Surgeon stewardship of the opioid epidemic: An introduction

The management of health care and health care institutions has changed dramatically in recent decades. The discussions on value-based care and the focus on the patient experience—from the initial consultation, throughout the perioperative period, and followed by discharge and rehabilitation—have forced a paradigm shift in how value is evaluated. Value is now quantifiable with metrics for assessment.

In 1996, the American Pain Society (APS) introduced the concept of “pain as the fifth vital sign.”1 In 2001, The Joint Commission released its pain management standards, which catapulted this concept to the forefront of patient care.2,3 The Joint Commission protocol essentially required that health care professionals ask patients about their pain and identify whether it was undertreated. Moreover, pain is a component of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), the patient satisfaction survey that the Centers for Medicare & Medicaid Services (CMS) uses as a component of hospital reimbursement, thereby creating a financial incentive for hospitals to maintain high HCAHPS scores.

Most Americans agree that the U.S. is in the midst of an opioid epidemic. According to the Centers for Disease Control and Prevention, opioid abuse costs the nation approximately $78.5 billion annually due to lost productivity, the costs associated with substance abuse and addiction treatment, and the financial toll on the criminal justice system.4

Nearly 40 percent of all outpatient prescriptions that surgeons write are for opioids, a rate that is second only to that of pain medicine specialists (49 percent.)5 Hence, surgeons are uniquely positioned to effect change at the national, state, and local levels, but, most importantly, directly at the patient level.

According to many health care industry experts, linking reimbursement to patient satisfaction for pain control results in overprescribing; furthermore, aggressive management of pain should not be equated with the delivery of quality health care as made manifest by better HCAHPS scores. The bipartisan Promoting Responsible Opioid Prescribing (PROP) Act (H. R. 4499) was introduced by Rep. Alexander Mooney (R-WV) in February 2016 to ensure that pain management questions on patient surveys would be omitted from the Medicare reimbursement formula.6 The bill has been endorsed by a number of health care associations, including the American Medical Association, the American Hospital Association, the American Society of Addiction Medicine, the American Osteopathic Association, the Physicians for Responsible Opioid Prescribing, and the American Association of Orthopaedic Surgeons, among others. The U.S. Senate has followed suit with a companion bill, S. 2758, introduced by Sen. Ron Johnson (R-WI) in April 2016.

ACS efforts

The American College of Surgeons (ACS) Division of Advocacy and Health Policy and the ACS Division of Education have done a great deal of work to address the opioid epidemic, ultimately resulting in the ACS Statement on the Opioid Abuse Epidemic. The guiding principles outlined in the statement include the following:

  • Promote the use of prescription drug monitoring programs (PDMPs)
  • Support research and training developed in collaboration with specialists in pain management for safe prescribing practices of opioids and nonopioid analgesics
  • Recognize and address issues specific to military veterans
  • Change the direct relationship between provider reimbursement and patient pain control
  • Support patient safety legislation

A critical gap in knowledge and communication has been identified in perioperative pain management, particularly education and resources aimed at the use of opioids in individuals undergoing surgery. With that in mind, the Division of Education is developing a new educational curriculum called Opioids and Surgery: Use, Abuse, and Alternatives. The program comprises professional and patient education materials aimed at supporting comprehensive training for surgical professionals and provides evidence-based data to help physicians meet the necessary guidelines for health literacy, surgical safety, and informed consent.7

The four standing committees of the Resident and Associate Society of the ACS (RAS-ACS) have unanimously selected the opioid crisis as the overarching theme for the August issue of the Bulletin. Surgical trainees are at the forefront of this epidemic, and as Chair of the RAS-ACS, I am impressed by the fact that RAS-ACS members have demonstrated such keen interest in tackling this crisis head on. It is a testament to their commitment to accepting responsibility for policing the profession and protecting our patients.

To further illustrate the enthusiasm and vigor of surgical trainees when it comes to the opioid epidemic, several groups of residents have been studying and surveying the prescribing practices of residents and fellows. By involving the RAS-ACS, we were able to consolidate these efforts into a large national survey that was delivered to 12,047 surgical trainee members. The survey was partitioned into several themes focused on pain management, prescribing practices, knowledge, beliefs and attitudes, and public policy. Data analysis is under way and is expected to be completed in the fall 2017.

The political arena, changes in health policy, and public health crises, such as the opioid epidemic, are all salient topics that continue to galvanize our discipline and reaffirm our cohesive desire to work on behalf of our patients. With specific points that apply to each RAS-ACS standing committee—Advocacy and Issues, Communications, Education, and Membership—members of the RAS-ACS present the following articles describing the effects of the opioid crisis on each area of surgical training and practice. The authors explore the surgeon’s role in enhancing patient education, the use of preoperative communication for opioid stewardship, methods to reverse and alleviate the opioid crisis, as well as treatment and education strategies for the practicing surgeon. As RAS-ACS Chair, it has been both an honor and a privilege to work with these young minds and to help enhance their efforts to lead the House of Surgery in the future.


  1. American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA. 1995;274(23):1874-1880.
  2. Joint Commission on Accreditation of Healthcare Organizations. Pain Standards 2001. Available at: Accessed May 30, 2017.
  3. Baker DW. History of The Joint Commission’s pain standards: Lessons for today’s prescription opioid crisis. JAMA. 2017;317(11):1117-1118.
  4. Florence CS, Zhou C, Luo F, Xu L. The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. Med Care. 2016;54(10):901-906.
  5. 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.
  6. Library of Congress. Promoting Responsible Opioid Prescribing Act of 2016, H. R. 4499, 114th Congress. 2016. Available at: Accessed June 20, 2017.
  7. American College of Surgeons. American College of Surgeons launches education program on opioids and surgery: Use, abuse, and alternatives. News release. 2016. Available at: Accessed May 30, 2017.

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