Substance Use Disorder (SUD) causes significant social and healthcare burdens. [1] While previously thought to be mostly an outpatient and emergency room issue, new research has found that one in six critical care admissions involved a substance-related diagnosis. [2] This highlights the need for faster and more reliable multi-drug screening to identify those at risk before they require a critical care admission.
The finding: Epidemiology of substance-use related ICU admissions
This new research analyzed 4.74 million ICU admissions across the U.S from 2016 to 2019. [2] Crucially, the study did not cover the COVID-19 pandemic years, which would have skewed the results. [2] They found that 16% of ICU admissions, roughly one in six, involved a substance-related diagnosis, with alcohol being the most common substance. [2]
Patients suffering from SUD often have substance-related complications, leading to longer stays and poorer outcomes. [3] This includes organ dysfunction, infections, sepsis, withdrawal symptoms, and medication interactions. [3] This is a significant challenge that is affecting critical care units across the U.S.
Breakdown by substances
As mentioned, alcohol was the most prevalent substance involved in an ICU admission, accounting for 9% of all encounters. [4] Additionally, alcohol was the only substance linked with an increased mortality during the hospital stay. [2][4] This finding reflects the severe medical complications associated with alcohol use disorder, including liver failure, gastrointestinal bleeding, seizures, and increased susceptibility to infections.
The second most prevalent substance associated with ICU admission was opiates, accounting for 4%. [4] Of these, heroin use was only identified in 6.5%, highlighting that the majority of these individuals were using other opiates, such as fentanyl. [4] This shift away from heroin toward more potent synthetic opioids reflects broader trends in the opioid epidemic.
Stimulant drugs accounted for 3% of all encounters, with these admissions often involving acute cardiovascular emergencies, neurological complications, or severe agitation requiring ICU management. [4]
Demographic patterns
The study found that substance-related ICU admissions peaked in those between 55-64 years old for nearly all substances. [4] Rates were also higher in males and those who identified as non-Hispanic or ‘other’ race (not identifying as White, Black, or Asian), for example, American Indian or multiple races. [4]
When comparing ethnicities, opioid-related ICU admissions were higher in White patients, whereas stimulant-related admissions were higher in Black patients. [4] In-hospital mortality rate was found to be higher in females and those identifying as non-Hispanic. [4] These demographic differences reflect broader systemic issues, including unequal access to addiction treatment services and socioeconomic factors.
Trends and context that led to substance-related ICU admissions
Alcohol is one of the most widely available drugs in the U.S, and is also one of the most misused, with sustained high levels of alcohol use over the past few years. [5] With over 27 million Americans suffering from Alcohol Use Disorder (AUD), and with alcohol being the leading cause of preventable deaths in the United States, perhaps this research data isn’t surprising. [5][6]
Similarly, the opioid epidemic, which began in the late 1990s with increased prescription of pain medications, has evolved significantly over the past two decades. [7] Prescription opioid misuse is still a big issue throughout the U.S., contributing to the increase in substance-related ICU admissions.
What substance-related ICU admissions look like
Substance-related ICU admissions can vary widely depending on the substance involved and the patient's overall health. Alcohol-related admissions can involve managing severe withdrawal (delirium tremens), which can lead to life-threatening seizures, alongside complications such as gastrointestinal bleeding and infections.
Opioid-related admissions typically result from overdose with respiratory depression. This often requires mechanical ventilation and prolonged ICU stays if there has been a brain injury resulting from a lack of oxygen. Substance-related ICU admissions are generally medically complex, require a lot of resources, and often have poor outcomes. [1][8] This can have consequences on the wider healthcare provision due to the high treatment cost and resource use.
Public health and policy considerations
ICU care is among the most expensive healthcare services, and substance-related admissions place substantial strain on already limited critical care resources. This creates a clear case for increased investment in prevention and early intervention programs.
Increasing access to addiction treatment, including medication-assisted treatment for opioid and alcohol use disorders, could potentially reduce the number of patients who progress to requiring critical care. Harm reduction strategies, such as supervised consumption sites and widespread naloxone distribution, have shown promise in reducing overdose deaths and may also decrease ICU admissions. [9]
Policymakers should also consider focusing on addressing the social factors that contribute to substance use disorders. This includes improving access to mental health services, stable housing, and economic opportunities. Additionally, integrating substance use screening and brief interventions in primary care and emergency department settings could help identify at-risk individuals before they require ICU-level care.
What this means for clinicians and families
For clinicians, this data highlights the importance of being prepared to manage substance-related complications in the ICU setting. This includes having protocols in place for managing withdrawal syndromes, understanding drug interactions, and being equipped to provide non-judgmental care. ICU teams should work closely with addiction specialists to develop treatment plans that address both the acute medical crisis and the underlying substance use disorder.
For families, having a loved one admitted to the ICU with a substance-related diagnosis can be overwhelming and emotionally challenging. Families should feel able to ask questions about their loved one's treatment plan and prognosis, and to advocate for comprehensive care that includes addiction treatment alongside medical management.
Final thoughts
The fact that one in six ICU admissions is related to substance use highlights the need to address SUDs in the community, allowing individuals to get treatment before an admission is needed. These admissions are often preventable with adequate access to treatment and support.
Moving forward, a collaborative effort is required between public health agencies, healthcare systems, and policymakers. By having robust prevention strategies, early intervention, and accessible treatment options, substance-related ICU admissions could be reduced. If you or a loved one is suffering from substance use, please reach out to a medical professional.
