The opioid epidemic: What can surgeons do about it?

In September 2016, a photo taken by the East Liverpool, OH, Police Department went viral on social media. The photo showed two unresponsive adults sitting in the front seat of a car. Their heads were slung back and their mouths wide open. The woman in the passenger seat was slumped over to the side. In the back seat, a wide-awake four-year-old wearing a dinosaur t-shirt stared vacantly at the camera.1

Although this photograph is seemingly unrelated to surgical practice, the image starkly underscored an opioid epidemic that is upending communities throughout the country—and surgeons can play a role in curtailing it. In Ohio, a hot spot for this scourge, drug overdose deaths have surpassed motor vehicle collisions as the leading cause of accidental death. Prescription opioid-related deaths accounted for nearly half of these.2 Although Ohio may be an extreme example of this problem, the opioid epidemic—and particularly the role of prescription drugs—is a nationwide crisis.3 Between 2000 and 2014, opioid-related overdose deaths nearly quadrupled, and in 2014, 61 percent of drug overdose deaths involved some type of opioid.4 This increase in deaths was accompanied by a near-concurrent fourfold increase in the sale of opioid pain relievers.5

A recent study by the U.S. Centers for Disease Control and Prevention indicates that more than 54 million people ages 12 and older have abused prescription drugs at some point in their lives, and nearly 15 million people had done so in 2014. Opioid prescriptions reached 259 million that year, which is more than enough to give every American adult their own bottle of pills.3 Opioids account for more than one-third of the prescriptions surgeons write, and 70 percent of patients who have never used an opioid and undergo a surgical procedure fill a prescription within one week of an operation.6,7

It makes sense that surgeons would prescribe opioids with some frequency. Surgeons perform procedures that are painful. Helping to control the acute pain that our patients experience is a professional and moral imperative. Moreover, national professional organizations, including The Joint Commission, have focused on addressing the pain of postoperative patients, in part by encouraging opioid-based pain control. Nevertheless, these prescriptions carry risks, which include chronic usage, addiction, and overdose. In the midst of this public health crisis, surgeons have a major responsibility to understand and mitigate the risks associated with prescribing opioids and to consider how they can be part of a broader solution. This article summarizes some of the actions that individual surgeons can take, the role of health care systems in effecting change, and the steps the American College of Surgeons (ACS) is taking to address this crisis by assisting surgeons as they help their patients avoid drug addiction.

Individual strategies to combat the opioid epidemic

First, we must be aware of the existing resources to help curb opioid overuse. Current mechanisms for monitoring, counseling, and treating patients across the continuum of care can help minimize risk to our patients and our communities.

Preoperative management

The surgeon’s role in addressing the opioid epidemic starts during the preoperative period by setting patient expectations and assessing the potential risk for opioid misuse or addiction.8 A candid preoperative discussion with patients about the pain they can expect as a result of their procedure can help set expectations postoperatively, specifically the fact that the patient will not immediately (or perhaps ever) reach zero on the pain scale. This discussion should include information about the potential benefits of nonopioid analgesics. Additionally, this preoperative conversation is an opportunity to discuss the adverse systemic effects of opioids as well as the fact that opioids are unsuitable for treating all types of pain.

Beyond these conversations, surgeons should also check prescription drug monitoring programs (PDMPs) as part of their routine preoperative practice. These statewide registries collect information on the distribution of controlled substances and can help health care professionals determine an individual patient’s pattern of prescription drug use. PDMPs are used to track opioid prescriptions in some manner in all states except for Missouri. More than 30 states require prescribers to check the PDMP if certain conditions are met, although these conditions vary by state.9 These databases, in conjunction with risk screening tools such as the Brief Risk Inventory, will allow surgeons to better identify patients at high risk for opioid abuse and tailor their prescribing behavior accordingly.10 A review of the CDC Guidelines for Prescribing Opioids on Chronic Pain—United States 2016 provides a good resource to identify high-risk populations and those with the highest risk of abuse and mortality.11

Inpatient management

The immediate postoperative period is a critical time when the patient’s need for analgesia is greatest and a pattern of the provider’s prescribing behavior is established. For a patient in the hospital, continued management of expectations regarding pain are important. Establishing realistic expectations involves a multidisciplinary approach with physician providers (surgeons, anesthesiologists, residents, and physician delegates) and allied health care providers (pharmacists, registered nurses, and social workers) playing an important role in this process.

Although the assessment of pain as a “fifth vital sign” has gained widespread use, it must not be blindly used to determine whether and how much of an opioid should be prescribed.12 A patient with a high pain scale may benefit from a discussion with the nurse and surgeon about the nature of postoperative pain and the associated expectations and management. Additionally, surgeons are using multimodal therapies to manage pain, including applying local analgesics directly into the surgical site and maximizing the use of oral nonopioid analgesics such as nonsteroidal anti-inflammatory drugs and acetaminophen. In addition, use of epidural analgesia and long-acting nerve blocks are important tools for postoperative management. Ultimately, consultation with an inpatient pain management team may be warranted. Guidelines on the Management of Postoperative Pain developed by the American Pain Society and endorsed by numerous societies can help in this decision making. 13

Outpatient management

Upon discharge, patients assume management of their opioid use. In this setting, surgeon-prescribers can control the total amount but not the frequency of drug administration. To help control use, surgeons must be judicious in the amount of opioids they prescribe and avoid prescribing additional doses or refills “just in case” the patient feels they need more intense or extended drug therapy.

Whereas pain is subjective and can vary substantially from individual to individual, the use of specialty or procedure-specific guidelines can help inform surgeons, physician extenders, and residents regarding what constitutes appropriate prescribing behavior. For patients requiring more opioid pain relief than expected, in-person consultation allows for objective assessment of the patient, consideration of alternative explanations for the pain, and reevaluation of the PDMP before re-prescribing opioids.

Some states have established legal limits on the amount of opioids that can be prescribed, which would supersede any hospital-based guidelines. In 2016, states began limiting the length of opioid prescriptions. Connecticut, Maine, Massachusetts, New York, and Rhode Island passed laws limiting initial prescriptions to seven days. Vermont passed a law that requires the state health department to set an opioid prescribing limit through the regulatory process in consultation with the Vermont Medical Society.9

Whenever patients administer their own opioids in an unmonitored setting, patients and their caregivers must be educated on safe administration and disposal. The Centers for Disease Control and Prevention and the U.S. Surgeon General have released opioid prescribing guidelines to turn the tide on addiction. While the guidelines are designed for treatment of chronic pain, and surgeons more commonly treat acute pain, several points are noteworthy. Specifically, surgeons must consider the effects of polypharmacy on their patients and continue to work with the ACS to identify best practices for patients already managing opioid addictions and those receiving methadone, as well as patients on high-risk medications such as benzodiazepines. For patients who suffer from chronic pain and who may be receiving particularly high doses of opioids (greater than 50 morphine milligrams equivalents daily or approximately 10 tablets of 5 mg hydrocodone daily), the U.S. Surgeon General recommends offering a naloxone prescription for accidental overdose.14

Proper medication disposal can have a major effect on decreasing the opioid epidemic. Among persons ages 12 or older in 2012–2013 who used pain relievers that were not medically necessary in the past year, 53 percent obtained the drug from a friend or relative for free, and 11 percent bought the drug from a friend or relative. Another 21 percent reported that they got the drug through a prescription from one physician. An annual average of only 4 percent of these individuals obtained pain relievers from drug dealers or other strangers, and 0.1 percent bought them on the Internet.3

Health system strategies

Individual efforts to combat the opioid epidemic are critical and can help prevent misuse among the thousands of patients each surgeon treats annually. Still, an improvement in the broader health systems can facilitate large-scale improvements across our profession. First, while PDMPs have increased dramatically in number, they are not standardized and are poorly integrated into existing workflows. As a result, checking PDMPs is cumbersome, time-consuming, and may yield incomplete information. Integration of PDMPs into hospital electronic health records (EHRs) could greatly improve feasibility of checking patterns of patient opioid use and thereby increase utilization.

As noted earlier, each state has its own set of laws governing what type of drug use data are available, what type of prescriber can access the PDMP, and how the data are shared. An ongoing push toward standardized databases with the ability to share information across state borders is essential to ensuring surgeons have access to accurate information. Furthermore, for these registries to maintain information that is beneficial for patient care, it is essential that they not be used for law enforcement purposes.

The U.S. health care delivery system has entered a state of near constant reform, with variable, ever-changing reimbursement schema. In recent years, the trend has been toward pay-for-performance measures. Although the financial incentives for treating pain are extremely limited, some providers still are concerned that they are being paid in part based on their ability to reduce patient pain.15 Thus, as pay-for-performance measures continue to develop, policymakers must take steps to ensure that these metrics do not rely on overly proximal measures of patient outcomes on pain scales, and focus instead on distal outcomes, such as patient function or overall patient satisfaction.

Considering the toll of the opioid epidemic on patients, it is essential that research on opioid use, addiction, and alternatives continue. Some of this research must focus on the role that surgeons play as opioid prescribers and how our practice patterns can best be adjusted to treat patients appropriately while also addressing a broader public health crisis. Additionally, this research must include a focus on high-risk populations. Veterans, for example, may be twice as likely to die from a drug overdose than non-veterans, and a better understanding of pain management and opioid safety in this population may be particularly important.16

Signs of progress

In the midst of the opioid crisis, signs of progress are emerging. In addition to the state mandates for PDMPs described earlier, the National Association of Boards of Pharmacy established PDMP InterConnect, helping to link state PDMPs and thereby breaking down data silos and providing prescribers with integrated, comprehensive information.17 Increased awareness among physicians and researchers has led to numerous published studies that evaluate the relationship between treatment of acute pain, chronic pain, and opioid use disorder. Even simple provider education about opioid overuse and the establishment of basic prescribing guidelines has been shown to be effective in reducing the amount of opioids prescribed.18 The results of these efforts to slow the opioid epidemic will take time to yield results.

As these changes unfold, it is critical that surgeons and major prescribers of opioids be part of the solution to this growing crisis. The College is committed to responsible prescribing and a multi-modal approach focused on policy, professional education, and patient/caregiver education in developing resources to address opioid abuse and overuse.

Opiod abuse will be addressed in further detail in the August Bulletin as the subject of the annual ACS Resident and Associate Society-themed issue.

ACS efforts

The ACS is responding to the opioid abuse problem on multiple levels, including advocacy, surgeon-prescriber education, and patient education.

Advocacy

Overall, ACS advocacy efforts in this area seek to reduce the abuse of prescription opioids and encourage continued research into nonopioid pain treatments and other alternative remedies. Following is a summary of the key issues that are currently being addressed by the College’s advocacy team:

  • PDMPs. To reduce variability across the states, the ACS strongly supports the use of governmental grant funding to enhance PDMPs, to make these registries accessible to appropriate members of the health care team, and to make them interoperable specifically with EHRs.
  • Prescribing limits and practices. The limits and restrictions placed on prescribers vary widely from state to state. The ACS asserts that medical decisions should be left to the prescribing physician and that limits should not affect patient care. The ACS supports provisions allowing the partial filling of opioid prescriptions and encourages states to implement disposal programs to prevent misuse of unfinished prescriptions.
  • Veterans’ issues. As noted, the Department of Veterans Affairs (VA) reports that veterans are twice as likely as non-veterans to die from accidental opioid overdose. The ACS supports a fully functional opioid tracking system for VA patients, and believes that prescriptions issued at all federal facilities, including the VA, should be trackable to outside treating providers and pharmacists.
  • Research funding. The opioid crisis cannot be solved overnight and surgeons must continue to study options for treatment and prevention. The ACS supports increased governmental research funding for drug addiction and treatment programs and for nonopioid pain management.
  • Reimbursement and payment. In some cases, pain scores form parts of quality measures used for payment or reimbursement. While there is conflicting evidence as to whether this policy has an impact on the opioid crisis, the ACS believes this correlation is an inappropriate way to value quality or payment.

Surgeon education

  • Nonopioid pain management. The ACS encourages evidence-based and comprehensive training for practicing surgeons and residents in identification of high-risk patients, management of opioid-addicted patients, and discharge training and monitoring of patients. The ACS supports optional training that includes the use of nonopioid options that are beneficial to surgical patients.
  • Continuing Medical Education (CME) and opioid-specific training. Increasing education and awareness surrounding the warning signs of opioid addiction and appropriate prescribing protocols will help to address the opioid epidemic. The ACS supports surgical specialty societies providing opioid and pain management CME relevant to their specialty and strongly recommends that mandated CME requirements not exceed one hour per year.

Patient education

The College further maintains that patient education about the dangers of opioid abuse and overuse is paramount to solving this problem. The ACS Patient Education Committee, under the aegis of the Division of Education, is working with the College’s Advisory Councils to develop patient and caregiver education that will address the safe use of opioids and how surgeons are using other methods to improve pain control and opioid prescribing.

Patients need to know that their pain can often be managed without opioids and that they have options, such as obtaining a partial prescription fill and using supplemental nonsteroidal medications. Patients also will be informed that screening tools and prescription drug monitoring will be used to identify individuals at a higher risk of opioid-related drug events, including patients chronically using opioids. John M. Daly, MD, FACS, Co-Chair of the ACS Patient Education Committee and a co-author of this article, remarked, “It is critical that surgeons and other caregivers make their patients partners in these education processes, for it is through patient engagement that proper perioperative pain management expectations can be created.”

Patient/caregiver resources should identify pain management options and safe use of pain medication, including the signs of overdose and other adverse effects, plus appropriate storage and disposal to prevent misuse by people other than the patient, including family members.

All ACS education programs will use best evidence to develop these resources. For example, education on how the body responds to pain and the negative effects of narcotics resulted in a 90 percent decline in opioid use, with pain scores significantly lower than the group with no education.19

At press time, the Board of Regents of the ACS had completed its review of and approved a policy statement on prescription opioids. The statement will be published in the August issue of the Bulletin.


References

  1. Park A. The story behind the viral photo of an opioid overdose. Time. Jan 24, 2017. Available at: time.com/4634809/photo-opioid-addiction/. Accessed May 18, 2017.
  2. Ohio Department of Health. 2014 Ohio drug overdose data: General findings. Available at: www.healthy.ohio.gov/-/media/ODH/ASSETS/Files/health/injury-prevention/2015-Overdose-Data/2014_Ohio-Overdose-Report–PDO-REPORT—5_20_2016.pdf?la=en. Accessed May 18, 2017.
  3. Centers for Disease Control and Prevention. Drug overdose death data. Available at: www.cdc.gov/drugoverdose/data/statedeaths.html. Accessed May 18, 2017.
  4. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths—United States, 2000–2014. Morb Mortal Wkly Rep. 2016;64(50):1378-1382.
  5. Paulozzi LJ, Jones CM, Mack KA, Rudd RA. Vital signs: Overdoses of prescription opioid pain relievers–United States, 1999–2008. Morb Mortal Wkly Rep. 2011;60(43):1487-1492.
  6. Levy B, Paulozzi L, Mack KA, Jones CM. Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007–2012. Am J Prev Med. 2015;49(3):409-413.
  7. Wunsch H, Wijeysundera DN, Passarella MA, Neuman MD. Opioids prescribed after low-risk surgical procedures in the United States, 2004–2012. JAMA. 2016;315(15):1654-1657.
  8. Kaafarni HMA, Weil E, Wakeman S, Ring D. The opioid epidemic and new legislation in Massachusetts: Time for a culture change in surgery? Ann Surg. 2016;265(4):731-733.
  9. Liepert AE, Ackerman TL. 2016 state legislative year in review and a look ahead. Bull Am Coll Surg. 2016;101(12):35-39.
  10. Jones T, Moore T, Levy JL et al. A comparison of various risk screening methods in predicting discharge from opioid treatment. Clin J Pain. 2012;28(2):93-100.
  11. Centers for Disease Control and Prevention. Guidelines for Prescribing Opioids on Chronic Pain—United States 2016. Available at: www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. Accessed May 29, 2017.
  12. Hanks S. The law of unintended consequences: When pain management leads to medication errors. Pharmacy and Therapeutics. 2008;33(7):420-425.
  13. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, executive committee, and administrative council. J Pain. 17(2):131-157.
  14. Murthy VH. Ending the opioid epidemic—A call to action. N Engl J Med 2016;375(35):2413-2415.
  15. Lee TH. The pain that results from pain measurement. NEJM Catalyst. May 25, 2016. Available at:  catalyst.nejm.org/the-pain-that-results-from-pain-measurement/. Accessed May 18, 2017.
  16. Bohnert AS, Ilgen MA, Galuea S, McCarthy JF, Blow FC. Accidental poisoning among patients in the Department of Veteran Affairs Health System. Med Care. 2011; 49(4):292-296.
  17. National Alliance for Model State Drug Laws. Compilation of prescription monitoring program maps. May 2016. Available at: www.namsdl.org/library/CAE654BF-BBEA-211E-694C755E16C2DD21/. Accessed May 18, 2017.
  18. Hill MV, Stucke RS, McMahon ML, Beeman JL, Barth RJ Jr. An educational intervention decreases opioid prescribing after general surgical operations. Ann Surg. 2017 [Epub ahead of print].
  19. Sugai DY, Deptula PL, Parsa AA, Parsa DF. The importance of communication in the management of postoperative pain. Hawaii J Med Public Health. 2013;72(6):180-184.

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