Prevalence of substance use and substance use disorder in medically ill patients: A cross-sectional, hospital-based study from India

INTRODUCTION

Substance use and substance use disorders (SUDs) are associated with complications in many spheres of the user’s life, including occurrence of various medical conditions. Untreated co-occurring SUDs in patients presenting for medical conditions may be associated with unfavourable medical outcomes, including prolonged hospital stay, readmission for health conditions and more frequent need for emergency care.^1–5 Thus, it is important to study the prevalence of substance use and SUDs among patients admitted in medical facilities as it may help in developing appropriate strategies to identify and treat SUDs in the hospital setting.^6,7

The prevalence of substance use and SUDs in hospital settings varies, depending on the type of health facility (primary care or hospital), hospital setting (outpatient, inpatient or emergency), across various hospital services and by patient characteristics. For example, the prevalence of alcohol use in attendees of accident and emergency services across different studies has ranged from 12% to as high as 37.5%.^8–10 Similarly, a meta-analysis of alcohol use disorder in hospitals in the UK found that approximately 1 in 5 patients suffer from harmful alcohol use, while 1 in 10 patients suffer from alcohol dependence syndrome.¹¹ The study also found that the prevalence of alcohol dependence is higher in accident and emergency services compared to general wards. Similarly, the prevalence of alcohol use and alcohol use disorder is higher in men and in younger adults than in the older ones.¹²

In India, a number of people use various psychoactive substances. As per a recent national survey on substance use, the prevalence of alcohol, cannabis and opioid use in those aged between 10 and 75 years was 14.6%, 2.8% and 2.1%, respectively.¹³ However, studies that have assessed the prevalence of substance use in general healthcare settings in the country are limited. Some of these have analysed referrals to the psychiatry department from other departments of the hospital,^14,15 whereas others have focused on the use of one substance rather than on the use of all substances and SUDs.^16–19 Furthermore, some studies have evaluated patients from one department rather than from all departments.^20–22 It is important to assess the prevalence of various psychoactive substances and SUDs in patients admitted to hospital in different medical specialties as it may help develop appropriate strategies for screening and treating patients with SUDs in the hospital setting.

We assessed the use of psychoactive substances as well as SUDs among patients admitted to different specialties in a tertiary care hospital in India. We also assessed whether substance use was associated with the medical illness for which the patient was admitted to the hospital.

METHODS

This cross-sectional study was done in an inpatient setting of a tertiary care multidisciplinary teaching medical institution in northern India.

The hospital has about 2500 beds, including intensive care units (ICU) beds. Anticipating the prevalence of any psychoactive SUD (including tobacco use disorder) to be 10%, confidence interval 95%, 5% absolute precision and design effect 2.5, we calculated that we would require a sample size of 317.

The first step in sampling in our study was choosing the bed. In each ward, we chose a random number, after which every third bed was approached to assess whether the patient in it met the inclusion criteria, i.e. (i) age >18 years, (ii) admitted for at least 24 hours, (iii) physically fit to participate in the study, and (iv) willing to participate in the study by providing written consent. If the selected bed was empty or the patient did not meet the inclusion criteria, we approached the patient on the next selected bed. We continued to choose every third bed in this manner, till the required sample size was covered. We excluded ICU beds, as well as beds in the Paediatrics and Psychiatry ward. The ICU beds were excluded as the patient would not have been able to participate in the study comfortably. We excluded beds in the paediatric ward, since the study was limited to adults. We also excluded beds in the psychiatry ward since the focus was to assess the rates of substance use and SUD in patients with medical illnesses.

RESULTS

Of the 322 patients approached, 32 were excluded (Fig. 1) and a total of 290 subjects were included in the study.

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FIG 1.

Flow-chart depicting the inclusion of participants in the study

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DISCUSSION

We assessed the prevalence of use of all psychoactive substances in a tertiary care, multi-disciplinary hospital in India. We used systematic sampling to select participants to reduce selection bias. We included adult patients from all clinical disciplines in the hospital, except for those admitted in ICUs and the psychiatry ward. Psychiatrists interviewed the selected participants which helped in making a diagnosis of SUDs and in assessing whether the participants’ substance use and medical illness could affect each other.

A sizeable proportion of hospital admissions in our study had substance use, as has been documented in other studies as well.^9,11,12 We found that almost one-third of the participants had used at least one psychoactive substance in their lifetime. Almost 1 in 5 participants reported using any psychoactive substance currently. As is the case with the general population in India, the prevalence of tobacco use was the highest followed by the use of alcohol and cannabis.¹³ The prevalence of tobacco use disorder and of alcohol use disorders in our study (of 27% and 8%, respectively) was higher than that in a general population survey in the country, i.e. the National Mental Health Survey (NMHS) of India (21% and 4.6%, respectively). Prevalence of SUD in patients admitted to hospital is often higher than that in the general population.^29,30 The rates of tobacco use disorder and alcohol use disorder in our participants was similar to that seen in other studies among general medical inpatients.^{20,29,31–33} Thus, our study shows that it is important to screen all patients admitted to a hospital for the presence of lifetime and current use of any psychoactive substance, especially tobacco and alcohol, and SUD. In case of current use, screening instruments such as ASSIST should be used to assess the risk category of substance use for appropriate clinical decision making.

In keeping with the data from the previous general population surveys, none of our participants reported lifetime use of cocaine, amphetamines or hallucinogens.¹³ An interesting finding was that none of our participants reported opioid use, which was reported by 2.1% of the general population aged 10–75 years in a recent national survey,¹³ and a sizeable proportion of patients admitted to hospital in previous studies.^34,35 Some studies, in fact, have linked higher prevalence of opioid admissions in recent years with the surge in opioid use in the community.^36,37 Some other studies from India also show lower prevalence of opioid use among patients admitted to hospital with a medical illness.^38,39 Studies from India have shown physical problems with opioid injecting drug use, including blocked veins, abscess and overdose episodes.^40,41 Yet, opioid users are not reflected in medical admissions to hospital. Further studies are required to explore reasons for the poor utilization of hospital services by opioid users, including whether they feel discriminated against in hospitals.^42,43 Presence of SUDs was strongly associated with male gender and lower education in our study. Additionally, alcohol use was also associated with injuries and diseases of the circulatory system. Unfortunately, other medical illnesses were less prevalent in our study; hence, their association with substance use could not be assessed.

Medical illness can serve as a strong motivating factor for individuals with SUDs to quit their substance use.^44–46 Almost 55% participants in our study with lifetime substance use tried to reduce or stop their substance use by themselves after the onset of their medical illness. Though two-thirds of the participants had informed their treating team about their lifetime substance use, only half were informed about the risk of substance use on their medical illness. It may be possible that the medical team would not have assessed for presence of substance use in their patients as seen in other studies as well.^35,47 The benefit of SUD interventions in hospitals on the course of SUD as well as in management of medical illness is well documented.^6,48 The data shows that an important opportunity to counsel patients using substances is missed by the primary clinician in-charge of the medical illness. Unfortunately, many clinicians are not well versed with the diagnosis and management of SUD as the medical curriculum does not cover this topic adequately. There is a need to provide adequate training on diagnosis and management of SUD during medical training.

Despite a sizeable number of participants suffering from and reporting substance use, a minor proportion of participants with substance use were offered treatment for their substance use in our study.

Various models exist for providing psychiatry (including addiction) services in medical/surgical settings. On one end of the spectrum is the demand-driven approach such as consultation model where the primary physician detects problematic substance use in their patients and sends referrals to the hospital psychiatrist.⁴⁹ At the other end exist Addict Consult Services (ACS), where a multi-disciplinary team of mental health professionals work with physicians to provide hospital care for patients with SUD.⁵⁰ Studies show that ACS works much better than other consultation–liaison addiction treatment models; however, ACS is resource intensive and it may not be feasible and viable to implement ACS in India.⁵¹ The best approach for hospitals in India would be to educate the non-psychiatry medical doctors on identification and initial management of patients with SUD. Studies show that approaches such as Screening, Brief Interventions and Referral to Treatment (SBIRT) are helpful in identifying at-risk substance users and linking them to appropriate treatment for SUD.⁵² Such approaches can be delivered in 5–10 minutes in various medical settings ranging from primary care to emergency departments.⁵³ Research has shown the effectiveness of brief interventions (BI) in problem substance users, especially alcohol use, delivered even by non-specialists.^54–56 Unfortunately, most studies on approaches such as SBIRT are from western countries. The effectiveness of such approaches in hospital settings have not been studied in India, though the effectiveness of BI in the Indian population has been well documented.^57–59

Our study has some limitations. While the sample size was enough for estimating the prevalence of SUD for all the substances combined, it was insufficient for individual substances, except tobacco. We did not include patients who were admitted for less than 24 hours, those admitted in ICU or those presenting to the emergency department, which may have affected the estimate of SUD in our study.