Analgesia and Sedation Requirements in Mechanically Ventilated Trauma Patients With Acute, Preinjury Use of Cocaine and/or Amphetamines

Bridgette Kram, PharmD; Shawn J. Kram, PharmD; Michelle L. Sharpe, PharmD; Michael L. James, MD; Maragatha Kuchibhatla, PhD; Mark L. Shapiro, MD


Anesth Analg. 2017;124(3):782-788. 

In This Article

Abstract and Introduction


Background: The purpose of this study was to determine whether mechanically ventilated trauma patients with a positive urine drug screen (UDS) for cocaine and/or amphetamines have different opioid analgesic and sedative requirements compared with similar patients with a negative drug screen for these stimulants.

Methods: This retrospective, single-center cohort study at a tertiary care, academic medical and level 1 trauma center in the United States included patients ≥16 years of age who were admitted to an adult intensive care unit with a diagnosis of trauma between 2009 and 2013 with a UDS documented within 24 hours of admission, and were mechanically ventilated for >24 hours. The primary end point was the daily dose of opioid received during mechanical ventilation, expressed as morphine equivalents, for patients presenting with a positive UDS for cocaine and/or amphetamines compared with patients with a negative UDS for these stimulants. Secondary end points included the daily benzodiazepine dose and median infusion rates of propofol and dexmedetomidine received during mechanical ventilation, duration of mechanical ventilation, intensive care unit and hospital length of stay, and in-hospital mortality. Analgesic and sedative goals were similar for the duration of the study period, and both intermittent and continuous infusions of opioids and sedatives were administered to achieve these targets, although a standardized approach was not used. A multivariate logistic regression analysis and a propensity-adjusted model evaluated patient characteristics predictive of a higher median opioid requirement.

Results: A total of 150 patients were included in the final analysis. In a univariate analysis, opioid and sedative requirements were similar for patients presenting with a positive UDS for cocaine and/or amphetamines compared with patients with a negative UDS for these stimulants. In the multivariate regression analysis, increasing age and Abbreviated Injury Scale (head and neck) were associated with decreased daily opioid requirements (odds ratio [OR], .95, 95% confidence interval [CI], .93–.97 and OR, .71, 95% CI, .65–.77, respectively), whereas preinjury stimulant use was not predictive of opioid requirements (OR, .88, 95% CI, .40–1.90). In a propensity score--adjusted model, preinjury stimulant use was similarly not predictive of opioid requirements during mechanical ventilation (OR, .97, 95% CI, .44–2.11).

Conclusions: For trauma patients presenting with acute, preinjury use of cocaine and/or amphetamines, analgesic and sedative requirements are variables and may not be greater than those patients presenting with a stimulant-negative UDS to achieve desirable pain control and depth of sedation, although this observation should be interpreted cautiously in light of the wide CI observed in the propensity score--adjusted model. Although unexpected, these findings indicate that empirically increasing analgesic and sedative doses based on positive UDS results for these stimulants may not be necessary.


Patients with drug use disorders are at increased risk of motor vehicle collisions and other traumatic injuries.[1–4] After traumatic injury, patients cointoxicated with alcohol and other drugs are more likely to experience complications, including the need for mechanical ventilation and pneumonia.[5] Sedation management for these patients is particularly challenging and often strategically focused on avoiding withdrawal syndromes and mitigating severe agitation to reduce the risk of self-extubation.[6]

Medical patients with a history of alcohol and drug abuse require mechanical ventilation more frequently and have longer duration of mechanical ventilation and longer intensive care unit (ICU) length of stay.[7,8] In a small, retrospective study, mechanically ventilated medical ICU patients with a history of alcohol and drug use disorders required 5-fold greater opioid equivalents and 2.5-fold greater benzodiazepine equivalents to achieve target sedation levels similar to patients without drug use disorders.[9]

The existing literature in both the medical and trauma populations has primarily focused on the consequences of alcohol use disorders, both acute intoxication and chronic use, and cointoxication with alcohol and other illicit substances. Studies directly examining the preinjury use of stimulants, such as cocaine and amphetamines, and postinjury analgesia and sedation requirements in the trauma population are lacking. According to the Substance Abuse and Mental Health Services Administration, the prevalence of cocaine use in adolescents and adults declined modestly between 2007 and 2012.[10] However, both prescription and nonmedical use of amphetamines is rising in adolescents and adults, particularly among college students.[11–15] In addition, driving under the influence of illicit drugs is increasing and is most prevalent among young adults 18 to 25 years of age,[10] highlighting a significant public health problem and the need for targeted therapies for these patients when traumatically injured.

The purpose of this study is to determine whether the analgesic and sedative requirements of mechanically ventilated trauma patients who have a urine drug screen (UDS) positive for cocaine and/or amphetamines are different from those who do not use these stimulants.