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Michigan OPEN

Substance Use Disorder Surgical Care

As substance use disorders (SUD) increase across the nation, helping patients progress safely and comfortably through surgical recovery after a procedure is critical. With our SUD Care Coordination initiative, we strive to educate providers on the importance of screening for SUD and how to screen using a standardized screening tool. We also cover the basics of interpreting screening results and acting on a high-risk score. Communicating with patients about their high-risk score in a non-stigmatizing way and providing appropriate referrals to treatment or educational interventions are key to SUD care. Looking to learn more about substance use disorder? Our patient section defines SUD and substances, signs and symptoms to look out for, treatment options and locations, and support for families

Why screen patients for SUD before surgery?

Patients with or at risk of SUD may be at higher risk for poorly controlled pain, longer lengths of stay, greater risk of complications, and greater healthcare utilization.

Preoperatively, as many as 2 in 5 patients may present with unhealthy substance use before elective surgery.1
Early identification presents an opportunity for further assessment, improved coordination of care, tailored pain management, and clear communication across the healthcare team. 2
Patients with any preoperative opioid use, even small amounts, are more likely to require additional opioid prescriptions after surgery. 2

How to Screen for Risky Substance Use

Screening is best completed using a validated, standardized screening tool such as the Tobacco, Alcohol, Prescription medications and other Substances (TAPS) questionnaire. National Institute on Drug Abuse (NIDA) provides the TAPS online for quick and easy screening as the patient or as the provider.

OPEN recommends TAPS because it is:

  • Quick and easy to complete online or paper by the patient or provider
  • Universal and non-judgemental way to detect risky substance use
  • Highly accurate for detecting unhealthy substance use 4

Patient responses to the questionnaire generate a risk score, which can help providers understand more about their patient and indicate if further assessment is needed in a non-biased way.

OPEN research shows using a standardized screening tool is best practice for detecting possible risky substance use.

    • OPEN conducted a pilot project where we compared 242 patient reported TAPS-1 screening to the unstandardized EMR documentation for substance use 
    • TAPS-1 tool detected positive screenings more often than standard of care EMR documentation in the tobacco (9.1% vs. 5.8%), alcohol use (31% vs. 0.0%), and illicit drug use (16.2% vs. 10.4%)
    • Determining a TAPS-1 screening result using the unstandardized documentation for alcohol use was challenging due to inadequate EMR documentation
    • Calculating a risk score from the standard EMR documentation using the TAPS-2 tool was not possible due to inadequate EMR documentation
    • Electronic screening of questions adds value and information about risky substance use not previously known in the course of medical care for a notable number of patients

OPEN recommends TAPS.

  • Quick and easy to complete online or paper by the patient or provider.
  • Universal and non-judgmental way to detect risky substance use.
  • Highly accurate for detecting unhealthy substance use.5

TAPS Screening Tool NIDA

 

Perioperative Pain Management and Care Coordination for Primary Care Providers CE Course

This free, 3-hour CE course will empower primary care providers to directly impact the opioid epidemic by learning best-practice care strategies.

 

How do patients feel about SUD screening?

Using the TAPS Screening Tool, OPEN found that it is both acceptable and feasible for patients.5 

  • 60-75% patient response rate
  • 98% of patients were comfortable with the screening
  • 99% of patients reported that the questions were easy to understand

 

When asking a patient to complete a substance use screening, the messaging, language, and framing impact response rates.6 

  • OPEN compared response rates when patients were sent a general message vs. a surgery-relevant email which included how the collected screening information impacts their surgical care. 
  • More patients completed screening in the surgery-relevant screening group compared to usual care (61.2% vs. 44.3%; P = 0.002).

How do providers view SUD screening?

Providers value a standardized, multidisciplinary approach to perioperative pain management.7

OPEN research using qualitative methods7, found that providers, including surgeons, PCPs, and anesthesiologists, value a standardized, multidisciplinary approach to perioperative opioid management focusing on:

  • Patient education
  • Provider communication
  • Tools that can identify patients at high risk

Screening can be done by any provider caring for the patient.

A systematic way for patients to be screened that doesn't rely on busy Surgeons… that definitely would be helpful. And, more standard support systems for postoperative pain management.
Surgery Interviewee

How to Interpret Screening Results

The TAPS screening is a two-part screening tool. TAPS-1 consists of 4 questions and results a positive or negative screen. If a patient screens positive, TAPS-2 substance-specific questions are activated and a risk score is calculated based on patient responses. Learn more about TAPS scoring here.8

OPEN has developed templates with recommendations for care and communication suggestions to notify a patient’s care team of positive screening results for risky substance use. For patients with positive screens for multiple categories, both categories’ resources can be cohesively combined and sent in one notification message. Prescription and non-prescription opioids have the same templates. Prescription and non-prescription stimulants have the same templates.

Substance Use Disorder in Surgery Toolkit

Use these customizable email templates to communicate best care practices for patients with positive TAPS screening category.

 

 

What to do with a high-risk screening

A high-risk score indicates that additional assessment is needed. It is a starting point for a patient and provider conversation about substance use and how this can impact the patient’s surgical journey and long-term health outcomes. 

General Recommendations

1. CONFIRM through clinical interview and review of substance use.

2. EXPRESS CONCERN using empathy.

3. CREATE A PERIOPERATIVE PLAN proactively.

4. EDUCATE/ADVISE patient.

Talking to Patients About Substance Use

Having a conversation with a patient about substance use can be uncomfortable. Use the conversation starters below adapted from Empathy: Talking to Patients About Substance Use Disorder (CDC.gov).9 Additionally, check out how to use thoughtful person-centered language through OPEN’s Stigma Initiative and Shatterproof’s Addiction Language Guide.

 

ASK PERMISSION + PROVIDE OPTIONS“Would it be ok with you if I asked you some questions about your substance use?”
NORMALIZE THE CONVERSATION“This is not unusual. Many patients find it hard to talk about their substance use.”
“Talking about substance use can be uncomfortable.”
BE TRANSPARENT“I need to ask you some specific questions about your use of (substance). This will help us to determine the best plan of care for you for surgery.”
ADDRESS CONFIDENTIALITY + CONCERNS HONESTLY“I want you to know that everything you share with me and that we discuss today is confidential. However, there are some limited exceptions under the state law that I want to make sure you know and understand such as reports of threats of harm to yourself or others.”
ESTABLISH TRUST AND SHOW EMPATHYActively listen and engage with patients in a non-judgmental way.
Treat patients with respect and address their SUD as the medical disease that it is.
WORK TOGETHER WITH PATIENTSMeet patients where they are in their journey. Not every patient will be ready to stop their substance use.

Treatment for Substance Use Disorder

Substance Abuse and Mental Health Services Administration

“The mission of the Center for Substance Abuse Treatment is to promote community-based substance use disorder treatment, and recovery support services for individuals and families in every community. CSAT provides national leadership to improve access, reduce barriers, and promote high-quality, life-saving, and effective treatment and recovery support services.”

Michigan Department of Health and Human Services

“The Substance Use, Gambling and Epidemiology Section is responsible for clinical services within the Substance Use Disorder (SUD) Treatment System. Staff provide technical assistance regarding Substance Use Disorder Treatment and Recovery to Prepaid Inpatient Health Plans, providers of services, and the public. Staff are also responsible for monitoring of the system to ensure federal funding requirements are met. If you, a family member, or a friend needs treatment services for substance abuse, click above link for a local phone number to call for immediate assistance.”

If you reside in the following counties call:

  • Livingston County, MI – (517) 546-4126
  • ​Monroe County, MI – (734) 243-7340
  • ​Lenawee County, MI – (517) 263-8905

FindTreatment.gov

“FindTreatment.gov is a product of SAMHSA’s Center for Behavioral Health Statistics and Quality (CBHSQ). It is the most comprehensive resource for persons seeking treatment for mental and substance use disorders in the United States and its territories. FindTreatment.gov provides the ability to search for substance use and mental health facilities, health care centers, buprenorphine practitioners, and opioid treatment providers.”

Home of New Vision

“Home of New Vision is a leader in the field of substance use disorder treatment and a voice in the State of Michigan. We help people find the hope, confidence, and courage to change, leading them to a new and better vision for their future. Our experience teaches us that change is possible, that treatment works, and that recovery does happen!”

Workit Health

“Workit Health is an online, on-demand substance use disorder treatment provider that offers medications for opioid use disorder (MOUD) via telemedicine. Workit provides treatment through mobile and web apps that keep members on track in the comfort of their own homes. Workit is in-network with commercial, Medicaid, and Medicare plans with funding available for individuals living in Washtenaw, Lenawee, Livingston, and Monroe counties who are underinsured or uninsured. Workit’s programs include provider visits, remote drug testing, 1:1 and group counseling, and online recovery courses. We offer 24/7 recovery that fits into daily life, designed by experts.”

Dawn Farm

“For many years, Dawn Farm has offered a continuum of services to help addicts and alcoholics achieve long-term recovery. With residential services, supportive transitional housing, outpatient treatment, sub-acute detoxification, and a range of active outreach programs, Dawn Farm has always been there to help.”

Ann Arbor Comprehensive Treatment Center

“Providing high-quality medication-assisted treatment to individuals aged 18 and older, Ann Arbor Comprehensive Treatment Center assists individuals who are struggling with addictions to opioids by offering the care necessary to achieve lasting recovery.”

WHI: Opioid Project

“The WHI Opioid Project is a volunteer organization that brings together people from across Washtenaw County to end the opioid misuse and overdose epidemic in our community.”

COVID'S Impact on the Treatment of Opioid Use Disorder

The impact of COVID-19 on treatment for opioid use disorder has resulted in a number of policy changes: medicaid emergency authorities expanded, fewer restrictions on access to methadone, and increased telehealth opportunities.
Mark Bicket, MD PhD

What is Substance Use Disorder?

Substance use disorder (SUD) is a complex condition that involves a problematic pattern of substance use. It can range from mild to severe (addiction). SUD is treatable just like hypertension or diabetes mellitus. It’s important to seek help as soon as possible if you think you or your child is developing SUD (Cleveland Clinic, 2022).

Substance use disorder is common. Over 20 million people in the United States have at least one SUD and affects people of all ages, races, genders and socioeconomic levels.

About 20% of people in the U.S. who have depression or an anxiety disorder also have a substance use disorder.

Of the over 20 million people in the U.S. who have SUD:

  • 38% have a drug substance use disorder.
  • 73% have alcohol use disorder.
  • 12% have both a drug SUD and alcohol use disorder.

Tobacco use disorder is the most common substance use disorder worldwide and in the United States.

(Cleveland Clinic, 2022)

Substances are drugs that have addiction potential. They can be prescription drugs or non-medical drugs.

  • Alcohol
  • Cannabis (marijuana)
  • Hallucinogen, such as PCP and LSD
  • Sedatives, such as sleeping pills like Ambien® and Lunesta®
  • Anxiolytics (anti-anxiety medications), such as Xanax®, Klonopin®, Ativan®
  • Prescription and non-prescription opioids, such as codeine, oxycodone, fentanyl, heroin
  • Prescription and non-prescription stimulants, such as Adderall®, cocaine, methamphetamine
  • Tobacco/nicotine, such as smoking cigarettes and electronic cigarettes (e-cigarettes or vaping) 

While these substances are very different from each other, they all strongly activate the reward center of your brain and produce feelings of pleasure.

These substances vary in how likely they are to lead to SUD. The likelihood is called “addiction liability,” and it depends on multiple factors, including:

  • How you take the substance (such as orally, by injection or by inhaling).
  • The rate at which the substance crosses the blood-brain barrier and triggers the reward pathway in your brain.
  • The time it takes to feel the effect of the substance.
  • The substance’s ability to induce tolerance and/or withdrawal symptoms.

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, the signs of substance use disorder include:

  • Taking the substance in larger amounts and for a longer amount of time than you’re meant to if it’s a prescription.
  • Having a strong desire or urge to use the substance.
  • Having unsuccessful efforts to cut down on or control substance use.
  • Spending a lot of time obtaining or using the substance or recovering from its effects.
  • Having issues fulfilling responsibilities at work, school or home due to substance use.
  • Continuing to use the substance, even when it causes problems in relationships.
  • Giving up social, occupational or recreational activities because of substance use.
  • Using substances again and again, even when it puts you in danger.
  • Continuing substance use despite an ongoing physical or psychological problem that’s likely caused or worsened by the substance.
  • Developing tolerance (need for increased amounts to get the same effect).
  • Experiencing withdrawal symptoms, which can be relieved by taking more of the substance.

Seeking medical care as soon as you have signs of substance use disorder is essential.

Effective treatments are available for substance use disorder. Treatment is highly individualized — one person may need different types of treatment at different times.

Treatment for SUD often requires continuing care to be effective, as SUD is a chronic condition with the potential for both recovery and relapse.

As people with SUD often have co-occurring mental health conditions, treating them together rather than separately is generally better.

The three main forms of treatment include:

  • Detoxification
  • Cognitive and behavioral therapies
  • Medication-assisted therapies

There are also several different types of treatment settings, including:

  • Outpatient counseling
  • Intensive outpatient treatment
  • Inpatient treatment
  • Long-term therapeutic communities, such as sober living communities

How can I Help a Loved One with Substance Use Disorder?

It can be very challenging and stressful to learn that someone you love may have substance use disorder. Here are some tips to help your loved one and yourself:

  • Speak up sooner rather than later: The earlier a person with SUD receives treatment, the better. Address your concerns and help them find treatment as soon as possible. Suggest calling a helpline, talking to a healthcare provider or mental health professional, entering a treatment program or going to a 12-step program. Offer your help and support without being judgmental.
  • Practice empathy: Even when you don’t agree with your loved one, listen thoughtfully to them. The more your loved one feels heard, the more they’ll see you as someone they can trust.
  • Be patient: Don’t expect a single conversation or action to fix your loved one’s substance use. SUD is a complex chronic condition, and there’s no quick fix to overcoming it.
  • Take care of yourself: The friends and family members of people with SUD often experience stress, depression, grief and isolation. It’s important to take care of your mental health and seek help if you’re experiencing these symptoms.
  • Consider joining a support group or organization in your community.

 

 

Families Against Narcotics

Families Against Narcotics (FAN) is a community-based program for those seeking recovery, those in recovery, family members affected by addiction, and community supporters.

Cleveland Clinic

This patient information was derived from the Cleveland Clinic website. Please visit their page for more information.

OPEN'S RESOURCES

References

  1. Fernandez, A. C., Waljee, J. F., Gunaseelan, V., Brummett, C. M., Englesbe, M. J., & Bicket, M. C. (2022). Prevalence of unhealthy substance use and associated characteristics among patients presenting for surgery. Annals of Surgery. https://doi.org/10.1097/SLA.0000000000005767
  2. Vu, J. V., Cron, D. C., Lee, J. S., Gunaseelan, V., Lagisetty, P., Wixson, M., Englesbe, M. J., Brummett, C. M., & Waljee, J. F. (2020). Classifying Preoperative Opioid Use for Surgical Care. Annals of surgery, 271(6), 1080–1086. https://doi.org/10.1097/SLA.0000000000003109
  3. Wu, L. T., McNeely, J., Subramaniam, G. A., Sharma, G., VanVeldhuisen, P., & Schwartz, R. P. (2016). Design of the NIDA clinical trials network validation study of tobacco, alcohol, prescription medications, and substance use/misuse (TAPS) tool. Contemporary Clinical Trials, 50, 90–97. https://doi.org/10.1016/j.cct.2016.07.013
  4. Gryczynski, J., McNeely, J., Wu, L. T., Subramaniam, G. A., Svikis, D. S., Catchers, L. A., Sharma, G., King, J., Jelstrom, E., Nordeck, C. D., Sharma, A., Mitchell, S. G., O’Grady, K. E., & Schwartz, R. P. (2017) Validation of the TAPS-1: A four-item screening tool to identify unhealthy substance use in primary care. Journal of General Internal Medicine, 32, 990–996. https://doi.org/10.1007/s11606-017-4079-x
  5. Akbar, A., Rieck, H., Roy, S., Farjo, R., Preston, Y., Elhady, H., Englesbe, M., Brummett, C., Waljee, J., & Bicket, M. C. (2023) Patient-related acceptability of implementing preoperative screening for at-risk opioid and substance use. Pain Medicine. https://doi.org/10.1093/pm/pnad026
  6. Fernandez, A. C., Aslesen, H., Golmirzaie, G., Stanton, S., Gunaseelan, V., Waljee, J., Brummett, C. M., Englesbe, M., & Bicket, M. C. (2022). Patient responses to surgery-relevant screening for opioid and other risky substance use before surgery: A pretest-posttest study. Pain Medicine. https://doi.org/10.1093/pm/pnac190
  7. Hinds, S., Miller, J., Maccani, M., Patino, S., Kaushal, S., Rieck, H., Walker, M., Brummett, C. M., Bicket, M. C., & Waljee, J. F. (2022). Patient risk screening to improve transitions of care in surgical opioid prescribing: A qualitative study of provider perspectives. Regional Anesthesia & Pain Medicine, 47(8), 475–483. https://doi.org/10.1136/rapm-2021-103304 
  8. McNeely, J., Wu, L.-T., Subramaniam, G., Sharma, G., Cathers, L. A., Svikis, D., Sleiter, L., Russell, L., Nordeck, C., Sharma, A., O’Grady, K. E., Bouk, L. B., Cushing, C., King, J., Wahle, A., & Schwartz, R. P. (2016). Performance of the tobacco, alcohol, prescription medication, and other substance use (TAPS) tool for substance use screening in primary care patients. Annals of Internal Medicine, 165(10), 690. https://doi.org/10.7326/m16-0317
  9. Centers for Disease Control. (2022). Empathy: Talking to Patients About Substance Use Disorder. /https://www.cdc.gov/opioids/addiction-medicine/conversation-starters/pdf/talking-to-patients.pdf
  10. Substance use disorder (SUD): Symptoms & treatment. Cleveland Clinic. (n.d.). Retrieved May 1, 2023, from https://my.clevelandclinic.org/health/diseases/16652-drug-addiction-substance-use-disorder-sud#symptoms-and-causes