“To see what is in front of one’s nose is a constant struggle”. – George Orwell
The United States is grappling with an epidemic of prescription opioid medications, and the statistics are frightening. Opioid prescribing remains higher in the United States compared with anywhere else in the world, and 80% of the world’s opioids are prescribed and consumed in this country. Today, 1 out of every 25 adults regularly uses prescription opioids, and 78 individuals die each day from prescription opioid-related complications. Prescription opioid misuse and abuse is frequently a precursor to other forms of substance addiction and abuse, and approximately 75% of heroin users are introduced to opioids through prescription medications.
Although much of the attention regarding prescription opioid medications focuses on prescribing for chronic pain and in primary care settings, our contribution as surgeons to this epidemic cannot be ignored. Roughly 40% of opioids are prescribed by us for acute pain management following procedures, and the majority of prescribed pills remain unconsumed and at risk of diversion for non-medical use. Additionally, up to 10% of patients who were previously opioid-naïve remain dependent on opioids for months or longer following surgery. Given the reduction in morbidity and mortality of routine outpatient elective surgery performed today in the United States, opioid dependence could now be considered as one of the most common postoperative complications we create.
Unfortunately, guidelines to direct appropriate opioid prescribing following common surgical procedures are sparse. Pain is ubiquitous after surgery. However, the factors that mediate pain and the perception of pain are complex and elusive. We have long been taught that pain is the 5th vital sign and must be eliminated to achieve high quality care. Moreover, opioid medications have been advertised as non-addictive in the setting of acute postoperative pain. As such, we are left to prescribe opioids based on our “best guess,” which may be influenced by a mixture of past experiences, convenience, patient factors, and intuition. I fear I often over-prescribe in an attempt to prevent my patients from having to call during off-hours or return to the emergency department while in pain to obtain a prescription that cannot be called in over the phone. I also fear that I may under-prescribe and that my patients may be upset that I am unaware or insensitive to their discomfort following my surgery.
As surgeons, we have the power to make an impact. We can counsel and reassure our patients prior to surgery regarding the expectation of discomfort. We can encourage patients to use non-opioid analgesics when appropriate. We can also direct patients toward simple techniques that can reduce pain, minimize anxiety, improve mood, and enhance resilience, such as mindfulness-based stress reduction, massage, creating a comfortable recovery environment, and visualization techniques. These tools have been shown to be effective in acute pain settings such as childbirth, as well as for chronic pain conditions such as arthritis and back pain. We can also provide information regarding the appropriate disposal of excess opioids with our patients at the time we provide a prescription, and remind patients to dispose of unused opioids during their postoperative follow-up.
The opioid epidemic is right in front of us. As surgeons, we have an opportunity to engage in solutions that provide effective pain relief for our patients while protecting our communities from an influx of excess prescription opioid pills that lead to unintended consequences.