The management of substance abuse in the critically ill.

Substance abuse continues to increase the burden on the health care system. In Diagnostic and Statistical Manual of Mental Health Disorders, 5th edition, text revision (DSM-IV-TR), substance abuse and dependence disorders are now combined into substance use disorders. Substance abuse refers to a maladaptive pattern of substance use leading to clinically significant impairment or distress manifested by at least 1 symptom that interferes with life functioning within a 12-month period. A diagnostic criterion for substance dependence requires at least 3 of the following within a 12-month period: development of tolerance to the substance, withdrawal symptoms, persistent desire/unsuccessful attempts to stop the substance, ingestion of larger amounts of substance than was intended, diminished life functioning, and persistent substance use with physical or psychological problems. Estimates regarding the management of substance intoxication and withdrawal are increasingly high, and many of the current interventions remain heavily weighted on science vs evidence-based practices. In addition, informed consent required for clinical studies would be difficult to obtain due to the nature of the disease state. Randomized-based controlled interventions to help guide clinicians on disease state management are desperately needed. The presentation of patients into the emergency department and the intensive care unit can be firsttime users (naïve), social users, or chronic abusers. Individuals who are either social or chronic users of these intoxicants generally have an adapted tolerance to the substance, which results in the user requiring more drug over time to feel the same effects. Tolerance has a dual role, users develop a tolerance to the rewarding effect of these substances and they develop an adapted response and tolerance to the adverse effects. The synthesis of treatment care plans for patients admitted for substance intoxication or withdrawal requires an integration of drug/toxin, laboratory value(s), and clinical presentation. The integration of clinical information for an intoxication is critical, as the relationship is complex and dependent on multiple variables (e.g., treatment not based solely on a laboratory value(s)) (Fig. 1). Social, illicit, and prescription intoxicants (nicotine, alcohol, cocaine, marijuana, and opioids) are the focus of this review.