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“Houston, We Have a Problem!”: The Role of the Anesthesiologist in the Current Opioid Epidemic

Yaster, Myron MD*; Benzon, Honorio T. MD; Anderson, T. Anthony MD, PhD

doi: 10.1213/ANE.0000000000002395
Editorials: Editorial

From the *Department of Anesthesiology, Children’s Hospital Colorado, University of Colorado-Anschutz Medical Campus, Aurora, Colorado; Northwestern University Feinberg School of Medicine, Chicago, Illinois; and Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California.

Accepted for publication July 13, 2017.

Funding: None.

Conflicts of Interest: See Disclosures at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Myron Yaster, MD, Department of Anesthesiology, Children’s Hospital Colorado, University of Colorado-Anschutz Medical Campus, Aurora, CO 80045. Address e-mail to myron.yaster@childrenscolorado.org.

Pain is a more terrible lord of mankind than even death itself.

Albert Schweitzer

The therapeutic uses of medicinals derived from the opium (from “opos,” the Greek word for juice) poppy, Papaver somniferum (from “somnos,” the Greek God of sleep), have been used as euphoriants and as drugs to treat dysentery and pain since the poppy was first cultivated by the Sumerians almost 5000 years ago.1 Spread by Alexander the Great throughout his European, Persian, and Indian empire (around 330 BC), opium and its natural and synthetic derivatives have, over the last 2 millennia, become the fundamental building blocks in the management of moderate to severe pain. However, along with their analgesic properties, the euphoric and addictive properties of opioids have ensnared countless numbers of people in addiction, destroyed lives, and death.

Addiction, drug abuse, and tolerance have been described in western, Arabian, and Chinese literature since the 16th century. In the 1700s and 1800s, the problem of addiction was most intense in China, where opium was smoked after tobacco was banned.1 In the 1800s, efforts to suppress the sale and use of opium by the Chinese government failed because the British, later joined by the French, forced the Chinese to permit opium trade and consumption. In the United States, opioid addiction was called “the soldier’s disease” because of its association with American Civil War survivors who were treated with morphine (from “Morpheus,” the Greek God of dreams) for injuries sustained in conflict and who subsequently became addicted. This association of opioids with pain treatment and resultant addiction persists to the current day, and has resulted in a race among pharmaceutical companies to develop potent opioid analgesics with no, or minimal, addictive potential.2 Indeed, virtually every opioid currently used in our analgesic arsenal, namely, meperidine, oxycodone, hydrocodone, methadone, and OxyContin, was initially developed and marketed as an analgesic that did not produce addiction.2 Even heroin, developed by Bayer Pharmaceuticals in 1898, was initially marketed as a nonaddictive opioid for use as a cough suppressant, analgesic, and as a therapy for cocaine and morphine addiction. From 1875 to 1900, at least 200,000 Americans were addicted to opioids, alarming the public and government, and resulted in US federal and state laws designed to interdict supply, control distribution and consumption, and criminalize possession and sales (Table).1

Table

Table

It is our responsibility and duty as physicians to alleviate pain and suffering; the treatment of pain is considered a fundamental human right. Unfortunately, before the 1990s, pain was often undertreated.3 The American Pain Society proposed making the evaluation of pain the “fifth vital sign.”4 This idea was adopted by the Veterans Health Administration and the Joint Commission on Accreditation of Healthcare Organizations.5 Given the influence of these organizations, the assessment and treatment of pain became routine and a quality indicator tied to health care reimbursement.

Further, 2 widely quoted and misquoted publications, one a letter to the editor6 purporting that addiction was rare in patients treated with opioids, and the other, a retrospective analysis demonstrating the safety of opioids in 38 chronic pain patients,7 opened the flood gates to opioid prescription writing.2 Indeed, from the 1990s to the 2000s, these 2 publications were used in intense marketing efforts by pharmaceutical companies to convince physicians that opioids could be used safely in treating acute and chronic pain.2 The dangers associated with opioids, namely their high abuse potential and lethality when taken in excess or in combination with other drugs, were often downplayed.2 In fact, 3 executives of Purdue Pharma, the manufacturer of OxyContin, were criminally indicted and found guilty in 2007 of misdemeanor misbranding because of their (and their corporation’s) role in misleading regulators, doctors, and patients about OxyContin’s risk of addiction and its potential to be abused.2 Multiple studies documented a strong and consistent linear relationship between the increase in pain assessment,4 the volume of opioid sales for treatment, and the morbidity and mortality associated with these products.8 Opioid sales increased so dramatically that the United States became the highest consumer of opioids on a per capita basis in the world, consuming 80% of the world’s supply. This led to a surge in prescription opioid diversion, abuse, addiction, and overdose, fueling an epidemic of nonmedical use of prescription opioids (NMUPO).2 NMUPO is now one of the most serious public health problems in the United States, and has resulted in unprecedented rates of accidental death and opioid-related treatment admissions.9 Drug overdose death rates in the United States increased 5-fold between 1980 and 2008, mirroring the introduction of the fifth vital sign and making drug overdose a leading cause of injury and death.9,10 In 2013, opioid analgesics contributed to 16,235 deaths, far exceeding deaths from any other drug or drug class, licit or illicit. By 2016, the number likely exceeded 59,000.9 Thus, multiple studies have documented a strong and consistent relationship between opioid sales volume and opioid-related morbidity and mortality.11 Remarkably, the increase in opioid prescriptions did not improve patient pain scores.

To the anesthesiologist, management of both acute and chronic pain is fundamental to our practice. It provides myriad benefits, including reduced suffering, improved patient satisfaction, more rapid recovery, and a reduced risk of developing postsurgical chronic pain. Although a multimodal analgesia approach, including opioids, regional anesthetics, and adjuvants such as acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, N-methyl-D-aspartate receptor antagonists, and α-2 agonists, is now routinely used, the use of μ opioid receptor agonists is the standard paradigm for acute and often chronic pain management. Yet, it is clear that the perioperative use of opioids may also be detrimental to patient care, and may result in opioid-induced side effects including nausea, emesis, ileus, hyperalgesia, somnolence, pruritus, urinary retention, respiratory depression, and death. Perhaps most worrisome, up to 8% of opioid-naïve patients who undergo surgery and receive opioids perioperatively may become chronic opioid users.12

In this themed issue of Anesthesia & Analgesia, authorities from across the field of anesthesia and pain management have lent their expert opinion on the epidemic confronting us. The topics in this themed issue range from the risk assessment tools to help predict opioid abuse, rational use of opioids in cancer and noncancer pain, alternatives to opioids in acute and chronic pain management, novel nonopioid analgesics in the pipeline, perioperative multimodal management in adults and children, the role of interventional and perioperative procedures to decrease opioid use, and the place and function of enhanced recovery after surgery and in the perioperative surgical home to help reduce opioid use after surgery.

A public health response to the opioid crisis must focus on preventing new cases of opioid addiction, early identification of opioid-addicted individuals, and ensuring access to effective opioid addiction treatment, while at the same time continuing to safely meet the needs of patients experiencing pain. Equally important is how to shrink the enormous reservoir of unused opioids that fuel this epidemic. Most regulatory, medical, and research activity devoted to NMUPO has focused on the appropriateness and quantity of opioids prescribed in chronic, noncancer pain. There has been little attention paid to the amount and disposition of opioids prescribed for acute pain, particularly in pediatrics.

We know that regardless of prescriber or opioid or formulation prescribed, opioids are often dispensed in large quantities after surgery.13 How much is dispensed and actually used is unknown and may be procedure specific. Recent evidence suggests that most prescribed opioids are neither consumed nor disposed of.14 Invariably, some of these leftover, unused opioids become a reservoir to the general population or to family members for opioid sharing, selling, and diversion. Recently, the US Centers for Disease Control recommended limits on how much of an opioid to dispense for acute pain. Unfortunately, these recommendations are neither procedure specific nor pain specific.15 This one-size-fits-all approach is not supported by any evidence; some patients will receive too much medicine, and others may not receive enough. Aside from procedure, gender, race, ethnicity, and language may also play significant roles in pain perception and the amount of opioid dispensed and utilized. Leftover, unused opioids may be diverted either knowingly or unknowingly by the patient for whom we prescribe opioids or by their friends, families, or visitors to their home. Currently, there is no evidence-based data to guide practitioners on how much of an opioid to dispense after surgery. We urgently need these data to tailor how much of an opioid we should dispense to match how much is used. Additionally, we urgently need a better and more effective way to dispose of unused opioids so that they do not become a reservoir feeding this crisis.

The contents in this themed issue are in no way complete or definitive, as developments in the pharmaceutical, social, and legislative areas are rapidly evolving. However, it provides an overview of the problem, assesses present alternative regimens, and offers suggestions on which future research can be based on solid scientific foundations. The future of both acute and chronic pain management should focus on research into techniques and pharmacologic agents that reduce both short-term and long-term morbidity, including the risk of chronic opioid use and abuse. As anesthesiologists, we should be driving innovation into new analgesics and devising analgesic plans to help reduce opioid use for acute and chronic pain. As pain experts, anesthesiologists must also become information leaders, assisting the medical, legislative, and lay communities with the best approaches to pain management.

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DISCLOSURES

Name: Myron Yaster, MD.

Contribution: This author helped draft, review, and edit the manuscript.

Conflicts of Interest: Dr Yaster is a consultant and serves on data safety monitoring boards (DSMBs) for Purdue Pharma and Endo Pharmaceuticals.

Name: Honorio T. Benzon, MD.

Contribution: This author helped draft, review, and edit the manuscript.

Conflicts of Interest: None.

Name: T. Anthony Anderson, MD, PhD.

Contribution: This author helped draft, review, and edit the manuscript.

Conflicts of Interest: None.

This manuscript was handled by: Jianren Mao, MD, PhD.

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