Opioid Stewardship and the Surgeon Invited Commentary Invited Commentary Patrick R. Varley, MD; Brian S. Zuckerbraun, MD The opioid epidemic in the United States is a critical public tient expectations and the proposed plan, (U) use multi- health issue. There were 33 091 deaths from opioid over- modal therapy, (C) controlled prescribing, and (E) early referral doses in 2015, which represents a nearly 400% increase to pain specialists. since 1999. The role of prescription painkillers in this epi- Surgeons must appreciate patient risk factors for devel- demic cannot be ignored. oping dependence, including male sex, age older than 50 years, More than half of these and a history of depression or other drug abuse. By educat- Related article deaths in 2015 involved pre- ing patients and discussing expectations, surgeons can pre- scription opioids, and the pare patients for what to expect with respect to postopera- total amount of oxycodone hydrochloride and hydrocodone tive pain and management plans. It is important for patients bitartrate sold to retail pharmacies has increased by nearly to understand that the goal of postoperative pain manage- 300% from 2000 to 2016. In this issue of JAMA Surgery, ment is not to be “pain free” but to make the pain manage- Chen and colleagues present a timely assessment of the able in the context of their daily activities during recovery. Mul- association between inpatient opioid use and opioid pre- timodal analgesia reduces the amount of opioid equivalents scriptions at hospital discharge in a cohort of patients under- used by patients in the postoperative period, and should be going surgery at 2 academic medical centers. They identified used liberally. Control of prescribing patterns can be accom- wide variations in prescribing patterns, and found that, plished by creating procedure-specific guidelines for the strikingly, although one-third of patients did not receive opi- amount and duration of opioid prescriptions that take into ac- oids in the 24 hours prior to hospital discharge, 42.9% of count factors such as inpatient opioid use. Finally, for pa- these patients were prescribed opioids at hospital discharge. tients with a persistent opioid requirement, early referral to The sequelae of opioid overprescription to surgical pa- pain specialists qualified to offer adjunctive interventions as tients cannot be understated. Of patients undergoing minor well as supervise a period of weaning off opioids can be ben- or major surgical procedures, nearly 6% can be expected to de- eficial to both surgeons and patients. velop a new, persistent opioid dependence, as compared with In summary, surgical procedures represent a potential gate- less than 0.5% of a comparable nonoperative control group. way to opioid dependence, and surgeons must recognize their Opioid stewardship has been neglected and it is imperative that role as stewards of safe opioid use. Ongoing education of prac- surgeons take ownership of their role in this epidemic. We sug- ticing surgeons and residents in all surgical specialties is nec- gest a proactive reform in the way surgeons approach pain man- essary. Preoperative patient education and management of agement. We propose the acronym REDUCE as a framework expectations, coupled with minimized opioid prescribing and for opioid prescribing in surgical patients. The components in- maximized use of multimodal therapies, can affect this pub- clude: (R) recognize risk, (E) educate patients, (D) discuss pa- lic health epidemic. ARTICLE INFORMATION 2. Drug Enforcement Administration, US 5. Sun EC, Darnall BD, Baker LC, Mackey S. Department of Justice. Automation of Reports and Incidence of and risk factors for chronic opioid use Author Affiliations: Department of Surgery, Consolidated Orders System (ARCOS). among opioid-naive patients in the postoperative University of Pittsburgh, Pittsburgh, Pennsylvania. https://www.deadiversion.usdoj.gov/arcos/index period. JAMA Intern Med. 2016;176(9):1286-1293. Corresponding Author: Brian S. Zuckerbraun, MD, .html. Accessed September 19, 2016. 6. Elia N, Lysakowski C, Tramèr MR. Does Department of Surgery, University of Pittsburgh, 3. Chen EY, Marcantonio A, Tornetta P III. multimodal analgesia with acetaminophen, 200 Lothrop St, F1200 Presbyterian University Correlation between 24-hour predischarge opioid nonsteroidal antiinflammatory drugs, or selective Hospital, Pittsburgh, PA 15213 (zuckerbraunbs use and amount of opioids prescribed at hospital cyclooxygenase-2 inhibitors and patient-controlled @upmc.edu). discharge [published online December 13, 2017]. analgesia morphine offer advantages over Published Online: December 13, 2017. JAMA Surg. doi:10.1001/jamasurg.2017.4859 morphine alone? meta-analyses of randomized doi:10.1001/jamasurg.2017.4875 trials. Anesthesiology. 2005;103(6):1296-1304. 4. Brummett CM, Waljee JF, Goesling J, et al. New Conflict of Interest Disclosures: None reported. persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152(6): REFERENCES e170504. 1. Centers for Disease Control and Prevention. Wide-Ranging Online Data for Epidemiologic Research. Atlanta, GA: Centers for Disease Control and Prevention; 2016. jamasurgery.com (Reprinted) JAMA Surgery February 2018 Volume 153, Number 2 1/1 © 2017 American Medical Association. All rights reserved.
JAMA Surgery – American Medical Association
Published: Feb 13, 2018
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