July 29, 2019
A couple of days ago, I came across a news item that left me in a state of stunned disbelief. The most recent findings from the Centers for Disease Control (CDC) showed a downturn in U.S. life expectancy—specifically due to our inability to control heart disease and—wait for it—the increase in opioid abuse. Prior to 2015, the life expectancy index for Americans had not declined in decades, but there have been incremental and steady decreases in that metric from that time to this.
What is particularly sobering is that one of the two major drivers of this troublesome trend is the ever-increasing use and misuse of opioids among Americans of all ages. I mean, it’s one thing to reconcile ourselves to higher mortality rates being due to heart disease in an increasingly obese population; that is certainly understandable. It is very hard, however, to come to terms with the fact that Americans are living shorter lives now, in part, due to dependency upon painkillers!
We’ve all heard the phrase, “the opioid crisis,” but have we really seen it as such? Have we adjusted our lives in any way that would reflect that this is a genuine, honest-to-goodness, national emergency? In our current culture, everything is labeled a “crisis.” The term has become overused and oversold and as a result has lost some of its urgency and impact. The Cuban Missile Crisis was rightly named because the world came to the brink of near annihilation. Well, I would submit that anything that lowers an industrialized nation’s overall life expectancy index—especially in a time of modern medical advancements—should similarly be deemed a crisis.
The good news is that anesthesia practitioners are uniquely placed to play the hero in this modern American tragedy. You may be the vessels through which the nation’s health is decisively restored. Realizing, then, the severity of the situation and knowing the special role our industry might have in reversing the nation’s mortality rate, let us turn now to possible strategies that may be employed toward the saving of lives.
Understand the Background
To tackle the problem, we must first understand its origins. While the individual anesthesiologist or CRNA is typically not the culprit in this current crisis, we must acknowledge that certain external pressures within the medical industry have led to dependency in at least some patients. In the 1990s, various patient advocacy groups and medical societies called for the aggressive treatment of acute and chronic pain via opioids. The Joint Commission mandated the assessment and treatment of pain in the perioperative period. Hospitals came under increasing pressure to control postoperative pain due to the advent of quality metrics and patient satisfaction surveys. Anesthesia providers were among those tasked with ensuring patients were as pain-free as possible. Typically, this has been accomplished through the use and further prescription of opioids.
Educate the Patient
Many patients are simply uniformed as to the potential dangers of opioid dependency. The anesthesia provider would do well to spend at least some time counseling the patient on the importance of strictly adhering to the number of days/doses prescribed for the post-operative period. They should be informed of the current epidemic and the very real possibility that they could become one of the millions of Americans negatively affected by the overuse of these drugs. The entire group should be encouraged to document such counseling and to provide evidence of such to your hospital administrator.
Dependency due to postoperative pain prescriptions is not always connected to the actual patient for whom the pills were prescribed. Some studies have suggested that large numbers of narcotics users began, or were facilitated in, their addiction by finding unused portions of pain prescriptions in the discharged patient’s medicine cabinet. Part of the anesthesia provider’s counseling session with the patient should include guidance on safe means of drug disposal where a remainder of the prescription is no longer needed.
Work with Your Facility
A problem of this proportion is going to require new levels of cooperation. This is a team effort and each sector of the medical delivery system should work together to resolutely address this issue. Anesthesia groups should be encouraged to approach their facilities to work on a joint plan to lessen the likelihood of post-op dependency. A set of goals, measures, and follow-up protocols could be developed and implemented. Patient trends could then be tracked and used to tweak the joint processes and to cite successes.
This emphasis on a joint-action plan is not only humanitarian but utilitarian. A successful effort on the part of facility in combating this crisis would raise its profile in the community as a leader in this arena. Additionally, approaching the administration with such a plan would make your group a more valuable partner in the eyes of the hospital and surgery center.
Limit the Doses
Where possible, and in conjunction with hospital and Joint Commission policies, groups should seek ways to limit the amount of opioids a patient is given during the perioperative period. No one is suggesting that anesthesia providers are routinely providing more narcotics than are required. However, it is incumbent upon such providers to be even more judicious in the amounts of opioids they administer to patients.
According to one researcher, “opioids beget opioids.” Patients who are given large dosages of these agents intraoperatively tend to require greater dosages postoperatively. The patient may develop a tolerance to the drug and require higher doses to experience the same level of pain suppression postoperatively. In some patients, continued use of these narcotics may lead to a dependency that has less to do with eliminating pain and more to do with experiencing an enhanced state of well-being.
Similarly, greater care should be given to the amount of opioids given or prescribed during the postoperative period. Does the patient really need more than three days of these agents during the recuperative process in the facility? Does the patient really need 120 pills sent home with them? Obviously, this is up to the clinical judgment of each practitioner. However, the national push for good patient outcomes must take into consideration the potential hazards of drug dependency. With that in mind, is it possible that a lower dosage—either perioperatively or postoperatively—might be warranted?
It may prove beneficial for groups to schedule a conference session to discuss reasonable limits on the use of these drugs for each case type, patient weight, expected recovery period, and other parameters. Anesthesiologists may also want to provide written recommendations regarding reasonable limits to surgeons who will be providing prescriptions to discharged patients.
Consider Alternative Modalities
Studies over the last three decades have indicated that superior pain control—at least for certain types of surgeries—can be achieved through a multi-modal approach, rather than relying wholly or primarily on opioids. Such an approach, which may include opioids as a non-base component, has been shown in certain trials to reduce the use of opioids in the postoperative period by 30 percent.
There is strong support for the utilization of a combination of drugs or modalities in the fight against opioid dependency. For example, according to a June 2012 article in Anesthesiology, “in patients undergoing surgery with general anesthesia, there is evidence that perioperative systemic administration of α2 agonists decreases postoperative opioid consumption, pain intensity, and nausea.” In addition, certain antagonists, such as Ketamine, have been shown to reduce the reliance on postoperative opioids.
Finally, perioperative and postoperative usage of neuraxial and peripheral blocks/infusions have been shown to greatly reduce the risk of opioid addiction. It will be up to the anesthesia provider to determine if patient and procedure parameters allow for such regional options, as opposed to general anesthesia. Is it possible that a nerve block can provide safe and adequate pain control in the scheduled case? Would opting for a regional anesthetic in this surgical session comport with hospital and societal regulations? These are the questions each provider must ask. They’re worth asking.
Monitor Your Pain Practice
All of you are aware that pain practices are under the microscope as it concerns the current epidemic. If you have a chronic pain component to your group, you should meet with those doctors to review their protocols for pain prescriptions per patient and ensure that they are meeting all state and federal guidelines involving the control of narcotics. Quarterly follow-up with the pain practice in this regard should be part of the group’s compliance plan.
In conclusion, anesthesia groups should meet internally to discuss the above or other strategies that might help to roll back the wave of opioid dependency that is currently decimating our citizenry. Championing this cause may be your greatest legacy.