Perioperative Opioids and Public Health.

960 April 2016 A NESTHESIOLOGISTS and surgeons face three challenges in the quest to provide optimum perioperative pain care, particularly within the growing domain of “shared responsibility” for patients’ surgical outcomes with other physicians and providers. Two challenges are well known, and the third may not have yet registered in the collective conscience of the specialties. The first challenge is provision of adequate perioperative analgesia. Adequate pain relief has been deemed a fundamental right,1 but a plurality (more than 80%) of patients report inadequate postoperative pain relief.1–4 Adequate postsurgical pain treatment affords better patient and economic outcomes,5 whereas acute postoperative pain causes suffering, morbidity, and the risk of chronic postsurgical pain.6,7 Acute postoperative pain is a major risk factor for chronic postoperative pain, which occurs in 10 to 50% of patients.6 Moreover, the incidence of inadequately treated postoperative pain seems unimproved over the past two decades.4,8 For postoperative pain management, many unresolved issues, unmet needs, and unanswered questions that define a research agenda were previously articulated.9,10 Emphasis on multimodal approaches to postoperative pain therapy has grown,11,12 yet multimodal safety and the ideal regimen(s) are undefined.13 Opioids remain the primary systemic pharmacotherapy for intraoperative and postoperative analgesia, particularly for moderate to severe pain. The second challenge is to minimize or prevent opioidrelated side effects—the most serious of which is respiratory depression.14,15 The incidence of respiratory depression after major surgery was 0.3, 1.1, or 17% using requirement for naloxone, hypoventilation, or oxygen desaturation as indicators, respectively, even in those using patient-controlled analgesia.16 The consequence and importance of postoperative respiratory depression have been highlighted often by the Anesthesia Patient Safety Foundation.17 The third issue is the soaring volume of opioid prescribing, prescribing patterns, and the accompanying devastating surge in prescription opioid diversion, abuse, addiction, and overdose (fig. 118). The US Centers for Disease Control and Prevention defined prescription drug abuse as an epidemic19 and one of its top five health threats for 2014.20 Numerous other US federal agencies (e.g., Office of National Drug Control Policy and the National Drug Control Strategy, Substance Abuse and Mental Health Services Administration, National Institutes of Health, Food and Drug Administration, Drug Enforcement Administration) are intently focused on diversion, abuse, addiction, and their consequences. Opioid sales quadrupled between 1999 and 2010, and it has been stated that “the system is awash in opioids. ”21 The United States has the highest opioid use per capita in the world, and it alone consumes 80% of the world’s opioids; nevertheless, these problems are not limited to the United States.22,23 The toll of prescription opioid abuse is both human and financial. Myriad alarming and saddening statistics abound. Approximately 5 million Americans report using prescription pain relievers nonmedically (i.e., without a prescription or medical need),24 and the rate has risen dramatically over the last two decades (fig. 2). Prescription opioids were involved in more than 16,600 overdose deaths in the United States in 2010 or approximately 45 deaths every day.25 Such