Share this article on:

The US Opioid Crisis: A Role for Enhanced Recovery After Surgery

Stone, Alexander B. MD*; Wick, Elizabeth C. MD; Wu, Christopher L. MD*; Grant, Michael C. MD*

doi: 10.1213/ANE.0000000000002236
The Open Mind: The Open Mind

Published ahead of print July 1, 2017.

From the *Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland; and Department of Surgery, The University of California San Francisco Medical Center, San Francisco, California.

Accepted for publication April 27, 2017.

Published ahead of print July 1, 2017.

Funding: Drs Wu and Wick receive support from the AHRQ Safety Program for Improving Surgical Care and Recovery grant number: HHSP23337004T.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Alexander B. Stone, MD, Department of Anesthesiology, Zayed 6208-P, the Johns Hopkins Medical Institutions, 1800 Orleans St, Baltimore, MD 21287. Address e-mail to abstone89@gmail.com.

We are in the midst of a prescription opioid crisis. The United States, which makes up 4.4% of the world’s population, consumes a staggering 80% of the world’s supply of opioids.1 Between 1999 and 2014, the number of opioid prescriptions quadrupled while the number of drug-related deaths surpassed motor vehicle collisions to become the number 1 cause of accidental death across the nation.2,3 This increased use and abuse of opioids has paradoxically coincided with the perception that pain in the United States is both underappreciated and subsequently poorly treated. The National Academy of Medicine (formerly the Institute of Medicine) reported in 2011 that pain costs the nation $635 billion a year in medical treatment and lost productivity.4 The perceived failure to address a fundamental aspect of health care has led to an unintended pendulum swing toward heightened utilization of opioids.

Perioperative providers have played a role in the promulgation of the opioid crisis through their management of postsurgical pain. Large retrospective studies reveal that between 3% and 7% of previously opioid naive patients undergoing surgery continued to take opioids a year later.5,6 Compared with the nonsurgical population, patients undergoing surgery have an increased risk of chronic opioid use during the first year after surgery.7 Providers are incentivized to overestimate posthospital opioid needs to reduce the burden of hospital discharge, resulting in as many as 72% of pills going unused by patients after general surgery procedures.8 This seemingly innocuous strategy can lead to diversion, wherein unconsumed opioids find their way into unintended hands.9 In a survey of heroin users, approximately 75% reported that they initially started with opioid pain relievers; often these were not prescribed to them.10 Despite such statistics, surgeons and perioperative providers are confounded by indication, as their indicated surgical care innately results in pain. Opioids are among the most powerful analgesics available to many physicians. This, coupled with the fact that they have no analgesic ceiling, makes them useful tools for postsurgical pain. Their inherent effectiveness in eliminating breakthrough pain may be dangerous as it may reinforce the rote administration of opioids in lieu of attempts at, or early abandonment of, multimodal analgesia.

Despite evidence of an association between acute surgical care and subsequent chronic pain,11 we are only beginning to explore the transition of surgical pain management from the inpatient to outpatient setting. This area of research poses a challenge for a number of reasons. First, the transfer of care to the outpatient setting often involves multiple electronic health records and patients potentially fill their prescriptions at several pharmacies. Additional complication stems from multiple states requiring opioid prescriptions to be written out manually, which undermines both uniformity in prescription practices and the ability to provide automated controlled substance prescription surveillance. Certain state agency regulations often impede convenient prescription refills, leading providers to overprescribe and patients to seek more alternative means to secure opioid medications.12 Follow-up in clinic is often not standardized and dependent on the clinician and patients’ individual schedules. Finally, institutional pressures to improve performance on patient satisfaction surveys, which have multiple specific questions related to treatment of pain, may influence providers to prescribe more opioids.

Enhanced recovery after surgery (ERAS) pathways provide a framework that can be leveraged to avoid many of these perioperative-related drivers of the opioid crisis. ERAS pathways are multidisciplinary, patient-centered programs that bundle evidence-based process measures to both minimize the physiologic stress associated with surgery and improve rates of postoperative recovery. One of the central tenets of ERAS protocols is the application of multimodal pain interventions to reduce the reliance on opioid-based medications.13 Comprehensive acute pain regimens include the use of scheduled nonsteroidal medications such as acetaminophen or ibuprofen, neuroleptic modulators such as gabapentin, and N-methyl-D-aspartate receptor antagonists such as ketamine. Where feasible, surgeons are encouraged to work closely with anesthesiology colleagues to provide site-specific regional anesthesia in the form of neuraxial analgesia or peripheral nerve blocks. These measures have been repeatedly shown to limit the amount of opioids prescribed in the early postoperative phase and ultimately may reduce the need for providers to prescribe opioids across the inpatient and outpatient settings.14–16 In addition, the development of an ERAS pathway involved funding for increased staff for the preoperative evaluation center at our institution.17 This allowed for a wider and more comprehensive preoperative screening for patients at risk for opioid use disorder.

ERAS programs play a role in formalizing the transition of care from the inpatient to the outpatient setting as well. Multidisciplinary ERAS teams should include providers with expertise in postoperative pain. At our institution, an anesthesiologist-run acute pain service (APS) collaboratively manages pain-related interventions for all ERAS patients.18 ERAS implementation provided increased resources and staffing for the existing APS.19 A natural extension of this service would be to incorporate these specialists into formal round discussions regarding anticipated posthospital opioid requirements and establish directives to not only properly taper medications but also promote close postdischarge follow-up. It comes as no surprise that early work with multidisciplinary transitional pain centers has been piloted at institutions with robust ERAS programs.20,21 To date, groups in Toronto and Helsinki have published preliminary results of successful implementation of transitional pain services and outpatient expansions of APS.20,22 These programs rely on early identification of at-risk patients, multidisciplinary teams, and close outpatient follow-up to help wean patients from opioids after surgery. Incorporating a transitional pain service under the umbrella of an ERAS program would likely streamline implementation and widespread expansion at a time of critical need. Even without a formal APS, collaborations between surgeons and anesthesiologists fostered within ERAS programs can be used to devise institution-specific, safe opioid prescribing practices. Some ERAS programs integrate in-home nursing care into their programs.19 These frontline providers make it possible to directly monitor patients’ opioid use, as well as provide education about safe opioid disposal.

Beyond the individual procedural and collaborative measures, patient and family engagement is an essential aspect of ERAS programs. Administration of opioids for pain control has become engrained into the lay medical culture as a component of surgical care. Convincing health care providers, families, and patients to accept an analgesic regimen generally perceived as less potent (despite mounting evidence to the contrary) remains a significant challenge. ERAS programs recognize the importance of patient and family engagement in safe surgery and from the outset (before hospitalization and before they are in pain), patients and individuals who care about and for them are formally educated on all elements of their disease process and associated surgery, with particular emphasis placed on establishing realistic postoperative pain and functional goals. Individual medications and regional anesthesia techniques are introduced early and with conviction, which serves to optimize conditions for patient compliance. Health care providers themselves are further educated on nonopioid pain-related interventions, which permits them to offer multimodal options with the same authority that they offer their procedural skillsets. Finally, nursing and support staff recognize the substantial long-term benefits to adherence to nonopioid solutions, promoting an “opioid sparing” culture at unit and institutional levels.23,24 The net effect is the development of commonplace acceptance (and assertion) of alternatives to opioids for pain management in the postoperative period.

ERAS programs bring together multiple disciplines to facilitate optimal perioperative care. Because they deliver results, ERAS programs have spread quickly. Previous studies of regional anesthesia alone have yet to show an impact on persistent postsurgical opioid use, emphasizing the need for the coordination of interventions across specialties to combat this complex problem.25 By developing an ERAS program, clinicians have committed to transdisciplinary perioperative collaboration and developed an infrastructure in which new evidence-based elements can rapidly be implemented into various phases of care. To date, these efforts have largely centered on reducing length of stay and surgical complication rates. It is now time for ERAS programs to expand their objectives to leverage quality improvement frameworks to combat the opioid epidemic.

Back to Top | Article Outline

DISCLOSURES

Name: Alexander B. Stone, MD.

Contribution: This author helped prepare and review the manuscript.

Name: Elizabeth C. Wick, MD.

Contribution: This author helped prepare and review the manuscript.

Name: Christopher L. Wu, MD.

Contribution: This author helped prepare and review the manuscript.

Name: Michael C. Grant, MD.

Contribution: This author helped prepare and review the manuscript.

This manuscript was handled by: Honorio T. Benzon, MD.

Back to Top | Article Outline

REFERENCES

1. Compton WM, Jones CM, Baldwin GT. Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med. 2016;374:154–163.
2. Drug overdose deaths in the United States continue to increase in 2015. Available at: https://www.cdc.gov/drugoverdose/epidemic/. Accessed January 31, 2017.
3. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths—United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64:1378–1382.
4. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. 2011. Washington, DC: National Academies Press; Available at: http://www.ncbi.nlm.nih.gov/books/NBK91497/. Accessed January 24, 2017.
5. Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ. 2014;348:g1251.
6. Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med. 2012;172:425–430.
7. Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med. 2016;176:1286–1293.
8. Hill MV, McMahon ML, Stucke RS, Barth RJ Jr. Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg. 2017;265:709–714.
9. Waljee JF, Li L, Brummett CM, Englesbe MJ. Iatrogenic opioid dependence in the United States: are surgeons the gatekeepers? Ann Surg. 2017;265:728–730.
10. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers—United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013;132:95–100.
11. Perkins FM, Kehlet H. Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiology. 2000;93:1123–1133.
12. Gawande AA. It’s time to adopt electronic prescriptions for opioids. Ann Surg. 2017;265:693–694.
13. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152:292–298.
14. Wu CL, Cohen SR, Richman JM, et al. Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology. 2005;103:1079–1088.
15. Richman JM, Liu SS, Courpas G, et al. Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg. 2006;102:248–257.
16. Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA Jr, Wu CL. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA. 2003;290:2455–2463.
17. Stone AB, Grant MC, Pio Roda C, et al. Implementation costs of an enhanced recovery after surgery program in the United States: a financial model and sensitivity analysis based on experiences at a quaternary academic medical center. J Am Coll Surg. 2016;222:219–225.
18. Wu CL, Benson AR, Hobson DB, et al. Initiating an enhanced recovery pathway program: an anesthesiology department’s perspective. Jt Comm J Qual Patient Saf. 2015;41:447–456.
19. Wick EC, Galante DJ, Hobson DB, et al. Organizational culture changes result in improvement in patient-centered outcomes: implementation of an integrated recovery pathway for surgical patients. J Am Coll Surg. 2015;221:669–677.
20. Katz J, Weinrib A, Fashler SR, et al. The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain. J Pain Res. 2015;8:695–702.
21. McLeod RS, Aarts MA, Chung F, et al. Development of an enhanced recovery after surgery guideline and implementation strategy based on the knowledge-to-action cycle. Ann Surg. 2015;262:1016–1025.
22. Tiippana E, Hamunen K, Heiskanen T, Nieminen T, Kalso E, Kontinen VK. New approach for treatment of prolonged postoperative pain: APS Out-Patient Clinic. Scand J Pain. 2016;12:19–24.
23. Knott A, Pathak S, McGrath JS, et al. Consensus views on implementation and measurement of enhanced recovery after surgery in England: Delphi study. BMJ Open. 2012;2:pii:e001878.
24. Cakir H, van Stijn MF, Lopes Cardozo AM, et al. Adherence to enhanced recovery after surgery and length of stay after colonic resection. Colorectal Dis. 2013;15:1019–1025.
25. Ladha KS, Patorno E, Liu J, Bateman BT. Impact of perioperative epidural placement on postdischarge opioid use in patients undergoing abdominal surgery. Anesthesiology. 2016;124:396–403.
© 2017 International Anesthesia Research Society