Authors: Krishnan S. Ramanujan, M.D. et al
ASA Monitor 11 2018, Vol.82, 16-18.
The opioid epidemic is one of the largest and most recent public health crises to strike the United States, with the rate of opioid-related overdose deaths nearly quadrupling between 1999 and 2014. To combat this growing epidemic, research has been conducted to identify those at highest risk of death secondary to opioid overdose.1 Various public health policies have been implemented to prevent and treat opioid misuse and abuse.2,3 Such efforts have resulted in an 8.1 percent nationwide reduction in annual prescribing rate per 100 persons of all opioids and a 46.8 percent reduction in annual prescribing rate per 100 persons of high-dose opioids, defined as ≥90 morphine milligram equivalents per day. Despite these positive trends, rates of drug overdose deaths have continued to increase in recent years, with the rate of overdose deaths involving any opioid increasing by 15 percent annually between 2013 and 20154 . These harrowing statistics, combined with the fact that anesthesiologists and pain management specialists account for 5 percent of opioid prescriptions nationwide and often introduce patients to opioids for the first time in the perioperative period,5 demonstrate the increasing importance of critically analyzing current opioid prescription practices and identifying an ethical way to not only manage pain but also curb the opioid epidemic.
Several aspects of the current medical environment promote opioid prescription for pain management. One important factor is the way in which pain is evaluated. Pain is classically graded on a numeric rating scale of 0-10, with zero representing no pain and 10 representing the worst pain ever felt by the patient. This scale has resulted in both the physician and patient focusing on this numeric value rather than the physiological origin of the patient’s pain. Although the scale has its limitations, one benefit it provides is that treatment success can be determined by whether the patient’s subjective pain has decreased. However, the pain scale does not indicate whether the patient’s functional abilities have improved to ideally enable participation in activities of daily living (at a minimum). This emphasis on the act of treating pain, rather than on managing the sequelae of pain, is reinforced by the use of patient satisfaction surveys to evaluate physician effectiveness. These surveys reward physicians who aggressively treat pain and punish those who attempt a more long-term, less lucrative and more holistic approach to pain management.6 As a result, patient satisfaction surveys, hospital surveys, and payment models may prevent physicians from pursuing what they believe to be an optimal pain management strategy and steer them toward a faster approach such as prescribing opioids.
Early education on the management of pain is another factor that affects how opioids are currently prescribed. Standardized protocols are often advanced without opportunities for individualization or the inclusion of non-opioid therapies. A classic example is the management of postoperative pain. Junior residents are taught to rely on the preferences of senior residents, who in turn rely on their attending physicians and protocols when prescribing opioids.7 This folklorish method of pain management may prevent physicians from learning about non-opioid pain management strategies and perpetuates the primary use of opioids for postoperative pain. Due to these restrictive measures, opioids are prescribed to the vast majority of patients and often in quantities far above expected needs,8 increasing the likelihood of patient misuse, abuse or diversion.
Upon highlighting and acknowledging core issues surrounding potentially inappropriate prescription of opioids for pain, there appear to be some mindset shifts that can be adopted to reduce prescriptions further and combat the opioid epidemic. Assessing pain based on functional status rather than subjective experiences can encourage a clinical focus on increasing functional capabilities when discussing pain management. By doing this, physicians and patients can define expectations of treatment in more tangible ways that can significantly contribute to quality of life. Recent studies have shown that long-term opioid therapy does not improve functional status in chronic pain patients.9,10 Therefore, when assessing pain based on functional status, the role of opioids in chronic pain management becomes significantly diminished. Additionally, expanding the use of multimodal analgesia and non-pharmacological therapies may help reduce reliance on opioids. For example, non-steroidal anti-inflammatory drugs and acetaminophen can be just as effective as opioids for chronic pain management,11 and interdisciplinary chronic pain rehabilitation programs have been shown to reduce pain severity and functional impairment while simultaneously weaning patients off opioids.12 By modifying the standards for evaluating pain, redefining what it means to benefit chronic pain patients and exploring non-opioid approaches to pain management, it may be possible to significantly reduce the need for opioids in chronic pain management.
In redefining terms of treatment for chronic pain patients, it is equally essential to consider the harms that could befall patients who are prescribed opioid medications. The economic and societal burdens of opioid misuse and abuse have been extensively studied,13,14 and the annual opioid overdose-related mortality rate has been steadily increasing into this decade.15 While opioid misuse and abuse have commonly been associated with conditions resulting in chronic pain, recent analyses have shown that opioid-naïve patients who undergo surgery may be at an increased risk for chronic opioid use.16,17 Since the intraoperative and immediate postoperative periods may be the first instances in which many opioid-naïve patients receive their first significant exposure to opioids, perioperative opioid administration without multimodal analgesia and patient education may be much more harmful to patients than previously thought. Given that opioids are not uniquely beneficial from a functional standpoint and that initiating opioid use in the surgical setting may contribute to the rise of chronic opioid use, it is crucial to consider the use of multimodal analgesia and reevaluate the utility of perioperative opioids in order to do what is best for patients.
When determining whether a medical decision such as prescribing opioids is ethically appropriate, four issues must be considered: autonomy, beneficence, nonmaleficence and justice. Initially, when opioids were first made available for pain management, they were marketed as an effective way to treat many types of pain without any significant risk of side effects or dependence (beneficence and nonmaleficence). However, recent data has shown that opioids are not as effective at managing chronic non-cancer pain as previously thought and have a high potential for misuse and abuse, reversing both of these ethical principles and resulting in the current opioid epidemic. As a result of this new information, it is now more important than ever that physicians, especially those who directly manage pain on a regular basis, reassess the ethics of prescribing opioids. This includes involving the patient in discussions regarding the risks and benefits of opioid use (autonomy) and becoming increasingly aware that new patient populations are falling victim to the opioid epidemic and in need of our attention and care (justice). While there are undoubtedly situations in which the use of opioids is necessary, the lack of evidence showing an improvement in functional status of patients on chronic opioid therapy, efficacy of non-opioid therapies in treating pain, and association of perioperative opioid use with subsequent chronic opioid use, misuse and abuse may drastically reduce the number of cases in which opioids ought to be used. Therefore, in order to combat the opioid epidemic effectively, we must embrace a new ethical mindset regarding the use of opioids in order to be more judicious with prescriptions and reduce exposure of future patients to the consequences of opioid misuse and abuse.
1. Huang X, Keyes KM, Li G . Increasing prescription opioid and heroin overdose mortality in the United States, 1999–2014: an age–period–cohort analysis. Am J Public Health Res. 2018;108(1):131-136.
2. Patrick SW, Fry CE, Jones TF, Buntin MB . Implementation of prescription drug monitoring programs associated with reductions in opioid-related death rates. Health Aff (Millwood). 2016;35(7):1324–1332.
3. Giglio RE, Li G, DiMaggio CJ . Effectiveness of bystander naloxone administration and overdose education programs: a meta-analysis. Inj Epidemiol. 2015;2(1):10.
4. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Annual Surveillance Report of Drug-Related Risks and Outcomes — United States, 2017. https://www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf. Published August 31, 2017. Last accessed September 12, 2018.
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. Lembke A . Why doctors prescribe opioids to known opioid abusers. N Engl J Med. 2012;367(17):1580-1581.
7. Chiu AS, Healy JM, DeWane MP, Longo WE, Yoo PS . Trainees as agents of change in the opioid epidemic: optimizing the opioid prescription practices of surgical residents. J Surg Educ. 2018;75(1):65-71.
8. Hill MV, McMahon ML, Stucke RS, Barth RJJr . Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg. 2017;265(4):709-714.
9. Birke H, Ekholm O, Sjøgren P, Kurita GP, Højsted J . Long-term opioid therapy in Denmark: a disappointing journey. Eur J Pain. 2017;21(9):1516-1527.
10. Hoffman EM, Watson JC, St Sauver J, Staff NP, Klein CJ . Association of long-term opioid therapy with functional status, adverse outcomes, and mortality among patients with polyneuropathy. JAMA Neurol. 2017;74(7):773-779.
11. Krebs EE, Gravely A, Nugent S, et al Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 2018;319(9):872-882.
12. Huffman KL, Rush TE, Fan Y, et al Sustained improvements in pain, mood, function and opioid use post interdisciplinary pain rehabilitation in patients weaned from high and low dose chronic opioid therapy. Pain. 2017;158(7):1380-1394.
13. Kwong WJ, Diels J, Kavanagh S . Costs of gastrointestinal events after outpatient opioid treatment for non-cancer pain. Ann Pharmacother. 2010;44(4):630-640.
14. Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers – United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492.
15. Seth P, Rudd RA, Noonan RK, Haegerich TM . Quantifying the epidemic of prescription opioid overdose deaths. Am J Public Health. 2018;108(4):500-502.
16. Brummett CM, Waljee JF, Goesling J, et al New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152(6):e170504.
17. Sun EC, Darnall BD, Baker LC, Mackey S . Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med. 2016;176(9):1286-1293.