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  1. Substance use disorder is a common disease. It is characterized by loss of control over a substance of abuse, including an inability to voluntarily self-regulate substance use, compulsive preoccupation with obtaining or using a substance, and continued use despite adverse consequences.

  2. Substance use disorder may be managed successfully as a chronic disease, and many patients respond positively to treatment with long periods of abstinence.

  3. Consultation with an addiction medicine specialist is encouraged when providing care for active or recovering patients with substance use disorder during the perioperative period.

  4. Preoperative assessment of all patients presenting for surgery should include a routine evaluation for substance use disorder.

  5. Establishing a supportive, nonjudgmental but firm approach to the patient with active substance use disorder is vital for successful care.

  6. Preoperative history, physical examination, and laboratory testing should be guided by the known medical consequences of substance use disorder.

  7. A blood alcohol concentration and a urine drug screen should be obtained in all active and most recovering patients with substance use disorder.

  8. Polysubstance abuse is common.

  9. Infectious diseases are epidemic in injection drug users.

  10. Alcohol abuse has extensive medical consequences that affect every major organ system and is a major risk factor for perioperative morbidity and mortality.

  11. Abuse of sedative-hypnotics, opioids, cocaine, amphetamines, cannabis, hallucinogens, and inhalants is associated with a wide variety of drug-specific medical complications.

  12. Withdrawal is commonly encountered during the perioperative period in patients with substance use disorder, and prophylaxis against withdrawal should be instituted before surgery.

  13. Recovery involves abstinence in combination with a series of personal changes to maintain sobriety.


Substance use disorder represents a major public health problem in the United States, carrying a lifetime prevalence of 7% to 14% depending on the drug of abuse.1 This chapter reviews the preoperative assessment and anesthetic implications of substance use disorder.


For the sake of this discussion, a substance use disorder is defined by loss of control over a drug of abuse. Inability to voluntarily self-regulate drug use, preoccupation with obtaining or using a drug, and continuing use despite adverse consequences are central features of the disease.2 Initial drug use is usually voluntary, and most users do not develop substance use disorder. However, repetitive exposure in a susceptible individual causes fundamental changes in neurobiology that produce the disease. Alterations in neurocircuitry that enhance sensitivity to the reinforcing effects of drugs of abuse may contribute to genetic predisposition to developing substance use disorder, thereby overwhelming normal cognitive control of behavior.3 Substance use disorder is considered to be a chronic, relapsing disease that cannot be cured, but it may be managed successfully, as patients respond often to treatment with long periods of abstinence.4

The neurobiology of substance use disorder is well documented.3,5,6 Three central concepts are immediately relevant to ...

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