Anesthesiology in the Opioid Epidemic

By December 30, 2019 No Comments

In the past two decades, the United States has witnessed a marked increase in the use and abuse of prescription and illicit opioids.1 The annual number of deaths by overdose involving opioids has nearly quadrupled since 2000.2 In 2015, more than two million people in the United States were addicted to prescription opioids, and more than 12 million reported having misused these medications.2 The rise in opioid addiction and misuse has been associated with liberalization of laws governing opioid prescription for non-cancer pain1 and increased prescription of opioid pain relievers.2 Though the illegal drug heroin is a commonly abused opioid, the drug class also includes legal medical drugs such as fentanyl, oxycodone, hydrocodone, codeine, morphine and more.3 Given the widespread presence of opioids in anesthesia and analgesia, anesthesiology practitioners must consider their use of these drugs in the face of the United States’ opioid epidemic.4 When using opioids for anesthesia, medical providers should consider the addictive potential and side effects of these drugs,5 as well as the roles they can play for patients who are already suffering from opioid addiction.6

Almost all patients in the United States receive opioids for pain management during a surgical encounter.5 Oftentimes, a patient’s first encounter with opioids may be during the perioperative period.5 Because anesthesiologists are tasked with a patient’s perioperative pain management, they are well-positioned to take control of the patient’s opioid utilization and discourage drug abuse.7 For one, the anesthesia provider can aim to reduce unnecessary use of opioids throughout a procedure.5 A study by Brandal et al. found that many patients were discharged with an opioid prescription despite having low pain and no perioperative opioid use, suggesting that clinicians were not selective with their opioid prescribing practices.8 Meanwhile, a review by Wong et al. proposes the use of nonopioid alternatives for pain management in minimally invasive gynecological surgery.9 The authors found that nonopioid options include medications such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) and antiepileptics; minimally invasive surgical techniques; and enhanced recovery protocols.9 Many studies also recommend the use of multiple types of nonopioid anesthesia, including local anesthetics and nerve blockers.4,5,9 If opioids must be used, anesthesiology practitioners can aim to reduce opioid-related adverse events, including misuse or addiction.5 In orthopedic surgery, for example, anesthesiologists can prevent issues by educating patients about opioids, combining nonopioid medications for additional pain relief and standardizing postoperative taper regimens.10 Multiple authors cite patient education and communication as key to preventing opioid misuse.7,10 Using alternative pain relievers, educating patients and standardizing postoperative protocols seem to be key factors in preventing opioid misuse.

For patients who already suffer from opioid addiction, however, the anesthesia provider must take further precautions. While nonopioid medications and surgical techniques may be employed in opioid-addicted patients, they may not be enough to treat the patients’ post-surgical pain.6 For example, Hashemian et al. found that local anesthesia with lidocaine was less effective in opioid abusers than non-abusers undergoing hand surgery.11 Not only did the lidocaine have a delayed onset in these patients, but they also needed a higher dose for pain management.11 Another study found that opioid-tolerant pregnant women may need complex treatment, including multimodal pharmacotherapy combined with high doses of local anesthesia.12 If opioids are required, the authors suggest using less addictive versions such as methadone or buprenorphine for pain management.12 Overall, the anesthesia provider must balance relapse potential with adequate pain relief for patients with opioid use disorders.13

Anesthesiology practitioners are positioned to reduce the problems associated with the opioid epidemic. An anesthesia provider can stop unnecessary prescription of opioids and—if opioids are needed—provide patient education and standardized care to avoid abuse. For patients with opioid use disorder, anesthesiologists may need to intensify their use of nonopioid anesthetics or use opioids that have lower abuse potential. Future research should investigate nonopioid pain relief through alternative medications, altered surgical procedures and nonmedication therapies such as meditation.

1.         Manchikanti L, Helm S, Fellows B, et al. Opioid epidemic in the United States. Pain Physician. 2012;15(3 Suppl):ES9–38.

2.         Murthy VH. Ending the Opioid Epidemic—A Call to Action. New England Journal of Medicine. 2016;375(25):2413–2415.

3.         National Institute on Drug Abuse. Opioids. Drugs of Abuse 2019;

4.         Hah JM, Bateman BT, Ratliff J, Curtin C, Sun E. Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic. Anesthesia & Analgesia. 2017;125(5):1733–1740.

5.         Koepke EJ, Manning EL, Miller TE, Ganesh A, Williams DGA, Manning MW. The rising tide of opioid use and abuse: The role of the anesthesiologist. Perioperative Medicine. 2018;7(1):16.

6.         Thomas D-A, Boominathan P, Goswami J, Mukherjee S, Vadivelu N. Perioperative Management of Patients with Addiction to Opioid and Non-opioid Medications. Current Pain and Headache Reports. 2018;22(7):52.

7.         Alam A, Juurlink DN. The prescription opioid epidemic: An overview for anesthesiologists. Canadian Journal of Anesthesia/Journal canadien d’anesthésie. 2016;63(1):61–68.

8.         Brandal D, Keller MS, Lee C, et al. Impact of enhanced recovery after surgery and opioid-free anesthesia on opioid prescriptions at discharge from the hospital: A historical-prospective study. Anesthesia & Analgesia. 2017;125(5):1784–1792.

9.         Wong M, Morris S, Wang K, Simpson K. Managing Postoperative Pain After Minimally Invasive Gynecologic Surgery in the Era of the Opioid Epidemic. Journal of Minimally Invasive Gynecology. 2018;25(7):1165–1178.

10.       Labrum IV JT, Ilyas AM. The opioid epidemic: Postoperative pain management strategies in orthopaedics. JBJS Reviews. 2017;5(8):e14.

11.       Hashemian AM, Omraninava A, Kakhki AD, et al. Effectiveness of local anesthesia with lidocaine in chronic opium abusers. Journal of Emergencies, Trauma, and Shock. 2014;7(4):301–304.

12.       Raymond BL, Kook BT, Richardson MG. The opioid epidemic and pregnancy: Implications for anesthetic care. Current Opinion in Anesthesiology. 2018;31(3):243–250.

13.       Yaster M, Benzon HT, Anderson TA. “Houston, We Have a Problem!”: The Role of the Anesthesiologist in the Current Opioid Epidemic. Anesthesia & Analgesia. 2017;125(5):1429–1431.