Substance-Use Disorders in Young Patients
Myron Yaster MD and Rita Agarwal MD
Today’s PAAD by Kitzman et al.1 and its accompanying editorial published in the December 2024 issue of Anesthesia and Analgesia, reminds us once again that substance abuse in adolescents and young adults is a growing issue that is constantly evolving. “Because recreational drug use is a dynamic phenomenon, the last several decades have brought profound changes to drug markets, including the types of drugs being used, the potency of drugs, mode of sales, and the development of novel psychoactive substances.”1
“Given the prevalence of substance use disorder (SUD), anesthesiologists will encounter adolescents and young adults (AYAs) with known, or more commonly unidentified, SUD in the perioperative period. It is important for clinicians to familiarize themselves with the evolving climate and implications of SUD, consider incorporating screening tools used to identify patients with substance misuse or SUD, and develop perioperative plans to optimize care for these patients In this article, Kitzman et al. discuss the evolution of substance use in AYAs, the impact of the COVID-19 pandemic on adolescent substance use , treatment options and gaps in care for adolescents with SUD, and perioperative considerations of the adolescent patient.1
We have discussed many of these issues in previous PAADs (PAAD 08/08/2024 https://ronlitman.substack.com/p/cannabis-use-disorder-and-postoperative PAAD 05/30/2023 https://ronlitman.substack.com/p/ok-we-know-there-is-an-opioid-crisis PAAD 02/06/2024 https://ronlitman.substack.com/p/the-opioid-crisis-in-adolescents and today’s PAAD should remind us how much more we need to know.
It is beyond the scope of the PAAD to review all the issues discussed in today’s article and editorial, and I would urge all of you to read these articles in their entirety. We will concentrate on some of the highlights, particularly perioperative screening. Finally, I’ve asked Dr. Rita Agarwal of the PAAD’s pain team to assist even though she is the senior author of today’s article. Myron Yaster MD
Original article
Kitzman JM, Mesheriakova VV, Borucki AN, Agarwal R. Substance Use Disorders in Adolescents and Young Adults: History and Perioperative Considerations From the Society for Pediatric Pain Medicine. Anesth Analg. 2023 Jul 14. doi: 10.1213/ANE.0000000000006623. Epub ahead of print. PMID: 37450650. 139(6):1244-1255, December 2024.
Editorial
Martin, T. & Steele, E. (2024). Substance-Use Disorders in Young Patients—Much More Than Preop Questions and Potential for Drug Interactions. Anesthesia & Analgesia, 139 (6), 1240-1243. doi: 10.1213/ANE.0000000000007232.
“The perioperative period can be a particularly perilous time for patients with SUD, whether treated or untreated. Patients with (opioid use disorder) OUD are at increased risk for recurrence and relapse at discharge.”1 But why are adolescents and young adults at such increased risk? Remember when you had your first child? So angelic, so perfect and you were their stars and moon? And then BOOM! He/she became an adolescent and right of the movie the Exorcist they become possessed. “Adolescence is a period of active brain growth, synaptogenesis, and maturation. This period of change is second only to the growth and development that occurs during infancy. Adolescents are particularly susceptible to drug use and the development of SUDs as compared to adults due to developmental differences in the prefrontal cortex (PFC), striatal cortex, and limbic system. The PFC, the center for reasoning and decision-making, grows during childhood but remains immature in adolescence.2 Furthermore, the responsiveness of the striatal cortex to immediate rewards, such as sugar, money, and potential drugs of abuse, peaks during the adolescent period.2 The limbic region stores and retrieves events that evoke a strong emotional response, like pleasure in response to various substances. This center for processing emotions and memories matures sooner in adolescence compared to the reasoning center. Hence, adolescents are biologically primed to make decisions based on emotion and immediate rewards rather than reasoning through long-term consequences. Furthermore, studies suggest that 62% of adolescents with severe SUD will continue to experience SUD in adulthood.2”1,3
We can assume that many adolescents and young adults presenting for surgery or procedures under anesthesia will have experimented with or misused substances, some on a regular and recurring basis. Some may meet the criteria for SUD and may or may not have been diagnosed. Most will not be receiving any treatment. And let’s also assume that knowing what drugs patients are taking before you anesthetize a patient is important regardless of age or condition. How can you screen? There are 2 easy and quick screening tools: Short for Screening to Brief Intervention (S2BI) screen tool4 (figure) and the Car, Relax, Alone, Forget, Friends/Family, Trouble (CRAFFT) (https://crafft.org/ ),5,6 either of which should become a routine part of your practice for all adolescents, and should include appropriate time and place for these screenings to take place .7
Private, confidential screening should occur for all patients but , but we suspect that people and institutions are not doing this routinely. This is an area that we can and should be leaders in and is one that is begging for research, data, and implementation. Are you using these screening tools in your practice? Did you even know they existed? What are the impediments to implementation? Send your comments to Myron who will post in a Friday reader response.
OK, Why should you care? For most people exposure to opioids and other controlled substances often occurs during adolescence, and is associated with painful surgical or other ( 3rd molar extraction) procedures. “The perioperative period can be a particularly perilous time for patients with SUD, whether treated or untreated. Patients with OUD (opioid use disorder) are at increased risk for recurrence and relapse at discharge. Opioid exposure for the treatment of perioperative pain may serve as a priming event for persistent opioid use.”1 And this is important not only for opioids, for many other drugs of abuse like tobacco, alcohol, and cannabis which are the MOST common substances of misuse. In the adolescent and young adult population one of the most common methods of taking drugs is thru vaping. Many substances can be vaped including nicotine, caffeine, cannabis products, cocaine, heroin, a variety of synthetic drugs called novel psychoactive substances, vitamins, and supplements.8 All will affect perioperative pulmonary function and your anesthetic.
Finally, Kitzman et al. conclude: “Anesthesiologists can play a distinctive role in identifying youth at risk for SUDs and in optimizing the perioperative care of these patients. Families and primary care physicians may not know about the child’s use of substances, so the preoperative period may be an unparalleled opportunity to discuss the risks of recreational drug use and impact lifelong health outcomes. In daily practice. It means performing preoperative screening to identify at-risk patients and counseling patients and families about perioperative pain management expectations. In addition to optimizing the anesthetic plan with a goal to reduce PPOU and nonmedical use of opioids, anesthesiologists have the opportunity to educate patients, families, and other clinicians about patient-centered pain management approaches, including multimodal analgesia and nonpharmacologic therapy, in the perioperative period. Anesthesiologists can serve as patient advocates outside of the operating room, stressing the importance of close and consistent follow-up for patients on Medication Assisted Therapy (MAT) so they may safely reestablish treatment for their SUD, manage their pain, and reduce risk of opioid misuse and other SUDs in this critical period. As experts in pain management and pharmacology, anesthesiologists can lead efforts to make a significant impact on a patient’s life in a brief preoperative interaction and ameliorate this national crisis.”
What do you think? Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Kitzman JM, Mesheriakova VV, Borucki AN, Agarwal R. Substance Use Disorders in Adolescents and Young Adults: History and Perioperative Considerations From the Society for Pediatric Pain Medicine. Anesthesia and analgesia 2023 (In eng). DOI: 10.1213/ane.0000000000006623.
2. Hsiung H, Patel K, Hundal H, Baccouche BM, Tsao KW. Preventing Substance Abuse in Adolescents: A Review of High-Impact Strategies. Cureus 2022;14(7):e27361. (In eng). DOI: 10.7759/cureus.27361.
3. Galván A. Adolescent Brain Development and Contextual Influences: A Decade in Review. J Res Adolesc 2021;31(4):843-869. (In eng). DOI: 10.1111/jora.12687.
4. Levy S, Weitzman ER, Marin AC, Magane KM, Wisk LE, Shrier LA. Sensitivity and specificity of S2BI for identifying alcohol and cannabis use disorders among adolescents presenting for primary care. Substance abuse 2021;42(3):388-395. (In eng). DOI: 10.1080/08897077.2020.1803180.
5. Shenoi RP, Linakis JG, Bromberg JR, et al. Predictive Validity of the CRAFFT for Substance Use Disorder. Pediatrics 2019;144(2) (In eng). DOI: 10.1542/peds.2018-3415.
6. Knight JR, Shrier LA, Bravender TD, Farrell M, Vander Bilt J, Shaffer HJ. A new brief screen for adolescent substance abuse. Archives of pediatrics & adolescent medicine 1999;153(6):591-6. (In eng). DOI: 10.1001/archpedi.153.6.591.
7. Stone K, Rice-Weimer J, Tram NK, Tobias JD. Efficacy of an expanded preoperative survey during perioperative care to identify illicit substance use in teenagers and adolescents. Pediatric Anesthesia 2023;33(10):808-815. DOI: https://doi.org/10.1111/pan.14728.
8. Tai H, Swartz MD, Marsden D, Perry CL. The Future of Substance Abuse Now: Relationships among Adolescent Use of Vaping Devices, Marijuana, and Synthetic Cannabinoids. Subst Use Misuse 2021;56(2):192-204. (In eng). DOI: 10.1080/10826084.2020.1849305.