As fatal opioid overdoses have overtaken motor vehicle accidents as the leading cause of preventable death in the United States, there is increasing recognition of the role of surgical prescribing in the opioid epidemic. Surgeons prescribe 10% of all opioids in the United States, but up to 75% of these pills go unused, posing a risk to patients and the community for non-medical use (ie, used other than as prescribed or without a prescription).1,2 Emerging work in surgical prescribing has mainly focused on opioid-naïve patients progressing to persistent use, but less attention has been paid to other adverse effects of postoperative opioids, including overdose.3
Surgeons may not directly care for overdose patients and thus may not realize if one of their patients inadvertently overdoses using pills prescribed after surgery. However, one major overdose risk factor, chronic opioid use, is increasingly prevalent, with 14% of patients using opioids chronically before gastrointestinal surgery.4 Chronic use is associated with increased complications, readmissions, and expenditures, and acute-on-chronic opioid consumption after surgery may further increase overdose risk owing to the dose escalation.5,6 For these patients, surgeons face the challenge of balancing appropriate pain control with the risks of escalated doses.
Just as surgeons take precautions to avoid postoperative complications, they can take measures to protect patients from opioid overdose and other opioid-related adverse events. These prudent prescribing practices include screening for at-risk patients, educating patients about opioid safety, reducing excess prescribing, coordinating care with existing providers, and considering naloxone for high-risk patients.
Opioid Overdose in the Surgical Patient: A Hidden Outcome
The disconnect between opioid prescribing and overdose events hampers the ability to change practice. The best current evidence is sparse, with one study showing home opioid overdoses after urologic surgery are extremely rare at 0.09% in a national cohort.7 This study almost certainly underestimates the true incidence of overdose stemming from surgical prescribing, as these events are hard to capture in conventional data sources. For example, fatal overdoses may only be reflected in medical examiner data, and overdose patients who do reach the hospital may not be cared for in the same system where they received surgery. Additionally, overprescribing may provide patients with opioids that can be used nonmedically after any period of time, with the first exposure potentially increasing risk for opioid use disorder (also known as addiction). A resulting overdose would be nearly impossible to connect with the original prescribing behavior. The scope of the problem is thus more likely witnessed by rapid responders, law enforcement, emergency medicine providers, and other clinicians who care for patients who overdose.
Identifying Surgical Patients at Increased Risk of Opioid Overdose
The Center for Disease Control has highlighted overdose risk factors to consider when prescribing opioids for chronic pain, and although there are no corresponding guidelines for acute surgical prescribing, these factors may be important in surgical patients.8 In practice, screening patients for overdose risk may fit into the preoperative history. Surgeons should assess for history of substance use disorder or previous overdose, which are especially important risk factors.
Review of a patient's medication list may show medication-related overdose risk factors, including high opioid doses >50 morphine milligram equivalents (MME) per day, long-acting opioids such as fentanyl patches, or benzodiazepine or other sedative/hypnotic medications. In patients prescribed opioids, surgeons should ask whether or not the patient is taking the medications as prescribed. Additionally, many states and institutions are now requiring any provider, including surgeons, to use Prescription Drug Monitoring Programs (databases that track controlled medication prescriptions) before writing any opioid prescription to identify patients with multiple or overlapping prescriptions.
The preoperative assessment of comorbid conditions can also inform surgeons about a patient's overdose risk, especially in the setting of the above medication-related risk factors. Sleep-disordered breathing (eg, sleep apnea), renal or hepatic dysfunction that impairs drug metabolism, or mental health disorders, including depression, are associated with increased risk. Table 1 summarizes some of the overdose risk factors, as well as other prescribing behaviors to consider in the pre-, peri-, and postoperative period to guide opioid risk assessment. Further research may help prioritize these risk factors in surgical patients to help providers better assess for overdose risk.
Protecting Patients at Increased Risk of Overdose
After identifying high-risk patients, there are steps surgeons can take to mitigate overdose risk. Thoughful discussions about pain management remain critically important for all patients, including setting expectations that postoperative pain will be manageable rather than completely eliminated. Patients should be encouraged to use nonopioid pain medications if not contraindicated, and should also be counseled about safe opioid storage and disposal to prevent future nonmedical use. For higher-risk patients with the risk factors discussed above, clinicians should discuss with patients that additional postoperative opioids may increase their overdose risk, and patients and family members can be alerted to watch for the signs and symptoms of overdose. To aid in this education, our group has made engaging patient materials regarding safe opioid management, which are freely accessible and allow for branding and logos from other health systems and practices (Michigan Opioid Prescribing Engagement Network, patient materials, http://michigan-open.org/patient-resources/; last accessed 1/4/17).
Additionally, surgeons should continue to reduce overprescribing for all patients. Strides have been made in standardizing postoperative prescription amounts in an effort to reduce excess opioid supply. Studies using prospectively collected consumption data in opioid-naïve patients have provided prescribing recommendations for common operations, and our group has similarly developed recommendations for procedures including various hernia repairs, colectomy, and hysterectomy.9 (Michigan Opioid Prescribing Engagement Network and Michigan Surgical Quality Collaborative, Opioid Prescribing Recommendations for Surgery, https://opioidprescribing.info; last accessed 1/4/17.) Although these amounts may underestimate medication requirements for patients taking high preoperative doses, they offer a valuable starting point for tailoring postoperative prescriptions. Continued collection of consumption and refill data in this patient subpopulation will better inform prescribing. Finally, these recommendations serve as an important step toward safer opioid prescribing, but dedicated pain management education for surgical trainees and continuing medical education options for practicing surgeons may be needed to further affect surgical practice.
Another strategy to improve postoperative prescribing is thoughtful involvement of other healthcare providers. This includes communication with the providers managing chronic pain, mental health, and substance use disorders to coordinate appropriate transition of care. The discussion about postoperative opioid tapering is ideally performed preoperatively, to prepare patients for returning to baseline doses after the postoperative period. Additionally, a primary care provider who has a long-standing relationship with a patient can be a significant resource in tailoring postoperative pain management. After the surgeon can attest that post-surgical issues have resolved and pain requirements should have returned to baseline, opioid prescribing can be transitioned back to the previous prescriber, with clear communication and handoff.
Finally, an important tool to consider for opioid overdose in high-risk cases is the prescribing and distribution of naloxone. Naloxone, an opioid receptor antagonist used to reverse opioid overdose, is becoming widely available for layperson rescue use through pharmacies in either intranasal or intramuscular form. These formulations are easy to use and have saved many lives in communities, where targeted efforts have educated and distributed naloxone to at-risk individuals and potential bystanders.10 National campaigns such as Prescribe to Prevent (www.prescribetoprevent.org) provide clear information on using naloxone, and patients and family can be taught to respond to overdose by administering naloxone. However, it is currently unclear how to incorporate naloxone into acute opioid prescribing. A naloxone prescription for every patient receiving postoperative opioids may not be feasible or cost-effective. Additionally, patients and an individual at home will need education on how and when to use naloxone. Further research to clarify the appropriate target patient population and the cost-benefit ratio of prescribing naloxone may help incorporate this potentially life-saving medication into practice for surgical patients at risk for overdose.
The Surgeon's Role in Caring for the Patient at Risk of Overdose
Opioids are one of the most common medications surgeons prescribe, and acute pain management is an important part of surgical care. Despite this, little evidence exists to guide acute opioid prescribing, or how to identify patients at particularly high risk for negative opioid-related outcomes. Surgeons can improve care in many ways: by reducing opioid overprescribing, engaging in practices that protect patients from overdose, and perhaps most importantly, having frank discussions with patients to weigh benefits vs risks. Although surgeons should take ownership for responsible opioid prescribing in patients, they can also involve a patient's primary care or other providers in complex pain management after an operation. Finally, targeted naloxone prescribing for high-risk patients may become an important tool to prevent overdose events in surgical patients.
An operation often represents a major event in a patient's life, and these acute episodes can be a powerful driver of behavioral change. Surgeons are well-positioned to help curb the opioid epidemic by becoming active leaders in patient screening, appropriate prescribing, and patient education. More surgeon involvement in research, evidence-based practice, and education will help to combat opioid misuse and overdose after surgery.
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