor for development of sepsis, community acquired pneumonia, and ARDS (2-4x more likely in patients with AUD). If they have concurrent hepatic dysfunction, mortality rates are higher.
While AUD is often given higher priority during inpatient care, nicotine use disorder (NUD) can also lead to severe complications during an acute care admission. Patients with NUD have high rates of co-occurring depression and anxiety, often use alcohol, and are at risk of using other substances of abuse. Patients with NUD have increased agitation in the ICU vs nonsmokers, 64% vs 32% respectively, have a 2-4-fold increase in invasive pneumococcal pneumonia, and higher admission rates to the ICU (25-47% higher) than nonsmokers. Sepsis, death during hospitalization, ICU admissions, ventilator needs, vasopressor use, and agitation are also more common in smokers. Nicotine replacement therapy (topical patches in particular) are an extremely important part of admission orders.
Finally, patients that use opioids, licit and illicit, also have a potential increase in morbidity and mortality during an admission. 3-4% of the adult population is on chronic [licit] opioid therapy and 0.2% use heroin (likely and underestimate). Patients who are opioid-tolerant will often require higher doses of opioids for acute pain, which they often don’t receive. Post-ventilator patients on pain relievers and sedation may withdraw even after only 5 days of inpatient administered opioids; this is often not recognized, as hospital providers may think withdrawal from outpatient opioids wouldn’t happen this far into an admission, not recognizing that medications given for intubations can and will delay this or cause iatrogenic physical dependence. Most importantly, opioid use disorder (OUD) is often not uncovered for a variety of reasons, including lack of recognition, unable to give history, patients not being forthcoming or understanding, family unaware or downplaying use, use deemed not relevant, methadone from an opioid treatment program is not on the Prescription Monitoring Program, or providers simply don’t ask. When patients are using IV substances, they may have additional complications including soft tissue infections, endocarditis, hepatitis, or other invasive infections related to IVDU. Finally, patients who use illicit substances often have complicated discharge needs including food and housing insecurities, insurance and support system deficits, and legal issues such as warrants, probation, and child protection.
Heather Bell, MD
Originally posted in October 2020 Newsletter
It is important to remember that patients with substance use disorders can have additional complications during hospitalizations for non-related addiction issues (i.e. COVID-19). Excessive alcohol use impacts 1/5-1/3 of all patients admitted to an intensive care unit (ICU), 20-40% of inpatients have alcohol-related conditions, and up to 40% of hospitalized patients have alcohol use disorder (AUD). Patients that fit these categories have a high potential for withdrawal, and if they do not accurately disclose this information at admission, this can significantly complicate their hospital course. Five percent of patients with AUD admitted develop severe withdrawal or DTs, and many of those symptoms/signs overlap those found in patients with sepsis. Thinking of severe cases of COVID-19 with prolonged ventilation specifically, patients with AUD have a significantly higher need for mechanical ventilation and AUD serves as an independent risk factor for development of sepsis, community acquired pneumonia, and ARDS (2-4x more likely in patients with AUD). If they have concurrent hepatic dysfunction, mortality rates are higher.
While AUD is often given higher priority during inpatient care, nicotine use disorder (NUD) can also lead to severe complications during an acute care admission. Patients with NUD have high rates of co-occurring depression and anxiety, often use alcohol, and are at risk of using other substances of abuse. Patients with NUD have increased agitation in the ICU vs nonsmokers, 64% vs 32% respectively, have a 2-4-fold increase in invasive pneumococcal pneumonia, and higher admission rates to the ICU (25-47% higher) than nonsmokers. Sepsis, death during hospitalization, ICU admissions, ventilator needs, vasopressor use, and agitation are also more common in smokers. Nicotine replacement therapy (topical patches in particular) are an extremely important part of admission orders.
Finally, patients that use opioids, licit and illicit, also have a potential increase in morbidity and mortality during an admission. 3-4% of the adult population is on chronic [licit] opioid therapy and 0.2% use heroin (likely and underestimate). Patients who are opioid-tolerant will often require higher doses of opioids for acute pain, which they often don’t receive. Post-ventilator patients on pain relievers and sedation may withdraw even after only 5 days of inpatient administered opioids; this is often not recognized, as hospital providers may think withdrawal from outpatient opioids wouldn’t happen this far into an admission, not recognizing that medications given for intubations can and will delay this or cause iatrogenic physical dependence. Most importantly, opioid use disorder (OUD) is often not uncovered for a variety of reasons, including lack of recognition, unable to give history, patients not being forthcoming or understanding, family unaware or downplaying use, use deemed not relevant, methadone from an opioid treatment program is not on the Prescription Monitoring Program, or providers simply don’t ask. When patients are using IV substances, they may have additional complications including soft tissue infections, endocarditis, hepatitis, or other invasive infections related to IVDU. Finally, patients who use illicit substances often have complicated discharge needs including food and housing insecurities, insurance and support system deficits, and legal issues such as warrants, probation, and child protection.