In the past two decades, the United States has witnessed a marked increase in the use and abuse of prescription and illicit opioids. The annual number of deaths by overdose involving opioids has nearly quadrupled since 2000. 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. The rise in opioid addiction and misuse has been associated with liberalization of laws governing opioid prescription for non-cancer pain and increased prescription of opioid pain relievers. 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. 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. When using opioids for anesthesia, medical providers should consider the addictive potential and side effects of these drugs, as well as the roles they can play for patients who are already suffering from opioid addiction.
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. For example, Hashemian et al. found that "local anesthesia with lidocaine was less effective in opioid abusers than non-abusers undergoing hand surgery." Not only did the lidocaine have a delayed onset in these patients, but they also needed a higher dose for pain management. Another study found that opioid-tolerant pregnant women may need complex treatment, including multimodal pharmacotherapy combined with high doses of local anesthesia. If opioids are required, the authors suggest using less addictive versions such as methadone or buprenorphine for pain management. Overall, the anesthesia provider must balance relapse potential with adequate pain relief for patients with opioid use disorders.
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.