The opioid crisis: 'What have we learned and where do we go from here'?

October 23, 2017 - Anesthesiology and pain medicine should play a leading role in developing effective alternatives and solutions to the US opioid crisis, according to the November issue of Anesthesia & Analgesia--a special thematic issue presenting information on the "background, problems, and possible solutions to the opioid epidemic."

The special issue presents research reviews and expert commentaries on the opioid crisis--focusing on the role of anesthesia and pain medicine physicians who care for patients undergoing surgery and those in need of specialized pain clinic care. Guest Editors Honorio T. Benzon, MD, of Northwestern University Feinberg School of Medicine, Chicago, and T. Anthony Anderson, MD, PhD, of Stanford University School of Medicine write: "We wanted to show to the medical community that we, anesthesiologists, can play an active role in identifying and solving the issues."

Addressing the Opioid Epidemic - Special Issue Presents Essential Evidence

The opioid epidemic has reached crisis proportions. Even though opioid prescriptions have declined in the last few years, the number of opioid-related deaths has remained constant. Drs. Benzon and Anderson cite a report that in 2015 there were nearly 90 opioid overdose deaths each day in the United States--primarily from unprescribed opioids.

Anesthesiologists and pain medicine physicians prescribe the most opioids, followed by surgeons and physical medicine and rehabilitation physicians. Spinal pain and chronic pain are two of the most common diagnoses leading to initial opioid prescription. "These are the patients we see in the pain clinic," Drs. Benzon and Anderson note. "We are the leaders in opioid prescription...and should take the lead in solving the problem."

The special issue includes a series of targeted reviews, assembling current evidence in areas essential to developing solutions to the opioid crisis. The review topics include:

Alternatives to opioids for chronic pain. Many non-opioid drugs have been found effective in patients with various chronic pain conditions, but more studies are needed to identify effective treatments that address the mechanisms of chronic pain.

Integrative medicine in pain management. Studies have shown preliminary positive evidence for complementary and alternative medicine techniques such as yoga, massage, tai chi, relaxation techniques, and spinal manipulation. There is strong positive evidence that acupuncture can reduce opioid use.

Chronic opioid use after surgery. The risk factors associated with continued opioid use after surgery are discussed. Strategies taken before, during, and after surgery to help prevent patients from becoming persistent opioid users are proposed.

Opioid-sparing strategies. Some techniques have been shown to help reduce the dosage of opioids used after surgery and after interventional procedures for chronic pain. The use of adjunct medications including gabapentinoids, lidocaine, ketamine, and dexmedetomidine has been shown to reduce postoperative pain.

Emerging opioid and non-opioid medications. Basic science and translational research is being done to develop effective new medications with a lower risk of abuse, including nonopioid drugs targeting different kinds of pain receptors.

The Guest Editors outline the steps anesthesia and pain medicine clinicians can take to help reduce the opioid epidemic. For surgical patients, steps can include preoperative assessment to identify patients at risk and enhanced recovery protocols to reduce the risk of persistent opioid use after surgery. "As perioperative physicians, we can influence the culture of opioid overprescription."

Drs. Benzon and Anderson believe the special issue will provide a valuable evidence base for developing effective strategies for responding to the opioid crisis. "As the primary drivers in the pain clinic and gatekeepers in the perioperative setting, anesthesiologists should take the lead in identifying solutions to this problem." They add, "Measures necessary to combat nonessential opioid consumption...should be balanced with the legitimate needs of patients in pain."

Wolters Kluwer Health