To the Editor:
We read with interest the recent editorial by Kharasch et al.1 concerning opioid management. We agree with their assessment of “opioid phobia,” and we would say “not so fast with opioid-free anesthesia.” There is no doubt that opioids are highly addictive drugs, as shown by recurring waves of opioid abuse since the nineteenth century. We appreciate that those promoting opioid-free anesthesia are well intentioned. However, neither the elimination nor the reduction of perioperative opioids have been clearly associated with decreased long-term use and abuse. As noted by Kharasch et al., the increase in prescription opioids in the attempt to address inadequate perioperative pain management was a major factor in the evolution of the opioid abuse crisis.1 Ironically, perioperative pain continues to be undertreated at this time. Despite the potential advantages of multimodal analgesia, opioids remain an invaluable class of analgesics in the treatment of moderate to severe perioperative pain, and indiscriminate use of well-intentioned opioid free anesthesia may actually perpetuate inadequate perioperative pain control. Additionally, opioids are a distinctive component of balanced anesthesia. As reiterated in the recent review by Egan,2 opioids work synergistically with primary anesthetics to achieve immobility, unconsciousness, and control of adrenergic responses. Elimination of opioids from a balanced anesthetic necessitates increased reliance on other anesthetic drugs, which may have unintended consequences.
Although the solution to the current opioid abuse crisis is clearly complex and multifaceted, we highlight three significant issues that we believe have received insufficient attention.
First, there is an urgent need for evidence-based guidance for providers about optimal perioperative use of opioids for specific surgical procedures and groups of patients. In reality, providers, frequently do not know how to best use opioids. Recent clinical guidance documents published by professional organizations (e.g., enhanced recovery after surgery, American Society for Enhanced Recovery) have endorsed multimodal analgesia and reduction in the use of opioids but typically have not provided granular guidance regarding specific opioids and doses. In the absence of evidence-based recommendations, opioid-free anesthesia is attractive because, by default, the need to titrate opioids for a range of patients and procedures is eliminated. We suggest that many, if not most, patients would be better served by receiving optimal doses of opioids in the setting of multimodal analgesia, rather than no opioids. For example, appropriate use of intraoperative methadone has been shown to reduce postoperative analgesic requirements.3 Postprocedural dosing protocols and smaller prescription quantities may result in less consumption of opioids without impairing pain control.4,5 Health care providers need practical evidence-based guidance for both intraoperative and postoperative opioid administration that addresses the wide array of procedures currently performed.
Second, numerical pain scores should be replaced by functional pain assessment. The numerical pain score inadequately reflects the complicated nature of pain and has been implicated in perpetuating excessive administration of opioids.6 Functional pain assessment can include meaningful parameters of the recovery process such as participation in physical therapy, sleeping, eating, and engagement in social interactions. Development and endorsement of practical perioperative pain assessment tools should involve interdisciplinary input from multiple specialties including psychiatry, rehabilitation medicine, physical therapy, and pain medicine. We cannot evaluate our efforts to transform the use of opioids without better methodology for pain assessment. The medical community should rapidly abandon numerical pain scores by developing and adopting better systems for measuring the “fifth vital sign.”
Third, patients must be more engaged in pain management and safe opioid use. Ultimately, it is the patient who takes the opioids home to their community and is faced with decisions about use, sharing, storage, and disposal. Most patients do not appreciate the complex interactions between the central and peripheral nervous systems that produce pain, and have little knowledge of how to manage pain, much less opioids. Patients need education about pain as part of their recovery process. Patients also need a practical understanding of their medications in term of mechanisms, dosing, toxicity, and responsible stewardship. Simple tools such as medication scheduling and tracking apps, more objective pain self-assessment strategies, and improved disposal opportunities could help patients with safer opioid behavior and should be reinforced throughout the recovery process. As the medical community learns more about patient behaviors, we must simultaneously empower patients with knowledge and tools to be better guardians of both personal and community health.
The opioid crisis is humbling, as we realize that incorrect assumptions and lack of evidence-based practice contributed to a wave of addiction in our communities. Clearly, decisive action is needed, but we must not be rash in addressing our failures. A scientific and thoughtful approach is critical to advancing our practice in safe and meaningful ways. Anesthesiologists have a central role in the perioperative surgical home and in pain management and have a unique opportunity to support the medical community with better evidence-based guidance for opioid administration and prescription, meaningful pain assessment, and patient education and empowerment.
The opioid epidemic is a painful reminder that what we do matters.
Competing Interests
The authors declare no competing interests.