High-Risk Substance and Polysubstance Use Among Elective Surgery Patients: Prevalence and Risk Factors

BACKGROUND: Substance use is a modifiable risk factor that may adversely affect surgical outcomes, yet its prevalence using surgical risk-specific thresholds remains incompletely characterized in preoperative populations. STUDY DESIGN: We performed a cross-sectional analysis of preoperative screening data from a clinical trial (NCT05783635) at a large Midwestern health system. Between February 2024 and February 2025, 2,688 adults 21 to 75 years of age undergoing elective surgery completed validated self-report assessments of alcohol, nicotine, cannabis, and other drug use. High-risk use was defined as Alcohol Use Disorders Identification Test-Consumption scores ≥5 or weekly or daily use of other substances. Polysubstance use was defined as high-risk use of more than 1 substance. Multivariable logistic regression evaluated associations between patient and surgical factors and high-risk use. RESULTS: Overall, 27.6% (743) of patients reported high-risk substance use and 6.6% (177) reported polysubstance use. Cannabis was the most prevalent high-risk substance (15.0%), followed by alcohol (11.1%), nicotine (8.5%), and other drugs (0.4%). Younger age, male sex, and poorer self-reported health were associated with increased odds of high-risk use. Prevalence varied across surgical services, with the highest rates in neurosurgery (27.1% high risk and 11.4% polysubstance) and lowest in endocrine surgery (15.1% and 3.3%). CONCLUSIONS: More than 1 in 4 elective surgical patients report high-risk substance use before surgery. These findings support universal preoperative substance use screening to identify patients at elevated risk for adverse perioperative outcomes and enable targeted risk mitigation.