Perioperative opioids and the opioid epidemic

In this step, Dr Jamie Smart, Consultant in Anaesthesia and Pain Medicine and Chair of the Opioid Stewardship Committee at University College London Hospitals, discusses how perioperative opioid use has contributed to the opioid epidemic in the United States.

Most of the factors we have described so far which contributed to the opioid crisis relate to the management of chronic non-cancer pain, and increasing awareness of these has led to significant changes in practice in that setting: opioids are no longer routinely recommended in the management of persistent pain [1].

Opioids, however, remain an important and most often necessary part of the delivery of effective perioperative analgesia. Could the use of opioids around the time of surgery have also contributed to the opioid crisis in the US? There is substantial evidence that this is the case.

There is growing concern regarding the role played by the use of opioids around the time of surgery in contributing to the increasing prevalence of both prescription and illicit opioid use in many settings. As a result, a number of interventions have been recommended which aim to minimise the risk of harm resulting from their use.

Such coordinated approaches, which aim to improve, monitor, and evaluate the use of opioids, have been termed opioid stewardship. They have gained credibility and support from several national and international societies, as well as demonstrating early promise in reducing chronic opioid use after surgery [5]. We will outline the individual domains and interventions which comprise opioid stewardship later this week, as well as discussing them in greater detail in Week 3.

A note on terminology:

Through the course we will refer to the following terms, so it may be helpful to look at the definitions below:

• Opioid misuse: use of prescribed opioids in a way other than as directed by a healthcare professional.
• Opioid abuse: intentional opioid use (prescribed or illegal) for a purpose other than pain relief (eg for relaxation or ‘getting high’).
• Opioid diversion: transfer of a prescribed opioid medication to someone for whom it was not originally intended.
• Opioid use disorder: a medical condition caused by a problematic pattern of opioid use (prescribed or illegal) causing impairment or distress. This can feature tolerance (when taking the same dose of a drug has diminishing effects over time), dependence (when stopping the drug causes withdrawal symptoms), and addiction (a severe form of OUD with continued use in spite of negative consequences to the individual and their loved ones).

References

_{1. Opioids Aware. Opioids for long term pain. Faculty of Pain Medicine 2023 [Accessed 15 January 2023].}

_{2. Kent ML, Hurley RW, Oderda GM, Gordon DB, Sun E, Mythen M, et al. American Society for Enhanced Recovery and Perioperative Quality initiative-4 joint consensus statement on persistent postoperative opioid use: Definition, incidence, risk factors, and health care system initiatives. Anesthesia & Analgesia. 2019;129(2):543–52.}

_{3. Hill MV, Mcmahon ML, Stucke RS, Barth RJ. Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg 2017;265:709-14.}

_{4. Hero JO, McMurty C, Benson J, Blendon R. Discussing Opioid Risks With Patients to Reduce Misuse and Abuse: Evidence From 2 Surveys. Ann Fam Med 2016;14:575-577.}

_{5. Macintyre PE, Quinlan J, Levy N, Lobo DN. Current Issues in the Use of Opioids for the Management of Postoperative Pain: A Review. JAMA Surg 2022;157:158-66.}