How the sur­gi­cal set­ting con­tributes to the opi­oid cri­sis

The num­ber of Amer­i­cans who be­come ad­dict­ed to opi­oids fol­low­ing surgery is an un­der-re­port­ed im­pli­ca­tion of a cri­sis sweep­ing the na­tion. How did we get to a point where up to 440,000 peo­ple be­come ad­dicts this way — every year?

Amer­i­cans have the high­est rate of opi­oid con­sump­tion in the world. The per­son­al and pub­lic health costs of the opi­oid cri­sis are at the fore­front of the news cy­cle while the short- and long-term ef­fects in­crease every day. Un­der­stand­ing how the sur­gi­cal set­ting is a main con­trib­u­tor to the epi­dem­ic and tak­ing a snap­shot of its costs can spring­board ways to im­prove health­care by tak­ing a pre­ven­ta­tive ap­proach.

The re­liance on opi­oids in the sur­gi­cal set­ting

Opi­oids have been used in surgery since the sec­ond half of the 20th cen­tu­ry, as doc­tors ad­min­is­tered them in­tra­venous­ly along­side anes­thet­ic gas­es in an at­tempt to bal­ance anes­thet­ic tech­niques and min­i­mize the sig­nif­i­cant dan­gers and side ef­fects caused by use of the gas­es alone. While this progress fos­tered sur­gi­cal dis­cov­ery and ad­vance­ment, lit­tle room was made for con­cern about the ad­dic­tive na­ture of these med­i­cines. Re­lat­ed re­search was scant; in 1980, a short let­ter-to-the-ed­i­tor in the New Eng­land Jour­nal of Med­i­cine was heav­i­ly — and un­crit­i­cal­ly — cit­ed as ev­i­dence that ad­dic­tion was rare with long-term opi­oid ther­a­py. At the same time, the avail­abil­i­ty and af­ford­abil­i­ty of new syn­thet­ic opi­oids, like oxy­codone and hy­drocodone, in­creased as pain was viewed as a neg­a­tive out­come.

Mil­lions of surg­eries per­formed, mil­lions of opi­oids pre­scribed

In the Unit­ed States each year, 50 mil­lion surg­eries are per­formed and the con­tin­u­ing over-re­liance on post­op­er­a­tive opi­oids fu­els the cri­sis by both ex­pos­ing opi­oid naïve pa­tients to the nar­cotics and by leav­ing hun­dreds of mil­lions of left­over pills hid­ing in our com­mu­ni­ty med­i­cine cab­i­nets. Many peo­ple are first ex­posed to opi­oids at the time of surgery, fur­ther high­light­ing the role post-sur­gi­cal care can play in the opi­oid epi­dem­ic. Cur­rent stud­ies rou­tine­ly point to post­op­er­a­tive sur­gi­cal opi­oid use as a gate­way to overuse and ad­dic­tion. As many as 6.5% of pa­tients that take opi­oids to man­age pain af­ter surgery may be­come per­sis­tent opi­oid users, rep­re­sent­ing 2.6 mil­lion peo­ple – and hun­dreds of thou­sands of those will be­come ad­dict­ed.

In­creased costs to so­ci­ety & the health­care sys­tem

Opi­oid-re­lat­ed ad­verse drug events (ORADEs) that re­sult from opi­oids giv­en af­ter surgery add sig­nif­i­cant bur­den to a health­care sys­tem al­ready be­set by un­due fi­nan­cial pres­sure from all sides — and it’s use­ful to get an ap­prox­i­mate ac­count­ing of just how much and where the costs are in­curred.

A re­cent study in­di­cat­ed that 10.6% of pa­tients un­der­go­ing hos­pi­tal-based sur­gi­cal and en­do­scop­ic pro­ce­dures ex­pe­ri­ences at least one ORADE. Fur­ther, ORADEs were as­so­ci­at­ed with an $8225 in­crease in cost and 1.6-day in­crease in length of stay for the in­dex hos­pi­tal­iza­tion. This high­lights an im­por­tant op­por­tu­ni­ty for hos­pi­tals to im­prove both pa­tient safe­ty and cost through in­ter­ven­tions to re­duce opi­oids in the sur­gi­cal set­ting.

Be­yond the hos­pi­tal, chron­ic opi­oid users al­so con­sume more over­all health­care re­sources — to the tune of $18,074 ex­tra com­pared to nonusers.  This ac­counts for in­creased health­care spend­ing up­wards of $47 bil­lion an­nu­al­ly. Wor­ry­ing­ly, these num­bers may rep­re­sent an un­der­es­ti­ma­tion as sur­gi­cal pro­ce­dures may con­tin­ue to fun­nel pa­tients in­to ad­dic­tion faster than peo­ple tran­si­tion away from ad­dic­tion. And the fact re­mains that 46 peo­ple die every day from over­dos­es in­volv­ing pre­scrip­tion opi­oids.

Pre­vent­ing post-sur­gi­cal opi­oid use re­quires a mul­ti­fac­eted ap­proach

To ad­dress the scourge of ad­dic­tion that can fol­low from this un­der-re­port­ed path­way, a mul­ti-pronged strat­e­gy emerges.

A big step is ed­u­cat­ing health­care providers on the role of post-sur­gi­cal opi­oids in per­pet­u­at­ing the epi­dem­ic and il­lus­trat­ing meth­ods that uti­lize non-opi­oid treat­ment op­tions as the foun­da­tion of post­op­er­a­tive acute pain man­age­ment are key as they can pre­vent un­nec­es­sary ex­po­sure to opi­oids. There’s al­so the mat­ter of pa­tients ex­pect­ing ze­ro pain af­ter surgery. In­deed, many pa­tients ex­pect to have “pain-free” surgery. Pain is a nor­mal part of heal­ing and pa­tients should be giv­en re­al­is­tic ex­pec­ta­tions in or­der to pre­pare for the qual­i­ty, quan­ti­ty, lo­ca­tion, and du­ra­tion of pain that they will ex­pe­ri­ence. Teach­ing sur­geons and health­care providers new ways to re­boot the ex­pec­ta­tions of pa­tients with re­spect to post-sur­gi­cal pain is nec­es­sary — while al­so em­pha­siz­ing non-opi­oid treat­ment foun­da­tion to acute post­op­er­a­tive pain man­age­ment as a ma­jor step­ping stone in pre­ven­tion.

By putting an em­pha­sis on re­ly­ing on non-opi­oid treat­ment for acute post­op­er­a­tive pain man­age­ment and health­care provider ed­u­ca­tion strat­e­gy, we may be­gin to see sig­nif­i­cant re­duc­tions in health­care costs on top of po­ten­tial­ly curb­ing the opi­oid ad­dic­tions al­ready crip­pling so­ci­ety. Ad­di­tion­al­ly, non-opi­oid post­op­er­a­tive pain man­age­ment can re­sult in bet­ter pa­tient care and out­comes, pro­vid­ing ad­e­quate treat­ment with­out ex­pos­ing pa­tients to the risks as­so­ci­at­ed with opi­oids.

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