The theme in the November issue of Anesthesia & Analgesia was on the opioid epidemic. Some of the articles that did not meet the publication deadline will be included in next month’s issue. The overriding reason for our themed issue was to serve our readers—the clinical anesthesiologists—by presenting the background, problems, and possible solutions to the opioid epidemic. After all, we take care of patients with pain in the perioperative and clinic settings. We also wanted to show to the medical community that we, anesthesiologists, can play an active role in the identifying and solving the issues. After the seminal topics have been published, 2 questions remain. What did we learn? Where do we go from here?
We learned that the problems are multifactorial. Surgeons prescribe more opioids postoperatively than necessary. Some patients begin their addiction from exposure to a legal opioid prescription. Some are given leftover drugs by their relatives or other contacts. Acquaintance with prescription drugs became a gateway to the more serious drugs heroin and feloniously manufactured fentanyl. Just as important, there are societal issues related to the continued craving for these drugs.
The number of opioid prescriptions has stabilized or decreased.1 Opioid prescriptions increased from 2006 to 2010, were constant between 2010 and 2012, and diminished from 2012 to 2015.2 Still, the opioid prescription rate in the United States in 2015 was 3 times higher than in 1999 and almost 4 times higher than in Europe. Despite the decrease in opioid prescriptions, the number of opioid-related deaths has remained constant. In 2015, almost 90 people died each day from an opioid overdose primarily from unprescribed opioids. Opioid-related deaths are higher in some states and deaths from illegitimate use are concentrated in some areas of the country, notably West Virginia, New Hampshire, Kentucky, and Ohio.2
Not only has there been an increase in opioid-related deaths, but there has also been an increase in fatal motor vehicle accidents related to prescription opioids. The prevalence of prescription opioids detected in fatally injured drivers increased from 0.1% (95% confidence interval, 0.5–1.4) in 1995 to 7.2% (95% confidence interval, 5.7–8.8) in 2015.3 The drugs associated with the increased risk of motor vehicle accidents include buprenorphine, codeine, dihydrocodeine, methadone, tramadol, diazepam, flunitrazepam, flurazepam, lorazepam, temazepam, and zolpidem.4
There is variation in the prescription of opioids among providers and between states. Interestingly, the top 5 states in which the most immediate-acting opioids are prescribed (Alabama, Tennessee, West Virginia, Kentucky, Oklahoma) are different from those prescribing the most “long-acting/extended-release opioid pain relievers” (Maine, Delaware, New Hampshire, Oregon, Tennessee).5 Among specialties, pain medicine practitioners (defined as anesthesiology and pain medicine) prescribed the most opioids (48.6%), followed by surgeons (general, orthopedic, plastic, cardiothoracic, vascular, colorectal, spinal, and neurologic; 36.5%), and physical medicine and rehabilitation (35.5%) physicians.6 In contrast, general medicine clinicians (osteopathic medicine, general practice, and preventive medicine), nonphysician prescriber, family practitioner, and internal medicine physicians account for 7.5%, 7.2%, 5.6%, and 4.8%, respectively. Of the 5 most common diagnoses associated with initial opioid prescription, spine pain is number 1 while chronic pain is number 4.7 These are the patients we see in the pain clinic. We are the leaders in opioid prescription—an undesirable category—and should take the lead in solving the problem.
What can be done to reduce the use of opioids? The National Academy of Science, Engineering, and Medicine submitted a report to address the issue.8 Their document noted the substantial gaps in our contemporary knowledge of the neurobiology of the reward system and appreciation of the socioeconomic factors associated with opioid use disorder and endorsed research in these areas. The advisory group advocated that the US Food and Drug Administration collect data on the public health implications of new opioids and to have a thorough systems approach to the oversight of their opioid drugs. Tellingly, the group advised that the US Food and Drug Administration systematically reassess all opioids in the market today, assuring that the benefit of an opioid clearly exceeds its harms.
What can we, as anesthesiologists, do to help reduce the opioid epidemic? Anesthesiologists in the preoperative clinic should check the prescription monitoring program (PMP) website for patients who are on opioids. Additionally, the preoperative clinic is the place to use risk assessment tools to test patients who may be at higher risk of chronic opioid use, opioid use disorder, and chronic pain. These endeavors can lead to the development of perioperative analgesic plans to minimize these risks. The risks and harms of taking unnecessary opioids should be explained to the patients and their relatives. Alternatives to opioids, multimodal approaches, an established practice in chronic pain management, and supplemental drugs to reduce opioid dose should be espoused. Proper disposal of unused opioids should be advocated.
In the perioperative setting, we should reduce intraoperative opioid use and adopt enhanced recovery protocols as these are associated with decreased postoperative opioid intake.9 Surgeons, and not anesthesiologists, prescribe opioids after surgery. One of their thought leaders recommended the electronic prescription of opioids for improved monitoring and renewal of such prescriptions to reduce forgery, enable better monitoring, and allow smaller numbers of prescribed opioids.10 As perioperative physicians, we can influence the culture of opioid overprescription. Anesthesiologists should take the initiative in setting up quality improvement programs or task forces such as the one undertaken by Liguori and colleagues.11 Such projects should adapt to the expertise, programs, and facilities available in their hospital. Other specialties dealing with acute pain have proposed solutions to the opioid dilemma; some emergency medicine physicians have begun avoiding potent opioids (eg, hydromorphone) and to limit their opioid prescriptions in patients with noncancer pain.
In the pain clinic arena, we should routinely check the PMP website when we order opioids. Regrettably, this is an infrequent practice when it should be routine or mandatory, as implementation of the program is associated with reduction of deaths from opioids.12 It has been noted that patients who obtain opioids from multiple prescribers—easily detected on the PMP website—are more likely to die of opioid overdose than those who do not and those who obtain medications from more than 1 pharmacy have a higher chance of dying from an overdose.
Pain medicine practitioners should try alternatives to nonopioids in treating noncancer chronic pain syndromes. When opioids are prescribed, the dose should be limited and adjusted to the patient’s medical comorbidities, eg, sleep apnea. The rationale for continuing the opioid prescription should be noted in the patient’s record. Urine drug testing should be used appropriately especially in high-risk patients and those with aberrant behaviors. After weighing the benefits and risks, interventional procedures can be undertaken as they serve to break the cycle of pain and may decrease the patient’s opioid intake. Multimodal nonpharmacologic adjuncts should be attempted.
Both perioperative and pain anesthesiologists should work on the development and testing of new analgesics and opioid formulations with the potential for decreased risk of opioid-related adverse events, including abuse, addiction, and death. Anesthesiologists are eminently qualified and should take the lead in studying the pharmacokinetics of medical cannabis, a subject that is not completely understood partly because of legal barriers.
The increase in deaths from opioids due to illicit use calls for identification and solution of the societal issues associated with this problem, more efficient restriction of the entry of drugs into the country, and improved availability of naloxone. Increased opioid research funding, especially in addiction, has been advocated.8
The number of opioid-related patient deaths associated with overprescription from a few practitioners led attorney generals in some states to prosecute not only these practitioners but also the pharmaceutical companies who induce physicians to prescribe their drugs. Some states and star lawyers have sued the pharmaceutical companies hoping to extract a resolution, similar to the tobacco master settlement, to help defray the cost of the opioid epidemic.
Our themed issue unmasked problems related to opioids, one of which is related to cancer pain. While the prescription of opioids to patients with cancer-related pain is ethical, multiple unresolved issues remain and need to be addressed. These include abuse, diversion, over prescription, lack of appropriate screening for patients with and at risk for substance use disorder, and insufficiently trained medical personnel employed by hospice agencies.13 Another dilemma is the use of “designer drugs” or “new psychoactive substances.” Published studies on perioperative anesthesia-related problems in patients on cannabinoids and designer drugs involved mostly case reports. The informative review of Steadman and Birnbach14 discussed marijuana, cocaine, amphetamines, ecstasy, flunitrazepam (Rophenol or “the date rape drug”), and heroin. Their review did not contain information on other synthetic psychoactive substances, known as “designer drugs” or “legal highs,” the use of which has intensified.15 Cathinones (“bath salts”) have known psychostimulant properties with inherent anesthetic implications. Increasing numbers of surgical patients with recent exposure to these drugs have been noted anecdotally.
In summary, publication of the themed opioid issue has been painstaking but rewarding.
We hope that issues related to the opioid epidemic are now better understood. Measures necessary to combat nonessential opioid consumption have come from physicians and the government. These measures should be balanced with the legitimate needs of patients in pain. Our themed issue provides a platform from which researchers and opinion makers among our specialty can become leaders in this opioid discourse. As the primary drivers in the pain clinic and gatekeepers in the perioperative setting, anesthesiologists should take the lead in identifying solutions to this problem.
Name: Honorio T. Benzon, MD.
Contribution: This author helped in all aspects of data collection and manuscript preparation.
Name: T. Anthony Anderson, MD, PhD.
Contribution: This author helped in all aspects of data collection and manuscript preparation.
This manuscript was handled by: Jean-Francois Pittet, MD.
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