The opioid epidemic and how anesthesiologists can help

The 1990s marked a growing, but powerful movement that would drastically change the practice of medicine in the United States. This movement was led by well-intentioned, but poorly advised clinicians who promoted the agenda that patients’ pain was undertreated and patients were left to suffer in hospital wards and clinics, generating emphatic demand for more aggressive pain control. Historically, opioids were known for their powerful psychoactive and addictive properties and were used mainly for acute postoperative pain and end-of-life cancer patients. However, a few articles were used to challenge that belief; one major example is the infamous 1980 New England Journal of Medicine letter to the editor written by Porter and Jick,1 “Addiction is Rare in Patients Treated with Narcotics.”1 This letter is merely a few sentences long, gives no evidence or explanation of its methodology or statistical outcome, and yet was used by pain advocacy groups, and later by pharmaceutical companies, to promote their ideas and products. A second infamous article was published by Portenoy and Foley in the medical journal Pain in 1986 under the title “Chronic Use of Opioid Analgesics in Non-Malignant Pain: Report of 38 Cases.” On the basis of this small patient number, the article cited “suggestive evidence that opioid medications can be safely and effectively prescribed to selected patients with relatively little risk of producing the maladaptive behaviors which define opioid abuse.”2 Thus, a movement was born to fight the so-called “Opiophobia” and to promote a paradigm shift in medical practice: the use of opioids for chronic noncancer pain. The movement gained momentum and a critical mass of clinicians and advocates was reached. This was later followed by support from leaders of medical societies and governing organizations, resulting in widespread promotion of the idea that pain (ie, a subjective metric) should be treated as a vital sign (an objective metric). Dr James Campbell, then the president of the American Pain Society, stated “We need to train doctors and nurses to treat pain as a vital sign”. This idea was then literally adopted by the Veterans Health Administration, which made asking about pain part of taking a patient’s vital signs (ie, temperature, blood pressure, heart rate, and respiratory rate) even if the patient was in the hospital or clinic for an unrelated issue. The Federation of State Medical Boards (FSMB) and societies released policies and guidelines promoting the safe use of opioids for treatment of chronic noncancer pain (CNCP). The Joint Commission for Accreditation of Healthcare Organizations, the health care accreditation agency now known as The Joint Commission, made it mandatory to perform frequent pain assessments and treatments, and rigorously monitored and penalized organizations that failed to follow the new guidelines. Pain scales and “faces for pain” became dominant medical tools. At the same time, changes took place in the practice models of the United States’ health care system, leading to consolidation and more emphasis on productivity and efficiency. Large hospital organizations began acquiring small clinics, and established practices were pushed out or had to adapt to these changes. Physicians spent less time with patients and more time documenting in electronic health records, and patients could be seeing different providers at each clinic or hospital visit. What is now called the “health care industry” had to change and adapt to new business ideas and a model in which customer service and patient satisfaction rivaled clinical outcomes in importance. Patients’ expectations and “the right to pain relief” became the guiding principle. Physicians and hospitals are being judged by their Press-Ganey survey scores, which are sometimes directly linked to reimbursement and productivity bonuses.3 Pharmaceutical companies played a significant role in promoting and spreading the idea of safe opioids, the most prominent example of which was the marketing of OxyContin (Purdue Pharma, Stamford, CT), a sustained-release oxycodone preparation, which Purdue successfully grew into a blockbuster billion dollar drug. Some companies used aggressive marketing campaigns, targeting mainly primary care physicians by providing them with potentially misleading information and sponsoring “pain advocates” to publish books and articles and to speak at medical conferences. As a result, the pharmaceutical companies became one of the driving forces behind many medical societies’ guidelines and recommendations.4 The widespread availability of OxyContin correlated with increased abuse, diversion, and addiction, and by 2004, OxyContin had become a leading drug of abuse in the United States.5 In May 2007, high-profile pharmaceutical executives pled guilty to criminal charges of misbranding OxyContin by claiming that it was less addictive and less subject to abuse and diversion than other opioids, and paid $634 million in fines.4,6 Economic changes have been reshaping the country, most prominently among the so-called “Rust Belt” states, where deindustrialization and economic decline led to population loss and significant socioeconomic changes. These areas were the most impacted by the opioid epidemic. Opioid prescriptions soared and “pill mills” flourished in some towns, leaving hundreds of thousands of people addicted to prescription pain killers. It was estimated that, at one point, 20.8 million hydrocodone and oxycodone pills had been delivered to Williamson, West Virginia, alone, a town with fewer than 3200 residents.7 At the same time, the total amount of opioids prescribed to US patients increased, from 43.8 million prescriptions in 2000 to 89.2 million in 2010.8 This left thousands of people addicted to opioids, providing an easy conduit to an illegal drug market. With the emergence of black tar heroin and new delivery networks and techniques, dealers targeted this vulnerable population by going to their communities and by selling cheaper, more potent, and conveniently available products at rehabilitation facilities and methadone clinics.9 As a result, heroin overdoses reached historic, unprecedented numbers. The market for even more potent synthetic opioids grew, which resulted in deadlier overdoses.10 The current numbers are staggering. From 1999 to 2016, >630,000 people have died from a drug overdose. In 2016, the number of overdose deaths involving opioids was 5 times higher than it was in 1999. On average, 115 Americans die every day from an opioid overdose.11 The US government has declared the opioid epidemic a public health emergency. A chronological timeline of the opioid epidemic is shown in Table 1.Table 1: Chronological time line of the opioid epidemic.Efforts to stem this full-blown epidemic have been directed toward decreasing opioid prescriptions, preventing overdoses, and properly managing patients’ pain and addiction. Given the complexity of this problem, multiple stakeholders are exerting their efforts and expertise to help, including those in the medical, legal, legislative, drug enforcement, public advocacy, and other fields. In the medical arena, anesthesiologists are poised to play a critical and prominent role to mitigate this crisis, given their expertise in understanding and handling these medications and the wide range of services that they can provide to patients in the perioperative period and outpatient clinics.32 Four areas in which anesthesiologists can help are as follows: The perioperative period The outpatient clinic—chronic pain management Education Research The perioperative period Preoperative assessment For many people, the perioperative period represents their first encounter with opioids. Contrary to earlier statements by some that opioids given for pain have no risk for abuse or addiction, recent studies have shown that a significant percentage of opioid-naive patients can become chronic opioid users after the surgical procedure. In a retrospective study of over 36,000 opioid-naive patients who underwent elective surgery in the United States between 2013 and 2014, the incidence of chronic opioid use after surgery was ∼6%. This did not differ between major and minor surgical procedures.33 Seventy million patients are scheduled for surgical procedures annually; a significant fraction of these patients (in some studies as high as 20%) are chronically consuming opioids.34 Studies have shown that chronic preoperative opioid use (whether medically sanctioned or abuse-related) portends many short-term and long-term difficulties, including elevated levels of postoperative pain and opioid requirements, longer postoperative hospitalization, and elevated risks of postoperative respiratory depression.35,36 Beyond these immediate risks, chronic opioid users experience poorer surgical outcomes than their opioid-free counterparts. Examples include limited restoration of function after joint replacement surgery, poorer quality of recovery after spine surgery, and higher levels of persistent pain after gynecological procedures.37–39 The Perioperative Surgical Home (PSH) emerges as a collaborative and comprehensive model of care,40 in which the anesthesiologist could meet with the patient in the preoperative clinic, screen and identify high-risk patients, set expectations, educate patients about the surgical course and anesthetic/analgesic implications, tailor the anesthetic plan to meet each patient’s needs, and coordinate care with other healthcare providers. Intraoperative period There is growing evidence for, and understanding of the phenomenon called the “Opioid Paradox”: the more opioids used in the intraoperative period, the more opioids seem to be needed in the postoperative period.41,42 This could be attributed to opioid-induced hyperalgesia, which is a state of nociceptive sensitization caused by exposure to opioids,43 and acute opioid tolerance, in which opioid tolerance develops rapidly after administration of a potent opioid.44 These two different pharmacological phenomena may lead to similar clinical outcomes.42,45 Changes in attitudes and practice are shifting more toward opioid-free anesthesia compared with the more traditional opioid-based anesthesia, especially as integration of multimodal approaches to analgesia in Enhanced Recovery After Surgery (ERAS) Pathways gains traction. Multimodal analgesia is emerging as a new approach to achieve optimal analgesia and better outcomes, while reducing opioid use and its undesired side effects. These approaches include pharmacological agents such as acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentin/pregabalin, magnesium, ketamine, dexamethasone, alpha-2 blockers, duloxetine, and lidocaine.46–52 In addition to these pharmacological agents, regional anesthesia such as peripheral nerve blocks, neuraxial, and truncal blocks has been proven to be very effective in enhancing surgical recovery, decreasing complications, and improving patient outcomes and satisfaction.53,54 Postoperative period As mentioned previously, a considerable number of opioid-naive patients could become chronic opioid users after their first exposure to opioids in the perioperative period.33 Another study showed that the likelihood of chronic opioid use was impacted by the strength and the length of the first opioid prescription. The rate of long-term use was relatively low (6.0% on opioids 1 y later) for persons with at least 1 day of opioid therapy, but increased to about 15% for persons whose first episode of use was for ≥8 days and to 30% when the first episode of use was for ≥31 days. As expected, patients initiated on long-acting opioids had the highest probability of long-term use.55 A recent report examining opioid prescribing and use after shoulder surgery showed that the median number of opioid tablets prescribed was 60, but the median number of tablets actually used 90 days after surgery was only 13. A majority of these patients were not instructed on what to do with leftover tablets.56 Anesthesiologists working as part of a facility’s Acute Pain Service provide guidance to surgical colleagues on how to prescribe the appropriate amount of pain medications, educate the patient about postoperative pain management, and set reasonable expectations while promoting healing and recovery. There is an increasing demand to reach beyond the acute postoperative period by establishing a Transitional Pain Service, a multidisciplinary team that would identify patients at risk of developing chronic postsurgical pain and long-term opioid use and follow up after discharge to modify the pain trajectory and mitigate the misuse and abuse of opioids.57 The outpatient clinic—chronic pain management Anesthesiologists are leading experts in pain medicine. The specialty of pain management has grown steadily in recent years, largely because of the recognition of the complexity of chronic pain. As discussed, primary care practitioners with limited formal training in pain management have been the primary target of the pharmaceutical industry to prescribe more opioids to CNCP patients. Anesthesiologists, with extensive training in pain management and interventional procedures, can provide expert consultation for primary care practitioners and other prescribers to help manage patients with complex and challenging chronic pain conditions. In a recent analysis of closed claims related to outpatient medication management for CNCP, approximately half of the cases involved an allegation of patient death due to improper medication management.58 Patient medical comorbidities (ie, cardiopulmonary disease) and long-acting opioids were more closely associated with death than with other outcomes. Other risk factors were psychiatric comorbidities and aberrant drug behaviors. This study suggests that when treating opioid-dependent patients with complex medical and psychiatric comorbidities, physicians should educate patients about the risks, benefits, and alternatives of opioid therapy, perform compliance monitoring, and maintain vigilance for aberrant behaviors. Manchikanti et al59 found an overall decrease in the utilization of interventional pain procedures of about 0.6% per year from 2009 to 2016. At the same time, there was an unprecedented historical increase in the use of prescription opioids and prescription opioid-related deaths.60 Many experts are advocating increasing insurance coverage and access to nonopioid and nonpharmacological management of pain because opioids are likely less effective and can be more dangerous than other modalities of chronic pain management.61 To help practitioners better serve their patients, professional society guidelines,62,63 Centers for Disease Control and Prevention (CDC) guidelines, and risk evaluation and mitigation strategies from the Food and Drug Administration (FDA) for long-acting opioids offer some guidance to stratify risk, to identify and understand aberrant drug-related behaviors, and to tailor treatments accordingly.64 Among these recommendations are the use of a screening questionnaire such as the Opioid Risk Tool,65 a clear assessment of the patient’s chronic pain diagnosis, and documentation at each visit of the opioid’s effect on analgesia, activities of daily living, adverse side effects, and any aberrant drug behaviors. Education Education of all stakeholders plays a very important role and is often overlooked. To fight this epidemic, enriched and enhanced education of medical students, active medical practitioners, and the general public is essential. Currently, there is a lack of a common pain management curriculum that is broadly utilized for US medical, dental, pharmacy, or nursing schools. Neither is there an emphasis on education in addiction medicine and substance use disorders. Unfortunately, to date, many of these materials were sponsored by the pharmaceutical industry to fill the knowledge gap.15 As of 2010, a survey of US and Canadian medical schools concluded that pain education for North American medical students was limited, variable, and often fragmented. As little as 9 hours were devoted to pain education throughout the entire 4 years of medical school.66,67 More emphasis and effort are required to educate future physicians about the principles of pain, the modalities of pain management, and, equally important, the misuse and abuse of opioid pain medications and treatment of addiction. The consultant anesthesiologist is a valuable resource in the hospital for their emergency medicine, hospitalist, surgical, and oncology colleagues. Anesthesiologists with expertise in acute and chronic pain can help educate other practitioners about managing complex pain disorders and “acute on chronic” pain, offer counseling to patients, set realistic expectations about pain, review and modify medications, and perform different modalities of interventional pain management procedures. This will facilitate a safe and effective environment when challenging situations arise and could lead to better outcomes. Educating the general public is just as critical. Over the last 2 decades, the public received mixed messages about the use of opioids, with resultant doubt and mistrust of the medical community. Blendon and Benson,68 in a survey of public opinion on the opioid epidemic, asked who is mainly responsible for the growing problem. The survey showed that the public placed the most blame on doctors who inappropriately prescribe painkillers (33%) and people who sell prescription painkillers illegally (28%), whereas only a small number (10%) believe that people who take prescription painkillers are mainly responsible. Confusion still persists with no clear view; some patients still believe that opioids are safe and would request them as a first line of treatment for their conditions, whereas some see them as “evil” and would not use them despite being medically indicated. This shows a significant gap in understanding, and notable mistrust, demonstrating the importance of addressing the public image of opioids, providing facts and evidence, how the epidemic and what can be to Research pain medicine is still in its when at the and the of pain. New and are being and to help patients with their pain and to decrease the use of opioids. The most prominent example is the growing of mainly and peripheral nerve the first was by the in this has significant as have become more and more effective and for patients. Studies have shown that can or decrease opioid and earlier of has the to outcomes in complex chronic Another study has that earlier in the care for chronic pain may patient outcomes, with in clinic and opioid The of medicine and better understanding of and have the for in medicine. et how more can help the gap between care and medicine. More studies and better understanding of the will help There are many factors to the complexity of the current opioid epidemic. There are no easy or immediate to an epidemic that took to approaches are needed medical, legislative, and It is a and a to decrease the use of opioids, while at the same time provide appropriate care and pain to the patients who are in Anesthesiologists, as leading experts in pain management, should take on a role to the medical toward more responsible prescribing practices and administration of opioid medications in the perioperative Some to help the opioid epidemic are in Table which include and as as education and should educate patients, and the general public and to and to this by anesthesiologists to the opioid of has received or from and The that they have to

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