Author: Tony Mira
Despite education and efforts to reduce the abuse of opioids among Americans, the addiction crisis continues. To what extent can pain management and anesthesia practices play a part in reducing America’s dependence on these substances?
A new book has brought one of the nation’s most serious health crises into clear focus. Empire of Pain: The Secret History of the Sackler Dynasty by Patrick Radden Keefe traces the rise of the Sackler empire and how its production and promotion of OxyContin fueled the current opioid crisis. In addition, a recently released Hulu series called Dopesick traces the efforts of the Justice Department to reveal the inner workings of the Sackler family’s marketing and sales strategy for OxyContin.
Elephant in the Room
In the past year, 1.6 million Americans started using pain relievers for the first time. In 2019, 70,630 people died from drug overdoses. Most of us now know or have heard of friends or family members who have either become addicted or succumbed to addiction. Clearly, this is an issue that has gotten public attention. Ironically, any time there is a concern about the use and abuse of narcotics, anesthesia is always assumed to be involved, even though anesthesiologists and CRNAs are not the primary prescribers—unless they are practicing pain management.
The crux of the issue is addiction. Although Purdue Pharma argued that its OxyContin had a very low rate of addiction, this turned out to be a false and misleading claim. The following is an excerpt from a publication by NPACE (Nurse Practitioner Association for Continuing Education):
On October 26, 2017, the Department of Health and Human Services (HHS) declared a public health emergency to address the national opioid crisis, an epidemic claiming 91 lives a day at that time. The opioid crisis began in the 1990’s when pharmaceutical companies pushed these medications, assuring medical professionals that opioids had little to no risk of addiction. The 750,000 people who died from a drug overdose since 1999, 32% of which involved prescription opioids in 2018, tell a different story [Centers for Disease Control and Prevention (CDC), 2020].
The opioid crisis has resulted in a wide range of public and private initiatives to manage physician and patient behavior. The following excerpt from the Centers for Medicare and Medicaid Services (CMS) provides an example of how government is responding to the crisis:
In February 2019, CMS released an informational bulletin (PDF, 172.18 KB) to support the goal of reducing the use of opioids in pain management and expand on earlier guidance by providing information to states seeking to promote non-opioid options for chronic pain management. With the aim of leading to more appropriate prescribing of opioids the guidance describes:
- A multidisciplinary approach to chronic pain management that incorporates non-opioid pharmacologic and non-pharmacologic therapies
- Well-communicated treatment goals and expectations
- Careful consideration of the individual and the benefits and risks of a range of available treatment options
Anesthesia providers that work as pain management specialists are the most likely to prescribe opioids for their patients. As a result, there has been considerable discussion among practitioners about effective alternatives for the management of chronic and intractable pain. The literature is full of articles explaining the need for a multi-disciplinary approach to the management of chronic pain that does not involve opioids.
What About Anesthesia?
Some would also argue that the increased use of nerve blocks for post-operative pain management has been encouraged by a concern with the impact of opioids. Obviously, only a short list of procedures (primarily orthopedic cases) would qualify for interscalene, femoral, sciatic and TAP blocks; but, even so, the use of these has increased dramatically over the past ten years. While the overall impact of these blocks may not be significant in the overall scheme of an anesthesia practice, they are good examples of ways in which anesthesia care is being targeted to the specific needs of individual patients.
A new tool has been introduced for the management of patients undergoing surgery. It is called the NARX score. The score involves a three-digit figure that represents the number of controlled substances dispensed in each of three categories: narcotics, sedatives, and stimulants. The data is captured by the primary care physician and is part of the patient’s chart. The three-digit score is intended to provide the anesthesia provider with a point of reference for the advisability of administering controlled substances. It is yet another example of how anesthesia is expected to play a critical role in the management of the patient’s entire peri-operative experience.
The unfortunate reality is that despite public awareness of the problem and despite the revision and refinement of clinical guidelines, the crisis continues to grow. The United States’ population is 4.4 percent of the world’s population, but Americans consume 80 percent of all opioids prescribed worldwide. Clearly, this is a multi-disciplinary issue that requires a multi-disciplinary approach. As is so often the case, anesthesia is not the source of the problem, but may well play an important role in finding workable solutions. After all, no one specialty is more focused on the assessment of pain and the development of strategies to mitigate its impact.