Dissecting the Impact of Substance Use on Trauma: High Morbidity Does Not Uniformly Dictate Increased Mortality

Introduction Substance use is a known risk factor for traumatic injury. While prior studies have evaluated outcomes associated with individual substances, there is a paucity of literature comparing outcomes across multiple drug classes. This study aimed to compare 30-day mortality and in-hospital complications among trauma patients with positive vs negative urine drug screens (UDS). Methods We conducted a retrospective study using the American College of Surgeons Trauma Quality Improvement Program (TQIP) database from 2013 to 2021. Adult patients aged 18-90 years with a recorded UDS were included, and those with polysubstance use were excluded. Positive UDS was defined as detection of amphetamines, barbiturates, cocaine, methamphetamine, 3,4-methylenedioxymethamphetamine (MDMA), phencyclidine (PCP), tricyclic antidepressants (TCA), or cannabinoids. Each positive cohort was matched to a negative cohort by age, sex, and injury severity score. Logistic regression was used to estimate odds ratios (ORs). Results A total of 704,033 patients were included. Positive screens for amphetamines (OR 0.82, P < 0.001), cocaine (OR 0.78, P < 0.001), and cannabinoids (OR 0.67, P < 0.001) were associated with lower odds of 30-day mortality. No significant mortality differences were observed for other substances. Higher odds of in-hospital complications were observed for TCA (OR 1.74), PCP (OR 1.61), methamphetamine (OR 1.41), cocaine (OR 1.30), amphetamines (OR 1.22), and cannabinoids (OR 1.11) (all P < 0.001), barbiturates and MDMA were not significant. Conclusion Substance-specific differences exist in trauma outcomes. While some substances are associated with decreased mortality, many are associated with increased complications, suggesting a need to prioritize complication-focused management. Limitations include underreporting of substance use.