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Development of a perioperative drug screening algorithm for patients with a history of cocaine and methamphetamine use presenting for an elective procedure with anesthesia
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PERIOPERATIVE DRUG SCREENING ALGORITHM
Development of a Perioperative Drug Screening Algorithm for Patients
with a History of Cocaine and Methamphetamine Use Presenting for an Elective
Procedure with Anesthesia
by
Jacob Abel
A Doctoral Capstone Presented to the FACULTY OF THE USC KECK SCHOOL OF
MEDICINE UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE
May 2025
ii
PERIOPERATIVE DRUG SCREENING ALGORITHM
Distribution of Work
The following manuscript was contributed to in equal parts by "Jacob Abel, Laurent Estrada,
and Omar Silva.”
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PERIOPERATIVE DRUG SCREENING ALGORITHM
Acknowledgments
We would like to extend our deepest gratitude to the Program of Nurse Anesthesia at the
University of Southern California—program directors Dr. Jeffrey Darna and Dr. Elizabeth
Bamgbose, whose dedication to nurse anesthesiology education has made an immeasurable
impact on the profession. We would also like to thank the faculty members, as they have
dedicated numerous hours to our professional development and provided scholarly mentorship.
We extend our heartfelt gratitude to Dr. Jeffrey Darna, our esteemed faculty chair, whose
visionary insight inspired the inception of this scholarly project. His invaluable expertise has
been pivotal in the realization of this project. We are deeply grateful for his steadfast guidance
and unwavering encouragement throughout this journey. Dr. Darna's commitment to excellence
has been instrumental in elevating this project to a national platform.
A special thank you to our esteemed committee members and readers, Drs. Josh Carr and
Elizabeth Bamgbose. Their mentorship and expertise were instrumental in the development of
this project. We sincerely thank them for their invaluable contributions.
Fight On.
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PERIOPERATIVE DRUG SCREENING ALGORITHM
Table of Contents
Distribution of Work ii
Acknowledgments iii
Abstract vi
Chapter 1 1
Introduction 1
Background and Significance 2
Clinical Question and Specific Aims 5
Project Implications 6
Chapter 2 7
Literature Review 7
Pharmacology 7
Clinical Outcomes 13
Combined Outcomes of Drug Screen Positive Patients 18
Methods of Risk Stratification 19
Literature Synthesis 25
Cocaine Algorithm Recommendations 25
Methamphetamine Algorithm Recommendations 26
Risk Calculator Recommendations 26
Urine Drug Screen Recommendations 27
Chapter 3 29
Methodology 29
Operational Definitions 31
Chapter 4 33
Results 33
Research Findings and Clinical Recommendations 33
Safety of Anesthesia in Patients with Cocaine and Methamphetamine Use 33
Signs of Toxicity 34
Risk Calculators 35
The Role of Preoperative UDS on the DOS 35
Perioperative Algorithm 36
Conclusion 38
Chapter 5 39
Discussion 39
v
PERIOPERATIVE DRUG SCREENING ALGORITHM
Specific Aim Analysis 40
Project Impact 43
Practice Implications 43
Implications for Research 44
Future of Policy 44
Project Strengths 45
Project Limitations 46
Final Conclusion 48
References 50
Appendix A: Prisma Diagram 60
Appendix B: Physiologic Changes Associated with Cocaine & Methamphetamine Use 63
Appendix C: Perioperative Algorithm 65
vi
PERIOPERATIVE DRUG SCREENING ALGORITHM
Abstract
Patients with a history of cocaine or methamphetamine use present unique challenges to
anesthesia professionals. The management of these patients is marred by inconsistency due to the
absence of comprehensive clinical practice guidelines. This lack of guidance has led anesthesia
professionals to make ad hoc decisions, sometimes resulting in surgical delays or cancellations.
A thorough literature review evaluated the risks associated with cocaine and methamphetamine,
perioperative outcomes of patients with such history, means of risk stratification, and the utility
of urine drug screens (UDS). The evidence revealed that UDS alone was unreliable in predicting
perioperative mortality, myocardial infarction, or stroke. Additional tools to UDS, such as
cardiac risk calculators, may aid in clinical decision-making. An algorithm has been developed
to guide perioperative practice for patients with a history of cocaine or methamphetamine use,
specifically in the elective surgery setting.
Keywords: cocaine, methamphetamine, urine drug screen, anesthesia, algorithm
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PERIOPERATIVE DRUG SCREENING ALGORITHM
Chapter 1
Introduction
The National Survey on Drug Use and Health (NSDUH) reported illicit drug use has
increased in the United States (US) over the last decade (Han et al., 2021). Two illicit drugs
pertinent to the perioperative setting are cocaine and methamphetamine. The NSDUH estimated
that 5.2 million people in the US regularly used cocaine in the past year, and 2.5 million people
regularly used methamphetamine (Han et al., 2021). As illicit drug use becomes increasingly
prevalent and more people undergo elective surgery, nearly 4.3 million per month in the US,
anesthesia professionals will encounter patients who frequently use cocaine and
methamphetamine (Squitieri et al., 2021). This paper evaluated the current evidence and best
practices in perioperative care for the patient presenting positive for cocaine and
methamphetamine on the Day of Surgery (DOS).
A risk and safety assessment must be performed to determine whether to proceed with an
elective procedure when a drug screen is positive (Bartels & Schacht, 2021; Sakawi & Whitley,
2016). The decision to screen a patient varies among anesthesia professionals, which stems from
no clear published practice guidelines and lack of or mixed institutional policies. Clinical
practice can differ significantly between institutions and practitioners, with some anesthesia
professionals choosing to proceed to surgery without drug testing, provided a patient does not
exhibit signs of drug toxicity. However, other anesthesia clinicians routinely screen for illicit
drugs before elective procedures and cancel for a positive finding (Bartels & Schacht, 2021;
Sakawi & Whitley, 2016). Same-day case cancellations are an expensive, nonrecoverable cost to
healthcare systems and further delay the elective procedure (Bartels & Schacht, 2021; Campbell
et al., 2011).
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PERIOPERATIVE DRUG SCREENING ALGORITHM
A positive urine drug screen (UDS) for cocaine or methamphetamine is generally
perceived as a risk factor for adverse perioperative cardiac complications (Satish et al., 2021).
Both drugs exert powerful and potentially deleterious stimulating effects on the sympathetic
nervous system. Acute intoxication of cocaine and methamphetamine may increase the risk of
myocardial infarction (MI) and, thus, increase intraoperative morbidity and mortality (Sakawi,
2015). Interestingly, recent investigations found a positive drug screen for cocaine or
methamphetamine among patients undergoing emergency surgery was not predictive of
perioperative mortality, MI, or stroke (Culhane & Freeman, 2020; Satish et al., 2021). These
findings suggest that with appropriate risk stratification, it may be safe to proceed with an
elective procedure following a positive UDS. Clinical guidelines and evidence-based policies
may help anesthesia professionals appropriately screen and risk stratify patients with a history of
cocaine or methamphetamine use; departmental policy on drug screening with practice
recommendations may enhance resource allocation and promote timely access to perioperative
care.
Background and Significance
Anesthesia professionals must consider cocaine and methamphetamine use to risk stratify
patients who present on the DOS for an elective procedure. The National Center for Drug Abuse
Statistics (NCDAS, 2022) estimated cocaine and methamphetamine prevalence among adults 18
years and older was two percent and one percent, respectively, in 2020. The NCDAS further
reported that 874,000 Americans used cocaine and 205,000 used methamphetamines for the first
time in 2020. In 2005, the economic burden of methamphetamine use was estimated at $23.4
billion (Neeki et al., 2018). The high drug use prevalence in the US warrants serious
consideration for anesthesia professionals to adopt evidence-based policies and best practices on
3
PERIOPERATIVE DRUG SCREENING ALGORITHM
correct and appropriately timed drug screening during the preoperative phase in patients with a
history of cocaine and methamphetamine use.
Little research has evaluated the effectiveness or impact of drug screening in elective
surgery when a patient endorses a history of cocaine and methamphetamine use. Consequently,
wide practice variations occur and may depend on department policy and clinician opinion.
Anesthesia outcomes in patients presenting for emergency surgery with a history of
methamphetamine or cocaine have elucidated some perioperative risks and adverse events
associated with active drug use. Shymon et al. (2020) estimated that 40% to 50% of injuries in
trauma patients involve an illicit substance, which provided the basis for most of the research on
anesthesia outcomes for emergency surgery in patients with cocaine or methamphetamine use.
The Substance Abuse and Mental Health Services Administration (SAMHSA) reported
that 1,539 per 100,000 Emergency Department (ED) visits between 2004 and 2011 were related
to illicit drug use that also required surgical intervention. The emergency setting, where a
positive drug screen does not preclude anesthesia or surgical intervention, has provided the most
insight into the outcomes of UDS-positive patients.
Culhane & Freeman (2020) reviewed perioperative outcomes from the National Trauma
Data Bank. The investigators found patients with a positive UDS had lower mortality than those
with a negative UDS (RR = 0.76, p < 0.001). Satish et al. (2021) noted similar outcomes: a
positive UDS for cocaine or methamphetamine did not predict MI or stroke in trauma patients.
Interestingly, the research team found reduced risk for perioperative MI (RR = 0.45, p < .001)
and mortality (RR = 0.76, p < 0.001) in patients with a positive UDS for cocaine compared to
UDS-negative patients. Similar findings were reported for patients with a UDS positive for
methamphetamine with MI (RR = 0.58, p = .005) and mortality (RR = 0.83, p < .001). The
4
PERIOPERATIVE DRUG SCREENING ALGORITHM
protective mechanisms of positive UDS for cocaine and methamphetamine are unclear.
However, Satish et al. (2021) noted study patients had a mean age of 41.19 years for cocaine and
41.27 years for methamphetamine, indicating their baseline 10-year risk for MI was already low.
These data suggest that UDS status may not significantly predict perioperative complications and
outcomes in younger patients and patients with few risk factors for MI or stroke.
One anesthesia concern is the potential for hemodynamic instability associated with
cocaine and methamphetamine. A study of methamphetamine-positive patients compared to
methamphetamine-negative patients undergoing elective surgery found significant differences in
heart rate and systolic blood pressure between the two groups, yet no occurrence of
cardiovascular or cerebrovascular adverse events (Safdari et al., 2022). Alternatively, Moon et al.
(2021) studied cocaine-positive and cocaine-negative patients undergoing elective surgery and
found equivalent intraoperative hemodynamic events for mean arterial pressure (MAP) and heart
rate using a multivariable regression model. These findings provide insight into identifying safe
perioperative management of UDS-positive patients in the elective surgery setting.
Neither the American Association of Nurse Anesthesiology (AANA) nor the American
Society of Anesthesiologists (ASA) has published a clinical practice guideline or position
statement on perioperative management in patients with a positive drug screening for cocaine or
methamphetamine, although the AANA requires clinicians to perform a thorough verbal drug
history during the preanesthetic evaluation. The Veterans Health Administration (VHA), the
US's most extensive integrated healthcare system, has not issued practice guidance, deferring
drug screening policy to individual facilities. Elkassabany et al. (2013) surveyed 172 VHA
hospitals and discovered only 11 facilities had a formal drug screening policy, and two-thirds of
respondents canceled elective surgery in the setting of a positive UDS.
5
PERIOPERATIVE DRUG SCREENING ALGORITHM
In addition to upholding patient safety, anesthesia professionals must consider the
economic consequences of case cancellation. Modern UDS systems can detect cocaine use for up
to 14 days and methamphetamine use for up to 6 days after last use, potentially leading to
significant procedural delays if a clean screening result is required before the administration of
general anesthesia (Bartels & Schacht, 2021; Githens et al., 2019). Surgery cancellations impact
healthcare facilities and can decrease Operating Room (OR) efficiency and revenue. Using the
2009 Medicare repayment rates, the average revenue loss per canceled surgery was $4,550
(Campbell et al., 2011). Surgical delays and cancellations may also lead to suboptimal patient
outcomes, poor patient experience, and added financial burden on patients due to surgical
rescheduling (Wong et al., 2018).
Clinical Question and Specific Aims
We formulated the following clinical questions to guide the scholarship project and
subsequent literature review:
Can patients with a recent history of cocaine or methamphetamine use receive anesthesia
safely for an elective procedure on the day of surgery compared to patients who do not
use cocaine or methamphetamine?
The purpose of the scholarship inquiry was to develop an evidence-based approach to
guide anesthesia professionals on risk stratification and preoperative decision-making for
patients with a recent history of cocaine and methamphetamine use who present for an elective
procedure. We propose three specific aims for the project.
1. Determine the risks and benefits of proceeding with an elective procedure for patients
with a recent history of cocaine or methamphetamine use and test positive on a UDS.
6
PERIOPERATIVE DRUG SCREENING ALGORITHM
2. Evaluate the utility of preoperative UDS on the DOS in patients presenting for an
elective procedure who have a recent history of cocaine or methamphetamine use.
3. Develop a clinical decision-making algorithm for patients reporting a history of
cocaine or methamphetamine use in the elective procedure setting based on a synthesis of
the clinical research.
Project Implications
This scholarly project developed an evidence-based drug screening algorithm to guide the
perioperative management of patients with a history of cocaine and methamphetamine use. The
proposed algorithm encourages patient safety along the perioperative continuum through risk
stratification and appropriate patient selection. Furthermore, the algorithm may reduce
unnecessary surgical cancellations and delays in care. Likewise, healthcare organizations may
experience enhanced OR efficiency, increased revenue, and improved patient satisfaction.
Additionally, increasing anesthesia professional awareness of the value of perioperative UDS
and implementing appropriate management strategies during elective surgery can be an
opportunity to improve care for individuals with substance use disorders who are often
marginalized by social stigma associated with illicit drug use.
7
PERIOPERATIVE DRUG SCREENING ALGORITHM
Chapter 2
Literature Review
The purpose of the scholarship inquiry was to develop an evidence-based approach to
guide anesthesia professionals on risk stratification and preoperative decision-making for
patients with a recent history of cocaine and methamphetamine use who present for an elective
procedure. The scholarship project’s clinical question guided the literature review and synthesis.
We analyzed the effects of cocaine and methamphetamine use separately. Specifically, we
investigated the physiological changes caused by each drug and their implications for the
perioperative setting. Additionally, our review evaluated the perioperative outcomes of patients
who tested positive for cocaine or methamphetamine on UDS. Finally, we examined the various
UDS methods, including costs and potential ethical concerns.
Pharmacology
Cocaine Pharmacokinetics & Pharmacodynamics
Cocaine is synthesized from the Erythroxylum coca plant native to South America, the
Andes, Mexico, Indonesia, and the West Indies (Riezzo et al., 2012). The drug is produced in
these areas and illegally trafficked worldwide for recreational use. Cocaine may be consumed
intranasally, inhalational, or intravenously (Sakawi & Whitley, 2016). Following consumption,
cocaine results in dopamine accumulation in the nucleus accumbens of the brain, leading to
feelings of pleasure and satisfaction (Nestler, 2005). The increased dopamine levels partially
explain the drug’s recreational use and addictive properties.
Cocaine consumption produces systemic effects, some deleterious and specifically
affecting the heart, lungs, liver, kidneys, gastrointestinal tract, and musculature (Riezzo et al.,
2012). Cocaine activates the sympathetic nervous system through catecholamine reuptake at
8
PERIOPERATIVE DRUG SCREENING ALGORITHM
nerve terminals and induces arrhythmogenicity through the blockage of sodium and potassium
channels (Dominic et al., 2022; Riezzo et al., 2012; Stankowski et al., 2015). Pulmonary
complications occur mainly from inhalation activity that damages the alveolar-capillary
membrane and injures the pulmonary microvasculature (Riezzo et al., 2012). Cocaine increases
fatty acid infiltration in the liver, extends midzonal and periportal necrosis, and elevates aspartate
aminotransferase (AST) levels. The exact mechanism for these hepatic changes and subsequent
injuries remains unclear. Cocaine use may decrease renal blood flow and glomerular filtration by
degrading the glomerular matrix, promoting renal atherogenesis, and inducing sympatheticmediated rhabdomyolysis. Although the exact mechanisms are not fully understood, cocaine
promotes significant physiological changes throughout the body. Of the multiple systemic
effects, cardiovascular alterations pose the most clinically relevant challenge for anesthesia
professionals.
The cardiovascular consequences of cocaine use can predispose patients to MI,
arrhythmias, hypertension, prolonged QT interval, and coronary vasospasm (Saggese et al.,
2019). The potential cardiovascular effects can pose clinical management challenges for
anesthesia professionals and influence deciding whether to proceed or postpone an elective
procedure requiring anesthesia services. Stankowski et al. (2015) described the cardiotoxicity of
cocaine through three mechanisms involving sympathetic nervous system overactivation,
cardiomyocyte sodium and potassium channel blockade, and vasculature tone alteration that
promotes vessel constriction and thrombus formation. The cardiovascular effects of cocaine can
also be further divided into short- and long-term consequences. Short-term consequences
produce an imbalance in oxygen supply and demand, leading to MI or infarction. Arrhythmias
are common, with sinus tachycardia, reentry supraventricular tachycardias, and atrial fibrillation
9
PERIOPERATIVE DRUG SCREENING ALGORITHM
reported as the most prevalent. Arrhythmias can be triggered through MI, ion-channel blockade,
and sympathetic nervous system overstimulation. A common electrocardiogram (ECG) change is
a prolonged QT interval due to potassium channel blockade. Additionally, tachyarrhythmias
have been found in 56 to 84% of patients experiencing cocaine-associated chest pain (McCord et
al., 2008). In cocaine-positive patients with chest pain, ECG changes have a sensitivity of 36%
and specificity of 89.8% for predicting actual MI (McCord et al., 2008). Long-term use provokes
coronary atherosclerosis, aortic arteriosclerosis, and left ventricular remodeling from excess
afterload. Providing surgical and anesthetic care to patients under the influence of cocaine must
plan management with these considerations.
Methamphetamine Pharmacokinetics and Pharmacodynamics
Panenka et al. (2013) reviewed the molecular, pre-clinical, and clinical findings related to
methamphetamine use in the US. Methamphetamine is a psychostimulant first synthesized from
ephedrine in 1919 by Japanese scientist Akira Ogata. Methamphetamine is enjoyed
recreationally and may be consumed orally, intranasally, intravenously, or inhaled.
Methamphetamine produces euphoric symptoms, including increased libido, confidence, and
mood. Methamphetamine increases dopamine by enhancing its release from neuronal terminals.
Methamphetamine also increases norepinephrine levels. The catecholamine surge predisposes
the person to MI, stroke, and valvular heart disease. The cardiovascular effects of
methamphetamine provide clinically significant challenges to anesthesia professionals managing
care. The physiological effects are mainly sympathomimetic, increased heart rate and blood
pressure, gastrointestinal tract inhibition, and amplified stress hormone circulation. Long-term
use produces psychosocial effects that include irritability, aggression, and impulsivity. Cognitive
defects, such as memory impairment, appear with chronic use.
10
PERIOPERATIVE DRUG SCREENING ALGORITHM
Chronicity of Drug Use
The physiological effects of acute cocaine or methamphetamine use during anesthesia
have undergone extensive examination, consistently revealing no statistically significant
differences in mortality among patients testing positive for either substance (Satish et al., 2021;
Culhane & Freeman, 2020). Notably, these investigations have primarily focused on populations
with acute or hyperacute surgical needs, such as trauma patients, rather than those undergoing
elective procedures. Moreover, there is a notable gap in the research on chronic cocaine and
methamphetamine use in elective surgical patients. Chronic exposure to these substances
introduces complications like MI, fibrosis, and a surge in catecholamines, leading to adverse
outcomes such as myocyte apoptosis, ventricular remodeling, and an imbalance in myocardial
oxygen supply–demand (Ghuran & Nolan, 2000; Liaudet et al., 2014). Ghuran & Nolan (2000),
Safdari et al. (2022), and Neeki et al. (2018) propose that prolonged cocaine or
methamphetamine use may deplete catecholamines from both the cardiovascular and autonomic
nervous systems. Case reports further support the concept of cocaine-induced catecholamine
depletion leading to hypotension, hypothesized to involve the continuous release of
noradrenaline and dopamine (O'Donnell et al., 2022; Rich et al., 1998). This dynamic process
can culminate in refractory hypotension, necessitating vasopressor support even in otherwise
normal, healthy individuals.
The synthesis of crucial catecholamines, norepinephrine and dopamine, intricately linked
to the essential amino acid tyrosine, can become compromised with chronic cocaine or
methamphetamine use, especially depleting norepinephrine. This depletion attenuates vascular
tone and blood pressure, posing additional challenges to intraoperative hemodynamics (Ghuran
& Nolan, 2000; Liaudet et al., 2014). The optimal timing for anesthesia administration to
11
PERIOPERATIVE DRUG SCREENING ALGORITHM
leverage catecholamine repletion remains inadequately studied, relying on clinical experience
and retrospective studies (Culhane & Freeman, 2020; Satish et al., 2021). Despite limited direct
evidence, research on abstinence and dopamine levels suggests a potential correlation between
the duration of abstinence and catecholamine recovery, offering promise for more informed
anesthesia strategies (Culhane & Freeman, 2020; Satish et al., 2021).
The dysregulation of the dopamine system in individuals dependent on cocaine or
methamphetamine provides insights into the potential impact of prolonged abstinence on
catecholamine recovery and prompts considerations for optimizing catecholamine levels before
administering anesthesia. Imaging studies consistently show lower dopamine D2 receptors and
elevated dopamine transporter levels in cocaine-dependent individuals, impacting stimulated
dopamine release (Malison et al., 1998; Martinez et al., 2007; Volkow et al., 1993). Rodent
studies during abstinence reveal increased dopamine uptake and altered receptor expression,
indicating functional dysregulation in the early stages of withdrawal (Mateo et al., 2005;
Samuvel et al., 2008). Nonhuman primate research demonstrates prolonged abnormalities in
dopamine receptor levels, with recovery observed after 90 days of abstinence from cocaine
(Beveridge et al., 2009).
Similarly, methamphetamine users show increased dopamine transporter availability
during protracted abstinence, influenced by usage characteristics and duration of abstinence,
suggesting potential recovery of DAT availability in the striatum over time (Volkow et al.,
2001). These findings, particularly the extended recovery period observed in the 12-month
abstinence phase, suggest that alterations in the dopamine system due to cocaine or
methamphetamine exposure may not be permanent (Cass & Manning, 1999). Prolonged
abstinence could potentially lead to a more complete return to typical functioning levels. The
12
PERIOPERATIVE DRUG SCREENING ALGORITHM
connection to catecholamines is crucial, as individual differences in dopamine system
normalization, particularly during extended withdrawal, impact treatment outcomes (Hanlon et
al., 2013). Higher dopamine-stimulated release is associated with better outcomes, highlighting
the dynamic nature of neuroadaptations induced by stimulant exposure. Understanding the longterm effects of chronic sympathomimetic use on the cardiovascular system, including
catecholamine recovery during abstinence, can inform strategies to optimize catecholamine
levels and mitigate the risk of hypotensive events during surgery.
Cardiovascular Risk of Cocaine and Methamphetamine
The cardiovascular risks associated with cocaine and methamphetamine use are relevant
for anesthesia professionals. Chronic use of both substances can lead to catecholamine depletion,
resulting in intraoperative hypotension (Neeki et al., 2018; Rich et al., 1998; Safdari et al., 2022).
While intraoperative hypotension may occur, diligent preparation can preempt potential adverse
outcomes associated with this phenomenon. However, the risks associated with MI and
subsequent mortality demand heightened vigilance. The use of cocaine is associated with an
increased incidence of myocardial infarction (Hollander et al., 1994; Hollander & Hoffman,
1992; Sami et al., 2022). Notably, Mittleman et al. (1999) found that the risk of myocardial
infarction is significantly heightened, being 23.7 times more likely over baseline within the first
60 minutes after cocaine use.
Similar risks are associated with methamphetamine use, with potential consequences
including the development of coronary artery disease and coronary vasospasm, predisposing
patients to myocardial infarction (Kevil et al., 2019). Huang et al. (2016) observed a higher
incidence of cardiovascular and cerebrovascular events among methamphetamine users
compared to non-users (87.5/10,000 vs. 55.3/10,000 person-years, P < .001). Given these
13
PERIOPERATIVE DRUG SCREENING ALGORITHM
substantial cardiovascular risks, the administration of general anesthesia to individuals with a
history of cocaine or methamphetamine use calls for a focus on cardiovascular considerations.
Careful management and monitoring protocols should be in place to mitigate the potential
complications associated with these substances and ensure patient well-being.
Clinical Outcomes
Cocaine-Positive Population
Hill et al. (2006) explored perioperative outcomes of 40 cocaine-positive and 40 cocainenegative patients in the elective surgery setting. The cocaine-positive group was ascribed as nontoxic based on having normal blood pressure, heart rate, temperature, and ECG with a QT
interval <500 ms. The researchers investigated cardiovascular episodes between the two groups,
defined as a 30% change in heart rate or MAP relative to their pre-anesthetic baselines. The
study found three cardiovascular events related to MAP in the cocaine-positive group and four in
the cocaine-negative group. However, no significant differences were found between the groups
in systolic blood pressure (126 mmHg ± 6 mmHg vs 127 mmHg ± 7 mmHg for cocaine positive
and control, respectively, p = .49), MAP (93 mmHg ± 6 mmHg vs 95 mmHg ± 7 mmHg, for
cocaine positive and control, respectively p = .17), or heart rate (85 ± 4.5 vs. 84 ± 5 for cocaine
positive and control, respectively, p = .35). At the 24-hour postoperative follow-up, no
significant differences in patient outcomes were found between the two cohorts. The researchers
concluded that patients positive for cocaine via UDS and without signs of clinical toxicity
present no increased risk than cocaine-negative patients in the elective surgery setting.
A retrospective study by Baxter & Alexandrov (2012) identified 300 patients and
separated them into two groups based on their UDS status of cocaine-positive or cocainenegative. The research compared the occurrence of intraoperative hemodynamic events between
14
PERIOPERATIVE DRUG SCREENING ALGORITHM
the two groups, defined as a 20% change in heart rate, a 20% in blood pressure, severe elevation
of blood pressure with the use of any antihypertensive, severe drop in blood pressure with the
use of vasopressors, and any changes in the ECG. The researchers found no significant
difference in intraoperative hypotension, heart rate, or combined hypotensive and heart rate
events (p = NS). The cocaine-positive group required more antihypertensive (n = 8 [5.3%] vs. n
=26 [17%] for cocaine-negative and cocaine-positive, respectively, p = .02). Additionally, the
cocaine-positive group required the use of more vasopressor (n = 51 [34%] vs. n = 83 [55%] for
cocaine negative and cocaine positive, respectively, p = .003). The researchers noted the
increased antihypertensive and vasopressor requirements were unclear but might have been
influenced by the anesthesia professional’s knowledge of cocaine-positive status. The
researchers concluded that a cocaine-positive UDS status was not a significant risk factor for
elective surgical procedures.
A prospective study conducted by Moon et al. (2021) compared intraoperative
hemodynamic events between asymptomatic cocaine-positive and cocaine-negative patients in
328 patients scheduled for noncardiac surgery under general anesthesia. A UDS determined the
presence of cocaine. The research team measured the participant’s MAP and heart rate variance
that fell outside established parameters using a multivariable regression model. In this model, the
β coefficients of MAP and heart rate between both groups were measured for adverse
hemodynamic outcomes. In this statistical tool, a significant value would determine that the two
groups were significantly statistically equivalent. The researchers also measured troponin levels
in cocaine-positive patients. A comparison of the two groups found the percentage of
intraoperative hemodynamic events to be equivalent between the cocaine-positive group and the
cocaine-negative group with a 7.5% and 5% margin of equivalence for MAP (β coefficient = 2%,
15
PERIOPERATIVE DRUG SCREENING ALGORITHM
p = .003) and heart rate (β coefficient = 0.2%, p < .001). Arrhythmias did not occur in either
group and no clinically-relevant troponin levels were detected. The research team found no
significant difference between the two groups. The cocaine-positive group was further separated
into groups that reported consuming cocaine within 24 hours and outside 24 hours. Again, no
significant difference was found in percentage of hemodynamic intraoperative differences in
heart rate (7.3% ± 9.4% vs 9.2% ± 15.6% for cocaine use within 24 hours and outside 24 hours,
respectively, p = .49) and MAP (18.1% ± 16.7% vs 19.1% ± 17.2%) for cocaine use within 24
hours and outside 24 hours, p = .82) between the two groups. The findings support that
anesthesia can be safely provided for the cocaine-positive patient.
Methamphetamine-Positive Population
Unlike cocaine intoxication, methamphetamine use produces greater and longer
hemodynamic instability. Githens et al. (2019) studied perioperative complications from
orthopedic trauma surgery in patients with a methamphetamine-positive drug screen. The
researchers found that methamphetamine-positive drug screens frequently delayed a surgical
intervention because of anesthetic concerns. Potential cardiovascular complications related to
hemodynamic instability and temperature changes were the primary concerns cited. Anesthesia
professionals anticipated acutely intoxicated patients would have increased anesthetic
requirements, hemodynamic instability, and cardiac arrhythmias. Conversely, clinicians believed
that chronic methamphetamine consumption resulted in decreased anesthetic requirements and
refractory hypotension, requiring treatment with a direct-acting vasoactive agent. The
investigators noted a small increase in risk for cardiovascular complications (2.1%) in orthopedic
trauma patients with positive results for methamphetamine compared to orthopedic patients who
are not methamphetamine-positive (1.3%) (Githens et al., 2019). Overall, the researchers found
16
PERIOPERATIVE DRUG SCREENING ALGORITHM
no clear association between a methamphetamine-positive UDS on admission and increased inhospital mortality.
Safdari et al. (2022) explored the hemodynamic effects of methamphetamine and general
anesthesia. The authors found little data on the effects of general anesthesia in patients who test
positive for amphetamines on UDS before arriving at the OR, especially the supratherapeutic
doses consumed by illicit methamphetamine users. Prescription doses of methamphetamine
range from 2.5-10 mg/day (maximum 60 mg daily) compared with illicit use dosages that reach
5000 mg/day. The authors used previous studies on therapeutic doses consumed for ADHD or
narcolepsy as a baseline to assess hemodynamic instability among illicit amphetamine users. A
retrospective review of anesthesia records assessed hemodynamic instability: a 40% drop in
MAP for at least 5 minutes or the requirement of vasoactive medications. This study found a
significant increase in hemodynamic instability in patients who tested positive for amphetamines
by UDS within 48 hours of surgery (43 [31.4%]) compared to patients who tested positive
between 48 hours and seven days (18 [26.1%]) and patients who tested negative within a week of
surgery (10 [6.3%], p < .0001). The hemodynamic instability was attributed to depleted
catecholamine reserves taking longer than seven days to replenish and the long-lasting effects of
high-dose methamphetamines on the cardiovascular system. The authors found that healthy,
nontoxic patients positive for methamphetamine within 48 hours of surgery have more
hemodynamic instability during the first hour of general anesthesia than patients who do not use
methamphetamine. Methamphetamine-positive patients required significantly higher doses of
phenylephrine (905 ± 761 mcg vs. 550 ± 277 mcg, p = .028) and ephedrine (29.2 ± 28.8 mg vs.
8.6 ± 4.1 mg, p = .016) compared to methamphetamine-negative patients. Interestingly, the
methamphetamine-positive patients between 48 hours and seven days have a lower risk of
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PERIOPERATIVE DRUG SCREENING ALGORITHM
hemodynamic instability than those who were acutely intoxicated but still had increased risk
compared to the general population.
Neeki et al. (2018) analyzed trauma patient data to assess the impact of a
methamphetamine-positive UDS on hospital mortality. The study found trauma patients were
routinely screened for illicit drugs, yet the clinical value of a positive UDS and subsequent
management was not well defined in the literature. The research facility performs emergency
surgery regardless of UDS results; however, they may delay non-emergent surgeries in patients
with a methamphetamine-positive UDS for up to five days. The authors emphasized that
improving clinicians' understanding of methamphetamine may lead to better clinical
management and allocation of hospital resources. The study matched 449 methamphetaminepositive and methamphetamine-negative patients and found that methamphetamine-positive
patients have a significantly higher heart rate (99.96 ± 22.76 vs. 94 ± 20.61 for
methamphetamine-positive and methamphetamine-negative, respectively, p < .0001) and
significantly lower systolic blood pressure than the methamphetamine-negative group (126.89 ±
26.9 mmHg vs. 131.52 ± 24.34 mmHg for methamphetamine-positive and methamphetaminenegative, respectively, p < .0149). They found no significant difference in hospital mortality
between the two groups (3.3% vs. 2.7% for methamphetamine-positive and methamphetaminenegative, respectively, p = .5577). Although the physiologic variations were significant, the
authors concluded the changes were likely clinically insignificant. Furthermore, the study
reported a significant increase in length of stay, potentially due to surgical delays after a
methamphetamine-positive UDS (4 vs. 3 days; p < .0001). The authors concluded that despite no
significant increase in mortality among methamphetamine-positive patients, a UDS was still
warranted to assist with medical decision-making throughout the patient’s hospital course.
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PERIOPERATIVE DRUG SCREENING ALGORITHM
Combined Outcomes of Drug Screen Positive Patients
Culhane & Freeman (2020) conducted a propensity-matched analysis on perioperative
complications between positive and negative drug screen patients. The team matched 299,898
drug-screen-positive patients and drug-screen-negative patients from the National Trauma Data
Bank. The researchers compared the two groups based on mortality, MI, arrhythmia, and the sum
of all complications (AC). The study revealed that patients with a drug screen-positive status
showed lower mortality (RR = 0.84, p < 0.001); however, the rate of all complications remained
higher in the drug screen positive group (RR = 1.08, p < .001). Overall, a drug screen-positive
status was not associated with increased incidence of MI (RR = 0.79, p = .01). Cocaine by itself
was associated with increased incidence of MI (RR = 3.33, p = .05). The authors determined that
a positive drug screen was not associated with increased perioperative cardiac morbidity or
mortality. Furthermore, they noted that the results of screening tests do not correlate with
clinically significant morbidity or mortality. The researchers found that a drug screen-positive
status should be considered a high-risk group for perioperative complications. A study limitation
was that UDS status does not determine clinical toxicity.
Satish et al. (2021) evaluated the association between illicit stimulants and the risk of
cardiovascular complications risks and mortality in 317,688 National Trauma Data Bank
patients. The investigation analyzed mortality, MI, and stroke among patients with UDS positive
for cocaine or methamphetamine to UDS negative patients. The authors discovered cocaine was
not a significant predictor of MI (OR = 0.63, p = .065) or stroke (OR = 0.91, p = .502) in trauma
patients. Amphetamine was also a non-significant predictor of mortality (OR 0.97, p = .405), MI
(OR 0.80, p = .283), or stroke (OR 1.02, p = .857). Both cocaine and methamphetamine were
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PERIOPERATIVE DRUG SCREENING ALGORITHM
found to be protective against mortality. Satish et al. (2021) concluded that UDS positive for
cocaine or methamphetamine was not an adverse risk factor for death, stroke, or MI in trauma.
Methods of Risk Stratification
Risk Calculators
The use of cardiac risk calculators can be a simple way to predict perioperative risk and
facilitate decision-making. The goal of these calculators is to reduce the incidence of major
adverse cardiac events (MACE), which are defined as cardiovascular death, nonfatal myocardial
infarction, or nonfatal stroke (Arnott et al., 2020). MACE is a leading cause of death following
surgery and is associated with a significant increase in morbidity and mortality (Gupta et al.,
2011). While diverse definitions for adverse cardiac events exist, their common aim is to
mitigate the associated morbidity and mortality. Several cardiac risk calculators appear in the
literature and find practical application in clinical settings. These tools allow anesthesia
professionals to stratify patients into low-, moderate-, or high-risk categories based on
comorbidities or procedural characteristics. Understanding risk can help determine whether
surgery can proceed or whether further workup is warranted.
The Lee Revised Cardiac Risk Index (RCRI) uses six parameters to predict MACE (Lee et al.,
1999). The definition for MACE in this tool also includes the occurrence of ventricular fibrillation,
pulmonary edema, and complete heart block. The instrument should be used in patients older than 45
years or in patients 18 to 44 years old who have significant cardiovascular disease undergoing an elective
or urgent/semi-urgent non-cardiac surgery. A score of ≤ 1 designates a low risk for MACE, while a score
of 2 or more indicates a higher risk for MACE (Fleisher et al., 2014). Despite its age, the tool has been
researched and possesses moderate validity (Andersson et al., 2015; Ford et al., 2010). A limitation,
however, is noted in the original studies’ use of CK-MB rather than the more sensitive troponin as
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PERIOPERATIVE DRUG SCREENING ALGORITHM
evidence of myocardial injury (Ford et al., 2010). Additionally, Devereaux et al. (2011) and Sheth et al.
(2015) found the tool both overestimates and underestimates MACE risk depending on the assigned
population and context. Notwithstanding the limitations, the RCRI remains a reliable and validated
instrument for anesthesia professionals to stratify patients based on cardiac risk.
The American College of Surgeons (ACS) created two calculators: American College of
Surgeons National Surgical Quality Improvement (ACS-NSQIP) and ACS-NSQIP-MICA (myocardial
infarction or cardiac arrest). NSQIP-MICA assesses 5 criteria, with a key advantage being its specific
procedural type of utilization for evaluating MACE. Conversely, ACS-NSQIP is more comprehensive
tool, employing Current Procedural Terminology (CPT) codes and various other criteria to evaluate not
only cardiac risk but also other perioperative risks. These calculators can compute the risk of a MACE.
As per American Heart Association (AHA) guidelines, procedures with a risk of adverse cardiac events
are ≥ are considered elevated risk (Fleisher et al., 2014). The NSQIP risk calculators are validated tools
for identifying patients as low or high risk for MACE (Bilimoria et al., 2013; Vernooij et al., 2021).
However, its limitations include the use of the American Society of Anesthesiology Physical Status
(ASA), which as poor interrater reliability, and the narrow definition of MI, only considering ST-segment
Mis or a large troponin bump (>3 times normal) in symptomatic patients (Fleisher et al., 2014).
Functional status is a commonly evaluated parameter to determine perioperative risk. It is
expressed in terms of metabolic equivalents (METs), where 1 MET is the resting oxygen
consumption of a 40–year-old, 70-kg man (Fleisher et al., 2014). Functional capacity is classified
as excellent (>10 METs), good (7 METs to 10 METs), moderate (4 METs to 6 METs), poor (<4
METs), or unknown. The DASI (Duke Activity Status Index) and the Specific Activity Scale are
formal tools used to evaluate METs (Goldman et al., 1977; Hlatky et al., 1989). Patients
achieving 7-10 METs have low perioperative cardiovascular risk, while those achieving <4-5
METs face increased risk (Fleisher et al., 2014). Simple assessments like a patient's ability to
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PERIOPERATIVE DRUG SCREENING ALGORITHM
walk four blocks or climb two flights of stairs can also estimate cardiovascular risk (Reilly et al.,
1999). Patients unable to perform these tasks have higher adverse perioperative events (20.4%
vs. 10.4%; p<.001), involving myocardial ischemia (p = .02) and other cardiovascular events (p
= .04). The main limitation of functional status in perioperative settings is its subjective nature
(Fleisher et al., 2014).
Urine Drug Screen Policy
UDS as a preoperative assessment varies by facility and has not been included as a
standard practice. Elkassabany et al. (2013) conducted a seven-item survey of 172 anesthesia
chiefs from Veterans Affairs hospitals to estimate the frequency of encounters with patients with
a history of cocaine use and to report whether a formal policy existed for preoperative drug
screening. Of the 62% of facilities that responded, two-thirds of the anesthesia chiefs reported
delaying or canceling cases with a positive screen, regardless of symptomatology. Only 11
facilities had a formal policy; however, 80% of respondents believed having guidelines for the
perioperative management of cocaine-abusing patients would be beneficial. The study’s
limitations include the potential of recall bias by the chief anesthesia professionals, speculation
about the practice of other anesthesia professionals within the department, and survey
design. The authors emphasized the variance in managing patients with a positive UDS. They
implicitly asked how a positive urine drug screen should affect management, as only 12% of the
departments surveyed have a formal policy. For example, Birmingham Veteran Affairs Medical
Center (VAMC) has a formal policy and orders UDS as part of preadmission testing in the
preanesthesia evaluation clinic if a patient has signs and symptoms of acute toxicity. On the
morning of surgery, a positive UDS alone is not an indication for canceling the case. Conversely,
Philadelphia VAMC does not have a formal policy and cancels elective cases for a positive drug
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PERIOPERATIVE DRUG SCREENING ALGORITHM
screen one and a half times the rate of Birmingham VAMC. The authors found a significant
difference between the case cancellation rate of Birmingham VAMC (3.5%) and Philadelphia
VAMC (6%) and concluded that having a formal policy reduces UDS-positive case cancellations
(p = .03). These results highlight the need for standardized guidelines to aid perioperative
management.
Types of Urine Drug Screening
An Immunoassay (IA) and Gas Chromatography (GC) are two UDS-based instruments
used in the perioperative period (Hadland & Levy, 2016). IA is a fast, easy-to-use, highly
sensitive, and cost-effective drug screening method (Raouf et al., 2018). An IA UDS identifies
the presence of amphetamines, marijuana, PCP, cocaine, and natural opiates
(morphine/codeine/thebaine). The assay utilizes engineered antibodies that bind to drug
metabolites in the urine; the manufacturer sets a threshold for each drug. A qualitative report of
positive or negative is displayed if the drug metabolite is present in sufficient quantity.
Manufacturers validate the reliability of their UDS by testing specimens with known drug
concentrations or metabolites and report the assay's sensitivity and specificity based on the
results of their studies (Bertholf et al., 2016). Sensitivity and specificity data for UDS is highly
dependent on a given manufacturer and often not reported publicly. Bertholf et al. (2016)
reported a sensitivity of 100% in confirmed positive urine samples of their study among all drugs
tested but a specificity that ranged from 91-100% due to intra drug variability. IA can assist the
anesthesia professional because of their rapid, highly reliable results. However, IA provides no
data on the quantitative measurement of the drug metabolite, which may reduce their clinical
utility.
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PERIOPERATIVE DRUG SCREENING ALGORITHM
Limitations of the standard IA UDS are that the test cannot differentiate between
methamphetamine and prescription amphetamines since they are enantiomers, and the high
threshold set by the manufacturer may result in false positives and low specificity from common
medications and food items such as quinolone antibiotics and poppy seeds (Raouf et al., 2018).
IA drug screens cannot reliably establish a temporal relationship with the last use of a drug and
does not provide any information on patient intoxication. Cocaine may test positive for up to 14
days after acute use, and methamphetamine may test positive for up to 6 days (Bartels &
Schacht, 2021; Githens et al., 2019).
The GC UDS is often used as a confirmatory lab test after an initial positive IA finding,
as it quantitatively measures drug metabolites (Raouf et al., 2018). GC provides greater
specificity, identifies small quantities of specific drugs, and confirms their presence in urine.
This process uses gas or liquid to separate a urine sample by its molecular interactions. As the
sample is separated, all the individual compounds move into a mass spectrometer that ionizes
and detects mass-to-charge ratios, accurately identifying drugs utilizing their molecular
fingerprints (Raouf et al., 2018). However, this process takes longer (24-72 hours), requires more
resources, and is more expensive than IA.
Urine Drug Screen Costs
We reviewed several studies to obtain data on UDS costs; however, the cost structure was
often unclear or varied significantly. For example, Riccobonni and Darracq (2018) reported a
cost of $235 per UDS but did not specify if it included hospital markups. Another study by
Doyle and Strathmann (2016) did not present the exact cost per assay but suggested that
qualitative point-of-care UDS was more cost-effective than laboratory-processed quantitative
screening.
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PERIOPERATIVE DRUG SCREENING ALGORITHM
To obtain further information, we inquired about the cost structure of qualitative UDS by
three manufacturers (American Drug test, Utest Drug Testing, Drug Testing For Less).
According to their websites, the cost per unit for a 12-panel UDS was between $100 and
$127.50, and these costs were direct-to-consumer without hospital or laboratory surcharges.
However, quantitative testing can only be conducted in a laboratory due to its complexity;
therefore, no direct-to-consumer cost is available. However, according to Doyle and Strathmann
(2016), quantitative testing is significantly more expensive and time-consuming due to the
resources involved in the process. IA qualitative testing is the most cost-effective, accessible, and
quickest urinalysis method. However, it lacks specificity and provides limited information on
drug ingestion timing (Raouf et al., 2018).
Ethical Concerns of Urine Drug Screens
The perioperative drug screening protocol exhibits variability across healthcare facilities,
with anesthesia professionals often employing such tests when faced with patients having a
history or suspicion of drug abuse (Sakawi, 2015). The primary goal of perioperative drug
screening is to mitigate the risk of intraoperative hemodynamic changes, thereby reducing
morbidity and mortality (Safdari et al., 2022). The decision to order a UDS aligns with the
ethical principles of beneficence and nonmaleficence, emphasizing actions for the patient's
benefit, harm prevention, and the elimination of conditions that may cause harm (Varkey, 2019).
However, performing a drug measurement without directly informing the patient can
erode trust and potentially violate the ethical principle of autonomy and informed consent.
According to Varkey (2019), individuals possess intrinsic and unconditional worth, empowering
them to make rational decisions and moral choices, exercising their capacity for selfdetermination. Notably, there are currently no legal mandates in clinical practice requiring
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PERIOPERATIVE DRUG SCREENING ALGORITHM
anesthesia professionals to obtain informed consent for urinary or blood drug screening (Warner
et al., 2003). The decision to disclose the ordered drug testing to the patient is left to the
practitioner's discretion, presenting a potential dilemma.
The absence of information raises concerns related to privacy and autonomy, as patients
may prefer not to undergo testing for illicit drugs. Nevertheless, specific circumstances, like
maternal testing, invoke mandatory reporting obligations for healthcare providers. False positives
in such situations may have severe consequences, potentially leading to a mother losing custody
of her child to protective services (Child Abuse and Neglect Reporting Act, 2020). This
underscores the critical importance of effective provider-patient communication and establishing
and adhering to perioperative policies and protocols.
Literature Synthesis
Cocaine Algorithm Recommendations
Anesthesia professionals caring for patients with a history of cocaine use should be most
concerned with cardiovascular-associated risks such as arrhythmia and the potential for
hemodynamic instability. In the elective procedure setting, clinicians must weigh these risks
against the risks of postponing care. Examining outcomes from the trauma setting revealed a
cocaine-positive UDS status to be associated with a higher incidence of MI; however, it was not
a significant predictor of MI or stroke. Interestingly, a cocaine-positive UDS was found to be
protective for mortality. Trials conducted in the elective surgery setting found that the
hemodynamic profiles of cocaine-positive UDS status compared to cocaine-negative UDS status
to be equivalent. Furthermore, use within 24 hours and outside 24 hours was found to have
similar intraoperative hemodynamic profiles. However, cocaine-positive patients were found to
have a greater vasopressor and antihypertensive requirements. No significant adverse events,
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PERIOPERATIVE DRUG SCREENING ALGORITHM
such as MI or stroke, were observed in any trials within the elective surgery setting. On appraisal
of all available data, it is reasonable to conclude that certain patients with a positive cocaine
UDS who do not have signs or symptoms of acute intoxication may not exhibit a significantly
altered intraoperative hemodynamic course or significant change in clinical outcomes.
Methamphetamine Algorithm Recommendations
Anesthesia professionals caring for patients with a history of methamphetamine use
should know that methamphetamine has a longer elimination half-life than cocaine. This can
result in greater and longer hemodynamic instability. However, research on orthopedic trauma
patients indicates that the overall risk for cardiovascular complications related to
methamphetamine use is low. Patients who test positive for methamphetamine within two days
of surgery are at the highest risk of hemodynamic instability compared to those who test positive
between 48 hours to 7 days before surgery. Studies show increased heart rate and blood pressure
in patients with a positive methamphetamine UDS before surgery, but these changes are
generally considered clinically insignificant when assessing hospital mortality.
Methamphetamine use is not associated with increased in-hospital or 30-day mortality, nor does
it predict mortality, MI, or stroke. Certain patients who test positive for methamphetamine in a
UDS but do not exhibit signs or symptoms of acute intoxication and report last consumption of
methamphetamine to be greater than 48 hours ago may not experience significant changes in
clinical outcomes and could be considered for elective surgery.
Risk Calculator Recommendations
Risk calculators are reliable tools for assessing cardiovascular risk in patients undergoing
elective procedures. Numerous tools, such as the RCRI, ACS-NSQIP, ACS-NSQIP-MICA, and
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PERIOPERATIVE DRUG SCREENING ALGORITHM
functional capacity risk calculators, are validated and routinely employed in clinical practice.
Anesthesia professionals should use these tools to assist decision-making.
While cardiovascular risk assessment tools are reliable and validated, their utility has not
been established in patients with a history of cocaine or methamphetamine. Given the association
between cocaine or methamphetamine use and MI and other cardiac-related perioperative events,
these calculators may have a practical but limited application and should be used in conjunction
with other assessments and determinants for establishing overall perioperative risk. The
incorporation of these tools into the preoperative assessment may provide additional, valuable
information the anesthesia professional can use to determine if anesthesia can be safely
administered to patients with a recent history of cocaine or methamphetamine use.
Urine Drug Screen Recommendations
Management of UDS results in elective procedure varies depending on the institution and
anesthesia professional. Many clinicians delay procedures based on positive results regardless of
symptomatology. Patient care can be improved with a standardized approach to UDS-positive
findings through an algorithm that decreases delayed procedures through risk stratification based
on symptoms of toxicity. A patient who denies the use of cocaine or methamphetamine but
demonstrates the physiological signs of toxicity should receive a UDS to rule out illicit
substances and an appropriate diagnostic workup with expert consultation if the UDS is negative.
Appendix B features a table that details the manifestations of cocaine and methamphetamine
toxicity.
IAs are qualitative drug screening measurements that can be performed rapidly and are
the most cost-effective, which makes the assay an excellent option for the preprocedural setting.
However, due to methamphetamine’s chemical similarity to other amphetamines, IAs cannot
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PERIOPERATIVE DRUG SCREENING ALGORITHM
differentiate between the two substances and will yield a positive result if any amphetamine is
present. GC provides quantitative data about the amount of drug and can correctly identify
methamphetamine, but it has a longer processing time, is less cost-effective, and requires
advanced lab analysis, making it less useful in an outpatient setting. If anesthesia professionals
choose to drug screen on the DOS, the patient should be notified before the sample is obtained to
preserve patient autonomy and informed consent.
In summary, the evidence, although limited, supports the administration of anesthesia for
an elective procedure provided signs of systemic toxicity are absent and the anesthesia
professional has completed an appropriate assessment and risk stratification on the DOS.
Hemodynamic instability may occur in patients with chronic or recent use and should be
anticipated by the anesthesia professional. An evidence-based algorithm can organize the
research into a simplified approach to support clinical decision-making for patients with a recent
history of cocaine or methamphetamine use who present for an elective procedure with
anesthesia. Finally, qualitative IA UDS are rapid, cost-effective assessments that can be used on
the DOS. An IA UDS should be used in patients who endorse a recent history (<12 months) of
cocaine or methamphetamine use, patients who have an elevated MACE risk, and patients who
present with signs of drug toxicity on the DOS. Anesthesia professionals should notify patients
about the assessment before obtaining the UDS.
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Chapter 3
Methodology
The purpose of the scholarship inquiry was to develop an evidence-based approach to
guide anesthesia professionals on risk stratification and preoperative decision-making for
patients with a recent history of cocaine and methamphetamine use who present for an elective
procedure. The project began by identifying our clinical question and three specific aims, then
exploring the published literature relevant to the project’s clinical question and specific aims. We
established operational definitions early to maintain consistency throughout the project and
facilitate data analysis and algorithm development. We then reviewed available literature to
analyze the physiologic changes associated with cocaine and methamphetamine use and relevant
anesthesia implications. A review of preoperative urine drug screening was performed to identify
the various types of tests available to clinicians. The strengths and limitations of those tests were
reviewed to determine their role in our algorithm development.
To address specific aims one and two, we conducted a literature review encompassing
perioperative outcomes associated with cocaine use, methamphetamine use, and the utility of
UDS in the perioperative setting. We established research article inclusion and exclusion criteria
before the literature review to optimize the search strategy. The inclusion criteria encompassed
articles written in English, published within the last 25 years, and research that focused on
anesthetic implications and perioperative outcomes associated with cocaine or methamphetamine
use. The exclusion criteria included editorials, cardiac surgery, and pediatrics.
We resourced the PubMed, SCOPUS, & MEDLINE databases for relevant literature. The
scientific literature and gray literature pertaining to specific aims one and two were reviewed,
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PERIOPERATIVE DRUG SCREENING ALGORITHM
along with manufacturer information for various types of UDS. Our search terms and phrases
included “cocaine use and perioperative outcomes”, “methamphetamine use and perioperative
outcomes”, “preoperative screening and substance use disorder”, “physiological effects of
cocaine use”, “physiological effects of methamphetamine use”, “prevalence of substance use
disorder among trauma patients”, “hemodynamic effects of cocaine use”, “hemodynamic effects
of methamphetamine use”, “types of urine drug screen”, “perioperative urine drug screen”, and
“ethics of urine drug screen”. We identified 41 articles that met the inclusion criteria and
included them in the literature review. Appendix A shows our PRISMA Flow Diagrams.
For the second specific aim, we examined the benefits, cost, utilization, and effectiveness
of UDS on the DOS. In addition to the abovementioned literature review, we resourced UDS
manufacturing companies and the gray literature on costs, effectiveness, and processing
capabilities. We differentiated the types of UDSs most used in the clinical setting and drafted
drug screening recommendations based on the research findings, UDS cost-effectiveness, and
utility.
For specific aim three, we critically appraised all relevant literature on the perioperative
risks associated with patients who screen positive for cocaine or methamphetamine on the DOS.
The best available research, albeit limited, was used to build an evidence-based decision-making
algorithm for simplicity and clinical utility. We organized the research findings and algorithm
construction through discussion and consensus. To ensure process simplicity and clinician
understanding, we developed and presented several algorithm prototypes to clinically-active
anesthesia professionals for organization, flow, and logic feedback. We modified the layout and
wording based on the clinician’s response for simplicity and ease.
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PERIOPERATIVE DRUG SCREENING ALGORITHM
Operational Definitions
We adopted the following operational definitions for this project and used them
consistently throughout the literature review and algorithm development.
● Cocaine-negative urine drug screen is the laboratory result obtained from the urine
when cocaine metabolite benzoylecgonine is below the 150 ng/mL threshold. (SAMHSA,
2010)
● Cocaine-positive urine drug screen is the laboratory result obtained from the urine
when cocaine metabolite benzoylecgonine is detected above the 150 ng/mL threshold
(SAMHSA, 2010).
● Cocaine toxicity is the adverse effects that may occur in the setting of cocaine use:
tachydysrhythmia, severe hypertension, mydriasis, tachypnea, hyperthermia, paranoia,
diaphoresis, agitation (Richards & Le, 2022).
● Elective procedure is a procedure that can be rescheduled to a future time as the timing
of these cases is flexible and is unlikely to significantly impact the patient’s health
outcome (American College of Surgeons, 2020).
● Hemodynamic instability is a clinical state of perfusion failure: a 40% drop in mean
arterial pressure for at least 5 minutes or the requirement of vasoactive medication with
clinical signs and symptoms of circulatory shock or heart failure (Bose et al., 2015;
Safdari et al., 2022).
● Methamphetamine-negative urine drug screen is the laboratory result obtained from
the urine when amphetamine or methamphetamine is not detected at a threshold of 500
ng/mL (SAMHSA, 2010).
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PERIOPERATIVE DRUG SCREENING ALGORITHM
● Methamphetamine-positive urine drug screen is the laboratory result obtained from
the urine when amphetamine or methamphetamine is detected at a threshold of 500
ng/mL (SAMHSA, 2010).
● Methamphetamine toxicity is the adverse effects that may occur in the setting of
methamphetamine use: tachycardia, hypertension, atrial and ventricular dysrhythmias,
agitation, chest pain, abdominal pain, and hallucinations (Richards & Laurin, 2022).
● Urine Drug Screen (UDS) is a testing method that uses immunoassay technology to
detect drugs or metabolites of interest (Weiss et al., 2022).
Conclusion
This chapter served as a roadmap for the project by organizing the approach to our
recommendations for anesthesia professionals encountering patients with a history of cocaine or
methamphetamine use. We systematically explored existing literature using a structured
approach after carefully selecting a clinical question and establishing three specific aims. The
literature review covered perioperative outcomes, cardiac risk calculators, and the utility of UDS,
with adherence to predefined inclusion criteria. This critical appraisal of the literature led to the
development of an evidence-based decision-making algorithm. We established operational
definitions and included them to ensure precision and uniformity in the methodology.
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PERIOPERATIVE DRUG SCREENING ALGORITHM
Chapter 4
Results
The purpose of the scholarship project was to develop an evidence-based algorithmic
approach to safely administer anesthesia to patients with a recent history of cocaine or
methamphetamine use presenting for an elective procedure. We created a simple clinical
decision-making algorithm to guide anesthesia professionals in screening, risk stratification,
UDS testing, and clearance for anesthesia care. Anesthesia clinicians from different settings
reviewed and critiqued the algorithm and approach. We modified the algorithm based on the
feedback we received.
Research Findings and Clinical Recommendations
Safety of Anesthesia in Patients with Cocaine and Methamphetamine Use
The evidence suggests anesthesia can be safely provided to select patients who test
positive for cocaine or methamphetamine. Patients without signs of acute cocaine intoxication
may not exhibit a significantly altered intraoperative hemodynamic course or significant change
in clinical outcomes (Baxter & Alexandrov, 2012; Hill et al., 2006; Moon et al., 2021). Similarly,
certain patients positive for methamphetamine without signs of acute intoxication and report
their last consumption of methamphetamine to be greater than 48 hours ago may not experience
significant changes in clinical outcomes (Safdari et al., 2022). Lastly, a positive UDS for either
cocaine or methamphetamine is not associated with increased perioperative cardiac morbidity or
mortality, death, stroke, or MI (Culhane & Freeman 2020; Satish et al. 2021).
Chronic cocaine or methamphetamine use may lead to intraoperative hemodynamic
instability, even with a negative UDS. Catecholamine depletion, alteration to dopamine
receptors, and cardiac myocyte toxicity are implicated in this process (Beveridge et al., 2009;
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PERIOPERATIVE DRUG SCREENING ALGORITHM
Volkow et al., 2001). Recovery of these mechanisms is theorized to occur after 12 months of
abstinence, indicating minimal risk for hemodynamic instability beyond this period. Use of
cocaine or methamphetamine within the past 12 months warrants further investigation because
the risk for potential hemodynamic instability is potentially higher due to impaired physiologic
mechanisms described above.
Signs of Toxicity
Patients experiencing acute cocaine or methamphetamine toxicity often present with
similar clinical features. The cardiovascular impact of these substances typically manifests as
tachycardia and hypertension. Although these signs are common, they lack the sensitivity
required for clinicians to definitively diagnose toxicity in patients with a history of cocaine or
methamphetamine use. Clinicians need to consider a comprehensive range of toxic
symptomatology. Cocaine toxicity is represented in the literature as including tachydysrhythmia,
severe hypertension, mydriasis, tachypnea, hyperthermia, paranoia, diaphoresis, and agitation
(Richards & Le, 2022). Similarly, methamphetamine is represented in the literature as including
tachycardia, hypertension, atrial and ventricular dysrhythmias, agitation, chest pain, abdominal
pain, and hallucinations (Richards & Laurin, 2022). Appendix B details a comprehensive list of
side effects caused by cocaine and methamphetamine. In assessing these symptoms, clinicians
must also consider alternative diagnoses. White-Coat syndrome or missing a beta-blocker dose
may produce similar symptoms. A broad, non-exhaustive list of potential differential diagnoses
includes hypoglycemia, anticholinergic toxicity, delirium tremens, acute schizophrenia,
pheochromocytoma, neuroleptic malignant syndrome, acute myocardial infarction, hypertensive
crisis, thyroid storm, seizures, subarachnoid hemorrhage, or ischemic stroke (Richards & Laurin,
2022; Richards & Le, 2022). Recognizing the signs and symptoms of cocaine or
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PERIOPERATIVE DRUG SCREENING ALGORITHM
methamphetamine toxicity is subjective and depends heavily on clinician expertise. While not
entirely foolproof, the presence of various signs of symptoms should prompt clinicians to
investigate further.
Risk Calculators
Cocaine and methamphetamine use predisposes patients to MACE. RCRI, ACSNSQIP/ACS-NSQIP-MICA, and functional capacity risk calculators are validated tools that aid
risk stratification and allow clinicians to minimize the incidence of MACE. The applications of
these tools in patients with a history of cocaine or methamphetamine use may allow for risk
stratification and aid decision-making. Low-risk patients are defined as patients with an RCRI of
0-1, NSQIP of <1%, or METs of >4 (Gupta et al., 2011; Hlatky et al., 1989; Lee et al., 1999).
High-risk patients are defined as patients with an RCRI > 2, NSQIP >1%, and/or METs of <4.
Categorizing patients into these two groups provides clinicians a simple and effective method to
make informed decisions. Importantly, these tools were never originally designed by their
creators for these specific purposes and have not undergone evaluation for use with this
particular population. They are intended solely as aids for clinicians in conducting preanesthesia
assessments for cardiac risk. Anesthesia professionals should rely on their own judgment and
expertise to determine whether a patient is at low or high risk for MACE.
The Role of Preoperative UDS on the DOS
UDS can be useful but should not be the sole determinant in choosing whether to proceed
or delay an elective procedure. Assay limitations include the inability to pinpoint the last use,
quantify consumption, or determine toxicity threshold status, making UDS more suited for risk
stratification. Anesthesia professionals can forgo a UDS if the patient presents without signs of
toxicity and a remote history (>12 months) of cocaine or methamphetamine use. Patients with a
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recent history (<12 months) of cocaine or methamphetamine use, without signs of toxicity, and
are a low risk for MACE may not require a UDS, as it does not significantly impact perioperative
management or clinical outcomes.
Conversely, a patient with a recent history of cocaine or methamphetamine use who has
either signs of toxicity or is at a higher risk for MACE should be screened via UDS. The
potential for adverse clinical outcomes increases with each of these factors, and it is necessary to
determine if the effects of cocaine or methamphetamine may also be playing a role during the
intraoperative course. In this scenario, a UDS positive for cocaine or methamphetamine will be
more helpful in deciding whether a patient should or should not proceed to an elective procedure.
Perioperative Algorithm
Based on the above research findings and UDS effectiveness, we developed a simplified
approach to patients endorsing a history of cocaine or methamphetamine use presenting on the
DOS for an elective procedure. The first step of the algorithm involves identifying the patients to
whom this applies. This is accomplished with a thorough examination of health records and a
comprehensive preoperative patient interview. Health records may not reflect drug use patterns
or pertinent history the anesthesia professional needs to make a clinical decision. Patients with a
positive history of cocaine or methamphetamine use should undergo a detailed interview
identifying the timing, frequency, and duration of their substance use. Next, clinicians should
assess for the presence of signs and symptoms of cocaine or methamphetamine toxicity. This
step is essential in evaluating the immediate risk and potential complications associated with the
patient's substance use history. Lastly, all patients, irrespective of substance use history, should
undergo a cardiovascular risk assessment via RCRI, ACS-NSQIP/ACS-NSQIP-MICA, and/or
METs. By acquiring this information, clinicians can effectively risk stratify and make informed
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PERIOPERATIVE DRUG SCREENING ALGORITHM
decisions for patients with a history of cocaine or methamphetamine toxicity presenting on the
DOS for an elective procedure. A visual representation of this algorithm is featured in Appendix
C.
Last Use > 12 Months & No Toxic Signs and Symptoms
Clinicians encountering non-toxic patients whose reported last use of cocaine or
methamphetamine is greater than 12 months can proceed to an elective procedure without the
need for UDS. Although the risk of hemodynamic instability is generally low in this patient
group, anesthesia professionals should remain vigilant and develop an appropriate care plan for
potential hemodynamic challenges.
Last Use > 12 Months & the Presence of Toxic Signs and Symptoms
Clinicians encountering patients whose reported last use of cocaine or methamphetamine
is greater than 12 months and has signs and symptoms of toxicity should strongly consider UDS
and differential diagnoses. A positive UDS should prompt clinicians to delay surgery. A negative
UDS should prompt clinicians further to evaluate differential diagnoses for the presenting signs
and symptoms. The appropriateness of proceeding with an elective procedure should be
considered under further workup and, when appropriate, seek expert consultation.
Last Use < 12 Months & No Toxic Signs & Symptoms
Clinicians encountering non-toxic patients whose last use of cocaine or
methamphetamine is less than 12 months prior should consider their cardiovascular risk scores
for MACE. As defined above, low-risk patients should be allowed to proceed with their elective
procedure. Anesthesia professionals should remain vigilant and develop an appropriate care plan
for potential hemodynamic challenges.
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PERIOPERATIVE DRUG SCREENING ALGORITHM
As defined above, clinicians encountering high-risk patients should strongly consider
obtaining a UDS. A positive UDS should prompt clinicians to delay surgery; a negative UDS
should allow patients to proceed with their elective procedure. Anesthesia professionals must
remain vigilant and develop an appropriate care plan with potential hemodynamic challenges.
Last Use < 12 Months & the Presence of Toxic Signs and Symptoms
Clinicians encountering patients whose last use of cocaine or methamphetamine is less
than 12 months and who present with signs and symptoms of toxicity should strongly consider
obtaining a UDS. A positive UDS should prompt clinicians to delay surgery; a negative UDS
should prompt clinicians further to evaluate differential diagnoses for the presenting signs and
symptoms. The appropriateness of proceeding with an elective procedure should be considered
after additional workup and expert consultation, if appropriate.
Conclusion
We discovered through the literature review that patients with a history of cocaine or
methamphetamine use may receive anesthesia services for an elective procedure, provided no
toxicity signs or symptoms are present. We further found that a UDS on the DOS may not yield
clinically useful information but should be considered when clinicians suspect the patient
recently consumed an illicit substance. We synthesized the most relevant evidence and
developed a simple decision-making algorithm that provides anesthesia professionals with a
structured approach for determining which patients with a history of cocaine or
methamphetamine can proceed with an elective procedure. The algorithm emphasizes the drug
use history, evidence of intoxication, and baseline cardiac risk assessment. By considering these
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PERIOPERATIVE DRUG SCREENING ALGORITHM
variables in decision-making, the algorithm aims to enhance the overall safety and efficacy of
anesthesia care provided to these patient populations.
Chapter 5
Discussion
The purpose of the scholarship project was to assess the safety of administering
anesthesia to patients with a recent history of cocaine or methamphetamine use presenting for an
elective procedure. The project explored UDS utility, limitations, and risk assessment
calculators' role in evaluating and managing this patient population. After evaluating and
critically appraising the literature, we synthesized the evidence into a simple and practical
approach for the anesthesia professional. Based on the research findings, we developed a clinical
decision-making algorithm to guide anesthesia professionals in screening, risk stratifying, UDS
testing, and approving anesthesia care for patients with a recent history of cocaine or
methamphetamine use. Before project dissemination, we consulted with practicing
anesthesiology professionals across different perioperative settings on our algorithm's
organization, simplicity, and flow. We modified the final product based on the feedback we
received.
This scholarly project improves the clinical practice of anesthesia professionals and
enhances access to healthcare for patients with a history of cocaine or methamphetamine use.
The literature synthesis underscores the safe administration of anesthesia for patients with a
UDS-positive for cocaine or methamphetamine on the DOS. It is important to acknowledge the
project's limitations, notably the scarcity of literature on chronic substance use and reliance on
animal models and trauma studies. This prompts a call for a deeper understanding of the chronic
physiological effects of cocaine and methamphetamine use and additional trials specific to
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PERIOPERATIVE DRUG SCREENING ALGORITHM
elective surgery. The authors are hopeful the proposed algorithm finds its way into clinical
applications and prompts further investigation on optimizing care for this patient population.
Specific Aim Analysis
Specific Aim #1
The first aim of this project was to determine the risks and benefits of proceeding with an
elective procedure for patients with a recent history of cocaine or methamphetamine use and test
positive on a UDS. The risks of administering anesthesia for patients positive for cocaine or
methamphetamine involve intraoperative hemodynamic instability and risks for myocardial
infarction. A positive UDS for either cocaine or methamphetamine is not associated with
increased perioperative cardiac morbidity or mortality, death, stroke, or MI (Culhane & Freeman
2020; Satish et al. 2021). The literature establishes that patients with a history of cocaine or
methamphetamine use can safely receive anesthesia. Additionally, data from the literature
enables the identification of which patients with a history of cocaine or methamphetamine use
can safely receive anesthesia for elective procedures. The apprehension of the theoretical risks
associated with a positive UDS for cocaine or methamphetamine appears overstated and does not
necessarily relate to outcomes.
These equivocal outcomes of patients with a positive UDS compared to patients with a
negative UDS allow centers to enhance health care delivery to these patient populations. This
understanding empowers anesthesia professionals to consider a broader range of patients for
procedures, thereby reducing case cancellations and improving resource utilization and
operational efficiency. This knowledge is significant as patients with a history of cocaine or
methamphetamine use are prevalent in many communities across the United States, including
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PERIOPERATIVE DRUG SCREENING ALGORITHM
our own. Through this understanding, we can expand access to medical care for these
populations, offering them a better chance at a life of wellness and fulfillment.
Specific Aim #2
The second aim of this project was to evaluate the utility of preoperative UDS on the
DOS in patients presenting for elective surgery who have a recent history of cocaine or
methamphetamine use. UDS offers valuable insight into managing this patient population;
however, it should not be the sole determinant in whether to proceed with or delay an elective
procedure. Anesthesia professionals may forego UDS if the patient shows no signs of toxicity
and has a remote history (>12 months) of cocaine or methamphetamine use. Individuals with
recent substance use, signs of toxicity on DOS, significant cardiac comorbidities, or undergoing
moderate to high-risk surgery should undergo UDS screening. UDS is reasonable because recent
and significant comorbidities increase the likelihood of adverse clinical outcomes. In this
context, a positive UDS would become crucial in determining whether a patient should proceed
with an elective procedure.
Reducing unnecessary UDS testing in patients with remote substance use histories or
low-risk surgical profiles can translate into direct cost savings for healthcare organizations, i.e.,
hospitals or freestanding ambulatory surgery centers. By avoiding routine use of UDS in these
cases, healthcare facilities can minimize expenditures associated with laboratory testing
materials, staff time, and administrative resources. Furthermore, by focusing UDS screening
efforts on high-risk patients who stand to benefit most from its insights, hospitals can allocate
resources more efficiently, maximizing the cost-effectiveness of perioperative delivery.
Moreover, by tailoring UDS utilization to patients with recent substance use, signs of
toxicity, or significant comorbidities, anesthesia professionals can ensure that UDS testing is
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PERIOPERATIVE DRUG SCREENING ALGORITHM
employed where it is most clinically relevant. This targeted approach enhances the diagnostic
utility of UDS and facilitates more precise risk stratification and treatment planning. As a result,
patients receive the appropriate level of care tailored to their individual needs, leading to
improved clinical outcomes and patient satisfaction while avoiding over screening.
Specific Aim #3
The third aim of this project was to develop a clinical decision-making algorithm for
patients reporting a recent history of cocaine or methamphetamine use in the elective procedure
setting based on a synthesis of the clinical research. All relevant literature was appraised, and the
findings were used to develop an evidence-based decision-making algorithm. The algorithm
incorporates various parameters to aid anesthesia professionals in making well-informed care
decisions. Anesthesia professionals should consider recency of use, signs and symptoms of
toxicity, cardiac risk factors, and urine drug screen status to determine patient appropriateness
for surgery. Consideration of comorbidities, such as cardiovascular, respiratory, or renal
impairment, ensures a comprehensive evaluation that extends beyond substance use alone. By
integrating these elements, the algorithm should help anesthesia professionals streamline the
evaluation and risk-stratification process while enhancing the overall safety and appropriateness
of elective procedures for patients with a history of cocaine or methamphetamine use.
Our clinical decision-making algorithm represents a paradigm shift in preoperative
evaluations. It introduces an unprecedented approach to the assessment of patients with a recent
history of cocaine and methamphetamine use. This tool fills a crucial gap in current practice and
sets a new standard for clinical decision-making for anesthesia professionals working with this
specific patient population.
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PERIOPERATIVE DRUG SCREENING ALGORITHM
Project Impact
The importance of our project is in identifying if patients with a history of cocaine or
methamphetamine use can safely receive anesthesia for an elective procedure. Due to ethical and
patient safety concerns, limited studies focus on perioperative management and outcomes of this
patient population. This project synthesized available literature on patients with a history of
cocaine and methamphetamine use to provide anesthesia professionals with a clinical resource,
uphold patient safety, and reduce unnecessary procedure cancellations on the day of surgery. The
algorithm empowers anesthesia professionals with a tool to aid decision-making to proceed to
surgery when criteria are met safely.
Practice Implications
The consequences of procedure cancellations extend beyond a patient’s physical wellbeing. Procedure cancellations affect patients’ physical, emotional, and financial well-being.
Relying solely on a positive UDS to determine cancellations can lead to unnecessary delays in
crucial diagnostic and curative procedures. This, in turn, exacerbates emotional distress,
heightens anxiety, and inflicts financial strain due to missed workdays and lost wages. The
cumulative emotional and financial toll of unwarranted cancellations within this vulnerable
population raises the risk of patient disengagement. The stigma associated with substance abuse,
coupled with feelings of hopelessness, may override patients' decision-making processes,
increasing the likelihood of losing them to follow-up.
Beyond individual patient outcomes, implementing our algorithm extends benefits to
procedural areas and healthcare facilities. By reducing expenses associated with administering
unnecessary UDS and minimizing overall case cancellations, there is a tangible improvement in
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PERIOPERATIVE DRUG SCREENING ALGORITHM
operational efficiency. This translates to cost savings and contributes to a more streamlined and
effective healthcare system.
Implications for Research
The future trajectory of this scholarship project envisions further research on patients
who test positive for cocaine or methamphetamine preoperatively to observe for differences in
intraoperative events and perioperative outcomes. Future research on patients with a history of
cocaine or methamphetamine use undergoing elective procedures and studies focusing on the
chronicity of cocaine and methamphetamine use are also necessary to continue the development
of the algorithm. Ideally, future research would replicate our findings and validate the efficacy
and reliability of the developed algorithm.
Future of Policy
A lack of consensus persists on the management and decision-making of patients with a
history of cocaine and methamphetamine-positive use in the perioperative setting. While some
healthcare organizations have policies, no formal guidelines have been published. Producing a
decision-making algorithm in literature can aid institutions in developing their own policies to
provide for these patient populations. On a local level, the algorithm can help communities that
are significantly impacted by users of cocaine and methamphetamine. These centers often have
fewer resources and are not reimbursed well for care rendered. The algorithm introduces more
efficiency into managing these populations by minimizing delays in care through appropriate
case cancellation and having a defined safety margin.
On a systemic level, introducing a formal algorithm by professional organizations can
empower clinicians in their decision-making and promote further research into the perioperative
management of these patient populations. Clinicians can now have a document to aid thinking
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PERIOPERATIVE DRUG SCREENING ALGORITHM
when it comes to making the not-so-clear decision to proceed or delay an elective procedure.
Wide-spread implementation can normalize a clinician's encounter with these patient
populations, thereby reducing the stigma these populations often encounter. The use of the
algorithm encourages dialogue and further research. More involvement and understanding of
these patient populations will only bring the profession closer to how to serve these populations
best.
Project Strengths
This scholarly project demonstrates several strengths. Our project was the first
comprehensive assembly of a clinical decision-making algorithm specific for anesthesia
professionals to use in patients with a history of cocaine or methamphetamine use presenting for
elective procedures. This effort paves the way for improved standardization and patient care.
Through the literature review, we examined the safety of administering anesthesia to patients
with a history of cocaine or methamphetamine use undergoing elective procedures. The limited
consensus among the anesthesia community prompted the necessity for our project. By
addressing this clinical practice gap, we contribute significantly to helping anesthesia
professionals appropriately evaluate and deliver evidence-based care to patients with a history of
cocaine or methamphetamine use. Our project's primary objective was to establish a standardized
approach for evaluating these patients, ensuring the safe administration of anesthesia without
compromising outcomes or elevating the risk for MACE.
Adopting a standardized approach is essential to limiting practice variability across
professionals and institutions. Moreover, the resulting algorithm is a valuable resource for novice
anesthesia professionals with limited experience working with this specific patient population. Its
user-friendly design and clear guidelines make it accessible to anesthesia professionals in various
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PERIOPERATIVE DRUG SCREENING ALGORITHM
clinical settings. This ease of use ensures that the algorithm is not only a theoretical resource but
a practical tool that can be seamlessly incorporated into daily practice.
This project will contribute to anesthesia professionals' ongoing education and
professional development. The algorithm becomes a valuable educational resource for training
programs and continuing education initiatives within the anesthesia community by offering a
structured approach. This educational dimension enhances the project's impact by promoting
knowledge dissemination and fostering a broader understanding of best practices in caring for
this specific patient population.
Project Limitations
An important limitation of our project is the absence of direct testing of the developed
algorithm. Instead, we engaged with many Certified Registered Nurse Anesthetists (CRNAs) and
physician anesthesiologists by presenting the algorithm for appraisal and eliciting detailed
feedback. This process involved actively seeking insights from anesthesia professionals to
identify crucial changes, utilizing an approach to receive and elicit valuable input. While this
strategy enhances the algorithm's relevance to real-world clinical scenarios, the lack of direct
testing leaves room for uncertainties regarding its efficacy and performance in practice.
Additionally, a significant challenge in our investigation is the exploration of the
cardiovascular consequences of chronic cocaine and methamphetamine use in elective surgery
patients. Ethical considerations restrict direct studies on the human cardiovascular system,
compelling us to rely on animal studies. Consequently, our reliance introduces a layer of
complexity, with the translatability of findings from rodents and primates to human physiology
remaining a subject of scrutiny. Importantly, the 12-month timeline for catecholamine recovery,
as detailed by Beveridge et al. (2009) in nonhuman primates, specifically emphasizes dopamine
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PERIOPERATIVE DRUG SCREENING ALGORITHM
repletion in the brain rather than the heart, accentuating the challenges in directly applying such
timelines to the human cardiovascular system.
Moreover, our methodology draws insights from retrospective studies, where data is
gleaned from past experiences and health records. While valuable in informing patterns and
associations, retrospective studies inherently carry limitations related to study design, data
accuracy, and potential bias, underscoring the intricacies of studying chronic sympathomimetic
use in a clinical context.
Despite these challenges, our synthesis of available evidence enriches our understanding
of catecholamine recovery during abstinence and its implications for anesthesia strategies.
Notably, Safdari et al. (2022) provided valuable clinical insights, bridging the gap between
animal models and human experiences by reporting a lower risk of hemodynamic instability in
methamphetamine-positive patients between 48 hours and seven days post-use. This observation
suggests that catecholamine recovery in the heart may be occurring to some extent during this
period, as evidenced by the attenuated hemodynamic effects. However, the inherent limitations
of both animal studies and retrospective analyses underscore the need for continued research to
refine our understanding of the dynamic interplay between chronic sympathomimetic use,
dopamine repletion, catecholamine recovery, and perioperative outcomes in elective surgical
patients. Importantly, while the study indicates potential catecholamine repletion within a shorter
timeframe, the study did not explore the impact of varying durations of substance use, such as
distinguishing between individuals using for the first time versus those with prolonged and
frequent use over several years. This underscores the need for further investigations to capture
the nuanced effects of different patterns and durations of chronic sympathomimetic use on
cardiovascular dynamics. Regardless of the timeline of recovery, Neeki et al. (2018) found that,
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PERIOPERATIVE DRUG SCREENING ALGORITHM
despite physiological variations, hospital mortality does not substantially increase overall among
methamphetamine-positive patients, although the length of stay does. This emphasizes the safety
of taking such patients to surgery while emphasizing the importance of addressing potential
surgical delays and optimizing perioperative care.
Another limitation arises from including data from emergency and elective surgery
settings in the existing literature. The overreliance on data from the emergency settings invites
limitations in the development of this project. The retrospective nature of the data involves
numerous variables that may impact the validity of our findings. Additional trials conducted
within the elective surgery setting on both cocaine and methamphetamine strengthen the findings
of this project.
The final limitation pertains to applying cardiac risk calculators beyond their intended
scope. The original trials involving these calculators do not specifically address the influence of
cocaine or methamphetamine. Furthermore, the true impact of cocaine or methamphetamine on
the incidence of MACE is not well understood. While it may seem reasonable to use cardiac risk
calculators in this population, the margin of safety that would be introduced by these instruments
may be minimal and even provide a false sense of security. The decision-making process
ultimately rests on the discretion of the anesthesia professional.
Final Conclusion
The development of a clinical decision-making algorithm represents a significant
advancement, providing anesthesia professionals with a structured approach to screening, risk
stratification, and decision-making for patients with a history of cocaine or methamphetamine
use. Our project addresses a critical gap in perioperative management in patients with a history
of cocaine or methamphetamine. The impact of this project extends beyond individual patient
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PERIOPERATIVE DRUG SCREENING ALGORITHM
care, with implications for healthcare facilities, policy development, and future research. By
developing standardized approaches and evidence-based policies, this project contributes to
enhanced patient outcomes and addresses the unique needs of vulnerable populations. This
scholarly project serves as a crucial step toward advancing the perioperative care of patients with
a history of cocaine or methamphetamine use by fostering dialogue and continuous improvement
within the anesthesia community. We hope our efforts allow for further understanding and
management of this complex patient population, ultimately improving healthcare delivery and
promoting patient well-being.
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PERIOPERATIVE DRUG SCREENING ALGORITHM
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Appendix A: Prisma Diagram
Search engine: Pubmed, Scopus, Medline
Search words: cocaine, positive, surgery
Inclusion: quantitative data, English, adults, humans
Exclusion: editorials, articles older than 2000, pediatrics, cardiac surgery
61
PERIOPERATIVE DRUG SCREENING ALGORITHM
Search engine: Pubmed, Scopus, Medline
Search words: methamphetamine, positive, surgery
Inclusion: quantitative data, English, adults, humans
Exclusion: editorials, articles older than 2000, pediatrics, cardiac surgery
62
PERIOPERATIVE DRUG SCREENING ALGORITHM
Search engine: Pubmed, Scopus, Medline
Search words: perioperative, screening, protocol
Inclusion: quantitative data, English, adults, humans
Exclusion: articles older than 2000
63
PERIOPERATIVE DRUG SCREENING ALGORITHM
Appendix B: Physiologic Changes Associated with Cocaine & Methamphetamine Use
Cocaine Methamphetamine
Neurological
● Reduction in cerebral blood flow (Riezzo et al.,
2012)
● Promotion of vasospasm and oxidative stress
(Riezzo et al., 2012)
● Increased risk intracranial hemorrhage, seizures,
movement disorders, and psychiatric illnesses
(Riezzo et al., 2012)
● Psychosis (Neeki et al., 2018)
● Hallucinations (Neeki et al., 2018)
● Erratic behavior (Neeki et al., 2018)
● Emotional lability (Neeki et al., 2018)
● Intracranial HTN (Neeki et al., 2018)
Cardiovascular
● Catecholamine reuptake at sympathetic nerve
terminals (Riezzo et al., 2012)
● Arrhythmogenic properties through blockage of
sodium and potassium channels. (Stankowski et
al., 2015)
● Tachycardia, hypertension, atrial and ventricular
dysrhythmias (Neeki et al., 2018)
● Chest pain, ischemia, cardiomyopathy, cardiac
arrest (Richards & Laurin, 2022)
● Hypotension may be observed with
methamphetamine overdose with profound
depletion of catecholamines. (Neeki et al., 2018)
Pulmonary
● Alveolar-capillary membrane damage (Riezzo et
al., 2012)
● Pulmonary microvasculature injury. (Riezzo et
al., 2012)
● Acute noncardiogenic pulmonary edema
(Richards & Laurin, 2022).
● Pulmonary hypertension (Richards & Laurin,
2022).
Hepatic
● Increased fatty acid infiltration (Riezzo et al.,
2012)
● Midzonal and periportal necrosis (Riezzo et al.,
2012)
● Hepatocellular injury: Extensive or focal necrosis
(mostly observed in MDMA studies) (Carvalho et
al. 2012)
● Disseminated Intravascular Dissemination (DIC)
(Carvalho et al. 2012)
64
PERIOPERATIVE DRUG SCREENING ALGORITHM
● Elevated aspartate aminotransferase (AST).
(Riezzo et al., 2012)
Renal
● Intrarenal hemodynamic changes (Riezzo et al.,
2012)
● Alterations in the glomerular matrix (Riezzo et
al., 2012)
● Renal atherogenesis (Riezzo et al., 2012)
● Renal failure (Richards & Laurin, 2022)
● Rhabdomyolysis (Richards & Laurin, 2022)
● Necrotizing angiitis (Richards & Laurin, 2022)
● Acute interstitial nephritis (Richards & Laurin,
2022)
● Tubular necrosis (Richards & Laurin, 2022)
Toxicity
● Tachydysrhythmia (Richards & Le, 2022)
● Severe hypertension (Richards & Le, 2022)
● Acute coronary syndrome (Richards & Le, 2022)
● Stroke (Richards & Le, 2022)
● Acute myocardial and renal failure (Richards and
Le, 2022)
● Seizure (Richards and Le, 2022)
● Hyperthermia (Richards and Le, 2022)
● Cocaine-induced rhabdomyolysis (Richards and
Le, 2022)
● Tachycardia
● Hypertension
● Atrial and ventricular dysrhythmias
● Chest pain
● Rhabdomyolysis
● Abdominal pain
● Ischemia
● Cardiomyopathy (Richards & Laurin, 2022).
65
PERIOPERATIVE DRUG SCREENING ALGORITHM
Appendix C: Perioperative Algorithm
Abstract (if available)
Abstract
Patients with a history of cocaine or methamphetamine use present unique challenges to anesthesia professionals. The management of these patients is marred by inconsistency due to the absence of comprehensive clinical practice guidelines. This lack of guidance has led anesthesia professionals to make ad hoc decisions, sometimes resulting in surgical delays or cancellations. A thorough literature review evaluated the risks associated with cocaine and methamphetamine, perioperative outcomes of patients with such history, means of risk stratification, and the utility of urine drug screens (UDS). The evidence revealed that UDS alone was unreliable in predicting perioperative mortality, myocardial infarction, or stroke. Additional tools to UDS, such as cardiac risk calculators, may aid in clinical decision-making.
An algorithm has been developed to guide perioperative practice for patients with a history of cocaine or methamphetamine use, specifically in the elective surgery setting.
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Development of a perioperative drug screening algorithm for patients with a history of cocaine and methamphetamine use presenting for an elective procedure with anesthesia
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