Discussion

Cocaine abuse poses a significant challenge in nasal surgery. This is the first study investigating the current practice and opinions of UK rhinologists on cocaine screening in patients undergoing nasal reconstructive surgery. Currently, no national consensus exists regarding the role of pre-operative screening for cocaine use. This is significant because cocaine users are often unlikely to disclose their habits to avoid potential experiences of stigma and discrimination.

Potent and highly addictive, cocaine is the second most commonly used illicit drug in the UK behind cannabis, with around 3 per cent of the population aged 16–59 years taking it last year.⁶ In comparison with the earlier part of last decade, the proportion of adults who had used cocaine in the last year has increased by 73 per cent.⁶ This abuse can be in the form of smoking, injecting, or more commonly, snorting.^{Reference Caulley, Takhar and Bast5} The acute effect of intra-nasal cocaine abuse is intense vasoconstriction, a mechanism that is often utilised in nasal surgery.^{Reference Harper and Jones7} Repeated use of intra-nasal cocaine causes pathological change to the nasal mucosa leading to ischaemic necrosis of structures, including the perichondrium and septal cartilage. The toxic effects of contaminants and cutting agents, such as levamisole, further contribute to the mucosal injury.^{Reference George, Freet, Cross and Huzar3,Reference Walker, Joshi and D'Souza8} Clinical presentations include epistaxis, crusting, ulceration and nasal deformities. In extreme cases, cocaine-induced midline destructive lesions can occur causing destruction of the midface osteocartilaginous structures involving the nasal lateral walls and hard palate.^{Reference Walker, Joshi and D'Souza8}

Complete abstinence from cocaine use is vital in improving the outcome and success of nasal reconstructive surgery, including minimising post-operative complications.^{Reference Guyuron and Afrooz9–Reference Bloom, Kaplan, Bleier and Goldstein11} Walker et al. recommended that patients should be free from cocaine use for more than 18–24 months prior to closure of septal perforations.^{Reference Walker, Joshi and D'Souza8} Guyuron and Afrooz stated that patients should be cocaine free for ‘several years’ before undertaking reconstructive surgery for cocaine-related nasal deformities.^{Reference Guyuron and Afrooz9} The majority of rhinologists in our survey agree that patients should cease using cocaine for more than 12 months prior to nasal reconstructive surgery, with two respondents stating a minimum period of abstinence of 24 months. None would offer surgical repair of septal perforation to active cocaine users, although a very small percentage would offer septoplasty and septorhinoplasty.

Obtaining a comprehensive clinical history and performing a thorough examination is important to identify patients who may be an ex- or active cocaine user. We found that only half of the respondents in our survey always asked about cocaine use prior to consideration of nasal reconstructive surgery. This is an important finding given that cocaine users are less likely to be forthcoming with their habits.^{Reference Slavin and Goldwyn10} Caulley et al. reported undisclosed cocaine use confirmed on urine drug screening in 37 per cent of patients who presented with features of cocaine-induced rhinitis.^{Reference Caulley, Takhar and Bast5} Absence of accurate information regarding a patient's abstinence can negatively impact the pre-operative informed consent process and ultimately affect patient and surgical outcomes.

We found that, although 16 per cent of rhinologists in our survey reported having a formal, pre-operative screening policy for cocaine use, 45 per cent performed testing on their patients. Cocaine drug screening can be performed on various biological specimens, such as blood, urine, saliva, sweat and hair.^{Reference Moeller, Kissack, Atayee and Lee12,Reference Verstraete13} Among the rhinologists who performed cocaine testing in our survey, urine drug screening was most commonly used, with 84 per cent of the respondents utilising urine testing, with or without other forms of testing. This is likely because of the ease of sample collection with urine specimens, the non-invasive nature of testing and the existing laboratory testing facilities in hospitals. Furthermore, the detection times of cocaine or benzoylecgonine, one of the main metabolites of cocaine, are extremely variable. The detection time of cocaine in blood is between 4–12 hours depending on the dose of cocaine. In chronic users, benzoylecgonine can be detectable up to eight days. In saliva, cocaine use can be detected for 12–24 hours. Urine testing can generally detect intra-nasal cocaine use for 48–72 hours.^{Reference Verstraete13} Therefore, abstinence of cocaine use for this period of time can result in a negative urine sample.

Hair testing was less often employed by the rhinologists in our survey. This screening method has a much larger detection window of months to years compared with other types of testing, depending on the length of the hair shaft.^{Reference Harrison and Fu14,Reference Boumba, Ziavrou and Vougiouklakis15} The large window of detection is useful in determining if a user's claim of abstinence is accurate. Sample preparation for hair, however, is extensive and more time-consuming; external contamination from the environment may lead to false positives.^{Reference Harrison and Fu14} Moreover, it is much less readily available in routine clinical practice^{Reference Walker, Joshi and D'Souza8} and costs roughly twice as much per test as the equivalent urine test.^{Reference DuPont and Baumgartner16}

In our survey, the timing of testing varied among the rhinologists who performed cocaine testing. Most performed cocaine testing at the first and/or subsequent clinic appointments. This may be because of the convenience of collection and the ability for surgeons to discuss the rationale of drug screening during clinic appointments. Plus, given the short detection window in most types of drug screening except hair testing, first clinic appointments may be preferable as patients are less likely to be aware of the need for drug screening and therefore unable to cheat the screening process by abstaining for a short period in order to generate a negative result. Testing at multiple stages of the patient journey can further enable surgeons to detect non-disclosures and poor compliance to abstinence. This process, however, is more time-consuming and costly.

Among the respondents who did not undertake cocaine testing, over half of them stated the reason as testing not being available or uncertainty regarding availability of testing. One-third stated no testing was performed because of a lack of formal policy or guidelines. A national database of current practice and protocols may help to establish UK consensus and guidance on cocaine screening in patients undertaking nasal reconstructive surgery. This may support and facilitate rhinologists to successfully implement cocaine screening capabilities in their local hospitals. We found that the majority of rhinologists in our survey demonstrated they would be keen to follow a formal national policy on cocaine screening in patients undergoing nasal reconstructive surgery. This may reduce any ambiguity, allow for practices to be audited clearly and lead to improved patient and surgical outcomes.