Surgery-Induced Opioid Dependence: Adding Fuel to the Fire?

Dr Murthy1 made national headlines in August 2016 when he, for the first time in the 145-year history of the Office of the Surgeon General, wrote a letter to all US physicians asking for their help in solving “the opioid epidemic.” He cited statistics from the US Centers for Disease Control and Prevention that both the amount of prescription opioids prescribed and the number of deaths from prescription opioids have quadrupled since 1999 and that as many as 2 million people suffer from prescription opioid use disorder.1 In his letter, Dr Murthy1 called on physicians to combat this epidemic by educating ourselves to treat pain safely and effectively and using evidence-based practices. This call to action raises many questions for our specialty. Recent studies show that surgery is associated with chronic opioid use,2–4 with 1 study reporting an incidence of new persistent opioid use of 5.9% and 6.5% after major and minor surgical procedures, respectively.2 One hundred million inpatient and outpatient surgeries and procedures occur each year in the United States. This places a tremendous number of patients at risk for chronic opioid use.5,6 Opioids have been a mainstay for the treatment of postsurgical pain; however, in a survey of 300 US adult patients who had surgery within the preceding 5 years, 86% reported having pain after surgery and 74% continued to experience moderate to severe pain after discharge. Eighty-eight percent received analgesic medications, with 80% experiencing adverse effects and 39% continuing to have moderate to severe pain even after receiving the first dose.7 These data suggest that inadequate treatment of perioperative pain and the risk of long-term opioid dependence after surgery are persistent concerns. As anesthesiologists, we almost invariably prescribe opioids for the treatment of acute pain in the perioperative setting. What role do we play in the opioid epidemic? Does the use of opioids for intraoperative nociception and acute postsurgical pain contribute to opioid dependence? If so, can this be prevented? Furthermore, does intraoperative opioid use affect the risk of hyperalgesia, postoperative opioid consumption, and the risk of chronic postoperative pain? In the 1990s, pain became known as the “fifth vital sign.”8 The 2000–2001 Joint Commission on Accreditation of Healthcare Organizations guidelines specified that pain must be assessed in all patients, based on the recognition that poor pain control was associated with negative outcomes and increased complications, including persistent postsurgical pain9 and poor health-related quality of life.10 This increased focus on adequate pain control was met with an increase in the number of opioid prescriptions.1 Data supporting an association between surgery and subsequent chronic postoperative opioid use are accumulating. In a retrospective study of 39,000 opioid-naive patients undergoing major elective surgery in Canada between 2003 and 2010, 49.2% were discharged with a prescription for opioids and 3.1% continued to require opioids 90 days after surgery.3 Factors associated with increased risk of prolonged postoperative opioid use included younger age, lower income, diabetes, and preoperative use of benzodiazepines and selective serotonin reuptake inhibitors. In a US population, Sun et al4 retrospectively analyzed 641,941 opioid-naive surgical patients compared to 18,011,137 opioid-naive nonsurgical patients. The prevalence of opioid use at 1 year was greater among postoperative surgical patients, ranging from 0.12% for cesarean delivery to 1.41% for total knee arthroplasty compared to nonsurgical patients.4 Surgical procedures associated with an increased risk of chronic opioid use at 1 year included total knee arthroplasty, total hip arthroplasty, laparoscopic cholecystectomy, open cholecystectomy, open appendectomy, cesarean delivery, and simple mastectomy. Additional factors associated with chronic opioid use included male sex, age >50 years, preoperative history of drug or alcohol abuse, depression, benzodiazepine use, or antidepressant use. A study of opioid-naive patients undergoing short-stay surgery also found significant rates of chronic opioid dependence 1 year after surgery (7.7%). Patients who received an opioid prescription within 1 week after surgery were significantly more likely to use opioids at 1 year than those who did not.11 The duration of acute postsurgical pain is typically 6 weeks. Why then do patients still require opioids a year (or more) after surgery? The causes are likely multifactorial and include both procedure-specific factors such as location and type of surgery and patient-specific factors such as age, gender, medical comorbidities, and psychologic factors.2,12 Surgeon prescribing practices may also contribute to this problem.13–15 Based on prescribing data from office-based physician visits, surgeons have a high opioid prescribing rate (37%), second only to pain medicine physicians at 49%.16,17 In addition, there is a wide variation in the amount of postoperative opioid prescribed for surgical procedures. Hill et al18 studied postoperative opioid prescription and consumption in 642 patients undergoing outpatient surgical procedures. The number of opioid pills prescribed ranged from a mean of 20 (range, 0–50) for postmastectomy to a mean of 30 (range, 15–120) for inguinal hernia repair.18 On average, patients reported taking only 28% of the total number of pills prescribed (15% of prescribed pills for postmastectomy and 31% for inguinal hernia). Similarly, a survey of quality of analgesia after hospital discharge found that 53% of cesarean delivery patients and 45% of thoracic surgery patients reported taking no or very little of the opioid medication prescribed.19 Waljee et al13 referred to surgeons as “gatekeepers for iatrogenic opioid dependence” and recommended a multidisciplinary approach with surgeons, anesthesiologists, primary care physicians, and pain psychologists working together to develop postoperative treatment regimens and identifying and caring for patients at risk for opioid dependence. Over the past 30 years, anesthesiologists have increasingly recognized the critical impact of anesthetic management on long-term patient outcomes.20 Just as we have come to recognize the vital role we play in issues ranging from the prevention of surgical site infection21 to myocardial injury after noncardiac surgery,22 anesthesiologists should accept some ownership of this important public health issue. What can the anesthesiologist do to prevent a surgical patient from becoming dependent on opioids? Avoiding or reducing perioperative opioids while providing adequate analgesia seems a logical and achievable goal. Preliminary data from our institution demonstrated that a successful 30% reduction in intraoperative opioid dosing was associated with a reduction in the postanesthesia care unit admission pain score of 1.5 points on an 11-point numerical rating scale of pain intensity.a We are currently investigating whether reducing intraoperative opioids results in reduced postoperative pain scores and chronic opioid use. Reducing intraoperative opioids may be very important, as high doses of intraoperative opioids may result in opioid-induced hyperalgesia and increased postoperative pain.23 The use of neuraxial and regional techniques and multimodal analgesic regimens with nonopioid analgesics such as ketamine, dexmedetomidine, and intravenous lidocaine may be helpful to decrease postoperative pain and reduce opioid consumption. Enhanced recovery protocols using multimodal analgesic regimens have become standard of care for colorectal surgery and are being expanded to other specialties.24 They have been shown to reduce opioid consumption during hospitalization and after discharge and are associated with decreased morbidity and length of hospital stay.25 It seems likely, though, that a real decrease in the incidence of surgery-associated opioid dependence will occur only through the development of interdisciplinary protocols. Limiting intraoperative opioids may have little benefit if excessive opioids are prescribed postoperatively. Patients at increased risk of developing opioid dependence, poor perioperative pain control, chronic pain postoperatively, and opioid-related adverse events should be identified preoperatively (and the anesthesia preassessment clinic might be a good place for that). Such patients would be ideal candidates for carefully designed care pathways that limit opioid exposure throughout the perioperative period. It is through such approaches that the risk of surgery-induced opioid dependence can potentially be mitigated. Anesthesiologists will play an important role in the perioperative surgical home to prevent surgery-induced opioid dependence and help curb the opioid epidemic. DISCLOSURES Name: Lauren K. Dunn, MD, PhD. Contribution: This author helped prepare the manuscript. Name: Marcel E. Durieux, MD, PhD. Contribution: This author helped prepare the manuscript. Name: Edward C. Nemergut, MD. Contribution: This author helped prepare the manuscript. Name: Bhiken I. Naik, MBBCh. Contribution: This author helped prepare the manuscript. This manuscript was handled by: Honorio T. Benzon, MD.

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