Diabetes and substance use: the hidden challenge

Abstract

Substance abuse in patients with diabetes mellitus (DM) significantly worsens morbidity and premature mortality, with notable associations in the use of cocaine and opioids. Acute complications are recurrent: alcohol causes delayed hypoglycemia (6-8 hours post-consumption), while stimulants such as cocaine, ecstasy, and amphetamines act as potent triggers of diabetic ketoacidosis (DKA) by stimulating the sympathetic nervous system, elevating counterregulatory hormones (cortisol, catecholamines), and inhibiting insulin secretion.

Although substance use in young people with type 1 diabetes (T1D) tends to catch up with their peers by adulthood, it is a problem that is frequently invisible in emergency departments, where less than 20% of patients initially disclose drug use. In adults with type 2 diabetes, the prevalence of substance use disorders (SUDs) is higher than in the general population; furthermore, chronic opioid use to treat neuropathic pain increases the risk of iatrogenic dependence and poorer metabolic control.

Effective management requires a non-punitive approach. It is imperative to integrate systematic screening (SBIRT) into routine clinical practice, educate patients on harm reduction strategies—such as frequent glucose monitoring, the use of alert bracelets, and adherence to insulin administration—and collaborate with addiction specialists, whose treatments have proven equally effective in diabetic patients.