The opioid epidemic has become a public health crisis in the U.S.


The opioid epidemic has become a public health crisis in the U.S. While primary care physicians have been writing fewer opioid prescriptions over the last several years, new opioid prescriptions by surgeons increased 18 percent from 2010-2016.

However, many surgeons are now diligently working to change their prescribing practices.

One approach has been to try reducing excessive opioid prescriptions by exploring pain management strategies that include fewer or no opioids at all for surgical patients.

One study team at the University of Michigan wanted to find out if an opioid-sparing strategy would be feasible for patients undergoing six different procedures at their institution.

Results from their pilot study showed that more than half of patients used no opioids after their operations, and almost all of the patients reported their pain was manageable, according to study findings published as an “article in press” on the website of the Journal of the American College of Surgeons ahead of print.

The study team, led by Michael Englesbe, MD, FACS, has been working to improve opioid prescribing in Michigan for two years.

Their work is motivated by the fact that many people not taking opioids before their operations (“opioid-naïve”) become new chronic opioid users after their operations, said Dr. Englesbe, the study’s corresponding author and a professor of surgery at the University of Michigan, Ann Arbor.

“We think a fundamental root cause of the opioid epidemic is opioid-naïve patients getting exposed to opioids and then really struggling to stop taking them postoperatively, and then moving on to chronic opioid use, abuse, addiction, and overdose,” Dr. Englesbe said. For this study, the goal was to have a majority of patients need no opioid pills after their operations.

The researchers enrolled 190 opioid-naïve patients undergoing six surgical procedures at their institution: laparoscopic cholecystectomy, laparoscopic inguinal hernia repair, thyroidectomy/parathyroidectomy, robotic prostatectomy, endoscopic sinus operations, and laparoscopic sleeve gastrectomy.

Participants received specific instructions regarding postoperative pain control, pain expectations, and counseling to learn to manage pain without opioids.

At their preoperative clinic visits, patients were told to take acetaminophen or ibuprofen every six hours around the clock and to stagger these medications every three hours for maximum continuous pain control.

After their operations, patients received prescriptions for 650 mg of acetaminophen and 600 mg of ibuprofen, as well as a small “rescue” prescription of opioids for uncontrolled breakthrough pain.

The prescription sizes of opioids – mostly oxycodone – varied based on the operation but were small.

For example, laparoscopic cholecystectomy patients were prescribed four oxycodone pills. Patients were instructed during both their preoperative and postoperative clinic visits that they didn’t have to use the opioids if they didn’t feel they needed to.

During the first week after their operations, patients were asked to rate their average pain score on a scale of no pain (0) to severe pain (3).

They were also asked to rate their surgical site pain at the time of the survey, their satisfaction with the operation, their quality of life after the operation, the percent recovered they felt at the time of the survey, and whether they regretted having the operation.

Patients also reported whether they used acetaminophen and/or ibuprofen, and whether their pain was manageable with this regimen.

Between 30 and 90 days after their operations, patients were asked to report the number of opioid pills they used postoperatively.

The study authors reported that 52 percent of patients used no opioids after their operations at all, and 98 percent used 10 pills or fewer.

Among the 48 percent of patients who did use opioids, the median use was four pills, and the median number of leftover pills was two.

The median pain score for the whole cohort was 1, or minimal pain; that number was 2 for patients who used opioids.

Overall, the median patient satisfaction score was 10 on a 10-point scale, or extremely satisfied, and the median quality of life score was 4 on a 5-point scale.

The median level of regret to undergo the operation was 5 (“absolutely no regret”).

There were no significant differences in the other variables when comparing opioid users with non-users, the authors reported.

Almost all patients – 91 percent – said their pain was manageable using this strategy.

While Dr. Englesbe said it was a bit surprising – and very motivating – that a significant percentage of patients took no opioids, it’s also important to understand that fewer opioids are only one component of the larger pain management strategy.

The focus has to be on what does work, which will not be the same for every patient.

“Just not giving opioids is not the answer – we have to give the best pain care,” Dr. Englesbe said.

In the case of this study, the team provided a full care pathway.

“From the beginning, everyone was on the same page with talking to patients about their pain and letting them know that operations hurt,” he added.

With the help of funding from Blue Cross Blue Shield of Michigan and the Michigan Department of Health and Human Services, Dr. Englesbe and his team are in the process of expanding this pain management strategy.

They will expand their list of selected surgical procedures from six to 18 and are working to implement the strategy to other institutions across the state.

“Our overall goal is to have half the operations done in the state of Michigan without patients needing opioids and still getting excellent pain care,” Dr. Englesbe said. “There are alternatives to opioids for surgical pain that work well and we should be using them more.”

Substance abuse is a major public health issue in America, especially given that the USA (US) is currently facing a national epidemic of overdose deaths, with more people dying from overdoses than ever recorded before [1].

From 1999 to 2016, drug overdose deaths more than tripled [2], making overdose the leading cause of accidental death in the US [3].

The increase in opioid abuse is one of the driving factors of this epidemic; currently more than half of overdoses in the US involve the use of opioids [4].

In 2016 in particular, there were over 63,600 drug overdose deaths, and opioids played a role in 42,249 of these [2,5].

In recent years, however, heroin and synthetic opioids in particular have contributed to the increased overdose rates [1,4].

In 2015, approximately 591,000 people had a heroin-use disorder in particular [6].

A heroin-use disorder is defined as an individual who uses heroin for potential drug-related euphoria, abuses heroin, or is physically dependent on heroin and struggles to stop using it.

From 2010 to 2016, the number of heroin-related overdose deaths showed a fivefold increase and death rates for heroin increased by 20% from 2015 to 2016 alone [7].

One factor that may account for the sharp increase in the number of heroin users is the potential association between prescription opioid misuse and heroin use [7], as roughly 80% of heroin users report first abusing prescription opioids [8].

Possible reasons for this association include the increased availability and lower cost of heroin, making it easier to obtain [7912].

Similar to increased rates of heroin overdose, rates of overdoses from synthetic opioids (excluding methadone) increased by 88% between 2013 and 2016 [2].

This significant increase seems to be primarily the result of illicitly manufactured fentanyl [13,14], which is commonly mixed into batches of heroin [15].

This is concerning given that fentanyl is 50–100 times more potent than morphine [16].

The issue of heroin and fentanyl abuse is a national public health crisis that needs to be addressed in order to counteract the devastating effects it has across the country, ranging from high numbers of overdose deaths and increasing incidences of medical conditions associated with intravenous drug use, such as HIV and Hepatitis C [17,18].

Successfully addressing the opioid and heroin epidemic requires a collaborative approach from law enforcement, public health, and social service agencies, as well as physicians [19,20].

Physicians serve a vital role within the opioid and heroin epidemic as it relates to (1) education (2), prescription of medication, and (3) screening and referrals for treatment of addiction.

With regards to education, physicians can provide educational materials along with verbal information for patients and their families about the risks related to developing opioid addiction.

For those patients who are at high risk to develop the addiction from an opioid to heroin transition, additional educational conversations should occur between the physician, patients, and families.

When physicians take into consideration the use of prescription of opioids for pain management, it is essential to consider if their patient is at risk for drug-seeking behavior, the differential diagnoses, and potential misuse of medication.

Finally, when physicians screen for addiction, the patient history is one of the most critical aspects for identifying addictive behavior.

Given the role of physicians in dealing with patients at risk for abuse or patients who are abusing (opioids/heroin), it is of utmost importance that physicians are aware of this issue and know how to respond appropriately.

Many physicians lack knowledge regarding the identification, assessment, and treatment of opioid addiction [21,22].

Increased awareness and education among physicians will enable them to identify patients at risk for substance abuse and overdose and manage patient care more effectively.

Unfortunately, a report from 2012 indicated that medical school curricula do not adequately cover or spend substantial time covering addiction medicine and that most doctors fail to identify or treat patients with substance abuse problems [2325].

Recognizing the growing importance of medical school curricula in effectively addressing the national drug overdose issue, the Association of American Medical Colleges created a statement that 74 medical schools signed in order to demonstrate their willingness toward better incorporating opioid-related topics in their training of medical students [26,27].

An AAMCNEWSarticle highlighted that many of these schools have developed ways to integrate such education into their curriculum [27].

For example, the University of Central Florida has implemented a module that educates students on topics related to pain management and opioid dependency and subsequently has students implement this new knowledge by developing treatment plans for patient cases that successfully prevent addiction development [27,28].

Another example is how Boston University, Harvard University, Tufts University, and University of Massachusetts medical schools now have a list of opioid-related competencies they must meet, which were developed by the governor of Boston [27,29].

Liaison Committee on Medical Education (LCME) reports show that 136/141 medical schools had curriculum content on substance abuse and pain management in 2015 [30].

While progress has certainly been made in adapting curricula to include opioid-related components, there is still more to be done.

As the nature of the prescription opioid epidemic changes and heroin and fentanyl take a more central role, they should have more focus in related curriculum as well.

While many schools have adapted curriculum to focus on opioid prescription and pain management, for schools that have not yet done so, curriculum should be further enhanced by adding more material and competencies related to the shift from prescription opioids to heroin and fentanyl, as well as how to treat such addictions in order to prevent future overdoses.

Due to the alarming increase in heroin use and overdose, coupled with the transition from opioid misuse to heroin use and increased fentanyl added to heroin, a heightened focus on heroin education is needed to adequately prepare medical students for dealing with issues of heroin abuse, dependence, and overdose in the future.

More information: Alexander Hallway et al. Patient Satisfaction and Pain Control Using an Opioid-Sparing Postoperative Pathway, Journal of the American College of Surgeons (2019). DOI: 10.1016/j.jamcollsurg.2019.04.020

Journal information: Journal of the American College of Surgeons
Provided by American College of Surgeons


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