Between 1999 and 2008, the rate of overdose deaths from prescription opioid pain relievers (OPR) in the United States increased 4-fold.1 This alarming increase in OPR-related death rate was paralleled by a simultaneous increase in the sales of OPR, and also an increase in the rate of admissions for opioid use disorder treatment nationally. Since then, the OPR overdose epidemic continued to worsen, with unintentional drug overdose now becoming the leading cause of accidental death in the United States, killing more Americans than motor vehicle crashes or firearms. Prescription opioids account for the greatest number of drug-related deaths in the United States: of 47,055 drug overdose deaths in 2014, 18,893 were related to OPR and 10,574 to heroin.2 Among individuals who have used an OPR for a nonmedical reason, 69% report getting the medication from a friend or relative, the majority of whom received the original prescriptions from a single physician.1,2
Massachusetts has been hit particularly hard by the opioid epidemic. In 2013, poisoning and overdoses were the leading cause of injury in the state, accounting for 37% of deaths, compared with falls and motor vehicle crashes that accounted for 20% and 11% of injury deaths, respectively.3 Examination of this trend reveals the driving role opioids have played in these trends: from 2009 to 2013, the rate of opioid overdoses in Massachusetts increased from 9.6 per 100,000 people to 14.2 per 100,000 people.4 In addition to the death toll, for every opioid overdose death in Massachusetts, there were twice as many hospitalizations and 4 times as many emergency room visits for nonfatal opioid overdose, resulting in a substantial burden on the healthcare system.5
In response to the opioid epidemic, Massachusetts Governor Baker proposed a comprehensive legislation in late 2015. After multiple revisions, The STEP Act, an act relative to Substance use, Treatment, Education, and Prevention, was signed into effect in March 2016. The law detailed several components focused on OPR prescription. Table 1 illustrates some of the key parts of the law that surgeons in Massachusetts not only need to understand but also need to legally abide by.
Although it is likely too early to fully understand the new opioid law in Massachusetts, interpret its mandates, or even get a sense of the degree to which it will be strictly enforced, 1 thing is now clear: our current approach to acute perioperative pain relief, as surgeons, needs to change. The predominant opioid-centric habits and traditions of OPR prescriptions in surgical fields have partially contributed to the epidemic, and a culture change in perioperative pain management is needed. Such a change will not be fast or easy and will require funds and resources, as it will probably affect multiple aspects of the surgical patient care that we cannot yet fathom, including current surgical and clinic workflow, patient expectations for perioperative pain, and the patient's care satisfaction. Patient-centered outcomes including patients’ perception of the quality of care they receive [eg, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores] might be negatively affected by limiting OPR use unless patients’ expectations are addressed and managed a priori. Several experts understandably debate the misconception that prescribing more opioids creates better patient satisfaction, but the message remains clear either way: preoperative empathetic discussions with the patients to optimize their coping mechanisms and the design of pathways for pain management that are not opioid-centric are both essential.
The Massachusetts General Hospital (MGH) is one of the 2 major hospitals of Partners Healthcare, the largest private employer and the biggest healthcare provider in the Boston Metropolitan area, serving more than a third of its population. MGH and its physician organization, the Massachusetts General Physicians Organization (MGPO), recognizing the need for a comprehensive strategy to support patients and prescribing physicians alike, established a multidisciplinary opioid task force in late 2015 with one of its goals being to provide guidance regarding the use of opioid therapy for acute nonmalignant pain. MGH is potentially the largest New England prescriber of opioids, with General and Orthopedic Surgery being 2 of the highest prescribing groups at MGH. Based on the task force work and guidelines, 6 areas deserve renewed and particular attention by surgeons when it comes to acute perioperative pain management: pain assessment; the use of nonopioid alternatives; assessment of the risk of opioid misuse; prescription guidelines; adequately preparing patients (and managing their expectations for perioperative pain) for surgery; and communication among providers.
Pain assessment: The prescription of OPR for surgical patients should correspond to the degree of tissue disruption (nociception) expected after a specific surgery. For example, the degree of tissue disruption is inherently different for a traumatic celiotomy as compared with an elective trigger finger release. In both situations, prescribers should consider nonopioid alternatives, the impact of pain on the functional ability of the patient, and also their knowledge of the individual patient and the risk/benefit of opioids in that specific patient. Specialty-specific (and procedure-specific) strategies for pain control should be sought and implemented, when appropriate. For example, developing pain-management guidelines and protocols for hand orthopedic surgery versus thoracic surgery not only promises a decreased dependence on opioids, but may also reassure patients that their pain is being managed in a well-established and standardized fashion. Before any prescription, surgeons should review the patient's history, including any psychiatric or substance use disorder history, and check the patient's Prescription Monitoring Program (PMP). Pain assessment can still be performed using visual analog or verbal scales from 0 to 10, but should be complemented with functional pain assessment, that is, investigating how the patients’ pain is impairing their daily functions (or not).
Nonopioid alternatives: Consistent with the WHO pain relief stepladder, opioids should be the last, not the first, resort in acute pain management. Working with other healthcare specialists, surgeons should aim to optimize other variables that contribute to the patient's perception of pain (eg, sleep disorders, stress, depression, anxiety), recommend nonpharmacological strategies for pain control including optimizing a patient's perioperative mindset and circumstances (eg, exercise, relaxation techniques, biofeedback, massage therapy, physical therapy, music therapy), and discuss nonopioid pain relievers (eg, nonsteroidal anti-inflammatory drugs, acetaminophen, gabapentin, clonidine), and also locoregional anesthesia (eg, lidocaine patches, regional nerve blocks).
Risk assessment: Surgeons are encouraged to review the PMP program for their state, including Massachusetts, to abide by the legal requirements before prescribing opioids, and should strongly consider screening patients for personal or family history of substance use disorder. Several validated instruments exist to do so, such as the Opioid Risk Tool (ORT), which is a 5-question instrument that can reliably differentiate between high and low-risk patients for opioid misuse. The help of addiction specialists should be solicited for patients showing early signs and symptoms of misuse and should be considered for high-risk patients.
Prescription guidelines: In general, surgeons should try to prescribe narcotics only for severe pain. The management of mild pain should start with a trial of nonopioid alternatives. If opioids are deemed necessary, they should be prescribed at the lowest effective dose possible and for a limited time period based on the expected duration of the pain, not to exceed 7 days. Justification for using opioids for more than 7 days should be clearly documented and additional refill “just in case” prescriptions should not be written.
Preparing patients for surgery: All patients undergoing similar surgical procedures have more or less similar nociception, based on the extent of tissue disruption and inflammation after traumatic injury or surgery. However, the cognitive, emotional, and behavioral response to nociception is highly variable among patients and largely impacted by psychosocial factors. For example, after orthopedic surgery in general6 and fracture surgery in specific,7 greater opioid use correlates with greater (not lesser) pain. The best pain reliever is self-efficacy (a sense that one can achieve one's goals). To enhance and facilitate return to daily routine after injury or surgery, patients benefit from mindful awareness of their circumstances (“My body needs time to heal; this is normal and expected, I can get through this”), and return to the things that give their lives meaning as soon as possible. Therefore, it is crucial that surgeons prepare their patients for pain relief, starting as soon as the decision is made to proceed with surgery. People who are not mindful of the fact that they are recovering from surgery or injury might feel like the pain means something is wrong, which makes the pain worse. According to many pain experts, the goal of pain relief should be 30% to 55% improvement, and therefore the patient should be expecting tolerable pain levels, not 0 pain levels perioperatively. In addition, patients need to be aware that not all pain requires opioids; and opioids have significant side effects (eg, gastrointestinal motility dysfunction, respiratory depression), and a real risk for addiction and overdose. The patients should be prescribed the minimum amount of pills needed, and the surgeon should discuss with them safe methods to store, lock, and dispose off any extra pills to avoid potential use by friends or relatives.
Communication: Communication between the different patient providers regarding pain management is crucial. Surgeons should reach out to the emergency room physicians, the primary care physicians, and other care providers to ensure coordination of opioid therapy in terms of amount and duration. Documentation in records after any opioid prescription should be prompt and made immediately available to all other healthcare providers, especially the primary care physician. In particular, for patients already receiving opioid agonist therapy (eg, methadone, buprenorphine) for underlying substance use disorder, close coordination with the prescribing clinician and/or consultation with a pain management specialist is strongly recommended.
In conclusion, the opioid use epidemic in the United States is unprecedented. The rise of opioid use disorder and overdose has been paralleled by an increase in OPR prescriptions by healthcare providers. In Massachusetts, one of the states hit hardest by the epidemic, a new law is in effect that limits the amount and duration of opioid prescription for patients with acute pain, and mandates several additional steps to assess and document patient risk. Concerted efforts among healthcare providers in the area are needed to be part of the solution to the epidemic and part of the adaptation to the new law. From the surgery perspective, curbing this epidemic will require a change in the strategies and culture of prescribing by surgeons, and a focus on adequate patient preparation for perioperative pain control.