Surgeons and perioperative opioid prescribing: An underappreciated contributor to the opioid epidemic

Appropriate management of postoperative pain is integral to a patient’s experience: it enhances recovery and minimizes complications after surgery. Historically, opioids were advertised as safe and effective for the treatment of pain, and this resulted in substantial increases in prescribing in the late 1990s and early 2000s. In contemporary practice, opioid analgesia remains a cornerstone in perioperative pain management, and this leads to an inherent conflict because of the current national opioid epidemic. Opioid use disorder, diversion, overdose, and death continue to devastate individuals and communities. Although illicit opioids are responsible for the majority of deaths, prescription opioids continue to account for a significant proportion and remain the gateway for the majority of illicit opioid use. The adverse effects of prescription opioids have been widely acknowledged, but much of the initial attention was focused on changing the management of chronic pain conditions. Although the national focus is beginning to shift toward curbing excess opioid prescribing for the management of acute pain, the role of surgeons and perioperative opioid prescribing remains an underappreciated contributor to the opioid epidemic. Herein, we seek to highlight the role of perioperative prescribing in the opioid epidemic, the limitations of existing state and national policies, and how physician-led efforts such as the one reported by Jacobs et al in this issue of Cancer have the potential to drive surgical opioid stewardship. Justifiably, early interventions aimed at decreasing opioid use focused on patients with chronic pain conditions using high daily doses of opioids because these patients are at the highest risk of overdose. In 2009, the American Pain Society and the American Academy of Pain Medicine published recommendations for safe chronic opioid therapy. Similar efforts were adopted more broadly by the Centers for Disease Control and Prevention, which in 2016 set forth guidelines aimed at providing clear recommendations for primary care physicians: how to assess the risks of chronic opioid use; when to start, continue, and discontinue chronic opioids; and how to select and monitor opioids. Nationally, the Comprehensive Addiction and Recovery Act of 2016 included provisions for Medicare Part D to address high-risk opioid use, including limiting the dosage (<200 morphine milligram equivalents) and duration of narcotic prescriptions (<7 days for opioid-naive members). These clinical practice guidelines were associated with a significant decline in narcotic prescribing. Despite this success, the guidelines did little to prevent initial opioid exposure or decrease the supply of unused opioids available for diversion (ie, the act of transferring legally obtained opioids to the illicit marketplace) and abuse in patients being treated for acute pain. Surgical prescribing accounts for more than 35% of opioid prescriptions in the United States. After surgery, there is wide variation in the amount of opioids prescribed for similar procedures. Moreover, the majority of patients use less than half of the prescriptions given, regardless of the type of surgery or whether it was minor or major. This overprescribing (ie, prescribing that exceeds patient need) is driven by the well-intended desire to ensure adequate pain control coupled with a lack of evidence regarding patient needs. However, this combination is problematic for several reasons. First, for many people, surgery serves as their initial exposure to opioids. Among these previously opioid-naive patients, 6% to 10% demonstrate prolonged opioid use (ongoing use for 3-6 months after surgery), and this potentially makes opioid use one of the most common postoperative complications. The degree to which this prolonged opioid use represents a true opioid use disorder is not well understood, but when we consider that many procedures can be safely performed without any postoperative opioids, many patients could avoid this initial exposure entirely. Second, higher doses and longer durations of prescribed opioids after surgery are directly associated with opioid use and abuse; however, this rate is relatively low (0.6%). Lastly and perhaps most importantly, this practice of overprescribing leads to a supply of unused opioids available for diversion