In 2017, the opioid epidemic was declared a public health emergency. In the past 2 decades, opioids had been implicated in 500,000 deaths in the United States, with more than 100,000 deaths in just 2015-2016.1,2 The opioid epidemic has roots in the 1980s when the World Health Organization discussed the undertreatment of cancer-related and postoperative pain in the Cancer Pain Monograph, declaring that “pain relief is an important but neglected public health issue.”1,3 A movement soon developed within the medical community that aimed to better recognize and treat pain.4 Health care systems in the United States began to adopt the pain scale as a “5th vital sign,” setting a precedent for regular and routine pain assessments based mostly on a numerical scale. The Joint Commission followed suit in 2001 by establishing pain treatment as a standard of care, linking health care quality and patient satisfaction to adequate pain control.5,6 This move was heavily influenced by profit-motivated pharmaceutical companies that claimed the need for improved pain management, citing scientific literature. Despite heavy scrutiny of the methodology used in these referenced studies, drug companies and other proponents of opioid use for chronic pain referred to research that claimed that long-term opioid therapy was efficacious, safe, and had low potential for abuse.7,8 During the next decade, physicians significantly increased their opioid-prescribing practices. Institutionally created practice guidelines for chronic pain management, increased advertisement and distribution of opioid samples, and stigmatization of opioid-prescribing hesitancy as “opiophobia” all served as drivers of the surge in opioid prescriptions.4,9 From 2002 to 2009, prescriptions for extended-release opioids increased by 146%, and in 2010, opioid prescription peaked at a rate of 81.2 prescriptions per 100 persons.4,6
Three distinct periods of opioid crisis have been observed: in the late 1990s, the first surge in overdoses occurred as a result of prescription opioids; in 2010, improved regulation of opioid prescription led to an increase in heroin overdoses, as opioid users substituted heroin for prescription drugs; and the current wave of opioid-related deaths starting in 2013 is related to synthetic and illicitly produced opioids such as fentanyl.10,11 In 2019, an estimated 10 million Americans above the age of 12 reported misusing opioids in the previous 12 months and, in the following year, almost 70,000 opioid overdoses were reported.12,13 Though loss of life is the primary concern related to opioid misuse, the economic burden that has resulted should not be minimized. Taking into consideration lost productivity, reduced quality of life, crime, and other societal expenses, the overall cost related to opioid misuse and fatal opioid overdose was estimated to be more than $1.02 trillion in 2017 alone, with $35 billion of the costs attributable to health care utilization.10
Chronic pain treatment has been a nidus for the opioid epidemic. Nearly 30% of patients who are prescribed opioids for chronic pain misuse them and ~10% develop opioid use disorder.13 Currently, there are between 6 and 8 million adults currently living with opioid use disorder (OUD), with estimated prevalence of between 2.04% and 2.77%.14 Studies using Medicare data show that, since 2013, estimated rates of OUD have increased by more than 3-fold in the United States.15 OUD is the problematic chronic use of opioids that, despite negative consequences, leads to compulsive drug seeking. OUD involves diminished self-control, risky behavior, and social impairments.16 OUD contributes significantly to overdoses and opioid-related deaths—diagnosis of substance use disorder or OUD in the past 6 months is the strongest predictor of overdose.17 Furthermore, of fatal opioid overdoses, more than 60% of individuals have a chronic pain diagnosis in their last year of life.18
Racial and ethnic distribution of opioid use disorder and related mortality
As with most health-related outcomes, the opioid epidemic has not affected all racial or ethnic groups equitably. At the beginning of the opioid epidemic, White individuals were disproportionately affected by prescription opioid misuse.19 The prevalence of prescription opioid use, which parallels opioid misuse, was 11.9% in the White population, compared with 9.3% in Black and 9.6% in Hispanic populations in the mid-1990s.20 This is likely related to racial disparities in pain treatment that translated to less frequent opioid use in minority patients during the years when opioids were initially liberalized.21–24 Some of the documented disparities in pain treatment include limited access to analgesics in minority neighborhoods, differential worker’s compensation for pain-related claims, and biases in pain assessment and analgesic prescription.23 Indeed, a large meta-analysis estimated that during the years 1989-2011, Hispanic and Black patients had a 22% and 30% lower rate of receiving an opioid prescription than Whites, respectively.23
As opioid prescriptions increased in the 1990s, so too did OUD-related hospitalizations and associated mortality.25 Among patients hospitalized for OUD, the mortality rate increased from 19.8 per 1000 OUD hospitalizations in 1998-2000 to 30.9 per 1000 OUD hospitalizations in 2015-2016.25 Though OUD hospitalizations and associated mortality has increased for all racial groups, Whites patients have a higher rate of discharge to rehabilitation facilities compared with minorities, who are more likely to be discharged home without supportive care.25 Similarly, drug-overdose deaths have more than tripled in the United States in the past two decades.25 In 1999, opioid-related mortality was similar across racial/ethnic groups.26 Presently, however, opioid-related deaths disproportionately affect members of certain races. Opioid-related death in the White population is currently 27.5 per 100,000, followed by Native Americans (25.7 per 100,000), Black Americans (20.6 per 100,000), and Hispanics (10.6 per 100,000).27 Asians have the lowest rate of opioid-related deaths (3.5 per 100,000). Despite the greater prevalence of opioid-related death in Whites, Black patients who are diagnosed with OUD are two times more likely to die than White patients diagnosed with OUD.27
In response to these high rates of opioid overdose deaths, public health campaigns were implemented in the past decade to improve prescription practices, chronic pain management, and opioid misuse treatment strategies. These public health campaigns largely targeted White communities and led to a declining annual rate of OUD and opioid-related mortality in Whites.19 OUD became viewed in the White population as a health condition and spurred a more compassionate and holistic approach to the care of Whites affected by OUD. On the other hand, minorities with OUD continue to be stigmatized and often criminalized.28 With less community support and resources for minorities with OUD, the replacement of prescription opioids with fentanyl and heroin has fueled increased opioid misuse in Black and Hispanic populations.19 The large gap between the prevalence of Black and White individuals with OUD that developed in the early opioid epidemic has now narrowed. Despite historically lower rates of opioid misuse and opioid-involved overdose deaths among Blacks compared with Whites, the growth in opioid-involved overdose deaths among Blacks now outpaces that of Whites. Opioid-related mortality rates in 2019 decreased by 0.3% in White patients but increased almost 20% in Blacks.29
The disparity in opioid misuse and mortality extends beyond Black individuals. Compared with Whites, Native Americans were more than 1.3 times as likely to misuse a prescription opioid in the previous 12 months during the period from 2003 to 2018.26 Also, Native Americans with OUD are seven times more likely to die from opioids than Whites.30 In 2020, the rate of opioid overdose death among indigenous people was 27.4 per 100,000 individuals.30,31 Nonetheless, fewer than 30% of Native Americans diagnosed with substance abuse are offered treatment.32 And although the effects of the opioid epidemic in Native Americans are disproportionate, this population receives little attention in public health discussions and research.
Racial and ethnic disparities of OUD in surgical patients
Population-based analyses of surgical outcomes in patients with OUD are limited, but nonetheless, racial disparities do exist. It is estimated that OUD is a comorbidity in up to 11% of hospitalized adult patients and 1% of surgical patients.33,34 Minority patients may make up a disproportionate number of those affected. In a population of patients hospitalized with head and neck cancers, Black and Hispanics were nearly twice as likely to have comorbid OUD as White patients.35 Similarly, of nearly 6 million adult patients undergoing cardiac surgery, patients with comorbid OUD were more likely to be Black or Hispanic than White.36 The presence of racial disparities in OUD in surgical populations is important because of the risk that comorbid OUD imparts in the perioperative setting. Patients with preexisting OUD undergoing surgery are more likely to suffer pulmonary complications, have longer length of stay (LOS), and incur greater hospital costs.37 Other studies have shown an increased risk of readmission, in-hospital death, and reoperation.37,38 The greater prevalence of OUD in minority surgical patients means that Blacks and Hispanics may have disproportionate risk of these poor surgical outcomes.
Not only is comorbid OUD problematic in the perioperative setting, but surgery may be an impetus for the development of OUD. Severe acute postoperative pain is predictive of the development of chronic pain, and chronic pain is a leading cause of opioid misuse.39,40 Indeed, the incidence of prolonged opioid use following a major surgery may be as high as 3%.40 Several surgeries are associated with increased risk of chronic opioid use in opioid-naïve patients including total knee and total hip arthroplasty, mastectomy, cholecystectomy, and cesarean section.40 Furthermore, pneumonectomy, spinal fusion, and colectomy surgeries carry a risk of between 1.0 and 1.8 overdoses per 1000 cases.39 Black patients seem to be more susceptible to misusing opioids in the postoperative period. Black race is an independent risk factor for new chronic opioid use in women undergoing hysterectomy.41 Also, following orthopedic procedures, Black patients are 3 times as likely to develop opioid misuse compared with White patients.42
Though studies examining the intersection of surgical outcomes and race in patients with OUD are sparse, some inequities in the perioperative management of pain and opioid provision to opioid-naïve patients have been noted. For mild pain in a pediatric postanesthesia care unit (PACU), the standard of care is typically non-pharmacologic measures such as tablets, popsicles, or play and consoling with the nurse. However, Black children with mild pain were noted to receive intravenous opioids more often than White children with mild pain.43 In addition, a prospective study of children undergoing adenotonsillectomy with a standardized anesthetic and analgesic regimen showed that Black children had higher postoperative pain scores, increased opioid consumption, and prolonged PACU stays related to difficult pain management, compared with White children.44 Other studies have noted challenges of pain management in patients with limited English proficiency and the inequities that can result. Limited English proficiency has been linked to greater postoperative pain burden and inadequate pain management access.45 Disparate pain management may also extend beyond the PACU. Following hand surgery, Hispanics are prescribed 16.6 more morphine equivalents than White patients.46 Following carpal tunnel release, Hispanics and Blacks are prescribed 20% more morphine equivalents than Whites. This excess opioid prescribing practice may put these minority patients at undue risk of opioid misuse or diversion.
Racial and ethnic disparities in access to care and treatment regimen
Despite significant advances in treatment approaches for OUD, inequities in the provision of care exist. A growing body of evidence suggests hospital-based or self-referral OUD services can lead to improved treatment engagement and can facilitate successful connections to the outpatient care.47,48 The delivery of hospital-based treatment improves patient outcomes such as reducing overdose rate, increasing patient involvement in post-discharge addiction treatment, and decreasing health-care utilization.49,50 However, communities with a higher percentage of Black and Hispanic residents have fewer hospitals that utilize prescriber guidelines for OUD treatment. Even after controlling for hospital factors, overdose burden, and neighborhood socioeconomic characteristics, minority communities are less likely to provide targeted risk education and harm reduction services to patients.51
A mere 20% of patients with OUD receive treatment, despite abundant evidence that demonstrates a lower risk of all-cause mortality in those participating in therapy, and in particular, those receiving OUD pharmacotherapies (buprenorphine, naltrexone, methadone).52 Studies have demonstrated that racial minorities are less likely to be offered OUD treatments by their health-care providers compared with Whites, and accordingly, Black and Hispanic patients have lower utilization of OUD treatment services.53,54 In 2019, Blacks and Hispanics were 26% and 29% less likely than Whites to have used OUD treatment services in the past year, respectively.54 In addition, Black and Hispanic women are less likely to receive medication-assisted treatment of OUD compared with their White counterparts. Given the effect these therapies have on mortality risk reduction, this disparity has profound consequences for minority patients with OUD.53
Perhaps the most compelling example of treatment inequities is in the selection of medication regimen (buprenorphine or methadone) for OUD treatment. Black patients with OUD have half the odds of receiving buprenorphine compared with White patients.55,56 Although both buprenorphine and methadone are effective in reducing opioid-related morbidity and mortality, buprenorphine offers significant social advantages to methadone. Buprenorphine can be obtained at any local pharmacy, lending to its convenience and social normalcy. Methadone, however, has a burdensome treatment regimen. Methadone is distributed daily at a treatment center; each medication administration is directly supervised, thereby forcing patients to work their schedules around the clinic. Methadone clinics are predominantly found in underprivileged neighborhoods, where urban minorities tend to be segregated. The social intrusion and stigma posed by daily methadone clinics can interfere with the ability to hold a job or perform other daily tasks of living. Accordingly, disparities in pharmacotherapy for OUD serve to perpetuate systemic discrimination.
Role of the physician anesthesiologist in prevention and treatment of opioid use disorder
There is an urgent need for a comprehensive approach to the management of all patients with OUD, regardless of race. Anesthesiologists may play an important role and already serve as a relatively common contact point for these patients. We encounter patients with comorbid OUD or risk of OUD every day — in the obstetrical ward, preoperative assessment clinic, perioperative units, chronic pain clinics, and intensive care unit. Not only do we have the ability to facilitate appropriate assessment and care of these patients, but we can do so equitably, to help reduce the racial gap in opioid-related morbidity and mortality.
The first and most pressing step is to identify the patient with comorbid OUD. In a recent retrospective study, only 7% of patients were screened for preoperative opioid use, but nearly 40% of patients self-reported opioid use in the previous year.57 The most common perceived barrier to screening by surgical providers in this study was insufficient clinic time. However, the opioid risk tool (ORT) and EMPOWER OUD screening protocol are quick and practical questionnaires that can be administered in less than a minute.58,59 These tools are essential to identifying patients with OUD or at risk for opioid abuse and should be employed equitably.
There are many challenges associated with the perioperative care of patients with OUD. Not only do patients with OUD often demonstrate physiological tolerance to opioids, they may also have lower pain tolerance, increased pain sensitivity, and more chronic pain conditions than opioid-naive patients.31 Furthermore, pain control in those taking opioid antagonists can be difficult and, therefore, patients with comorbid OUD undergoing surgery require meticulous attention to their opioid regimen. Perioperative care of patients with OUD is best achieved with the use of a transitional pain service. The transitional pain service consists of multidisciplinary experts who facilitate perioperative care coordination to ensure best surgical outcomes. The transitional pain team may include a pain specialist, anesthesiologist, hospitalist, addiction specialist, pain psychologist, and a licensed social worker.60 Similar to the framework of a perioperative surgical home, a transitional pain service provides individualized plans that may involve preoperative medication optimization, intraoperative analgesic and/or regional anesthetic suggestions, postoperative pain management, and even discharge planning. Given that physiological tolerance may decrease during hospitalization, patients with OUD are at high risk of overdose when resuming their home pain regimen after discharge.31 A transitional pain team is instrumental in making adjustments for home-going therapies and ensuring appropriate and timely follow-up for opioid tapering. Furthermore, a transitional pain team would be capable of initiating postoperative pharmacotherapies for patients suspected of having OUD and connecting the patient with outpatient services.
To decrease the disparate risk of postoperative opioid misuse that stems from poorly treated severe acute pain, anesthesiologists may also develop and implement the use of Enhanced Recovery After Surgery (ERAS) protocols. ERAS is an evidence-based protocol designed to return patients to their preoperative function safely and efficaciously, thereby achieving decreased hospital LOS and associated health care costs.61 ERAS protocols typically involve standardized perioperative medication management, particularly with regard to analgesic regimen. By standardizing perioperative approaches to pain control, ERAS implementation has decreased racial disparities in many instances. For example, ERAS implementation for a Cesarean section led to equitable postoperative pain scores in Black and White patients (before implementation Black patients had significantly higher postoperative pain scores).61 Likewise, ERAS implementation in a colorectal surgery population decreased the length of stay for Black patients, leading to similar postoperative hospital recovery time for Black and White patients.62 ERAS protocols may be broadly applied across a variety of surgical specialties to both optimize pain management and provide equitable perioperative care.
Anesthesiologists have an important role in the management of patients with OUD. With increased screening, optimization of surgical pain treatment regimens, and dedicated specialty services to manage at-risk patients, anesthesiologists can help address critical challenges with opioid misuse and inequities related to OUD.
Conflicts of interest
The authors declare that they have nothing to disclose.
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