Why should I care?

Misuse of opioids is a growing global problem, well established in the US and quickly appearing in many high-resource countries. One person dies every 15 minutes in the US from opioid overdose.

For many affected, the perioperative period is the first exposure event. In the US ~6% of previously opioid-naive patients progress to persistent opioid use after surgery.

What can anaesthetists and anesthesiologists do?

1. Identify patients at risk of opioid dependence.
2. Use multi-modal non-opioid analgesia perioperatively.
3. Educate patients on realistic expectations for post-operative pain.
4. Consider regional techniques intraoperatively when appropriate.
5. Limit discharge prescribing of opioids (42-71% of all postop opioid tablets go unused!).

The bigger picture...

Although inidividual practice changes are important, real impact will come through anesthesiologists as integrators of care (eg. ERAS interventions) and contributions to institutional strategies, patient and provider education.

Take a long view, this problem is not going away in a hurry...

summary

• Ellen M Soffin, Bradley H Lee, Kanupriya K Kumar, and Christopher L Wu.
• Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.
• Br J Anaesth. 2019 Jun 1; 122 (6): e198e208e198-e208.

AbstractReports of strategies to prevent and treat the opioid epidemic are growing. Significant attention has been paid to the benefits of opioid addiction research, clinical prescribing, and public policy initiatives in curbing the epidemic. However, the role of the anaesthesiologist in minimising opioid use and misuse remains underexplored. For many patients with an opioid use disorder, the perioperative period represents the source of initial exposure. As perioperative physicians, anaesthesiologists are in the unique position to manage pain effectively while simultaneously decreasing opioid consumption. Multiple opportunities exist for anaesthesiologists to minimise opioid exposure and prevent subsequent persistent opioid use. We present a global strategy for decreasing perioperative opioid use and misuse among surgical patients. A historical perspective of the opioid epidemic is presented, together with an analysis of opioid supply and demand forces. We then present specific temporal strategies for opioid use reduction in the perioperative period. We emphasise the importance of preoperative identification of patients at risk for long-term opioid use and misuse, review the evidence supporting the opioid sparing capacity of individual multimodal analgesic agents, and discuss the benefits of regional anaesthesia for minimising opioid consumption. We describe postoperative and post-discharge tools, including effective multimodal analgesia and the role of a transitional pain service. Finally, we offer general institutional strategies that can be led by anaesthesiologists, identify gaps in knowledge, and offer directions for future research.Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

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