For the first time in the 145-year history of the office of the U.S. Surgeon General, the nation’s leading physician issued a call to action letter to 2.3 million health care professionals in 2016 requesting that they play a role in addressing the rising opioid epidemic.1 The opioid crisis has evolved over the last few decades, culminating in reports indicating that one in every 25 U.S. adults uses prescription opioids regularly.2 This article looks at the possible causes of this epidemic, summarizes state and federal initiatives aimed at resolving the problem, and offers suggestions for treating pain effectively in different patient populations.
How did we get here?
One contributor to the prescription opioid crisis was the relaxation of prescribing regulations in the 1990s. This change in policy was based on unclear scientific evidence supporting the safety and effectiveness of opioids even for chronic noncancer pain.3 Another contributing factor was the consumer demand for pain relief, a movement fueled by continuous pharmaceutical marketing efforts. The increase in opioid prescriptions resulted in a nearly four times higher overdose death rate in 2010 than in the preceding decade.4,5 More recent research supports rising problems related to liberal opioid prescribing practices, including opioid hyperalgesia, abuse, and opioid-related accidents and deaths.6
Nearly 8.9 percent of the American population ages 12 or older reportedly engage in illicit drug use.6 When analyzing trends, the nonmedical use of psychotherapeutics increased 178 percent between 1998 and 2010, compared with 56 percent for marijuana and 17 percent for cocaine during that time frame.6 Specifically, OxyContin use more than tripled to 2.8 percent in 2010 from 0.8 percent in 2005.7
Overdose deaths have reached startling numbers, with 30,000 opioid-related fatalities in 2015, outnumbering motor vehicle-related accidents and the peak of mortality from the human immunodeficiency virus epidemic.8,9
Surgeons are well positioned to address the opioid epidemic at many checkpoints, but especially during the dispensation of outpatient narcotic prescriptions. Estimating patients’ pain medication needs is an inexact science, as evidenced by nearly 80 percent of filled prescriptions that are incompletely used.10 With little information on how to correctly dispose of excess opioids, this situation contributes to illicit use. Nearly 55 percent of illicit opioid users reported obtaining the medications from friends or family for free, 11.4 percent bought them from a friend or relative, 4.8 percent stole them, and 17.3 percent obtained the drug through a prescription.11 Decreased opioid abuse is an important step toward controlling overall illicit drug abuse, as almost 75 percent of heroin users reported introduction to heroin through prescription painkillers.12
State and federal initiatives
Many efforts at the federal and state levels have been implemented to combat the opioid crisis in the U.S. State-level efforts have focused on patient and provider education and enhanced access to naloxone (in addition to training on its use), medication assistance programs, and implementation of prescription drug monitoring programs. Educating the general public or targeted populations about the risks of addiction helps mitigate misuse, because patients are less likely to abuse these medications if they are perceived to be harmful.13
Guidelines for providers who prescribe opioids also have been developed, although they can vary widely.13 The Centers for Disease Control and Prevention (CDC) has issued the only standardized guideline for the use of prescription narcotics to control chronic pain.14 Surgeons should be familiar with these guidelines as we often operate on patients with chronic pain syndromes. Furthermore, provider education about the reversal agent naloxone and its proper distribution has increased steadily and the U.S. Department of Health and Human Services has identified naloxone as one of three major priorities in battling the opioid crisis.15 Opioid overdose education and community naloxone distribution is aided by educating bystanders, friends, family members, acquaintances, and first responders to recognize the signs of an opioid overdose and to administer naloxone.15,16 Most states have reduced the opioid crisis by increasing access and distribution of naloxone kits. While health care professionals may provide prescriptions for naloxone to family members, most states allow pharmacists to dispense naloxone kits without a prescription.17
Not only can reversal agents help reduce overdoses, but the use of a medication assistance program that uses methadone, buprenorphine, and extended release injectable naltrexone has proven effective in decreasing mortality and opioid use.13,18 Approximately 1,200 facilities across the U.S. have opioid treatment programs that provide such assistance.19 The number of patients who received methadone and buprenorphine prescriptions has increased in recent years, rising to more than 306,000 patients in 2011 from 7,020 in 2003.19 These medications have proven beneficial and have helped individuals regain some normality in their lives.19
Other methods that are useful in alleviating the opioid crisis include monitoring the use of narcotics. Prescription drug monitoring programs (PDMPs) were first developed in 1939 at the state level to help tackle opioid misuse in the U.S.13,20 PDMPs are electronic databases available to providers to help monitor the prescription of medications with high potential for abuse, such as Level II and Level III opioids.20 States that have implemented PDMPs have experienced a decrease in opioid deaths.21
Turn the Tide campaign
State-level and perioperative-focused initiatives may not be enough to ameliorate the negative effects of the opioid crisis. In his open letter to health care professionals mentioned at the beginning of this article, U.S. Surgeon General Vivek H. Murthy, MD, introduced the Turn the Tide Rx initiative.16 The campaign calls upon clinicians to pledge their commitment to the following:
- Educate themselves to treat pain safely and effectively
- Screen patients for opioid use disorder and help them find appropriate evidence-based treatment
- Educate members of their community on addiction and help them understand that addiction is a chronic illness—not a moral failing
The strength of this initiative is its focus on engaging all stakeholders—including health care providers, policymakers, educators, law enforcement officers, and the larger community—in a collaborative effort to change the course of the opioid epidemic.
The Turn the Tide Rx pocket guide includes information for providers that outlines the CDC guidelines on chronic pain management. This pocket guide serves as a valuable resource for physicians, particularly young surgeons, as they may encounter many chronic opioid users and may inadvertently enable or facilitate behaviors consistent with narcotic abuse or addiction.8 Participating in national campaigns like the Turn the Tide Rx initiative should be an ethical obligation for all surgeons.
Protocols for perioperative pain management
Considering that nearly 17.3 percent of opioid-dependent people initiated use through a physician-provided prescription, new and innovative approaches to maximizing perioperative pain control while minimizing use of excessive narcotics or medications with highly addictive potential are warranted.
Initially, the Enhanced Recovery After Surgery (ERAS) concept evolved as a byproduct of colorectal surgery research in an effort to decrease postoperative adverse events, length of stay, and bowel-related complications. The American College of Surgeons (ACS) has introduced the ERAS approach to hospitals throughout the U.S. through the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Surgical Care and Recovery (ISCR). The ISCR program supports hospitals in implementing perioperative evidence-based pathways to meaningfully improve clinical outcomes, reduce hospital length of stay, and improve the patient experience, and is a collaborative effort between the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, and the College.
Intrinsic to this initiative is an effort to limit the use of narcotic pain medication. Together, colorectal surgeons and urologists have been on the cutting edge of ISCR implementation, with significant improvements not only regarding complications and length of stay, but also in overall use of narcotic pain medications during the postoperative period of convalescence.22,23 Studies demonstrate that these protocols lower overall use rates and duration of opioid analgesic use following surgery.24
Integral to the education of both young and practicing surgeons is a basic understanding of the neuroanatomy of pain. Understanding the biochemical properties of tolerance, physical dependence, and addiction is paramount to responsible opioid prescribing. Tolerance is defined as the biophysical modulation of opioid receptors after chronic exposure. With chronic opioid exposure, the receptors require an increased amount of activation for the same result. As a consequence, escalating amounts of narcotics are needed to achieve the same level of pain relief.25,26 Physical dependence is the manifestation of withdrawal symptoms due to cessation of the medication. Physiologically, this will occur in all patients to a varying degree. The most pronounced symptoms of withdrawal include diaphoresis, agitation, tachycardia, vomiting, and diarrhea. Addiction is characterized by behavioral changes, such as seeking out the medication despite personal harm to themselves or others.26
Management of acute surgical pain poses several unique challenges. Recognizing the overlay of acute and chronic pain in the postoperative period can be difficult. Due to tolerance, postoperative pain control in patients with chronic pain will require increased amounts of narcotics to provide relief. Because opioid-tolerant patients experience more pain postoperatively, especially in the first 24 to 48 hours, recommendations include preoperative planning that involves input from the patient’s caretakers, and multimodal agents like nonsteroidals and acetaminophen.27-29
When developing a pain management plan, it is important to consider specific patient populations with respect to narcotic use. Exercise caution when administering opioids in elderly patients, for example, due to changing pharmacokinetics and pharmacodynamics associated with both aging and polypharmacy.30 Patients with cardiac and pulmonary comorbidities are susceptible to increased cardiac and respiratory depression.31 Renal and liver disease can prolong clearance and metabolism, leading to longer medication half-life and adverse events.32-34 In patients with obstructive sleep apnea (OSA), additive central depression and decreased neuromuscular tone can worsen obstruction and pulmonary complications.35,36 Because of a high percentage of undiagnosed OSA patients in the general population, clinical perioperative suspicion should remain high.35,37 Successful pain management strategies to help the surgeon with these populations include developing individualized plans, decreasing dosage amounts, and increasing intervals between administration.34,36,37
Patients with underlying mental illness and addictions can be especially challenging due to the biopsychosocial interactions of previous life experiences, current expectations, hypersensitivity to pain, and ineffective coping mechanisms.26,38,39 Setting patient expectations, shared decision making, and aggressive multimodal pain control postoperatively may improve pain outcomes.28,29,38,40
Multiple health care associations including the College, the American Pain Society (APS), the American Society of Anesthesiology, and the CDC have devised guidelines to help physicians manage acute pain (see statement on page 58).28 Setting patient expectations is a common theme for achieving overall improved pain control with less opioid use, decreased anxiety, improved patient satisfaction, and even decreased length of stay postoperatively.28,29,40,41 Strategies include engaging patients in preoperative discussions on pain control, shared decision making, and development of the postoperative pain plan.40 These discussions may reveal previous patient experiences, including personalized pain control that has worked well in the past. Documenting these discussions will help ensure continuity of care. It is also important to anticipate the expected length of acute postoperative pain and educate the patient on specialized chronic pain resources.
Alternative treatment modalities
The most recent APS postoperative pain management guidelines, released in 2016, present evidence-based nonnarcotic interventions that should be employed for all patients.28 The underlying principle guiding multimodal therapy is the synergy gained by the use of multiple agents resulting in an opioid-sparing effect.28,42-44 Therefore, the APS recommends routine scheduled nonopioid analgesics as part of the pharmacologic regimen. Cyclooxygenase (COX) inhibition prevents the generation of inflammatory mediators, like prostaglandins, that further increase the propagation of nociceptive pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) block this conversion and provide significant reduction in pain. When Tylenol and NSAIDs are combined, postoperative pain control improves, resulting in decreased opioid intake. Other nonopioid options include gabapentin or pregabalin, the selective COX-2 inhibitor Celecoxib, and the intraoperative use of ketamine. Gabapentin is thought to decrease the neuropathic component of pain and, as previously mentioned, COX inhibition effects nociceptive pain, thus together having an additive, synergistic effect.45,46 Pre-incisional tissue infiltration of local anesthesia, anesthesia-administered nerve blocks and epidurals, transcutaneous electrical nerve stimulation, and cognitive behavioral strategies all represent additional interventions that can be employed.
Evidence supporting the use of these multimodalities abounds in the medical literature, and it is beyond the scope of this article to fully explore each modality. Surgeons should familiarize themselves with all the possible perioperative interventions that are available to reduce pain and opioid use, specifically starting with consensus guidelines like those provided by the APS and the ACS.28
The over-prescription of narcotics in the U.S. has resulted in an opioid crisis. Surgeons will play an important role in addressing and mitigating this scourge. Continued efforts aimed at patient education regarding narcotics will be critical, and a team approach involving the patient, physicians, and other members of the health care team are essential to successfully curbing opioid misuse. Eradicating the opioid epidemic is a moral and ethical obligation for all surgeons in all specialties.
- Murthy VH. Ending the opioid epidemic—A call to action. N Engl J Med. 2016;375(25):2413-2415.
- Waljee JF, Li L, Brummett CM, Englesbe MJ. Iatrogenic opioid dependence in the United States: Are surgeons the gatekeepers? Ann Surg. 2017;265(4):728-730.
- Phillips DM. JCAHO pain management standards are unveiled. Joint Commission on Accreditation of Healthcare Organizations. JAMA. 2000;284(4):428-429.
- Centers for Disease Control and Prevention. Vital signs: Overdoses of prescription opioid pain relievers: United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492.
- Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths: United States, 2000–2014. MMWR Morb Mortal Wkly Rep. 2016;64(50-51):1378-1382.
- Manchikanti L, Helm S II, Fellows B, et al. Opioid epidemic in the United States. Pain Physician. 2012;15(3 Suppl):S9-38.
- Substance Abuse and Mental Health Services Administration. Substance Use and Mental Disorders in the Phoenix-Mesa-Glendale MSA. 2012. www.samhsa.gov/data/sites/default/files/NSDUHMetroBriefReports/NSDUHMetroBriefReports/NSDUH-Metro-Phoenix.pdf.
- Gawande AA. It’s time to adopt electronic prescriptions for opioids. Ann Surg. 2017;265(4):693-694.
- Centers for Disease Control and Prevention. From the Centers for Disease Control and Prevention. HIV and AIDS: United States, 1981–2000. JAMA. 2001;285(24):3083-3084.
- Bartels K, Mayes LM, Dingmann C, et al. Opioid use and storage patterns by patients after hospital discharge following surgery. PLoS One. 2016;11(1):1-10.
- Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration 2011. Available at: www.samhsa.gov/data/sites/default/files/NSDUHNationalFindingsResults2010-web/2k10ResultsRev/NSDUHresultsRev2010.pdf.
- Compton WM, Jones CM, Baldwin GT. Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med. 2016;374(2):154-163.
- Wickramatilake S, Zur J, Mulvaney-Day N, von Klimo MC, Selmi E, Harwood H. How states are tackling the opioid crisis. Public Health Reports. 2017:132(2):171-179.
- Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624-1645.
- Kerensky T, Walley AY. Opioid overdose prevention and naloxone rescue kits: What we know and what we don’t know. Addict Sci Clin Pract. 2017;12(4):1-7.
- Davis CS, Ruiz S, Glynn P, Picariello G, Walley AY. Expanded access to naloxone among firefighters, police officers, and emergency medical technicians in Massachusetts. Am J Public Health. 2014;104(8):e7-9.
- Davis CS, Walley AY, Bridger CM. Lessons learned from the expansion of naloxone access in Massachusetts and North Carolina. J Law Med Ethics. 2015;43(1 Suppl):19-22.
- Volkow ND, Frieden TR, Hyde PS, Cha SS. Medication-assisted therapies—tackling the opioid-overdose epidemic. N Engl J Med. 2014;370(22):2063-2066.
- Alderks CE. Trends in the use of methadone and buprenorphine at substance abuse treatment facilities: 2003 to 2011. The CBHSQ Report. Rockville, MD. 2013. Available at: www.ncbi.nlm.nih.gov/books/NBK384659/. Accessed June, 29 2017.
- Ali MM, Dowd WN, Classen T, Mutter R, Novak SP. Prescription drug monitoring programs, nonmedical use of prescription drugs, and heroin use: Evidence from the National Survey of Drug Use and Health. Addict Behav. 2017;69:65-77.
- Patrick SW, Fry CE, Jones TF, Buntin MB. Implementation of prescription drug monitoring programs associated with reductions in opioid-related death rates. Health Aff. 2016;35(7):1324-1332.
- Miller TE, Thacker JK, White WD, et al. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg. 2014;118(5):1052-1061.
- Sen H, Sizlan A, Yanarates O, et al. A comparison of gabapentin and ketamine in acute and chronic pain after hysterectomy. Anesth Analg. 2009;109(5):1645-1650.
- Karl A, Buchner A, Becker A. A new concept for early recovery after surgery for patients undergoing radical cystectomy for bladder cancer: Results of a prospective randomized study. J Urol. 2014;191(2):335-340.
- Pathan H, Williams J. Basic opioid pharmacology: An update. Br J Pain. 2012;6(1):11-16.
- Kosten TR, George TP. The neurobiology of opioid dependence: Implications for treatment. Sci Pract Perspect. 2002;1(1):13-20.
- Patanwala AE, Jarzyna DL, Miller MD, Erstad BL. Comparison of opioid requirements and analgesic response in opioid-tolerant versus opioid-naive patients after total knee arthroplasty. Pharmacotherapy. 2008;28(12):1453-1460.
- 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. 2016;17(2):131-157.
- Arthur HM, Daniels C, McKelvie R, Hirsh J, Rush B. Effect of a preoperative intervention on preoperative and postoperative outcomes in low-risk patients awaiting elective coronary artery bypass graft surgery. A randomized, controlled trial. Ann Intern Med. 2000;133(4):253-262.
- Gosch M. Analgesics in geriatric patients. Adverse side effects and interactions. Z Gerontol Geriatr. 2015;48(5):483-492.
- Richards S, Torre L, Lawther B. Buprenorphine-related complications in elderly hospitalised patients: A case series. Anaesth Intensive Care. 2017;45(2):256-261.
- Innaurato G, Piguet V, Simonet ML. Analgesia in patients with hepatic impairment. Rev Med Suisse. 2015;11(480):1380, 1382-1384.
- Imani F, Motavaf M, Safari S, Alavian SM. The therapeutic use of analgesics in patients with liver cirrhosis: A literature review and evidence-based recommendations. Hepat Mon. 2014;14(10):e23539.
- Rolke R, Rolke S, Hiddemann S, et al. Update palliative pain therapy. Internist (Berl). 2016;57(10):959-970.
- Hassamal S, Miotto K, Wang T, Saxon AJ. A narrative review: The effects of opioids on sleep disordered breathing in chronic pain patients and methadone maintained patients. Am J Addict. 2016;25(6):452-465.
- Bluth T, Pelosi P, de Abreu MG. The obese patient undergoing nonbariatric surgery. Curr Opin Anaesthesiol. 2016;29(3):421-429.
- Subramani Y, Wong J, Nagappa M, Chung F. The benefits of perioperative screening for sleep apnea in surgical patients. Sleep Med Clin. 2017;12(1):123-135.
- Eyler EC. Chronic and acute pain and pain management for patients in methadone maintenance treatment. Am J Addict. 2013;22(1):75-83.
- Martin TJ, Ewan E. Chronic pain alters drug self-administration: Implications for addiction and pain mechanisms. Exp Clin Psychopharmacol. 2008;16(5):357-366.
- Yek JL, Lee AK, Tan JA, Lin GY, Thamotharampillai T, Abdullah HR. Defining reasonable patient standard and preference for shared decision making among patients undergoing anaesthesia in Singapore. BMC Med Ethics. 2017;18(1):6.
- Crowe J, Henderson J. Pre-arthroplasty rehabilitation is effective in reducing hospital stay. Can J Occup Ther. 2003;70(2):88-96.
- Khobrani MA, Camamo JM, Patanwala AE. Effect of intravenous acetaminophen on post-anesthesia care unit length of stay, opioid consumption, pain, and analgesic drug costs after ambulatory surgery. PT. 2017;42(2):125-139.
- Moore RA, Derry S, Aldington D, Wiffen PJ. Single dose oral analgesics for acute postoperative pain in adults—an overview of Cochrane reviews. Cochrane Database Syst Rev. 2015(9):CD008659:1-33. Available at: onlinelibrary.wiley.com/doi/10.1002/14651858.CD008659.pub3/epdf/standard. Accessed June 30, 2017.
- Prabhakar A, Cefalu JN, Rowe JS, Kaye AD, Urman RD. Techniques to optimize multimodal analgesia in ambulatory surgery. Curr Pain Headache Rep. 2017;21:24.
- Ekman EF, Wahba M, Ancona F. Analgesic efficacy of perioperative celecoxib in ambulatory arthroscopic knee surgery: A double-blind, placebo-controlled study. Arthroscopy. 2006;22(6):635-642.
- Agarwal A, Gautam S, Gupta D, Agarwal S, Singh PK, Singh U. Evaluation of a single preoperative dose of pregabalin for attenuation of postoperative pain after laparoscopic cholecystectomy. Br J Anaesth. 2008;101(5):700-704.