Substance Use screening preoperatively
Myron Yaster MD, Lynne G. Maxwell MD, and Rita Agarwal MD
Many patients with substance abuse disorders (SUDs) are undiagnosed at the time of surgery. Short screening questionnaires as well as urine drug screening tools are available but we suspect that they are rarely used in most pediatric anesthesia practices. In previous PAADs we raised the question of preoperative screening for suicide and SUDS. Similarly, if and how we use these tools in elective and emergent pediatric anesthesia is unknown and not well studied. And what to do with positive results is even less clear. In today’s PAAD Stone et al.1 compared responses of a substance abuse (alcohol, tobacco, marijuana, vaping, and opioid use) survey completed by the patient and the preoperative survey completed by parents or guardians.
Original article
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. Paediatr Anaesth. 2023 Oct;33(10):808-815. doi: 10.1111/pan.14728. Epub 2023 Jul 12. PMID: 37435702
The stark reality is that according to Monitoring the Future approximately 20% of American 8th, 10th and 12th graders report using illicit substances2 and a recent CDC study found that overdose deaths in children aged 11-19 have increased 109%.3 Monitoring the Future is an investigator-initiated study that originated with, and is conducted by, a team of research professors at the University of Michigan’s Institute for Social Research. It was started in 1975 and had been continuously funded by the National Institute on Drug Abuse, and includes extensive surveys on substance use, ease of access to illicit substances, alcohol, over the counter medications attitudes, perceptions of safety, beliefs, experiences, cumulative use and much more.
Today’s study by Stone et al. was performed at Nationwide Children’s Hospital (Columbus OH). “At our children's hospital, preoperative information regarding health issues, previous surgeries, nil per os times, and other preoperative concerns is generally obtained from the parents. Given these practices, it is also common for screening for illicit substance use to rely primarily on parental reporting during the preoperative evaluation. Additionally, even if information is obtained directly from the patient, this questioning may be influenced if it is performed in the presence of parents. The current study compares answers regarding the history of illicit substance use between a survey completed by the patient on the day of surgery and the preoperative survey completed by parents or guardians during the pre-admission testing phone call.”1
The authors studied English speaking patients who were not cognitively impaired and scheduled for elective surgery between 7 AM and 4 PM, Monday-Friday. Patients completed the survey on an iPad without parental oversight. “The survey consisted of drop-down questions regarding illicit substance use in general and then specifically including alcohol, tobacco, vaping, marijuana, and narcotics. Using the drop-down survey, patients were asked to indicate “yes” or “no” to the use of various substances. If a participant selected “yes” to using any of the illicit substances, additional questions populated the survey asking about the age they started using the substance, and the last time they used the substance. Each participant could select any number of different substances, and drop-down questions would populate for each one. For vaping, an additional question asked about the substance they vaped with the options of nicotine, flavoring, and marijuana, tetrahydrocannabinol (THC) or cannabis. For marijuana consumption, a drop-down question asked about the method of drug intake with the options of smoking, vaping, and ingestion/edibles. The narcotics question began by asking the participant if they had ever received narcotics, with drop-down questions asking about use of narcotics.”1
“A total of 346 patients were initially approached regarding participation to accrue a final study cohort of 250 patients, resulting in an accrual rate of 72.3%. The final study cohort of 250 patients ranged in age from 12 to 21 years (mean age 15.8 ± 2.3 years.”1
What did they find? Consistent with the results from Monitoring the Future2 ,“Alcohol report rates were highest with 69 (27.6%) patients reporting use compared to only 5 parental reports (2%). There was a similar discrepancy in reported rates of vaping use (40 patient reports, 16.0% vs. 11 parental reports, 4.4%) and illicit substance use including marijuana (52 patient reports, 20.8% vs. 11 parental reports, 4.4%). Reported rates of tobacco use were lowest among the survey responses with 12 patient reports (4.8%) and 5 parental reports (2.0%).
Other than extent of alcohol, marijuana and vaping abuse, we don’t think any of us are surprised by these results. Parents (and we include ourselves in this category) are essentially clueless. The key to the success of this study is that “patients completed the survey without parental oversight and they were assured that data would be kept anonymous…so that their parents and treating physicians would not have access to the data collected.”1
The 800 pound gorilla in the room is what to do with this information? In adults, the perioperative period is considered a “teachable moment” and can be used to help with tobacco and opioid cessation. Would this also be true for adolescents? As we’ve discussed in a previous PAAD about suicide screening: Should elective surgery be postponed if recent substance use is identified? Adult studies usually recommend postponement only during acute intoxication, should the same be true in children? Does your institution have a process for doing such screening? Is there a process for referral and counseling? What, if, and how should the parents/guardians be informed? If patients have been told that their answers will not be disclosed, how can responses indicating substance abuse be acted upon? At what age should patients be screened? 10? 12? 14? 16? Should intraoperative or postoperative pain be management be modified in light of this information?
We applaud Stone et al. for this really important study which will hopefully be the first of many future studies based on these results. Let us know what you think and Myron will post in a future Friday Reader response.
PS from Myron: I’ve made the editorial decision to hold off, as much as possible, on reviewing articles for the PAAD until they appear in print (many are first published on-line). A related paper published on line by Jamie Kitzman et al. in Anesth and Analgesia (PMID: 37450650) which addresses many of the questions raised above will be reviewed once it is in print, so stay tuned.
References
1. 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
2. Miech R, Johnston L, Patrick ME, O'Malley PM, Bachman JG, Schulenberg JE. Monitoring for the future: National survey results on drug use, 1975-2022: Secondary School Students. The National Institute on Drug Abuse at The National Institutes of Health. Accessed 09/20/2023, 2023. https://monitoringthefuture.org/wp-content/uploads/2022/12/mtf2022.pdf
3. Tanz LJ, Dinwiddie AT, Mattson CL, O'Donnell J, Davis NL. Drug Overdose Deaths Among Persons Aged 10-19 Years - United States, July 2019-December 2021. MMWR Morbidity and mortality weekly report. Dec 16 2022;71(50):1576-1582. doi:10.15585/mmwr.mm7150a2