Postoperative opioid prescriptions: How surgeons can alleviate the opioid crisis

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

Understanding pain

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

Conclusion

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.

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