Commentary: Neurosurgery and the Ongoing American Opioid Crisis

Commentary: Neurosurgery and the Ongoing American Opioid Crisis ABBREVIATIONS ABBREVIATIONS AANS American Association for Neurological Surgeons ACA Affordable Care Act ACGME Accreditation Council for Graduate Medical Education APS–AAPM American Pain Society–American Academy of Pain Medicine ASIPP American Society of Interventional Pain Physicians CDC Centers for Disease Control and Prevention DEA Drug Enforcement Agency EPCS Electronic Prescribing of Controlled Substances FDA Food and Drug Administration FSMB Federation of State Medical Boards PDMP prescription drug-monitoring program NSAID nonsteroidal anti-inflammatory drug VA/DoD Department of Veterans Affairs/Department of Defense THE OPIOID EPIDEMIC Opioid analgesia can be highly effective for a wide range of pain syndromes. However, there are unintended consequences of such potent analgesia, including potential for recreational use, physiological and psychological dependence, and lethal overdose. Worldwide, an opioid epidemic rages; the United Nations estimates between 26 and 36 million people illicitly use opiates annually.1 Globally, approximately 69 000 people die from opioid overdose each year, more than from suicide and major trauma combined.2 In the United States, these statistics are even more disturbing. Although comprising less than 5% of the world's population, Americans consume 80% of the global opioid supply.3 According to a comprehensive assessment of opioid use in the United States, published by the pharmaceutical management company Express Scripts (St Louis, Missouri), 36 million opioid prescriptions were filled by 6.8 million Americans between 2009 and 2013.4 During this time span, there was a 9.2% decline in the number of patients filling opioid prescriptions, but the total number of prescriptions overall increased by 8.4%. Furthermore, almost half (46.9%) of these patients were identified as chronic opioid users, using these medications for more than 3 yr. Deaths from prescription opioid overdose have risen sharply over the last several decades.5 The US Centers for Disease Control and Prevention (CDC) reported 16 651 deaths due to prescription opioid overdose in 2010.6 Between 2013 and 2014, the death rate associated with natural and semisynthetic opioids, heroin, and synthetic opioids (fentanyl) increased 9%, 26%, and 80%, respectively.7 Prior prescription opioid dependence has been identified as a major risk factor for future heroin abuse,8 and increasing opioid prescriptions may partially account for a resurgence of heroin use in the United States, which nearly doubled between 2005 and 2012.9 The US CDC declared the prescription drug crisis an epidemic in 2012.10 As a result of enhanced public health interventions since that time, the overall number of opioid prescriptions has fallen by an estimated 12% to 18%.11 Despite this progress, the overall death rate from opioids has paradoxically risen during this time period: in 2015, opioids (including heroin) led to 33 091 deaths.7 According to the CDC, almost half (45%) of all opioid prescriptions written in the United States are written by primary care physicians.12 Surgeons, both generalists and subspecialists, account for 10% of opioid prescriptions. However, the rate of prescribing opioids, compared to nonopioid alternatives, was higher in surgeons compared to primary care practitioners, 37% vs 6%, respectively. In one study, orthopedic surgeons were found to more commonly prescribe opioid analgesics to patients with chronic, noncancer pain, compared to physicians from other medical specialties.13 According to a 2016 Washington Post/Kaiser Family Foundation survey of chronic opioid users, more US adults attribute the opioid epidemic to physicians who prescribe painkillers, as opposed to patients taking prescribed drugs or to the prescription drug companies.14 OPIOIDS AND NEUROSURGERY Surgical subspecialists, including neurosurgeons, are particularly vulnerable to overprescribing opioid analgesics, given the relative high exposure to pain-related conditions. According to a 2014 study of Medicaid patients who were prescribed opioids for chronic pain, the most common associated diagnoses were back pain (55%), neck pain (25%), and headache (8%).13 Analysis of US national survey data between 1997 and 2006 highlights a 600% increase in spending on opioids for spine problems, a result of both higher prices and increased utilization.15 Within the same time period, there was only a 49% increase in number of patients seeking care for spine-related diagnoses. According to one retrospective analysis published in 2011, of patients who presented with low back pain, 42% were prescribed opioids within 3 mo of index diagnosis, whereas only 2% eventually underwent surgery.16 For patients undergoing spine surgery, preoperative opioid use has been correlated with long-term postoperative opioid dependence,17-19 as well as increased length of hospital stay following surgery.20 According to one systematic review published in 2015, several randomized controlled trials have demonstrated some efficacy of opioids on chronic low back pain. The implications, however, are limited, as no trial lasted more than 4 mo and all had high dropout rates (>20%) due to adverse effects or inefficacy.21 Furthermore, pain relief with opioid use was enhanced by only about 30%. Although the analgesic effects of opioids for acute low back pain have been well established,22 the clinical practicality of opioids for acute pain is more controversial. In one national assessment of patients presenting with new-onset low back pain, those prescribed high doses of opioids within the first 15 d of treatment were more likely to have prolonged disability, higher overall medical costs, higher risk for eventual surgery, and chronic opioid use.23 In another study of primary care patients presenting with low back pain, one-third were prescribed opioids in the acute setting.24 At 6-mo follow-up, patients taking opioids were found to have worse functionality, compared to patients receiving NSAID (nonsteroidal anti-inflammatory drug) therapy. Despite significant controversy, opioids universally remain the gold standard for intraoperative and immediate postoperative analgesia.25 Adequate postoperative pain management correlates with improved patient experience and functional outcomes.26 Therefore, with a relatively low risk of opioid addiction when used in the short term, anesthesiologists and surgeons alike frequently use opioids to control postoperative pain.25-27 According to the 2012 American Society of Anesthesiologists practice guidelines for acute pain management in the perioperative setting,28 systemic opioids are recommended for postoperative analgesia, after considering the risks and benefits for the individual patient. Yet, even in opioid-naïve patients, the rate of prolonged postoperative opioid use ranges between 3% and 7% in large, population studies, regardless of the invasiveness of surgery.29,30 Studies assessing opioid use following craniotomy have demonstrated efficacy and safety of short-term therapy, typically limited to the inpatient setting.31 Morphine use after craniotomy has been shown to improve postoperative pain, with minimal risk when used in appropriate doses.32 Patient controlled analgesia with opioids after craniotomy safely and effectively provides subjective pain improvement.33,34 Adjunctive treatments, such as acetaminophen and dexamethasone, provide a synergistic effect when used with opioids for postoperative pain.31,35 Intraoperative local anesthetic infiltration and scalp nerve blockade are associated with less regional postoperative pain and lower opioid requirements after craniotomy.36,37 Overall, these data suggest that opioids are safe and effective analgesics following cranial surgery, especially in the immediate postoperative period. The incidence of chronic headache syndromes following craniotomy is highly variable in the literature.38-40 Chronic headaches are more common following posterior fossa or skull base surgery, compared to supratentorial craniotomies. Fortunately, postcraniotomy headaches typically improve and resolve spontaneously over time. Various pharmacological (NSAIDs, tricyclic antidepressants, valproic acid) and nonpharmacological (physical therapy, cognitive behavioral therapy, acupuncture) treatment modalities have been found to be effective.31 There is a distinct lack of data for the use of opioids in chronic, postcraniotomy headache. Postoperative analgesia following spinal surgery can be more challenging. Up to 65% of patients with spinal pathology have used opioids prior to surgery.41,42 Fortunately, nearly all (99.9%) opioid-naïve patients who undergo spinal surgery discontinue opioid use by 6 mo postoperatively.41 In contrast, patients with preoperative opioid use have been found to have worse postoperative pain and disability following both lumbar and cervical spinal surgery, compared to opioid-naïve patients.42-44 Furthermore, preoperative opioid use is associated with greater immediate postoperative opioid demand and higher rates of delayed opioid dependence following spinal surgery.17,19 The recent proliferation of chronic opioid use has challenged postoperative pain management for anesthesiologists and surgeons alike. Inadequate postoperative analgesia in opioid-tolerant patients is not uncommon, due both to provider prejudice and fear of overmedicating.45 Despite these preconceptions, opioids must be administered at higher doses and greater frequencies to maintain equivalent analgesic levels in an opioid-tolerant patient.46 As an adjunct, regional and nonopioid analgesics should be included as part of a multimodal regimen to reduce overall opioid consumption.47,48 With increased recognition of the US opioid crisis, further research into opioid-sparing analgesia is ongoing. Two meta-analyses published in 2017 highlight the use of supplemental perioperative ketamine49 and gabapentin50 in reducing opioid consumption up to 24 h after spinal surgery. Perioperative treatment with dexamethasone has not been shown to reduce postoperative opioid consumption.51 The range of pathologies inherent in cranial and spinal neurosurgery requires neurosurgeons to be familiar with various pain syndromes and their indicated treatment strategies. In 2010, the World Health Organization (WHO) declared pain management to be a fundamental human right.52,53 Thus, as a neurosurgeon, it is essential to understand the current opioid prescribing guidelines and contemporary public health policy initiatives regarding the US opioid epidemic. CONTEMPORARY CHRONIC OPIOID USE GUIDELINES Over the last decade, several institutional bodies have released evidence-based recommendations for medical practitioners prescribing opioids. Extensive research efforts have proven the efficacy of opioids for chronic cancer pain,54-57 acute postoperative pain,58-60 and short-term, chronic noncancer pain.61 However, the prescription of opioids for long-term, chronic, noncancer pain is more controversial. Thus, chronic opioid prescribing guidelines have been created to assist practitioners in effectively treating pain for this patient population. The American Pain Society–American Academy of Pain Medicine (APS – AAPM) released evidence-based guidelines on opioid prescribing for chronic noncancer pain in 2009.62 The guidelines were composed by a panel of multidisciplinary experts, and intended for widespread use in primary care and subspecialty pain management. A summary of the recommendations can be reviewed in the Table. The APS–AAPM guidelines strongly recommend a clinician–patient discussion of the risks and benefits of opioid use prior to the initiation of therapy, culminating in a personalized management plan. The group also suggests the integration of psychotherapeutic interventions concomitant with chronic opioid therapy. TABLE. Summary of Recommendations From Various Physician Organizations and Government Institutions APS – AAPM 2009  Patient selection and risk stratification  Before initiating opioid therapy, conduct a history, examination, and appropriate testing, including an assessment of risk of substance abuse, misuse, or addiction.  If chronic pain is moderate or severe, consider a trial of opioid therapy, especially if pain is impacting quality of life and potential benefits outweigh potential harms.  A benefit-to-harm evaluation should be performed before, and ongoing during, opioid therapy.  Informed consent and opioid management plans  When starting opioid therapy, informed consent should be obtained. A continuing discussion should include goals, expectations, risks, and alternatives.  Consider a written opioid management plan to document patient and clinician responsibilities, expectations, and education.  Initiation and titration of opioid therapy  Clinicians and patients should regard initial treatment with opioids as a therapeutic trial to determine whether opioids are appropriate.  Opioid selection, initial dosing, and titration should be individualized according to patient's health status, previous exposure to opioids, attainment of therapeutic goals, and predicted or observed harms.  There is insufficient evidence to recommend short- vs long-acting opioids, or as needed vs scheduled opioids.  Monitoring  Reassess patients on chronic opioid therapy periodically and as warranted by changing circumstances. Monitoring should include pain intensity, level of functioning, progress toward therapeutic goals, adverse events, and adherence to prescribed therapies.  Patients at high risk for aberrant drug-related behaviors should be periodically screened with urine drug tests for adherence to the plan of care. (strong recommendation)  Patients not at high risk for aberrant drug-related behaviors should be periodically screened with urine drug tests for adherence to the plan of care. (weak recommendation)  High-risk patients  Clinicians may consider opioid therapy for patients with chronic pain and history of drug abuse, psychiatric issues, or serious aberrant drug-related behaviors only if they are able to implement more frequent and stringent monitoring parameters.  Evaluate patients engaging in aberrant drug-related behaviors for appropriateness of opioid therapy or need for restructuring of therapy, referral for assistance in management, or discontinuation of opioid therapy.  Dose escalation, high-dose opioid therapy, opioid rotation, and indications for discontinuation of opioid therapy  When repeated dose escalations occur, evaluate potential causes and reassess benefits relative to harms.  In patients who require relatively high doses of opioid, evaluate for opioid-related adverse effects, changes in health status, and adherence to treatment plan, and consider more frequent follow up.  Consider opioid rotation when patients experience intolerable adverse effects or inadequate benefit despite dose increase.  Taper off opioid therapy in patients who engage in repeated aberrant drug-related behaviors or drug abuse/diversion, experience no progress toward meeting therapeutic goals, or experience intolerable adverse effects.  Opioid-related adverse effects  Anticipate, identify, and treat common opioid-associated adverse effects  Use of psychotherapeutic co-interventions  As chronic, noncancer pain is often a complex biopsychosocial condition, clinicians who prescribe chronic opioid therapy should routinely integrate psychotherapeutic interventions, functional restoration, interdisciplinary therapy, and other adjunctive nonopioid therapies.  Driving and work safety  Counsel patients on chronic opioid therapy about transient or lasting cognitive impairment that may affect driving and work safety.  Identifying a medical home and when to obtain consultation  Patients on chronic opioid therapy should identify a clinician who accepts primary responsibility for their overall medical care. This clinician may not necessarily prescribe opioid therapy, but should coordinate consultation and communication between other members of the patient's care team.  Clinicians should pursue consultation, including interdisciplinary pain management, when patients may benefit from expert skill or resources.  Breakthrough pain  In patients on around-the-clock opioid therapy, consider as-needed opioids based upon an initial and ongoing analysis of therapeutic benefit vs risk.  Opioids in pregnancy  Counsel women of childbearing potential about the risks and benefits of chronic opioid therapy during pregnancy and after delivery. Encourage minimal or no use of opioids during pregnancy, unless potential benefits outweigh risks. If opioids are used during pregnancy, clinicians should be prepared to anticipate and manage risks to the patient and newborn.  Opioid policies  Clinicians should be aware of current federal and state laws, regulatory guidelines, and policy statements that govern the medical use of opioids for chronic, noncancer pain.  APS – AAPM 2009  Patient selection and risk stratification  Before initiating opioid therapy, conduct a history, examination, and appropriate testing, including an assessment of risk of substance abuse, misuse, or addiction.  If chronic pain is moderate or severe, consider a trial of opioid therapy, especially if pain is impacting quality of life and potential benefits outweigh potential harms.  A benefit-to-harm evaluation should be performed before, and ongoing during, opioid therapy.  Informed consent and opioid management plans  When starting opioid therapy, informed consent should be obtained. A continuing discussion should include goals, expectations, risks, and alternatives.  Consider a written opioid management plan to document patient and clinician responsibilities, expectations, and education.  Initiation and titration of opioid therapy  Clinicians and patients should regard initial treatment with opioids as a therapeutic trial to determine whether opioids are appropriate.  Opioid selection, initial dosing, and titration should be individualized according to patient's health status, previous exposure to opioids, attainment of therapeutic goals, and predicted or observed harms.  There is insufficient evidence to recommend short- vs long-acting opioids, or as needed vs scheduled opioids.  Monitoring  Reassess patients on chronic opioid therapy periodically and as warranted by changing circumstances. Monitoring should include pain intensity, level of functioning, progress toward therapeutic goals, adverse events, and adherence to prescribed therapies.  Patients at high risk for aberrant drug-related behaviors should be periodically screened with urine drug tests for adherence to the plan of care. (strong recommendation)  Patients not at high risk for aberrant drug-related behaviors should be periodically screened with urine drug tests for adherence to the plan of care. (weak recommendation)  High-risk patients  Clinicians may consider opioid therapy for patients with chronic pain and history of drug abuse, psychiatric issues, or serious aberrant drug-related behaviors only if they are able to implement more frequent and stringent monitoring parameters.  Evaluate patients engaging in aberrant drug-related behaviors for appropriateness of opioid therapy or need for restructuring of therapy, referral for assistance in management, or discontinuation of opioid therapy.  Dose escalation, high-dose opioid therapy, opioid rotation, and indications for discontinuation of opioid therapy  When repeated dose escalations occur, evaluate potential causes and reassess benefits relative to harms.  In patients who require relatively high doses of opioid, evaluate for opioid-related adverse effects, changes in health status, and adherence to treatment plan, and consider more frequent follow up.  Consider opioid rotation when patients experience intolerable adverse effects or inadequate benefit despite dose increase.  Taper off opioid therapy in patients who engage in repeated aberrant drug-related behaviors or drug abuse/diversion, experience no progress toward meeting therapeutic goals, or experience intolerable adverse effects.  Opioid-related adverse effects  Anticipate, identify, and treat common opioid-associated adverse effects  Use of psychotherapeutic co-interventions  As chronic, noncancer pain is often a complex biopsychosocial condition, clinicians who prescribe chronic opioid therapy should routinely integrate psychotherapeutic interventions, functional restoration, interdisciplinary therapy, and other adjunctive nonopioid therapies.  Driving and work safety  Counsel patients on chronic opioid therapy about transient or lasting cognitive impairment that may affect driving and work safety.  Identifying a medical home and when to obtain consultation  Patients on chronic opioid therapy should identify a clinician who accepts primary responsibility for their overall medical care. This clinician may not necessarily prescribe opioid therapy, but should coordinate consultation and communication between other members of the patient's care team.  Clinicians should pursue consultation, including interdisciplinary pain management, when patients may benefit from expert skill or resources.  Breakthrough pain  In patients on around-the-clock opioid therapy, consider as-needed opioids based upon an initial and ongoing analysis of therapeutic benefit vs risk.  Opioids in pregnancy  Counsel women of childbearing potential about the risks and benefits of chronic opioid therapy during pregnancy and after delivery. Encourage minimal or no use of opioids during pregnancy, unless potential benefits outweigh risks. If opioids are used during pregnancy, clinicians should be prepared to anticipate and manage risks to the patient and newborn.  Opioid policies  Clinicians should be aware of current federal and state laws, regulatory guidelines, and policy statements that govern the medical use of opioids for chronic, noncancer pain.  FSMB 2013  Understanding pain  In order to cautiously prescribe opioids, physicians must understand the relevant pharmacological and clinical issues in the use of such analgesics, and carefully structure a treatment plan that reflects the particular benefits and risks of opioid use for each individual patient.  Patient evaluation and risk stratification  Prior to initiation of opioid therapy, a full assessment should be made, including screening for depression and mental health disorders, as well as prior substance abuse. Recommend use of a validated screening tool, such as the Screener and Opioid Assessment for Patients with Pain. Consult a state's prescription drug monitoring program (PDMP) for previously prescribed controlled substances.  Development of treatment plan and goals  The patient's goals of treatment should be reasonably attainable. The treatment plan should include both pharmacological and nonpharmacological therapies.  Informed consent and treatment agreement  Use of a written informed consent and treatment agreement (sometimes referred to as a “treatment contract”) is recommended.  Initiating an opioid trial  Generally, safer alternative treatments should be considered before initiating opioid therapy for chronic, nonmalignant pain. Opioid therapy should be presented to the patient as a therapeutic trial or test for a defined period of time (usually no more than 90 d) and with specified evaluation points.  The physician should explain that progress will be carefully monitored for both benefit and harm in terms of the effects of opioids on the patient's level of pain, function, and quality of life, as well as to identify any adverse events or risks to safety.  Ongoing monitoring and adapting the treatment plan  The physician should regularly review the patient's progress, including any new information about the etiology of the pain or the patient's overall health and level of function.  Continuation, modification, or termination of opioid therapy for pain should be contingent on the physician's evaluation of (1) evidence of the patient's progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as overdose or diversion.  Periodic drug testing  Periodic drug testing may be useful in monitoring adherence to the treatment plan, as well as in detecting the use of nonprescribed drugs.  Consultation and referral  The treating physician should seek a consultation with, or refer the patient to, a pain, psychiatry, addiction or mental health specialist as needed.  Discontinuing opioid therapy  Throughout the course of opioid therapy, the physician and patient should regularly weigh the potential benefits and risks of continued treatment and determine whether such treatment remains appropriate.  Reasons for discontinuing opioid therapy include resolution of the underlying painful condition, emergence of intolerable side effects, inadequate analgesic effect, failure to improve the patient's quality of life despite reasonable titration, deteriorating function, or significant aberrant medication use.  Medical records  The medical record must include all prescription orders for opioid analgesics and other controlled substances, whether written or telephoned. In addition, written instructions for the use of all medications should be given to the patient and documented in the record.  Good records demonstrate that a service was provided to the patient and establish that the service provided was medically necessary. Even if the outcome is less than optimal, thorough records protect the physician as well as the patient.  Compliance with controlled substance laws and regulations  To prescribe, dispense or administer controlled substances, the physician must be registered with the DEA, licensed by the state in which he or she practices, and comply with applicable federal and state regulations.  FSMB 2013  Understanding pain  In order to cautiously prescribe opioids, physicians must understand the relevant pharmacological and clinical issues in the use of such analgesics, and carefully structure a treatment plan that reflects the particular benefits and risks of opioid use for each individual patient.  Patient evaluation and risk stratification  Prior to initiation of opioid therapy, a full assessment should be made, including screening for depression and mental health disorders, as well as prior substance abuse. Recommend use of a validated screening tool, such as the Screener and Opioid Assessment for Patients with Pain. Consult a state's prescription drug monitoring program (PDMP) for previously prescribed controlled substances.  Development of treatment plan and goals  The patient's goals of treatment should be reasonably attainable. The treatment plan should include both pharmacological and nonpharmacological therapies.  Informed consent and treatment agreement  Use of a written informed consent and treatment agreement (sometimes referred to as a “treatment contract”) is recommended.  Initiating an opioid trial  Generally, safer alternative treatments should be considered before initiating opioid therapy for chronic, nonmalignant pain. Opioid therapy should be presented to the patient as a therapeutic trial or test for a defined period of time (usually no more than 90 d) and with specified evaluation points.  The physician should explain that progress will be carefully monitored for both benefit and harm in terms of the effects of opioids on the patient's level of pain, function, and quality of life, as well as to identify any adverse events or risks to safety.  Ongoing monitoring and adapting the treatment plan  The physician should regularly review the patient's progress, including any new information about the etiology of the pain or the patient's overall health and level of function.  Continuation, modification, or termination of opioid therapy for pain should be contingent on the physician's evaluation of (1) evidence of the patient's progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as overdose or diversion.  Periodic drug testing  Periodic drug testing may be useful in monitoring adherence to the treatment plan, as well as in detecting the use of nonprescribed drugs.  Consultation and referral  The treating physician should seek a consultation with, or refer the patient to, a pain, psychiatry, addiction or mental health specialist as needed.  Discontinuing opioid therapy  Throughout the course of opioid therapy, the physician and patient should regularly weigh the potential benefits and risks of continued treatment and determine whether such treatment remains appropriate.  Reasons for discontinuing opioid therapy include resolution of the underlying painful condition, emergence of intolerable side effects, inadequate analgesic effect, failure to improve the patient's quality of life despite reasonable titration, deteriorating function, or significant aberrant medication use.  Medical records  The medical record must include all prescription orders for opioid analgesics and other controlled substances, whether written or telephoned. In addition, written instructions for the use of all medications should be given to the patient and documented in the record.  Good records demonstrate that a service was provided to the patient and establish that the service provided was medically necessary. Even if the outcome is less than optimal, thorough records protect the physician as well as the patient.  Compliance with controlled substance laws and regulations  To prescribe, dispense or administer controlled substances, the physician must be registered with the DEA, licensed by the state in which he or she practices, and comply with applicable federal and state regulations.  CDC 2016  Determining when to initiate or continue opioids for chronic pain  Nonpharmacological and nonopioid pharmacological therapies are preferred for chronic pain.  Before starting opioid therapy, clinicians should establish realistic treatment goals for pain and function. Continue therapy only if there is meaningful improvement in pain and function that outweighs risks to patient safety.  Before starting and periodically during opioid therapy, discuss known risks and realistic benefits.  Opioid selection, dosage, duration, follow-up, and discontinuation  When starting therapy for chronic pain, prescribe immediate-release, rather than extended-release/long-acting opioids.  Use lowest effective dosage when starting opioid therapy.  When treating acute pain, use lowest effective dosage of immediate-release opioids, and prescribe no greater quantity than needed for expected duration of pain. Usually 3 d or less will be sufficient; rarely will more than 7 d be necessary.  Evaluate benefits and harms with patients within 1 to 4 wk of initiating opioid therapy, or after dose escalation. If benefits do not outweigh harms, optimize other therapies and work with patients to taper and discontinue opioids.  Assessing risk and addressing harms or opioid use  Before starting and during continuation of opioid therapy, evaluate for risk factors of opioid-related harms. Incorporate in to the management plan strategies to mitigate risk, including offering naloxone, when risk factors present (history of overdose, history of substance abuse, higher opioid dosages, concurrent benzodiazepine use).  Review patient's history of controlled substance prescriptions using state PDMP, when starting, and periodically during, opioid therapy. Determine whether patient is receiving opioid dosages or combinations that put him or her at high risk for overdose.  Consider urine drug testing to assess for prescribed medications, as well as other controlled prescription drugs and illicit drugs.  Avoid prescribing opioids and benzodiazepines concurrently.  Offer or arrange evidence-based treatment for patients with opioid use disorder (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies).  CDC 2016  Determining when to initiate or continue opioids for chronic pain  Nonpharmacological and nonopioid pharmacological therapies are preferred for chronic pain.  Before starting opioid therapy, clinicians should establish realistic treatment goals for pain and function. Continue therapy only if there is meaningful improvement in pain and function that outweighs risks to patient safety.  Before starting and periodically during opioid therapy, discuss known risks and realistic benefits.  Opioid selection, dosage, duration, follow-up, and discontinuation  When starting therapy for chronic pain, prescribe immediate-release, rather than extended-release/long-acting opioids.  Use lowest effective dosage when starting opioid therapy.  When treating acute pain, use lowest effective dosage of immediate-release opioids, and prescribe no greater quantity than needed for expected duration of pain. Usually 3 d or less will be sufficient; rarely will more than 7 d be necessary.  Evaluate benefits and harms with patients within 1 to 4 wk of initiating opioid therapy, or after dose escalation. If benefits do not outweigh harms, optimize other therapies and work with patients to taper and discontinue opioids.  Assessing risk and addressing harms or opioid use  Before starting and during continuation of opioid therapy, evaluate for risk factors of opioid-related harms. Incorporate in to the management plan strategies to mitigate risk, including offering naloxone, when risk factors present (history of overdose, history of substance abuse, higher opioid dosages, concurrent benzodiazepine use).  Review patient's history of controlled substance prescriptions using state PDMP, when starting, and periodically during, opioid therapy. Determine whether patient is receiving opioid dosages or combinations that put him or her at high risk for overdose.  Consider urine drug testing to assess for prescribed medications, as well as other controlled prescription drugs and illicit drugs.  Avoid prescribing opioids and benzodiazepines concurrently.  Offer or arrange evidence-based treatment for patients with opioid use disorder (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies).  ASIPP 2017  Initial steps  Comprehensive assessment and documentation  Screening for opioid abuse  Utilization of PDMPs  Utilization of urine drug testing  Establish appropriate physical or psychological diagnosis  Consider imaging, physical diagnosis, and psychological status to collaborate with subjective complaints  Establish medical necessity based on average moderate to severe pain (≥4/10) and/or disability  Stratify patients based on risk  Establish treatment goals of opioid therapy with regard to pain relief and improvement in function  Obtain robust opioid agreement, followed by all parties  Assessment of effectiveness of long-term opioid therapy  Initiate opioid therapy with low-dose, short-acting drugs, with appropriate monitoring  Consider up to 40 morphine milligram equivalent (MME) as low dose, 41 to 90 MME moderate dose, and greater than 91 MME high dose  Avoid long-acting opioid drugs for initiation of opioid therapy  Recommend methadone only for use after failure of other opioid therapy and only by clinicians with specific training in its risks and uses  Understand and educate the patients of the effectiveness and adverse consequences  Similar effectiveness for long-acting and short-acting opioids with increased adverse consequences of long-acting opioids  Periodically assess pain relief and/or functional status improvement of ≥30% without adverse consequences  Recommend long-acting or high-dose opioids only in specific circumstances with severe intractable pain  Monitoring for adherence and side effects  Monitor for adherence, abuse, and noncompliance by urine drug tests and PDMPs  Monitor patients on methadone with an electrocardiogram periodically  Monitor for side effects including constipation and manage them appropriately, including discontinuation of opioids when indicated  Final phase  May continue with monitoring with continued medical necessity, with appropriate outcomes  Discontinue opioid therapy for lack of response, adverse consequences, and abuse with rehabilitation  ASIPP 2017  Initial steps  Comprehensive assessment and documentation  Screening for opioid abuse  Utilization of PDMPs  Utilization of urine drug testing  Establish appropriate physical or psychological diagnosis  Consider imaging, physical diagnosis, and psychological status to collaborate with subjective complaints  Establish medical necessity based on average moderate to severe pain (≥4/10) and/or disability  Stratify patients based on risk  Establish treatment goals of opioid therapy with regard to pain relief and improvement in function  Obtain robust opioid agreement, followed by all parties  Assessment of effectiveness of long-term opioid therapy  Initiate opioid therapy with low-dose, short-acting drugs, with appropriate monitoring  Consider up to 40 morphine milligram equivalent (MME) as low dose, 41 to 90 MME moderate dose, and greater than 91 MME high dose  Avoid long-acting opioid drugs for initiation of opioid therapy  Recommend methadone only for use after failure of other opioid therapy and only by clinicians with specific training in its risks and uses  Understand and educate the patients of the effectiveness and adverse consequences  Similar effectiveness for long-acting and short-acting opioids with increased adverse consequences of long-acting opioids  Periodically assess pain relief and/or functional status improvement of ≥30% without adverse consequences  Recommend long-acting or high-dose opioids only in specific circumstances with severe intractable pain  Monitoring for adherence and side effects  Monitor for adherence, abuse, and noncompliance by urine drug tests and PDMPs  Monitor patients on methadone with an electrocardiogram periodically  Monitor for side effects including constipation and manage them appropriately, including discontinuation of opioids when indicated  Final phase  May continue with monitoring with continued medical necessity, with appropriate outcomes  Discontinue opioid therapy for lack of response, adverse consequences, and abuse with rehabilitation  VA/DoD 2017  Initiation and continuation of opioids  Recommend against long-term opioid therapy for chronic pain, rather recommend nonpharmacological and nonopioid treatments  If prescribing opioid therapy, recommend short duration (<90 d)  For patients on chronic opioid therapy, recommend ongoing risk mitigation strategies, assessment for abuse disorder, and consideration for tapering when risk exceeds benefits  Recommend against long-term opioid therapy in patients with untreated substance abuse disorder  Recommend against the concurrent use of benzodiazepines and opioids  Recommend against long-term opioid therapy for patients under 30 yr, secondary to a higher risk of opioid use disorder and overdose  Risk mitigation  Recommend implementing risk mitigation strategies upon initiation of long-term opioid therapy, starting with an informed consent, conversation covering the risks and benefits of opioid therapy as well as alternative therapies  Recommend assessing suicide risk  Recommend re-evaluating risks and benefits of continued opioid therapy at least every 3 mo  Type, dose, follow-up, and taper of opioids  If prescribing opioids, recommend prescribing the lowest dose  As opioid dosage and risk increase, recommend more frequent monitoring for adverse events.  Recommend against doses over 90 MME for treating chronic pain  Recommend against prescribing long-acting opioids for acute pain, as an as-needed medication, or on initiation of therapy  Recommend tapering to reduced dose or discontinuation of opioids when risks of long-term opioid therapy outweigh benefits  Individualize opioid tapering based on risk assessment and patient needs  Recommend interdisciplinary care that addresses pain, substance use disorders, and mental health problems for patients presenting with high-risk behavior  Recommend offering medication assisted treatment for opioid use disorder to patients with chronic pain and opioid use disorder  Opioid therapy for acute pain  Recommend alternatives to opioids for mild-to-moderate acute pain  If take-home opioids are prescribed, recommend prescribing low-dose, immediate-release opioids, with reassessment after 3 to 5 d to determine if adjustments or continuing opioid therapy is indicated  Opioid risks and alternatives should be discussed when prescribing opioids  VA/DoD 2017  Initiation and continuation of opioids  Recommend against long-term opioid therapy for chronic pain, rather recommend nonpharmacological and nonopioid treatments  If prescribing opioid therapy, recommend short duration (<90 d)  For patients on chronic opioid therapy, recommend ongoing risk mitigation strategies, assessment for abuse disorder, and consideration for tapering when risk exceeds benefits  Recommend against long-term opioid therapy in patients with untreated substance abuse disorder  Recommend against the concurrent use of benzodiazepines and opioids  Recommend against long-term opioid therapy for patients under 30 yr, secondary to a higher risk of opioid use disorder and overdose  Risk mitigation  Recommend implementing risk mitigation strategies upon initiation of long-term opioid therapy, starting with an informed consent, conversation covering the risks and benefits of opioid therapy as well as alternative therapies  Recommend assessing suicide risk  Recommend re-evaluating risks and benefits of continued opioid therapy at least every 3 mo  Type, dose, follow-up, and taper of opioids  If prescribing opioids, recommend prescribing the lowest dose  As opioid dosage and risk increase, recommend more frequent monitoring for adverse events.  Recommend against doses over 90 MME for treating chronic pain  Recommend against prescribing long-acting opioids for acute pain, as an as-needed medication, or on initiation of therapy  Recommend tapering to reduced dose or discontinuation of opioids when risks of long-term opioid therapy outweigh benefits  Individualize opioid tapering based on risk assessment and patient needs  Recommend interdisciplinary care that addresses pain, substance use disorders, and mental health problems for patients presenting with high-risk behavior  Recommend offering medication assisted treatment for opioid use disorder to patients with chronic pain and opioid use disorder  Opioid therapy for acute pain  Recommend alternatives to opioids for mild-to-moderate acute pain  If take-home opioids are prescribed, recommend prescribing low-dose, immediate-release opioids, with reassessment after 3 to 5 d to determine if adjustments or continuing opioid therapy is indicated  Opioid risks and alternatives should be discussed when prescribing opioids  ASIPP = American Society of Interventional Pain Physicians; APS – AAPM = American Pain Society – American Academy of Pain Medicine; CDC = Centers for Disease Control and Prevention; DEA = Drug Enforcement Agency; FSMB = Federation of State Medical Boards; VA/DoD = Department of Veterans Affairs/Department of Defense View Large The Federation of State Medical Boards (FSMB) adopted its “Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain” in July 2013.63 The stated mission was to provide a “resource for use by state medical boards in educating their licensees about cautious and responsible prescribing of controlled substances while alleviating fears of regulatory scrutiny.” A summary of FSMB guideline recommendations is included in the Table. The FSMB guidelines specifically highlight the importance of the medical record in documenting discussions between clinician and patient, especially regarding risks of chronic opioid therapy and indications for treatment. The guidelines recommend thorough record keeping in order to “protect the physician as well as the patient.” In 2016, the US CDC released its Guideline for Prescribing Opioids for Chronic Pain.64 The stated purpose was “to ensure that clinicians and patients consider safer and more effective treatment, improve patient outcomes such as reduced pain and improved function, and reduce the number of persons who develop opioid use disorder, overdose, or experience other adverse events related to these drugs.” Assimilating the best available clinical research, with review by a federally chartered advisory committee, the CDC proposed several evidence-based recommendations in its guidelines. These recommendations are summarized in the Table. Importantly, the CDC concludes that for chronic pain, nonpharmacological therapy and nonopioid pharmacological therapy are preferred. When starting opioid therapy, the CDC recommends that practitioners and patients establish overall treatment goals, discuss risks and benefits of opioid use, and plan frequent follow-up visits for reassessment. The CDC also suggests that clinicians must frequently assess patients for opioid-related harms, and consult a prescription drug-monitoring program (PDMP) for a patient's individual controlled substance use history. Furthermore, if risk factors for an opioid use disorder exist, the guidelines serve to aid clinicians in both preventing prescription misuse and treating medication dependence. Based on these guidelines, the CDC developed a checklist for prescribing opioids in patients with chronic pain.65 This 1-page guide serves as a succinct reference for clinicians to determine a patient's candidacy for opioid therapy (Figure). FIGURE. View largeDownload slide The US CDC checklist for chronic opioid prescribing, based on the 2016 CDC guidelines. Freely available on the CDC website (https://www.cdc.gov/drugoverdose/pdf/pdo_checklist-a.pdf). Public Domain, US Government work. FIGURE. View largeDownload slide The US CDC checklist for chronic opioid prescribing, based on the 2016 CDC guidelines. Freely available on the CDC website (https://www.cdc.gov/drugoverdose/pdf/pdo_checklist-a.pdf). Public Domain, US Government work. As suggested in the CDC guidelines, a federal effort to address chronic pain management on a population-level was developed by the National Institutes of Health, and outlined in the 2016 report, National Pain Strategy.66 A significant focus of this work pertains to prevention of illnesses and injuries that lead to chronic pain. The report also suggests targeting health care payers to strengthen coverage for nonpharmacological therapy, patient counseling, and medication-assisted treatment. In order to provide a “consistent philosophy” among clinicians prescribing opioids, the American Society of Interventional Pain Physicians (ASIPP) released their “Responsible, Safe, and Effective Prescription of Opioid for Chronic, Non-Cancer Pain” in early 2017.67 A summary of recommendations can be viewed in the Table. Overall, the ASIPP guidelines imply a more liberal approach to opioid prescribing. The authors describe an “overwhelming opposition” to the 2016 CDC opioid prescribing guidelines, suggesting “a disconnect between authorities, regulators, academic opponents, and practicing physicians and chronic pain patients.”67 The group cites a 2016 Washington Post/Kaiser Family Foundation survey of long-term prescription painkiller users and their household members, in which 92% respondents claimed a reduction in pain with opioid use, and 57% report a better quality of life with chronic opioid use.14 However, the same survey suggests that household members are more likely to believe a patient taking chronic opioids is addicted or dependent, and that his or her prescription drug use contributes negatively to finances, relationships, and health. Most recently, in early 2017, the US Department of Veterans Affairs/Department of Defense (VA/DoD) released their third version of “Clinical Practice Guidelines for Opioid Therapy for Chronic Pain.”68 As stated, these guidelines serve to provide a framework for clinicians in evaluating and managing patients with chronic pain, with an emphasis on patient-centric care. The VA/DoD guidelines are summarized in the Table. In contrast to the ASIPP guidelines, the VA/DoD explicitly recommend against prescribing opioids for chronic pain. Furthermore, these guidelines are the only to include commentary on opioid prescribing for acute pain. Based on these recommendations, the VA/DoD developed several patient-centric algorithms for determining appropriateness of opioid therapy, initiation of opioid therapy, tapering opioid therapy, and managing patients currently on opioid therapy. These are freely available on the VA/DoD website,69 and serve to allow clinicians to personalize their management decisions for a given patient, at each stage of therapy. CONTEMPORARY PUBLIC POLICY INITIATIVES Since the declaration of a US opioid epidemic by the CDC, there have been significant, bipartisan public health policy efforts enacted in order to curb the expansion of both opioid use and dependence. With the passage of the US Patient Protection and Affordable Care Act (ACA) in March 2010, an expansion of the state-federal low-income health insurance program, Medicaid, included mandates for several essential benefits, including substance abuse coverage. Subsequently, in July 2016, President Barack Obama signed into law the Comprehensive Addiction and Recovery Act.70 This bill improved access to addiction and overdose treatment, by expanding prescribing privileges for medication-assisted treatment (buprenorphine) to nurse practitioners and physician assistants, and facilitating access to naloxone for those at risk of overdose. Furthermore, the act allocated further funding for the improvement of state-based PDMPs. As part of the ACA, the meaningful use of electronic health records became mandatory, and targets for electronic prescribing were set for providers (50% of all prescriptions by 2014). The Electronic Prescribing of Controlled Substances (EPCS) initiative by the US Department for Health and Human Services was established specifically as a monitoring program for opioid prescribing.71 Presently, medical practitioners in 3 states (New York, Maine, and Minnesota) are required to be fully compliant with EPCS, such that no paper prescriptions for opioids are written, in an effort to track opioid prescribing by clinicians and overuse by patients. In March 2017, President Donald Trump presented an executive order establishing the President's Commission on Combating Drug Addiction and the Opioid Crisis,72 and appointed as chairman New Jersey Governor Chris Christie. The Trump administration considers “opioid addiction … as a nonpartisan issue in need of a bipartisan solution.”73 The presidential opioid commission is set to release its final recommendations in October 2017, after the writing of this article. Recently, in May 2017, the State of Ohio filed a lawsuit against 5 major drug manufacturers for their role in fueling the opioid epidemic.74 The Ohio state Attorney General Mike DeWine alleges “fraudulent marketing regarding the risks and benefits of prescription opioids … for the purpose of increasing sales.” Both Ohio and Mississippi have filed such a suit at this time, states with populations particularly vulnerable to opioid use and abuse. Subsequently, in June 2017, the US Food and Drug Administration (FDA) requested removal of the drug Opana ER (oxymorphone hydrochrloride) from the market by its manufacturer Endo Pharmaceuticals (Malvern, Pennsylvania), citing the overall high risk of abuse with this particular formulation.75 This milestone decision marks the first step by the FDA to curb an actively marketed opioid “due to public health consequences of abuse.” Recent evidence proposed by the US CDC suggests that an opioid prescription for less than 7 d can decrease the chance of unintentional chronic use.76 Based on this, federal legislation is being developed in the US Senate to limit opioid prescriptions to a 7-d supply.77 Although many states have existing prescription supply limits, this would represent the first federal effort to curb opioid over-prescribing. ASSIMILATING GUIDELINES AND POLICY: SPECIAL RELEVANCE TOWARDS NEUROSURGERY Both cranial and spinal neurosurgeons will encounter patients with acute and chronic pain on a daily basis. Given its high prevalence in this subspecialty, a fundamental understanding of pain and its multimodality management is necessary. As referenced in this article, many physician organizations and governmental bodies have released evidence-based consensus guidelines on the use of opioid pain medication for chronic pain. While there are no official recommendations by a US neurosurgical association at this time, several key conclusions from the aforementioned guidelines and policies can be applied to pain management in the practice of neurosurgery. First, it is important to understand the timing of a patient's pain prior to prescribing analgesia, whether is it postoperative, acute, or chronic. Opioids are the cornerstone of pain control following surgery, and can be used safely and effectively in the immediate postoperative period, for both spinal and cranial surgery. Following surgery, a tapered course of opioid therapy for less than 7 d (ideally less than 3 d) can be considered after discharge from the hospital. For acute pain, nonpharmacological therapies and pharmacological alternatives to opioids are preferred, but low-dose opioids can be effectively used in the short term (3-7 d) after a discussion of the risks and benefits with the patient. Chronic opioid therapy is highly controversial, with limited evidence to support its use. As most of the professional guidelines suggest, consultation with a pain management physician is recommended for patients with atypical or chronic pain syndromes. In evaluating patients with chronic pain, a neurosurgeon must make the critical etiological distinction between nociceptive and neuropathic pain. Nociceptive pain, such as pain due to a postoperative incision or spinal fracture, is effectively and appropriately treated with opioid analgesia. In contrast, there is little role for opioids in treating pain of neuropathic origin, such as in trigeminal neuralgia. This analysis is often overlooked by clinicians and consequently leads to inappropriate opioid prescribing, a fundamental misunderstanding at the core of the opioid epidemic. Ultimately, prescriber education should be expanded to include pain pathophysiology, policy change that can be made at both the institutional and governmental level. Second, formulation of a therapeutic plan is necessary prior to prescribing opioids for chronic pain. When chronic opioid therapy is considered, an in-depth discussion of the risks, benefits, and objective therapeutic goals with the patient is required. Many guidelines recommend the patient signing an informed consent, documenting both their understanding of the risk–benefit profile as well as their agreement of adherence to the therapeutic plan. If eventually prescribed, monotherapy with a short-acting opioid is recommended at the lowest effective dose for a short trial period (no more than 90 d). Third, regular follow-up is essential to ensure the proper utilization of chronic opioid use, and to prevent misuse. At each time point, the risks and benefits should be re-evaluated, and therapy should be discontinued if the risks outweigh benefits. State PDMPs should be consulted regularly, and periodic drug testing should be used to ensure adherence to the therapeutic plan. Some guidelines suggest a patient nominate 1 physician (preferably primary care or pain management) to coordinate care of their chronic pain, thereby preventing a multiplicity of opioid prescriptions. On follow-up, if misuse is suspected, referral to a specialist is indicated for tapering of opioid medication, abuse counseling, and possible medication-assisted treatment. Ultimately, it is up to prescribers of all specialties to understand the risks and benefits associated with opioid therapy prior to treating a patient's pain. It is within the realm of medical education where these principles must be taught and reinforced. In response to the opioid crisis, the Association of American Medical Colleges released a statement in March 2016 committing US medical schools and teaching hospitals to improving opioid education.78 In 2015, Massachusetts Governor Charlie Baker issued a novel set of core competencies to be implemented by all 4 of the state's medical colleges, regarding the prevention and management of prescription drug misuse.79 Arming medical students with the knowledge to appropriately treat pain and prevent addiction is a fundamental step in changing the culture of opioid overprescribing. However, this education must continue during residency and beyond in order to have a lasting clinical impact. Some national specialty associations, such as emergency medicine, have dedicated efforts to expand pain management curricula in response to the opioid epidemic.80 In its current form, the American Association for Neurological Surgeons (AANS)/Accreditation Council for Graduate Medical Education (ACGME) neurosurgery residency milestones do not require formal opioid education.81 While many neurosurgery residents are mandated by some states and institutions to have continuing medical education on opioid prescribing, there is no universal neurosurgical opioid curriculum at this time. Perhaps the current AANS milestones should be amended to ensure a more thorough understanding of pain management and addiction prevention, prior to graduating from neurosurgery residency. As it stands in the current political landscape, opioid prescribing policy is in considerable flux. As summarized, federal and state legislation is trending toward more conservative policies on opioid prescribing, with various governing bodies directly taking on the opioid pharmaceutical industry. With opioid-related deaths rising, changes must be made at both the institutional and individual levels. This will require modifying the underlying philosophies of politicians and prescribers, respectively. By understanding the current evidence-based guidelines on chronic opioid prescribing, neurosurgeons can make more informed clinical decisions on patients with chronic pain, and ultimately uphold the responsibility to do no harm. CONCLUSION AND FUTURE ACTION Opioid overuse continues to plague the United States, with an increasing number of lives lost and healthcare expenditures as a direct result. Neurosurgeons, as surgical subspecialists treating patients with various pain syndromes, are responsible for understanding proper opioid stewardship. 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National Pain Strategy - A Comprehensive Population Health-Level Strategy for Pain . 2016. Available at: https://iprcc.nih.gov/docs/HHSNational_Pain_Strategy.pdf. Accessed May 21, 2017. PubMed PubMed  67. Manchikanti L, Kaye AM, Knezevic NN et al.   Responsible, safe, and effective prescription of opioids for chronic non-cancer pain: American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Physician . 2017; 20( 2S): S3- S92. Available at: http://www.ncbi.nlm.nih.gov/pubmed/28226332. Accessed May 25, 2017. Google Scholar PubMed  68. Department of Veterans Affairs, The Office of Quality S and V. VA/DoD Clinical Practice Guideline For Opioid Therapy For Chronic Pain . 2017. Available at: https://www.healthquality.va.gov/guidelines/Pain/cot/VADoDOTCPG022717.pdf. Accessed June 2, 2017. 69. VA/DoD. Management of Opioid Therapy (OT) for Chronic Pain (2017) - VA/DoD Clinical Practice Guidelines . 2017. Available at: https://www.healthquality.va.gov/guidelines/pain/cot/. Accessed June 17, 2017. 70. 114th U.S. Congress H of R. Comprehensive Addiction and Recovery Act of 2016 . 2016. Available at: http://docs.house.gov/billsthisweek/20160704/CRPT-114HRPT-S524.pdf. Accessed June 4, 2017. 71. HealthIT.gov. Electronic Prescribing of Controlled Substances (EPCS).  2016. Available at: https://www.healthit.gov/opioids/epcs. Accessed April 15, 2017. 72. The White House O of the PS. Presidential Executive Order Establishing the President's Commission on Combating Drug Addiction and the Opioid Crisis . 2017. Available at: https://www.whitehouse.gov/the-press-office/2017/03/30/presidential-executive-order-establishing-presidents-commission. Accessed June 4, 2017. 73. Thistle S. Trump health secretary hears, in private, about Maine opioid crisis. Portland Press Herald . Available at: http://www.pressherald.com/2017/05/10/trumps-top-health-official-visits-maine-to-hear-about-opiate-crisis/. Published May 10, 2017. Accessed June 4, 2017. 74. Dwyer C. Ohio Sues 5 Major Drug Companies For “Fueling Opioid Epidemic.” Natl Public Radio . 2017. Available at: http://www.npr.org/sections/thetwo-way/2017/05/31/530929307/ohio-sues-5-major-drug-companies-for-fueling-opioid-epidemic. Accessed June 4, 2017. 75. U.S. Food and Drug Administration. Press Announcements - FDA Requests Removal of Opana ER for Risks Related to Abuse . 2017. Available at: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/UCM562401.htm. Accessed June 17, 2017. 76. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015 MMWR Morb Mortal Wkly Rep . 2017; 66( 10): 265- 269. Google Scholar CrossRef Search ADS PubMed  77. Brooks M. New bill to put 7-day limit on pain med prescriptions. MedScape . 2017. Available at: http://www.medscape.com/viewarticle/878795. Accessed June 17, 2017. 78. Krisberg K. Medical schools confront opioid crisis with greater focus on pain, addiction education. AAMC . 2016. Available at: https://www.aamc.org/newsroom/newsreleases/464576/medical_schools_confront_opioid_crisis_08042016.html. Accessed July 15, 2017. 79. Medical School Program to Curb Opioid Crisis Announced. Official Website of the Governor of Massachusetts . 2015. Available at: http://www.mass.gov/governor/press-office/press-releases/fy2016/medical-school-program-to-curb-opioid-crisis-announced.html. Accessed July 15, 2017. 80. Poon SJ, Nelson LS, Hoppe JA et al.   Consensus-based recommendations for an emergency medicine pain management curriculum. J Emerg Med . 2016; 51( 2): 147- 154. Google Scholar CrossRef Search ADS PubMed  81. Abosch A, Barrow D, Byrne RW et al.   The Neurological Surgery Milestone Project . 2012. Available at: https://www.acgme.org/Portals/0/PDFs/Milestones/NeurologicalSurgeryMilestones.pdf. Accessed July 15, 2017. COMMENT This timely paper compares a series of evidence-based guidelines that were developed by various organizations outside neurosurgery concerning opioid use. The hope of the authors is to provide direction for neurosurgeons and suggest a policy for the specialty as a whole. I believe that neurosurgeons are keenly aware of the national opioid crisis and that they are uniquely positioned to assist with this important public health epidemic. Unfortunately, they also face an insoluble dilemma. Major surgery by its nature is a painful endeavor but social pressure is mounting against using opioid painkillers even when they are indicated and appropriate. Many times, the patient has been treated with opioids for a long duration before even arriving into the care of the neurosurgeon. According to the Joint Commission of Accreditation Healthcare and Certification (JACHO), pain is considered to be the fifth vital sign. Surgeons must effectively treat pain or face rebuke from hospital administrators or patients in the form of negative satisfaction evaluations. It is also inherently ego dystonic sometimes for the physician to deny or restrict a treatment that helps alleviate pain and suffering. This conundrum is very effectively summarized in a recent satirical video.1 These authors have provided a concise and feasible recommendation for managing opioid medications. They have clearly articulated the process of first defining the type and timing of pain to justify opioid use, followed by formulation of a therapeutic plan. Careful monitoring of the response to therapy is an essential component. A key failsafe in my view, is the recognition of abuse or failure of response. Perhaps there is an opportunity for a technological solution that would improve reporting and tracking of opioids so that abuse could be recognized quickly and appropriate measure instituted. Most existing systems are operated on a state-by-state basis and have variable degrees of success. This should prompt early referral to a pain management specialist. Chronic pain management in particular often requires a multimodality approach that is beyond the scope and facility of most neurosurgeons. Hopefully a useful and evidence based policy will be forthcoming from our national organizations. We are in the best position to investigate and implement solutions for patients with neurosurgical disease. Joel D. MacDonald Salt Lake City, Utah 1. ZDoggMD. Doc Vader Vs. Hospital Administrator . https://youtu.be/QHfan71zHKk. Accessed November 1, 2017. Copyright © 2018 by the Congress of Neurological Surgeons http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Neurosurgery Oxford University Press

Commentary: Neurosurgery and the Ongoing American Opioid Crisis

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Congress of Neurological Surgeons
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Copyright © 2018 by the Congress of Neurological Surgeons
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0148-396X
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1524-4040
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10.1093/neuros/nyx584
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Abstract

ABBREVIATIONS ABBREVIATIONS AANS American Association for Neurological Surgeons ACA Affordable Care Act ACGME Accreditation Council for Graduate Medical Education APS–AAPM American Pain Society–American Academy of Pain Medicine ASIPP American Society of Interventional Pain Physicians CDC Centers for Disease Control and Prevention DEA Drug Enforcement Agency EPCS Electronic Prescribing of Controlled Substances FDA Food and Drug Administration FSMB Federation of State Medical Boards PDMP prescription drug-monitoring program NSAID nonsteroidal anti-inflammatory drug VA/DoD Department of Veterans Affairs/Department of Defense THE OPIOID EPIDEMIC Opioid analgesia can be highly effective for a wide range of pain syndromes. However, there are unintended consequences of such potent analgesia, including potential for recreational use, physiological and psychological dependence, and lethal overdose. Worldwide, an opioid epidemic rages; the United Nations estimates between 26 and 36 million people illicitly use opiates annually.1 Globally, approximately 69 000 people die from opioid overdose each year, more than from suicide and major trauma combined.2 In the United States, these statistics are even more disturbing. Although comprising less than 5% of the world's population, Americans consume 80% of the global opioid supply.3 According to a comprehensive assessment of opioid use in the United States, published by the pharmaceutical management company Express Scripts (St Louis, Missouri), 36 million opioid prescriptions were filled by 6.8 million Americans between 2009 and 2013.4 During this time span, there was a 9.2% decline in the number of patients filling opioid prescriptions, but the total number of prescriptions overall increased by 8.4%. Furthermore, almost half (46.9%) of these patients were identified as chronic opioid users, using these medications for more than 3 yr. Deaths from prescription opioid overdose have risen sharply over the last several decades.5 The US Centers for Disease Control and Prevention (CDC) reported 16 651 deaths due to prescription opioid overdose in 2010.6 Between 2013 and 2014, the death rate associated with natural and semisynthetic opioids, heroin, and synthetic opioids (fentanyl) increased 9%, 26%, and 80%, respectively.7 Prior prescription opioid dependence has been identified as a major risk factor for future heroin abuse,8 and increasing opioid prescriptions may partially account for a resurgence of heroin use in the United States, which nearly doubled between 2005 and 2012.9 The US CDC declared the prescription drug crisis an epidemic in 2012.10 As a result of enhanced public health interventions since that time, the overall number of opioid prescriptions has fallen by an estimated 12% to 18%.11 Despite this progress, the overall death rate from opioids has paradoxically risen during this time period: in 2015, opioids (including heroin) led to 33 091 deaths.7 According to the CDC, almost half (45%) of all opioid prescriptions written in the United States are written by primary care physicians.12 Surgeons, both generalists and subspecialists, account for 10% of opioid prescriptions. However, the rate of prescribing opioids, compared to nonopioid alternatives, was higher in surgeons compared to primary care practitioners, 37% vs 6%, respectively. In one study, orthopedic surgeons were found to more commonly prescribe opioid analgesics to patients with chronic, noncancer pain, compared to physicians from other medical specialties.13 According to a 2016 Washington Post/Kaiser Family Foundation survey of chronic opioid users, more US adults attribute the opioid epidemic to physicians who prescribe painkillers, as opposed to patients taking prescribed drugs or to the prescription drug companies.14 OPIOIDS AND NEUROSURGERY Surgical subspecialists, including neurosurgeons, are particularly vulnerable to overprescribing opioid analgesics, given the relative high exposure to pain-related conditions. According to a 2014 study of Medicaid patients who were prescribed opioids for chronic pain, the most common associated diagnoses were back pain (55%), neck pain (25%), and headache (8%).13 Analysis of US national survey data between 1997 and 2006 highlights a 600% increase in spending on opioids for spine problems, a result of both higher prices and increased utilization.15 Within the same time period, there was only a 49% increase in number of patients seeking care for spine-related diagnoses. According to one retrospective analysis published in 2011, of patients who presented with low back pain, 42% were prescribed opioids within 3 mo of index diagnosis, whereas only 2% eventually underwent surgery.16 For patients undergoing spine surgery, preoperative opioid use has been correlated with long-term postoperative opioid dependence,17-19 as well as increased length of hospital stay following surgery.20 According to one systematic review published in 2015, several randomized controlled trials have demonstrated some efficacy of opioids on chronic low back pain. The implications, however, are limited, as no trial lasted more than 4 mo and all had high dropout rates (>20%) due to adverse effects or inefficacy.21 Furthermore, pain relief with opioid use was enhanced by only about 30%. Although the analgesic effects of opioids for acute low back pain have been well established,22 the clinical practicality of opioids for acute pain is more controversial. In one national assessment of patients presenting with new-onset low back pain, those prescribed high doses of opioids within the first 15 d of treatment were more likely to have prolonged disability, higher overall medical costs, higher risk for eventual surgery, and chronic opioid use.23 In another study of primary care patients presenting with low back pain, one-third were prescribed opioids in the acute setting.24 At 6-mo follow-up, patients taking opioids were found to have worse functionality, compared to patients receiving NSAID (nonsteroidal anti-inflammatory drug) therapy. Despite significant controversy, opioids universally remain the gold standard for intraoperative and immediate postoperative analgesia.25 Adequate postoperative pain management correlates with improved patient experience and functional outcomes.26 Therefore, with a relatively low risk of opioid addiction when used in the short term, anesthesiologists and surgeons alike frequently use opioids to control postoperative pain.25-27 According to the 2012 American Society of Anesthesiologists practice guidelines for acute pain management in the perioperative setting,28 systemic opioids are recommended for postoperative analgesia, after considering the risks and benefits for the individual patient. Yet, even in opioid-naïve patients, the rate of prolonged postoperative opioid use ranges between 3% and 7% in large, population studies, regardless of the invasiveness of surgery.29,30 Studies assessing opioid use following craniotomy have demonstrated efficacy and safety of short-term therapy, typically limited to the inpatient setting.31 Morphine use after craniotomy has been shown to improve postoperative pain, with minimal risk when used in appropriate doses.32 Patient controlled analgesia with opioids after craniotomy safely and effectively provides subjective pain improvement.33,34 Adjunctive treatments, such as acetaminophen and dexamethasone, provide a synergistic effect when used with opioids for postoperative pain.31,35 Intraoperative local anesthetic infiltration and scalp nerve blockade are associated with less regional postoperative pain and lower opioid requirements after craniotomy.36,37 Overall, these data suggest that opioids are safe and effective analgesics following cranial surgery, especially in the immediate postoperative period. The incidence of chronic headache syndromes following craniotomy is highly variable in the literature.38-40 Chronic headaches are more common following posterior fossa or skull base surgery, compared to supratentorial craniotomies. Fortunately, postcraniotomy headaches typically improve and resolve spontaneously over time. Various pharmacological (NSAIDs, tricyclic antidepressants, valproic acid) and nonpharmacological (physical therapy, cognitive behavioral therapy, acupuncture) treatment modalities have been found to be effective.31 There is a distinct lack of data for the use of opioids in chronic, postcraniotomy headache. Postoperative analgesia following spinal surgery can be more challenging. Up to 65% of patients with spinal pathology have used opioids prior to surgery.41,42 Fortunately, nearly all (99.9%) opioid-naïve patients who undergo spinal surgery discontinue opioid use by 6 mo postoperatively.41 In contrast, patients with preoperative opioid use have been found to have worse postoperative pain and disability following both lumbar and cervical spinal surgery, compared to opioid-naïve patients.42-44 Furthermore, preoperative opioid use is associated with greater immediate postoperative opioid demand and higher rates of delayed opioid dependence following spinal surgery.17,19 The recent proliferation of chronic opioid use has challenged postoperative pain management for anesthesiologists and surgeons alike. Inadequate postoperative analgesia in opioid-tolerant patients is not uncommon, due both to provider prejudice and fear of overmedicating.45 Despite these preconceptions, opioids must be administered at higher doses and greater frequencies to maintain equivalent analgesic levels in an opioid-tolerant patient.46 As an adjunct, regional and nonopioid analgesics should be included as part of a multimodal regimen to reduce overall opioid consumption.47,48 With increased recognition of the US opioid crisis, further research into opioid-sparing analgesia is ongoing. Two meta-analyses published in 2017 highlight the use of supplemental perioperative ketamine49 and gabapentin50 in reducing opioid consumption up to 24 h after spinal surgery. Perioperative treatment with dexamethasone has not been shown to reduce postoperative opioid consumption.51 The range of pathologies inherent in cranial and spinal neurosurgery requires neurosurgeons to be familiar with various pain syndromes and their indicated treatment strategies. In 2010, the World Health Organization (WHO) declared pain management to be a fundamental human right.52,53 Thus, as a neurosurgeon, it is essential to understand the current opioid prescribing guidelines and contemporary public health policy initiatives regarding the US opioid epidemic. CONTEMPORARY CHRONIC OPIOID USE GUIDELINES Over the last decade, several institutional bodies have released evidence-based recommendations for medical practitioners prescribing opioids. Extensive research efforts have proven the efficacy of opioids for chronic cancer pain,54-57 acute postoperative pain,58-60 and short-term, chronic noncancer pain.61 However, the prescription of opioids for long-term, chronic, noncancer pain is more controversial. Thus, chronic opioid prescribing guidelines have been created to assist practitioners in effectively treating pain for this patient population. The American Pain Society–American Academy of Pain Medicine (APS – AAPM) released evidence-based guidelines on opioid prescribing for chronic noncancer pain in 2009.62 The guidelines were composed by a panel of multidisciplinary experts, and intended for widespread use in primary care and subspecialty pain management. A summary of the recommendations can be reviewed in the Table. The APS–AAPM guidelines strongly recommend a clinician–patient discussion of the risks and benefits of opioid use prior to the initiation of therapy, culminating in a personalized management plan. The group also suggests the integration of psychotherapeutic interventions concomitant with chronic opioid therapy. TABLE. Summary of Recommendations From Various Physician Organizations and Government Institutions APS – AAPM 2009  Patient selection and risk stratification  Before initiating opioid therapy, conduct a history, examination, and appropriate testing, including an assessment of risk of substance abuse, misuse, or addiction.  If chronic pain is moderate or severe, consider a trial of opioid therapy, especially if pain is impacting quality of life and potential benefits outweigh potential harms.  A benefit-to-harm evaluation should be performed before, and ongoing during, opioid therapy.  Informed consent and opioid management plans  When starting opioid therapy, informed consent should be obtained. A continuing discussion should include goals, expectations, risks, and alternatives.  Consider a written opioid management plan to document patient and clinician responsibilities, expectations, and education.  Initiation and titration of opioid therapy  Clinicians and patients should regard initial treatment with opioids as a therapeutic trial to determine whether opioids are appropriate.  Opioid selection, initial dosing, and titration should be individualized according to patient's health status, previous exposure to opioids, attainment of therapeutic goals, and predicted or observed harms.  There is insufficient evidence to recommend short- vs long-acting opioids, or as needed vs scheduled opioids.  Monitoring  Reassess patients on chronic opioid therapy periodically and as warranted by changing circumstances. Monitoring should include pain intensity, level of functioning, progress toward therapeutic goals, adverse events, and adherence to prescribed therapies.  Patients at high risk for aberrant drug-related behaviors should be periodically screened with urine drug tests for adherence to the plan of care. (strong recommendation)  Patients not at high risk for aberrant drug-related behaviors should be periodically screened with urine drug tests for adherence to the plan of care. (weak recommendation)  High-risk patients  Clinicians may consider opioid therapy for patients with chronic pain and history of drug abuse, psychiatric issues, or serious aberrant drug-related behaviors only if they are able to implement more frequent and stringent monitoring parameters.  Evaluate patients engaging in aberrant drug-related behaviors for appropriateness of opioid therapy or need for restructuring of therapy, referral for assistance in management, or discontinuation of opioid therapy.  Dose escalation, high-dose opioid therapy, opioid rotation, and indications for discontinuation of opioid therapy  When repeated dose escalations occur, evaluate potential causes and reassess benefits relative to harms.  In patients who require relatively high doses of opioid, evaluate for opioid-related adverse effects, changes in health status, and adherence to treatment plan, and consider more frequent follow up.  Consider opioid rotation when patients experience intolerable adverse effects or inadequate benefit despite dose increase.  Taper off opioid therapy in patients who engage in repeated aberrant drug-related behaviors or drug abuse/diversion, experience no progress toward meeting therapeutic goals, or experience intolerable adverse effects.  Opioid-related adverse effects  Anticipate, identify, and treat common opioid-associated adverse effects  Use of psychotherapeutic co-interventions  As chronic, noncancer pain is often a complex biopsychosocial condition, clinicians who prescribe chronic opioid therapy should routinely integrate psychotherapeutic interventions, functional restoration, interdisciplinary therapy, and other adjunctive nonopioid therapies.  Driving and work safety  Counsel patients on chronic opioid therapy about transient or lasting cognitive impairment that may affect driving and work safety.  Identifying a medical home and when to obtain consultation  Patients on chronic opioid therapy should identify a clinician who accepts primary responsibility for their overall medical care. This clinician may not necessarily prescribe opioid therapy, but should coordinate consultation and communication between other members of the patient's care team.  Clinicians should pursue consultation, including interdisciplinary pain management, when patients may benefit from expert skill or resources.  Breakthrough pain  In patients on around-the-clock opioid therapy, consider as-needed opioids based upon an initial and ongoing analysis of therapeutic benefit vs risk.  Opioids in pregnancy  Counsel women of childbearing potential about the risks and benefits of chronic opioid therapy during pregnancy and after delivery. Encourage minimal or no use of opioids during pregnancy, unless potential benefits outweigh risks. If opioids are used during pregnancy, clinicians should be prepared to anticipate and manage risks to the patient and newborn.  Opioid policies  Clinicians should be aware of current federal and state laws, regulatory guidelines, and policy statements that govern the medical use of opioids for chronic, noncancer pain.  APS – AAPM 2009  Patient selection and risk stratification  Before initiating opioid therapy, conduct a history, examination, and appropriate testing, including an assessment of risk of substance abuse, misuse, or addiction.  If chronic pain is moderate or severe, consider a trial of opioid therapy, especially if pain is impacting quality of life and potential benefits outweigh potential harms.  A benefit-to-harm evaluation should be performed before, and ongoing during, opioid therapy.  Informed consent and opioid management plans  When starting opioid therapy, informed consent should be obtained. A continuing discussion should include goals, expectations, risks, and alternatives.  Consider a written opioid management plan to document patient and clinician responsibilities, expectations, and education.  Initiation and titration of opioid therapy  Clinicians and patients should regard initial treatment with opioids as a therapeutic trial to determine whether opioids are appropriate.  Opioid selection, initial dosing, and titration should be individualized according to patient's health status, previous exposure to opioids, attainment of therapeutic goals, and predicted or observed harms.  There is insufficient evidence to recommend short- vs long-acting opioids, or as needed vs scheduled opioids.  Monitoring  Reassess patients on chronic opioid therapy periodically and as warranted by changing circumstances. Monitoring should include pain intensity, level of functioning, progress toward therapeutic goals, adverse events, and adherence to prescribed therapies.  Patients at high risk for aberrant drug-related behaviors should be periodically screened with urine drug tests for adherence to the plan of care. (strong recommendation)  Patients not at high risk for aberrant drug-related behaviors should be periodically screened with urine drug tests for adherence to the plan of care. (weak recommendation)  High-risk patients  Clinicians may consider opioid therapy for patients with chronic pain and history of drug abuse, psychiatric issues, or serious aberrant drug-related behaviors only if they are able to implement more frequent and stringent monitoring parameters.  Evaluate patients engaging in aberrant drug-related behaviors for appropriateness of opioid therapy or need for restructuring of therapy, referral for assistance in management, or discontinuation of opioid therapy.  Dose escalation, high-dose opioid therapy, opioid rotation, and indications for discontinuation of opioid therapy  When repeated dose escalations occur, evaluate potential causes and reassess benefits relative to harms.  In patients who require relatively high doses of opioid, evaluate for opioid-related adverse effects, changes in health status, and adherence to treatment plan, and consider more frequent follow up.  Consider opioid rotation when patients experience intolerable adverse effects or inadequate benefit despite dose increase.  Taper off opioid therapy in patients who engage in repeated aberrant drug-related behaviors or drug abuse/diversion, experience no progress toward meeting therapeutic goals, or experience intolerable adverse effects.  Opioid-related adverse effects  Anticipate, identify, and treat common opioid-associated adverse effects  Use of psychotherapeutic co-interventions  As chronic, noncancer pain is often a complex biopsychosocial condition, clinicians who prescribe chronic opioid therapy should routinely integrate psychotherapeutic interventions, functional restoration, interdisciplinary therapy, and other adjunctive nonopioid therapies.  Driving and work safety  Counsel patients on chronic opioid therapy about transient or lasting cognitive impairment that may affect driving and work safety.  Identifying a medical home and when to obtain consultation  Patients on chronic opioid therapy should identify a clinician who accepts primary responsibility for their overall medical care. This clinician may not necessarily prescribe opioid therapy, but should coordinate consultation and communication between other members of the patient's care team.  Clinicians should pursue consultation, including interdisciplinary pain management, when patients may benefit from expert skill or resources.  Breakthrough pain  In patients on around-the-clock opioid therapy, consider as-needed opioids based upon an initial and ongoing analysis of therapeutic benefit vs risk.  Opioids in pregnancy  Counsel women of childbearing potential about the risks and benefits of chronic opioid therapy during pregnancy and after delivery. Encourage minimal or no use of opioids during pregnancy, unless potential benefits outweigh risks. If opioids are used during pregnancy, clinicians should be prepared to anticipate and manage risks to the patient and newborn.  Opioid policies  Clinicians should be aware of current federal and state laws, regulatory guidelines, and policy statements that govern the medical use of opioids for chronic, noncancer pain.  FSMB 2013  Understanding pain  In order to cautiously prescribe opioids, physicians must understand the relevant pharmacological and clinical issues in the use of such analgesics, and carefully structure a treatment plan that reflects the particular benefits and risks of opioid use for each individual patient.  Patient evaluation and risk stratification  Prior to initiation of opioid therapy, a full assessment should be made, including screening for depression and mental health disorders, as well as prior substance abuse. Recommend use of a validated screening tool, such as the Screener and Opioid Assessment for Patients with Pain. Consult a state's prescription drug monitoring program (PDMP) for previously prescribed controlled substances.  Development of treatment plan and goals  The patient's goals of treatment should be reasonably attainable. The treatment plan should include both pharmacological and nonpharmacological therapies.  Informed consent and treatment agreement  Use of a written informed consent and treatment agreement (sometimes referred to as a “treatment contract”) is recommended.  Initiating an opioid trial  Generally, safer alternative treatments should be considered before initiating opioid therapy for chronic, nonmalignant pain. Opioid therapy should be presented to the patient as a therapeutic trial or test for a defined period of time (usually no more than 90 d) and with specified evaluation points.  The physician should explain that progress will be carefully monitored for both benefit and harm in terms of the effects of opioids on the patient's level of pain, function, and quality of life, as well as to identify any adverse events or risks to safety.  Ongoing monitoring and adapting the treatment plan  The physician should regularly review the patient's progress, including any new information about the etiology of the pain or the patient's overall health and level of function.  Continuation, modification, or termination of opioid therapy for pain should be contingent on the physician's evaluation of (1) evidence of the patient's progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as overdose or diversion.  Periodic drug testing  Periodic drug testing may be useful in monitoring adherence to the treatment plan, as well as in detecting the use of nonprescribed drugs.  Consultation and referral  The treating physician should seek a consultation with, or refer the patient to, a pain, psychiatry, addiction or mental health specialist as needed.  Discontinuing opioid therapy  Throughout the course of opioid therapy, the physician and patient should regularly weigh the potential benefits and risks of continued treatment and determine whether such treatment remains appropriate.  Reasons for discontinuing opioid therapy include resolution of the underlying painful condition, emergence of intolerable side effects, inadequate analgesic effect, failure to improve the patient's quality of life despite reasonable titration, deteriorating function, or significant aberrant medication use.  Medical records  The medical record must include all prescription orders for opioid analgesics and other controlled substances, whether written or telephoned. In addition, written instructions for the use of all medications should be given to the patient and documented in the record.  Good records demonstrate that a service was provided to the patient and establish that the service provided was medically necessary. Even if the outcome is less than optimal, thorough records protect the physician as well as the patient.  Compliance with controlled substance laws and regulations  To prescribe, dispense or administer controlled substances, the physician must be registered with the DEA, licensed by the state in which he or she practices, and comply with applicable federal and state regulations.  FSMB 2013  Understanding pain  In order to cautiously prescribe opioids, physicians must understand the relevant pharmacological and clinical issues in the use of such analgesics, and carefully structure a treatment plan that reflects the particular benefits and risks of opioid use for each individual patient.  Patient evaluation and risk stratification  Prior to initiation of opioid therapy, a full assessment should be made, including screening for depression and mental health disorders, as well as prior substance abuse. Recommend use of a validated screening tool, such as the Screener and Opioid Assessment for Patients with Pain. Consult a state's prescription drug monitoring program (PDMP) for previously prescribed controlled substances.  Development of treatment plan and goals  The patient's goals of treatment should be reasonably attainable. The treatment plan should include both pharmacological and nonpharmacological therapies.  Informed consent and treatment agreement  Use of a written informed consent and treatment agreement (sometimes referred to as a “treatment contract”) is recommended.  Initiating an opioid trial  Generally, safer alternative treatments should be considered before initiating opioid therapy for chronic, nonmalignant pain. Opioid therapy should be presented to the patient as a therapeutic trial or test for a defined period of time (usually no more than 90 d) and with specified evaluation points.  The physician should explain that progress will be carefully monitored for both benefit and harm in terms of the effects of opioids on the patient's level of pain, function, and quality of life, as well as to identify any adverse events or risks to safety.  Ongoing monitoring and adapting the treatment plan  The physician should regularly review the patient's progress, including any new information about the etiology of the pain or the patient's overall health and level of function.  Continuation, modification, or termination of opioid therapy for pain should be contingent on the physician's evaluation of (1) evidence of the patient's progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as overdose or diversion.  Periodic drug testing  Periodic drug testing may be useful in monitoring adherence to the treatment plan, as well as in detecting the use of nonprescribed drugs.  Consultation and referral  The treating physician should seek a consultation with, or refer the patient to, a pain, psychiatry, addiction or mental health specialist as needed.  Discontinuing opioid therapy  Throughout the course of opioid therapy, the physician and patient should regularly weigh the potential benefits and risks of continued treatment and determine whether such treatment remains appropriate.  Reasons for discontinuing opioid therapy include resolution of the underlying painful condition, emergence of intolerable side effects, inadequate analgesic effect, failure to improve the patient's quality of life despite reasonable titration, deteriorating function, or significant aberrant medication use.  Medical records  The medical record must include all prescription orders for opioid analgesics and other controlled substances, whether written or telephoned. In addition, written instructions for the use of all medications should be given to the patient and documented in the record.  Good records demonstrate that a service was provided to the patient and establish that the service provided was medically necessary. Even if the outcome is less than optimal, thorough records protect the physician as well as the patient.  Compliance with controlled substance laws and regulations  To prescribe, dispense or administer controlled substances, the physician must be registered with the DEA, licensed by the state in which he or she practices, and comply with applicable federal and state regulations.  CDC 2016  Determining when to initiate or continue opioids for chronic pain  Nonpharmacological and nonopioid pharmacological therapies are preferred for chronic pain.  Before starting opioid therapy, clinicians should establish realistic treatment goals for pain and function. Continue therapy only if there is meaningful improvement in pain and function that outweighs risks to patient safety.  Before starting and periodically during opioid therapy, discuss known risks and realistic benefits.  Opioid selection, dosage, duration, follow-up, and discontinuation  When starting therapy for chronic pain, prescribe immediate-release, rather than extended-release/long-acting opioids.  Use lowest effective dosage when starting opioid therapy.  When treating acute pain, use lowest effective dosage of immediate-release opioids, and prescribe no greater quantity than needed for expected duration of pain. Usually 3 d or less will be sufficient; rarely will more than 7 d be necessary.  Evaluate benefits and harms with patients within 1 to 4 wk of initiating opioid therapy, or after dose escalation. If benefits do not outweigh harms, optimize other therapies and work with patients to taper and discontinue opioids.  Assessing risk and addressing harms or opioid use  Before starting and during continuation of opioid therapy, evaluate for risk factors of opioid-related harms. Incorporate in to the management plan strategies to mitigate risk, including offering naloxone, when risk factors present (history of overdose, history of substance abuse, higher opioid dosages, concurrent benzodiazepine use).  Review patient's history of controlled substance prescriptions using state PDMP, when starting, and periodically during, opioid therapy. Determine whether patient is receiving opioid dosages or combinations that put him or her at high risk for overdose.  Consider urine drug testing to assess for prescribed medications, as well as other controlled prescription drugs and illicit drugs.  Avoid prescribing opioids and benzodiazepines concurrently.  Offer or arrange evidence-based treatment for patients with opioid use disorder (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies).  CDC 2016  Determining when to initiate or continue opioids for chronic pain  Nonpharmacological and nonopioid pharmacological therapies are preferred for chronic pain.  Before starting opioid therapy, clinicians should establish realistic treatment goals for pain and function. Continue therapy only if there is meaningful improvement in pain and function that outweighs risks to patient safety.  Before starting and periodically during opioid therapy, discuss known risks and realistic benefits.  Opioid selection, dosage, duration, follow-up, and discontinuation  When starting therapy for chronic pain, prescribe immediate-release, rather than extended-release/long-acting opioids.  Use lowest effective dosage when starting opioid therapy.  When treating acute pain, use lowest effective dosage of immediate-release opioids, and prescribe no greater quantity than needed for expected duration of pain. Usually 3 d or less will be sufficient; rarely will more than 7 d be necessary.  Evaluate benefits and harms with patients within 1 to 4 wk of initiating opioid therapy, or after dose escalation. If benefits do not outweigh harms, optimize other therapies and work with patients to taper and discontinue opioids.  Assessing risk and addressing harms or opioid use  Before starting and during continuation of opioid therapy, evaluate for risk factors of opioid-related harms. Incorporate in to the management plan strategies to mitigate risk, including offering naloxone, when risk factors present (history of overdose, history of substance abuse, higher opioid dosages, concurrent benzodiazepine use).  Review patient's history of controlled substance prescriptions using state PDMP, when starting, and periodically during, opioid therapy. Determine whether patient is receiving opioid dosages or combinations that put him or her at high risk for overdose.  Consider urine drug testing to assess for prescribed medications, as well as other controlled prescription drugs and illicit drugs.  Avoid prescribing opioids and benzodiazepines concurrently.  Offer or arrange evidence-based treatment for patients with opioid use disorder (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies).  ASIPP 2017  Initial steps  Comprehensive assessment and documentation  Screening for opioid abuse  Utilization of PDMPs  Utilization of urine drug testing  Establish appropriate physical or psychological diagnosis  Consider imaging, physical diagnosis, and psychological status to collaborate with subjective complaints  Establish medical necessity based on average moderate to severe pain (≥4/10) and/or disability  Stratify patients based on risk  Establish treatment goals of opioid therapy with regard to pain relief and improvement in function  Obtain robust opioid agreement, followed by all parties  Assessment of effectiveness of long-term opioid therapy  Initiate opioid therapy with low-dose, short-acting drugs, with appropriate monitoring  Consider up to 40 morphine milligram equivalent (MME) as low dose, 41 to 90 MME moderate dose, and greater than 91 MME high dose  Avoid long-acting opioid drugs for initiation of opioid therapy  Recommend methadone only for use after failure of other opioid therapy and only by clinicians with specific training in its risks and uses  Understand and educate the patients of the effectiveness and adverse consequences  Similar effectiveness for long-acting and short-acting opioids with increased adverse consequences of long-acting opioids  Periodically assess pain relief and/or functional status improvement of ≥30% without adverse consequences  Recommend long-acting or high-dose opioids only in specific circumstances with severe intractable pain  Monitoring for adherence and side effects  Monitor for adherence, abuse, and noncompliance by urine drug tests and PDMPs  Monitor patients on methadone with an electrocardiogram periodically  Monitor for side effects including constipation and manage them appropriately, including discontinuation of opioids when indicated  Final phase  May continue with monitoring with continued medical necessity, with appropriate outcomes  Discontinue opioid therapy for lack of response, adverse consequences, and abuse with rehabilitation  ASIPP 2017  Initial steps  Comprehensive assessment and documentation  Screening for opioid abuse  Utilization of PDMPs  Utilization of urine drug testing  Establish appropriate physical or psychological diagnosis  Consider imaging, physical diagnosis, and psychological status to collaborate with subjective complaints  Establish medical necessity based on average moderate to severe pain (≥4/10) and/or disability  Stratify patients based on risk  Establish treatment goals of opioid therapy with regard to pain relief and improvement in function  Obtain robust opioid agreement, followed by all parties  Assessment of effectiveness of long-term opioid therapy  Initiate opioid therapy with low-dose, short-acting drugs, with appropriate monitoring  Consider up to 40 morphine milligram equivalent (MME) as low dose, 41 to 90 MME moderate dose, and greater than 91 MME high dose  Avoid long-acting opioid drugs for initiation of opioid therapy  Recommend methadone only for use after failure of other opioid therapy and only by clinicians with specific training in its risks and uses  Understand and educate the patients of the effectiveness and adverse consequences  Similar effectiveness for long-acting and short-acting opioids with increased adverse consequences of long-acting opioids  Periodically assess pain relief and/or functional status improvement of ≥30% without adverse consequences  Recommend long-acting or high-dose opioids only in specific circumstances with severe intractable pain  Monitoring for adherence and side effects  Monitor for adherence, abuse, and noncompliance by urine drug tests and PDMPs  Monitor patients on methadone with an electrocardiogram periodically  Monitor for side effects including constipation and manage them appropriately, including discontinuation of opioids when indicated  Final phase  May continue with monitoring with continued medical necessity, with appropriate outcomes  Discontinue opioid therapy for lack of response, adverse consequences, and abuse with rehabilitation  VA/DoD 2017  Initiation and continuation of opioids  Recommend against long-term opioid therapy for chronic pain, rather recommend nonpharmacological and nonopioid treatments  If prescribing opioid therapy, recommend short duration (<90 d)  For patients on chronic opioid therapy, recommend ongoing risk mitigation strategies, assessment for abuse disorder, and consideration for tapering when risk exceeds benefits  Recommend against long-term opioid therapy in patients with untreated substance abuse disorder  Recommend against the concurrent use of benzodiazepines and opioids  Recommend against long-term opioid therapy for patients under 30 yr, secondary to a higher risk of opioid use disorder and overdose  Risk mitigation  Recommend implementing risk mitigation strategies upon initiation of long-term opioid therapy, starting with an informed consent, conversation covering the risks and benefits of opioid therapy as well as alternative therapies  Recommend assessing suicide risk  Recommend re-evaluating risks and benefits of continued opioid therapy at least every 3 mo  Type, dose, follow-up, and taper of opioids  If prescribing opioids, recommend prescribing the lowest dose  As opioid dosage and risk increase, recommend more frequent monitoring for adverse events.  Recommend against doses over 90 MME for treating chronic pain  Recommend against prescribing long-acting opioids for acute pain, as an as-needed medication, or on initiation of therapy  Recommend tapering to reduced dose or discontinuation of opioids when risks of long-term opioid therapy outweigh benefits  Individualize opioid tapering based on risk assessment and patient needs  Recommend interdisciplinary care that addresses pain, substance use disorders, and mental health problems for patients presenting with high-risk behavior  Recommend offering medication assisted treatment for opioid use disorder to patients with chronic pain and opioid use disorder  Opioid therapy for acute pain  Recommend alternatives to opioids for mild-to-moderate acute pain  If take-home opioids are prescribed, recommend prescribing low-dose, immediate-release opioids, with reassessment after 3 to 5 d to determine if adjustments or continuing opioid therapy is indicated  Opioid risks and alternatives should be discussed when prescribing opioids  VA/DoD 2017  Initiation and continuation of opioids  Recommend against long-term opioid therapy for chronic pain, rather recommend nonpharmacological and nonopioid treatments  If prescribing opioid therapy, recommend short duration (<90 d)  For patients on chronic opioid therapy, recommend ongoing risk mitigation strategies, assessment for abuse disorder, and consideration for tapering when risk exceeds benefits  Recommend against long-term opioid therapy in patients with untreated substance abuse disorder  Recommend against the concurrent use of benzodiazepines and opioids  Recommend against long-term opioid therapy for patients under 30 yr, secondary to a higher risk of opioid use disorder and overdose  Risk mitigation  Recommend implementing risk mitigation strategies upon initiation of long-term opioid therapy, starting with an informed consent, conversation covering the risks and benefits of opioid therapy as well as alternative therapies  Recommend assessing suicide risk  Recommend re-evaluating risks and benefits of continued opioid therapy at least every 3 mo  Type, dose, follow-up, and taper of opioids  If prescribing opioids, recommend prescribing the lowest dose  As opioid dosage and risk increase, recommend more frequent monitoring for adverse events.  Recommend against doses over 90 MME for treating chronic pain  Recommend against prescribing long-acting opioids for acute pain, as an as-needed medication, or on initiation of therapy  Recommend tapering to reduced dose or discontinuation of opioids when risks of long-term opioid therapy outweigh benefits  Individualize opioid tapering based on risk assessment and patient needs  Recommend interdisciplinary care that addresses pain, substance use disorders, and mental health problems for patients presenting with high-risk behavior  Recommend offering medication assisted treatment for opioid use disorder to patients with chronic pain and opioid use disorder  Opioid therapy for acute pain  Recommend alternatives to opioids for mild-to-moderate acute pain  If take-home opioids are prescribed, recommend prescribing low-dose, immediate-release opioids, with reassessment after 3 to 5 d to determine if adjustments or continuing opioid therapy is indicated  Opioid risks and alternatives should be discussed when prescribing opioids  ASIPP = American Society of Interventional Pain Physicians; APS – AAPM = American Pain Society – American Academy of Pain Medicine; CDC = Centers for Disease Control and Prevention; DEA = Drug Enforcement Agency; FSMB = Federation of State Medical Boards; VA/DoD = Department of Veterans Affairs/Department of Defense View Large The Federation of State Medical Boards (FSMB) adopted its “Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain” in July 2013.63 The stated mission was to provide a “resource for use by state medical boards in educating their licensees about cautious and responsible prescribing of controlled substances while alleviating fears of regulatory scrutiny.” A summary of FSMB guideline recommendations is included in the Table. The FSMB guidelines specifically highlight the importance of the medical record in documenting discussions between clinician and patient, especially regarding risks of chronic opioid therapy and indications for treatment. The guidelines recommend thorough record keeping in order to “protect the physician as well as the patient.” In 2016, the US CDC released its Guideline for Prescribing Opioids for Chronic Pain.64 The stated purpose was “to ensure that clinicians and patients consider safer and more effective treatment, improve patient outcomes such as reduced pain and improved function, and reduce the number of persons who develop opioid use disorder, overdose, or experience other adverse events related to these drugs.” Assimilating the best available clinical research, with review by a federally chartered advisory committee, the CDC proposed several evidence-based recommendations in its guidelines. These recommendations are summarized in the Table. Importantly, the CDC concludes that for chronic pain, nonpharmacological therapy and nonopioid pharmacological therapy are preferred. When starting opioid therapy, the CDC recommends that practitioners and patients establish overall treatment goals, discuss risks and benefits of opioid use, and plan frequent follow-up visits for reassessment. The CDC also suggests that clinicians must frequently assess patients for opioid-related harms, and consult a prescription drug-monitoring program (PDMP) for a patient's individual controlled substance use history. Furthermore, if risk factors for an opioid use disorder exist, the guidelines serve to aid clinicians in both preventing prescription misuse and treating medication dependence. Based on these guidelines, the CDC developed a checklist for prescribing opioids in patients with chronic pain.65 This 1-page guide serves as a succinct reference for clinicians to determine a patient's candidacy for opioid therapy (Figure). FIGURE. View largeDownload slide The US CDC checklist for chronic opioid prescribing, based on the 2016 CDC guidelines. Freely available on the CDC website (https://www.cdc.gov/drugoverdose/pdf/pdo_checklist-a.pdf). Public Domain, US Government work. FIGURE. View largeDownload slide The US CDC checklist for chronic opioid prescribing, based on the 2016 CDC guidelines. Freely available on the CDC website (https://www.cdc.gov/drugoverdose/pdf/pdo_checklist-a.pdf). Public Domain, US Government work. As suggested in the CDC guidelines, a federal effort to address chronic pain management on a population-level was developed by the National Institutes of Health, and outlined in the 2016 report, National Pain Strategy.66 A significant focus of this work pertains to prevention of illnesses and injuries that lead to chronic pain. The report also suggests targeting health care payers to strengthen coverage for nonpharmacological therapy, patient counseling, and medication-assisted treatment. In order to provide a “consistent philosophy” among clinicians prescribing opioids, the American Society of Interventional Pain Physicians (ASIPP) released their “Responsible, Safe, and Effective Prescription of Opioid for Chronic, Non-Cancer Pain” in early 2017.67 A summary of recommendations can be viewed in the Table. Overall, the ASIPP guidelines imply a more liberal approach to opioid prescribing. The authors describe an “overwhelming opposition” to the 2016 CDC opioid prescribing guidelines, suggesting “a disconnect between authorities, regulators, academic opponents, and practicing physicians and chronic pain patients.”67 The group cites a 2016 Washington Post/Kaiser Family Foundation survey of long-term prescription painkiller users and their household members, in which 92% respondents claimed a reduction in pain with opioid use, and 57% report a better quality of life with chronic opioid use.14 However, the same survey suggests that household members are more likely to believe a patient taking chronic opioids is addicted or dependent, and that his or her prescription drug use contributes negatively to finances, relationships, and health. Most recently, in early 2017, the US Department of Veterans Affairs/Department of Defense (VA/DoD) released their third version of “Clinical Practice Guidelines for Opioid Therapy for Chronic Pain.”68 As stated, these guidelines serve to provide a framework for clinicians in evaluating and managing patients with chronic pain, with an emphasis on patient-centric care. The VA/DoD guidelines are summarized in the Table. In contrast to the ASIPP guidelines, the VA/DoD explicitly recommend against prescribing opioids for chronic pain. Furthermore, these guidelines are the only to include commentary on opioid prescribing for acute pain. Based on these recommendations, the VA/DoD developed several patient-centric algorithms for determining appropriateness of opioid therapy, initiation of opioid therapy, tapering opioid therapy, and managing patients currently on opioid therapy. These are freely available on the VA/DoD website,69 and serve to allow clinicians to personalize their management decisions for a given patient, at each stage of therapy. CONTEMPORARY PUBLIC POLICY INITIATIVES Since the declaration of a US opioid epidemic by the CDC, there have been significant, bipartisan public health policy efforts enacted in order to curb the expansion of both opioid use and dependence. With the passage of the US Patient Protection and Affordable Care Act (ACA) in March 2010, an expansion of the state-federal low-income health insurance program, Medicaid, included mandates for several essential benefits, including substance abuse coverage. Subsequently, in July 2016, President Barack Obama signed into law the Comprehensive Addiction and Recovery Act.70 This bill improved access to addiction and overdose treatment, by expanding prescribing privileges for medication-assisted treatment (buprenorphine) to nurse practitioners and physician assistants, and facilitating access to naloxone for those at risk of overdose. Furthermore, the act allocated further funding for the improvement of state-based PDMPs. As part of the ACA, the meaningful use of electronic health records became mandatory, and targets for electronic prescribing were set for providers (50% of all prescriptions by 2014). The Electronic Prescribing of Controlled Substances (EPCS) initiative by the US Department for Health and Human Services was established specifically as a monitoring program for opioid prescribing.71 Presently, medical practitioners in 3 states (New York, Maine, and Minnesota) are required to be fully compliant with EPCS, such that no paper prescriptions for opioids are written, in an effort to track opioid prescribing by clinicians and overuse by patients. In March 2017, President Donald Trump presented an executive order establishing the President's Commission on Combating Drug Addiction and the Opioid Crisis,72 and appointed as chairman New Jersey Governor Chris Christie. The Trump administration considers “opioid addiction … as a nonpartisan issue in need of a bipartisan solution.”73 The presidential opioid commission is set to release its final recommendations in October 2017, after the writing of this article. Recently, in May 2017, the State of Ohio filed a lawsuit against 5 major drug manufacturers for their role in fueling the opioid epidemic.74 The Ohio state Attorney General Mike DeWine alleges “fraudulent marketing regarding the risks and benefits of prescription opioids … for the purpose of increasing sales.” Both Ohio and Mississippi have filed such a suit at this time, states with populations particularly vulnerable to opioid use and abuse. Subsequently, in June 2017, the US Food and Drug Administration (FDA) requested removal of the drug Opana ER (oxymorphone hydrochrloride) from the market by its manufacturer Endo Pharmaceuticals (Malvern, Pennsylvania), citing the overall high risk of abuse with this particular formulation.75 This milestone decision marks the first step by the FDA to curb an actively marketed opioid “due to public health consequences of abuse.” Recent evidence proposed by the US CDC suggests that an opioid prescription for less than 7 d can decrease the chance of unintentional chronic use.76 Based on this, federal legislation is being developed in the US Senate to limit opioid prescriptions to a 7-d supply.77 Although many states have existing prescription supply limits, this would represent the first federal effort to curb opioid over-prescribing. ASSIMILATING GUIDELINES AND POLICY: SPECIAL RELEVANCE TOWARDS NEUROSURGERY Both cranial and spinal neurosurgeons will encounter patients with acute and chronic pain on a daily basis. Given its high prevalence in this subspecialty, a fundamental understanding of pain and its multimodality management is necessary. As referenced in this article, many physician organizations and governmental bodies have released evidence-based consensus guidelines on the use of opioid pain medication for chronic pain. While there are no official recommendations by a US neurosurgical association at this time, several key conclusions from the aforementioned guidelines and policies can be applied to pain management in the practice of neurosurgery. First, it is important to understand the timing of a patient's pain prior to prescribing analgesia, whether is it postoperative, acute, or chronic. Opioids are the cornerstone of pain control following surgery, and can be used safely and effectively in the immediate postoperative period, for both spinal and cranial surgery. Following surgery, a tapered course of opioid therapy for less than 7 d (ideally less than 3 d) can be considered after discharge from the hospital. For acute pain, nonpharmacological therapies and pharmacological alternatives to opioids are preferred, but low-dose opioids can be effectively used in the short term (3-7 d) after a discussion of the risks and benefits with the patient. Chronic opioid therapy is highly controversial, with limited evidence to support its use. As most of the professional guidelines suggest, consultation with a pain management physician is recommended for patients with atypical or chronic pain syndromes. In evaluating patients with chronic pain, a neurosurgeon must make the critical etiological distinction between nociceptive and neuropathic pain. Nociceptive pain, such as pain due to a postoperative incision or spinal fracture, is effectively and appropriately treated with opioid analgesia. In contrast, there is little role for opioids in treating pain of neuropathic origin, such as in trigeminal neuralgia. This analysis is often overlooked by clinicians and consequently leads to inappropriate opioid prescribing, a fundamental misunderstanding at the core of the opioid epidemic. Ultimately, prescriber education should be expanded to include pain pathophysiology, policy change that can be made at both the institutional and governmental level. Second, formulation of a therapeutic plan is necessary prior to prescribing opioids for chronic pain. When chronic opioid therapy is considered, an in-depth discussion of the risks, benefits, and objective therapeutic goals with the patient is required. Many guidelines recommend the patient signing an informed consent, documenting both their understanding of the risk–benefit profile as well as their agreement of adherence to the therapeutic plan. If eventually prescribed, monotherapy with a short-acting opioid is recommended at the lowest effective dose for a short trial period (no more than 90 d). Third, regular follow-up is essential to ensure the proper utilization of chronic opioid use, and to prevent misuse. At each time point, the risks and benefits should be re-evaluated, and therapy should be discontinued if the risks outweigh benefits. State PDMPs should be consulted regularly, and periodic drug testing should be used to ensure adherence to the therapeutic plan. Some guidelines suggest a patient nominate 1 physician (preferably primary care or pain management) to coordinate care of their chronic pain, thereby preventing a multiplicity of opioid prescriptions. On follow-up, if misuse is suspected, referral to a specialist is indicated for tapering of opioid medication, abuse counseling, and possible medication-assisted treatment. Ultimately, it is up to prescribers of all specialties to understand the risks and benefits associated with opioid therapy prior to treating a patient's pain. It is within the realm of medical education where these principles must be taught and reinforced. In response to the opioid crisis, the Association of American Medical Colleges released a statement in March 2016 committing US medical schools and teaching hospitals to improving opioid education.78 In 2015, Massachusetts Governor Charlie Baker issued a novel set of core competencies to be implemented by all 4 of the state's medical colleges, regarding the prevention and management of prescription drug misuse.79 Arming medical students with the knowledge to appropriately treat pain and prevent addiction is a fundamental step in changing the culture of opioid overprescribing. However, this education must continue during residency and beyond in order to have a lasting clinical impact. Some national specialty associations, such as emergency medicine, have dedicated efforts to expand pain management curricula in response to the opioid epidemic.80 In its current form, the American Association for Neurological Surgeons (AANS)/Accreditation Council for Graduate Medical Education (ACGME) neurosurgery residency milestones do not require formal opioid education.81 While many neurosurgery residents are mandated by some states and institutions to have continuing medical education on opioid prescribing, there is no universal neurosurgical opioid curriculum at this time. Perhaps the current AANS milestones should be amended to ensure a more thorough understanding of pain management and addiction prevention, prior to graduating from neurosurgery residency. As it stands in the current political landscape, opioid prescribing policy is in considerable flux. As summarized, federal and state legislation is trending toward more conservative policies on opioid prescribing, with various governing bodies directly taking on the opioid pharmaceutical industry. With opioid-related deaths rising, changes must be made at both the institutional and individual levels. This will require modifying the underlying philosophies of politicians and prescribers, respectively. By understanding the current evidence-based guidelines on chronic opioid prescribing, neurosurgeons can make more informed clinical decisions on patients with chronic pain, and ultimately uphold the responsibility to do no harm. CONCLUSION AND FUTURE ACTION Opioid overuse continues to plague the United States, with an increasing number of lives lost and healthcare expenditures as a direct result. Neurosurgeons, as surgical subspecialists treating patients with various pain syndromes, are responsible for understanding proper opioid stewardship. 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COMMENT This timely paper compares a series of evidence-based guidelines that were developed by various organizations outside neurosurgery concerning opioid use. The hope of the authors is to provide direction for neurosurgeons and suggest a policy for the specialty as a whole. I believe that neurosurgeons are keenly aware of the national opioid crisis and that they are uniquely positioned to assist with this important public health epidemic. Unfortunately, they also face an insoluble dilemma. Major surgery by its nature is a painful endeavor but social pressure is mounting against using opioid painkillers even when they are indicated and appropriate. Many times, the patient has been treated with opioids for a long duration before even arriving into the care of the neurosurgeon. According to the Joint Commission of Accreditation Healthcare and Certification (JACHO), pain is considered to be the fifth vital sign. Surgeons must effectively treat pain or face rebuke from hospital administrators or patients in the form of negative satisfaction evaluations. It is also inherently ego dystonic sometimes for the physician to deny or restrict a treatment that helps alleviate pain and suffering. This conundrum is very effectively summarized in a recent satirical video.1 These authors have provided a concise and feasible recommendation for managing opioid medications. They have clearly articulated the process of first defining the type and timing of pain to justify opioid use, followed by formulation of a therapeutic plan. Careful monitoring of the response to therapy is an essential component. A key failsafe in my view, is the recognition of abuse or failure of response. Perhaps there is an opportunity for a technological solution that would improve reporting and tracking of opioids so that abuse could be recognized quickly and appropriate measure instituted. Most existing systems are operated on a state-by-state basis and have variable degrees of success. This should prompt early referral to a pain management specialist. Chronic pain management in particular often requires a multimodality approach that is beyond the scope and facility of most neurosurgeons. Hopefully a useful and evidence based policy will be forthcoming from our national organizations. We are in the best position to investigate and implement solutions for patients with neurosurgical disease. Joel D. MacDonald Salt Lake City, Utah 1. ZDoggMD. Doc Vader Vs. Hospital Administrator . https://youtu.be/QHfan71zHKk. Accessed November 1, 2017. Copyright © 2018 by the Congress of Neurological Surgeons

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NeurosurgeryOxford University Press

Published: Apr 1, 2018

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