A Gathering Storm: Are Perioperative Opioids Problematic? Perspectives From the Next Generation of Pain Practitioners

Author: Michael M. Bottros

Pain is an unfortunate part of human existence, and the pursuit of relief has been an integral part of the medical profession for thousands of years. Researchers and practitioners have continued to innovate and create newer research platforms in the pursuit of improving our understanding of the basic physiologic mechanisms of pain. Over the last century the development of current pain management practices was developed with good intentions, but today, the United States is in the midst of an opioid crisis. Much of the focus on this debate has been on outpatient prescription drugs and the prescribing patterns of physicians. Only recently has attention been drawn to the perioperative setting and its potential contribution to our current climate. Acute postsurgical pain is unique in that we as medical professionals subject our patients to an expected amount of pain in the hope of providing an improved outcome as a whole; however, if not managed properly, evidence shows it can add to the current epidemic.

In the 1800s, opium, its derivatives, and cocaine were mostly unregulated and by the end of the 19th century opium and morphine were commonly used in the United States both medically and recreationally.1 These drugs were used for many maladies ranging from cough to gastrointestinal upset. By 1914, it was thought that 1 in 400 Americans were addicted to some form of opium. In effect, and partly due to addiction not being considered a disease at the time, physicians who prescribed maintenance doses to addicted patients risked loss of license, arrest, or imprisonment.

The role of opioids in pain management is contentious. With the current controversy, it can be easy to swing the pendulum in the completely opposite direction. The purpose of this article is not to debate if perioperative opioids are appropriate—far from it. The intent is to elucidate historical and current prescribing pattern problems. Based on population health statistics, a large number of patients continue postoperative opioid use indefinitely. In addition, current postoperative prescribing practices across specialties are flooding the community with unused opioid analgesics. These unused opioid analgesics are the main source of abused or diverted drugs, which appear to act as a gateway to heroin and cocaine use. Extending our reach beyond solely using opioids in perioperative pain management by using a multimodal approach can impact both patients and society and even potentially decrease persistent postsurgical pain syndromes.

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