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Adding Insult to Injury—Are We Fueling the Opioid Crisis During the Perioperative Period?

2021; Elsevier BV; Volume: 35; Issue: 6 Linguagem: Inglês

10.1053/j.jvca.2021.02.059

1532-8422

Sibtain Anwar, Brian Herath, Ben O’Brien,

Anesthesia and Pain Management

CHURCHILL WOULD HAVE APPROVED: “Never let a good crisis go to waste.” Although others have since rephrased his sentiment—including President Obama's chief of staff, Rahm Emanuel, when referring to the financial crisis of 2008—it was the British Prime Minister Winston Churchill who first posed this idea in the 1940s. He was forging alliances in the middle of a world war with, among others, Joseph Stalin, in the great hope of developing a United Nations to prevent another one. We currently find ourselves in at least one crisis. Before the world came to a standstill to deal with the coronavirus disease 2019 (COVID-19) pandemic, the medical world had been coming to terms with the opioid epidemic sweeping across advanced healthcare systems. Could this now become the next pandemic? In this issue of the Journal, Pena et al. presented data principally from the long-standing public health emergency of opioid deaths in the United States.1Pena JJ Chen CJ Clifford H et al.Introduction of an analgesia prescription guideline can reduce unused opioids after cardiac surgery: A before and after cohort study.J Cardiothorac Vasc Anesth. 2021; 35: 1704-1711Abstract Full Text Full Text PDF Scopus (1) Google Scholar This partially was fueled by the tripling of opioid prescriptions since 1999,2Guy Jr, GP Zhang K Bohm MK et al.Vital signs: Changes in opioid prescribing in the United States, 2006-2015.MMWR Morb Mortal Wkly Rep. 2017; 66: 697-704Crossref PubMed Scopus (598) Google Scholar with more than 40% of all overdose deaths involving a prescription opioid,3Seth P Scholl L Rudd RA et al.Overdose deaths involving opioids, cocaine, and psychostimulants—United States, 2015-2016.MMWR Morb Mortal Wkly Rep. 2018; 67: 349-358Crossref PubMed Scopus (457) Google Scholar but the specific role of medication initiated during hospital care remains unclear. It is possible that the perioperative introduction of opioids and continuation in the community could contribute to this crisis and these authors proposed a simple but elegant intervention. The study reported the prospective development and evaluation of a tailored approach to estimate the amount of opioid required at discharge after cardiac surgery; in turn, to successfully reduce the numbers of unused medications in patients’ homes. A commonly held perception of the opioid crisis is that it stems from the community, but the data reveal secondary care as the most likely initiation of treatment. In one study, surgery was found to be the most common reason for commencing opioids in chronic users when surveyed at three months and beyond.4Callinan CE Neuman MD Lacy KE et al.The initiation of chronic opioids: A survey of chronic pain patients.J Pain. 2017; 18: 360-365Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar Likewise, the greatest doses and durations of opioid therapy result from postsurgical and musculoskeletal pain, respectively.5Pasricha SV Tadrous M Khuu W et al.Clinical indications associated with opioid initiation for pain management in Ontario, Canada: A population-based cohort study.Pain. 2018; 159: 1562-1568Crossref PubMed Scopus (30) Google Scholar The use of intraoperative opioids is highest during cardiac surgery.6Kwanten LE O'Brien B Anwar S Opioid-based anesthesia and analgesia for adult cardiac surgery: History and narrative review of the literature.J Cardiothorac Vasc Anesth. 2018; 33: 808-816Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Is this just innocuous use, to facilitate hemodynamic stability during high-risk surgery, or is there potential for long-term harm? Does this risk begin to erode, or even outweigh, some of the benefits? There is some evidence to suggest that orthopedic patients receive the highest doses of opioids,7Volkow ND McLellan TA Cotto JH et al.Characteristics of opioid prescriptions in 2009.JAMA. 2011; 305: 1299-1301Crossref PubMed Scopus (492) Google Scholar but most series concluded that cardiac surgery is at least among the most culpable surgical specialties.8Brescia AA Waljee JF Hu HM et al.Impact of prescribing on new persistent opioid use after cardiothoracic surgery.Ann Thorac Surg. 2019; 108: 1107-1113Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar With as many as one-in-ten cardiac patients still using opioids at 90 days,9Brown CR Chen Z Khurshan F et al.Development of persistent opioid use after cardiac surgery.JAMA Cardiol. 2020; 5: 889-896Crossref PubMed Scopus (20) Google Scholar this certainly outstrips the prevalence of 3% in all-comers to surgery.10Clarke H Soneji N Ko DT et al.Rates and risk factors for prolonged opioid use after major surgery: Population based cohort study.BMJ. 2014; 348: g1251Crossref PubMed Scopus (501) Google Scholar Perspective and scale are important:1Not all opioid deaths are directly prescription-related, although some illicit procurement may result from abrupt halting and rapid weaning programs. It could be said that well-intended proposals, such as limiting individual use to a dose of 90 morphine milligram equivalents per day, may best serve future patients more than those with current requirements above that threshold.2Not all prescription opioids are related to secondary care, although surgery seems to play its part.3Not all intra- and postoperative use is excessive, but perhaps it should influence decisions about discharge dosing. Given the number of patients undergoing surgery worldwide, even moderate reductions in the final steps could have a greater impact on postoperative mortality—maximal returns—than many of the other interventions we deliver in the name of “marginal gains.”11Fleming IO Garratt C Guha R et al.Aggregation of marginal gains in cardiac surgery: Feasibility of a perioperative care bundle for enhanced recovery in cardiac surgical patients.J Cardiothorac Vasc Anesth. 2016; 30: 665-670Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar Although tempting at face value, unilateral reductions in postoperative opioid use may not be in the best interest of all surgical patients. Pain relief after cardiac surgery is far from ideal and opioids play an important role in the armamentarium available to the cardiac anesthesiologist and surgeon during recovery. Although dependency and diversion are a public health dilemma—with the clinical challenge of opioid-induced hyperalgesia also of increasing concern to physicians12Colvin LA Bull F Hales TG. Perioperative opioid analgesia—When is enough too much? A review of opioid-induced tolerance and hyperalgesia.Lancet. 2019; 393: 1558-1568Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar—it is important not to throw the proverbial “baby out with the bathwater.” This risks leaving patients in acute pain, encouraging persistent postsurgical pain (PPP),13Glare P Aubrey KR Myles PS. Transition from acute to chronic pain after surgery.Lancet. 2019; 393: 1537-1546Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar and, therefore, increasing healthcare use, both in terms of short-term recovery profile (eg, length of stay) as well as long-term quality of life.14Anwar S Cooper J Rahman J et al.Prolonged perioperative use of pregabalin and ketamine to prevent persistent pain after cardiac surgery.Anesthesiology. 2019; 131: 119-131Crossref PubMed Scopus (20) Google Scholar A fine balance ought to be struck between over-prescription (dependence and diversion) and over-zealous reductions leading to undertreatment (acute and PPP.) An alternative approach is the judicious and continued use of opioids in the postoperative period alongside adjunct analgesics—to opioid-spare, or even strive to deliver opioid-free, cardiac surgery. This could, in turn, be combined with tailored strategies to calculate the expected needs during recovery and discharge patients with the right amount to allow successful tapering and avoid dependency or diversion. An overlooked contributor is the milieu of psychosocial risk factors, particularly anxiety and catastrophizing, and their strong association with acute pain, PPP, and, perhaps, also persistent postoperative opioid use.14Anwar S Cooper J Rahman J et al.Prolonged perioperative use of pregabalin and ketamine to prevent persistent pain after cardiac surgery.Anesthesiology. 2019; 131: 119-131Crossref PubMed Scopus (20) Google Scholar,15Weinrib AZ Azam MA Birnie KA et al.The psychology of chronic post-surgical pain: New frontiers in risk factor identification, prevention and management.Br J Pain. 2017; 11: 169-177Crossref PubMed Scopus (46) Google Scholar It follows that targeting these factors before surgery, as well as during recovery, could improve outcomes, including opioid use. Clarke et al. in Toronto arguably have led the way in this approach for more than 15 years by pioneering a potential solution: a transitional pain service.10Clarke H Soneji N Ko DT et al.Rates and risk factors for prolonged opioid use after major surgery: Population based cohort study.BMJ. 2014; 348: g1251Crossref PubMed Scopus (501) Google Scholar This multidisciplinary team pre-assesses surgical patients for pre-existing pain, opioid use, and psychological risk factors. Early interventions are multimodal but include optimization of analgesia before surgical insult and in the crucial period following hospital discharge and before PPP is established (at three postoperative months and beyond.) Increasingly, the use of technology to facilitate remote consultation and monitoring has made this service more cost-effective and sustainable. Others have advocated for the use of behavioral economics principles to nudge practitioners toward appropriate prescription practices and patients toward accepting titrated total dose of opioids on discharge, as well as subsequent weaning plans. These can be summarized best by taking a “top-down” approach from the wider healthcare system down to individual patient actions:•National Quality Improvement (QI) projects and networks to disseminate best practice; for example, sending letters to curb overprescribing among the most prolific.•Medical student education of appropriate prescribing habits. One study revealed that primary care physicians educated at the lowest-ranked medical schools prescribed nearly three times as many opioids per year compared with peers attending the top-ranked institutions.•Prescription drug monitoring programs, including databases of prescriptions filled by patients to identify multiple prescribers as well as risks from drug interactions.•Electronic prescribing systems to reduce the initial dose dispensed at hospital discharge and allow physicians to supplement remotely in the community depending on recovery trajectory.•Practice guidelines to set procedure-specific duration, as well as dose. These also cover refill expectations and triggers for referral to specialist weaning services.•Patient education, as well as provision of facilities for disposal of leftover opioids on completion of recovery from surgery, at home.•Shared decision-making with patients before surgery regarding pain expectations and acceptable postoperative durations of treatment to minimize risk.•Opioid-sparing with adjuncts (eg, gabapentinoids) and regional anesthesia (placement of epidural or nerve catheters and infusions), although with limited proven benefit in preventing the long-term use of opioids. Despite an established evidence base for these interventions, persistent opioid use, until recently, was not considered an important outcome to measure until.•Algorithms to analyze opioid consumption in the hospital before discharge and calculate the likely requirement at home. The latter approach lacks compelling data, especially after cardiac surgery, which led Pena et al. to develop a simple algorithm to predict opioid requirement after discharge using consumption during the hospital stay and prospectively test it in this “before-and-after study.” They demonstrated a reduction in prescription as well as leftover medication in the homes of cardiac surgical patients after recovery. Practice changes are notoriously difficult to assess in an objective and, therefore, randomized manner. Although the methodology is limited to observational study, it is prospective and any more rigorous methodology would likely require a multicenter, cluster, randomized trial design, for example, with stepped wedge introduction of the intervention. This may, therefore, be the highest level of evidence we easily can assemble for such an intervention. Many of these approaches are based on hypothesis-generating studies of retrospective data sets or simply hypotheses born of the time imperative to try to stem the emergent tide of opioid deaths—evaluation will follow. Dissemination and uptake of these ideas have, therefore, been variable. The authors had organized the first stakeholder meeting in the United Kingdom for this exact purpose, at the Royal Society of Medicine, to explore some of these challenges with patients, clinicians, and policy makers. However, this forum recently was postponed due to the other crisis of our times and, hopefully, will be rescheduled. The question remains: how could the current crisis be wasted? Countries across the world have been criticized during the last year for poor pandemic preparedness, but, likewise, our opioid awareness may well be judged poorly if we simply reinstate large-scale surgical programs along legacy lines. Elective surgery, particularly for painful conditions (eg, hip and knee replacement for osteoarthritis), essentially has been stopped in countries most affected by the pandemic. This, in itself, may increase opioid requirements, leading to worse postoperative outcomes. The temptation is to simply restart surgical practice urgently and return to established methods rather than to “build back better.” However, in this scenario, clinicians and patients alike risk facing the wrath of another Churchillian statement: “Those who fail to learn from history are condemned to repeat it.” SA is President of the Pain Medicine Council at the Royal Society of Medicine and represents the Faculty of Pain Medicine of the Royal College of Anaesthetists on its ‘Opioids Aware’ Working Group. Introduction of an Analgesia Prescription Guideline Can Reduce Unused Opioids After Cardiac Surgery: A Before and After Cohort StudyJournal of Cardiothoracic and Vascular AnesthesiaVol. 35Issue 6PreviewThe authors aimed to assess whether the introduction of a tailored Analgesia Prescription Guideline would decrease the amount of unused opioid following discharge from cardiac surgery. Full-Text PDF