Opioids have become the watchword for dangerous drugs and life-threatening overdoses. But these drugs have been used for many centuries for pain relief, and their utility to alleviate suffering is not in question.
It is the means of administration and the misapplication of these drugs that have become problematic. There have been three great waves of opioids flooding the illicit drug market, the first related to over-prescription of oral agents by doctors, followed by heroin and, most recently, by illicit fentanyl.
Acute Care And Opioids
For acute care physicians, and especially for anesthesiologists, opioids remain a bedrock of our practice, despite their recent reputation. These drugs are invaluable for intraoperative pain control (and control of the body’s response to pain), as well as for pain relief in the early recovery period, extending into the first few days of the postoperative course.
Virtually all anesthetics provided for surgeries with incisions will include opioids. Some have suggested opioid-free anesthetics in anesthesia, but reducing opioids, without eliminating them, seems far more practical. In particular, substituting nerve blocks or surgeon-injected local anesthetics, to reduce opioid use has gained great popularity. Among opioids used in the operating room, fentanyl is by far the most common, given its rapid effect and short duration; others include morphine, hydromorphone and methadone.
The Rise of Opioids In the US
The emergence of opioid over-prescription coincided with the recognition of the pain epidemic in the United States, a phenomenon that affects an estimated 40 million adults, including a subset with unremitting chronic pain, afflicting over 10 million people.
In 2000, governing health care bodies began to urge practitioners to address pain, which had been poorly controlled prior to these declarations. In fact, pain was declared a “fifth vital sign” by accrediting bodies, which required more aggressive monitoring and therapy.
In response, physicians began to treat pain much more aggressively, both in the office and in the hospital. In effect, pain control became a required component of recovery from surgery for those of us in anesthesia. In outpatient medicine, opioid prescriptions became much more common, as physicians struggled to achieve benchmarks for analgesia.
Over the next ten years, opioid use climbed dramatically among patients with painful conditions, whether acute or chronic. Patients began to expect opioid management of most painful conditions, putting further pressure on physicians to accommodate these desires.
Statistics related to the development of opioid use disorder among postoperative patients were staggering—by one estimate, 6 to 7% of opioid-naïve patients who received prescriptions for these drugs after surgery would develop dependence.
Dependence in the US
The result was both dramatic and tragic, a true upheaval in public health in our country. Almost a half-million Americans have died of opioid-related causes in the past two decades.
The financial burden of this epidemic has been oppressive: the cost in 2018 alone was nearly $1 trillion dollars. This resulted in a major change in direction in terms of recommendations for pain control promulgated by public health departments, policy institutes and hospital administration.
No longer were opioids to be used as the only means to control pain-new recommendations stressed the use of multimodal techniques, non-opioid medications, and nerve blocks whenever possible.
Responding to the Opioid Crisis
The response to the opioid crisis by physicians has been impressive. Opioid prescribing has decreased by over 40% since 2012. In my own practice, this has been very clear—while nearly 10% of patients with shoulder pain came for surgery while on an opioid prescription just a few years ago, I see very few patients on such outpatient therapy currently.
Frustratingly, however, this does not seem to have affected overdose deaths. Last year, nearly 100,000 people perished in the U.S. from an overdose, the vast majority due to opioids, and nearly 80% of these from illicit fentanyl.
In fact, deaths from synthetic opioids increased 10 fold from 2013 to 2019, and have continued to accelerate during the pandemic years.
The opioid crisis has impacted many aspects of our culture, and it has far-reaching consequences. While health systems played an important role in the creation of this epidemic, physicians and other providers have made important strides to reduce the flow of these drugs into society. But the staggering increase in the use of synthetic opioids poses a new and perhaps more dangerous problem, with which our public health leaders continue to grapple.
For those with an interest in the opioid crisis, and particularly how it may affect health care workers, please read my novel “The Stairs on Billy Buck Hill,” a sordid tale of opioid use, abuse, diversion and destruction.