Table.

Proposed universal substance use guidelines for patients being evaluated for heart transplantation.

1. General: Unless medically indicated, all patients being evaluated for heart transplant must abstain from using tobacco products and illicit substances. Patients must demonstrate an ability to abstain from excess alcohol, and must abstain completely if there is a history of prior alcohol abuse/dependence or testing to suggest alcohol abuse.

a. Tobacco products include cigarettes, cigars, E-cigarettes (“vaping”), and chewing tobacco

b. Illicit substances include cocaine, heroin, amphetamines, hallucinogens, non-medically prescribed marijuana,4 and any other non-prescribed controlled substance.

2. Verification: Toxicology should be performed at the initiation of a heart transplant evaluation and randomly thereafter for all patients, including:

a. Drug screen (urine),

b. Cotinine levels (blood or urine), and

c. Phosphitidylethanol (PEth, blood).13

3. Exceptions for Approved Substance Use: Patients must notify the heart transplant team regarding medically prescribed controlled substances, including narcotics, benzodiazepines, and cannabis. Copies of prescriptions, medical letters, and/or provider contact information need to be provided to the heart transplant team. Patients may be required to cease use when alternative agents are felt to be more efficacious or the original reason for prescribing no longer exists.

a. Use of controlled substances should be reported by patients to transplant programs prospectively.

b. Chronic narcotic use must be prescribed by a pain management clinic or by a clinician experienced in the management of chronic pain disorders, with consideration for tapering off or using alternate options.11 Such long-term narcotic use should be reviewed and approved by the heart transplantation team.

c. Cannabis (marijuana) may only be used if prescribed legally by a medical provider—and only if it is ingested or used topically, not smoked—with consideration for tapering off or using alternate options. Use must be reviewed and approved by the heart transplantation team.

4. Actions for Known Abuse: For patients with positive screens or who endorse a history of substance abuse, a trained individual (i.e. licensed social worker, psychologist, or psychiatrist) will assess and determine if the patient has an active substance-related disorder using established mental health criteria.14 If so, prior to listing the patient must do the following:

a. Sign a standard contract outlining expectations.

b. Undergo a formal substance use assessment as directed by the trained individual.

c. Participate in a recommended treatment program. Ideally, this should result in demonstration of the following: insight into past substance misuse, understanding of how substance misuse has had an impact on current health, development of adequate coping skills for dealing with stressors, and presence of a social network which acknowledges the issue posed by substance misuse and supports the patient's commitment to abstinence.

d. Demonstrate abstinence through toxicology screening at least monthly for a minimum of 6 consecutive months. Patients with positive screens during this time period will have to re-establish at least 6 consecutive months of negative screening tests. Patients who develop positive screens while listed for transplant should be made inactive or delisted until they re-establish at least 6 consecutive months of negative screening tests.