Bonnie L. Milas, MD, Professor, Clinical Anesthesiology & Critical Care Medicine, University of Pennsylvania Medical Center, Perelman School of Medicine.

Bonnie L. Milas, MD, Professor, Clinical Anesthesiology & Critical Care Medicine, University of Pennsylvania Medical Center, Perelman School of Medicine.

Albert J. Varon, MD, MHPE, FCCM, FASA, Committee on Trauma and Emergency Preparedness, Miller Professor and Vice Chair for Education, Department of Anesthesiology, University of Miami Miller School of Medicine, and Chief of Anesthesiology, Ryder Trauma Center, Miami.

Albert J. Varon, MD, MHPE, FCCM, FASA, Committee on Trauma and Emergency Preparedness, Miller Professor and Vice Chair for Education, Department of Anesthesiology, University of Miami Miller School of Medicine, and Chief of Anesthesiology, Ryder Trauma Center, Miami.

Arman Dagal, MD, FRCA, MHA, Professor, Anesthesiology and Pain Medicine, Orthopedic Surgery and Sports Medicine, Neurological Surgery (Adj), Harborview Medical Center, UW Medicine, Seattle.

Arman Dagal, MD, FRCA, MHA, Professor, Anesthesiology and Pain Medicine, Orthopedic Surgery and Sports Medicine, Neurological Surgery (Adj), Harborview Medical Center, UW Medicine, Seattle.

Anesthesiologists occupy a unique position to address the opioid epidemic, and ASA's Committee on Trauma and Emergency Preparedness (COTEP) is initiating a project to help them do just that. We are qualified to prescribe and administer opioids. We are also trained to manage opioid side-effects, including overdose, and provide naloxone and resuscitation. As an anesthesiologist and mom, I rescued my opioid-overdosing son successfully on multiple occasions. Just imagine the emotions felt performing rescue maneuvers on your child, or conversely being unskilled and not knowing what to do until help arrives. Ultimately, on the crest of this wave of opioid destruction, both of my sons succumbed to this addiction. I am not alone in this loss. Tens of thousands of parents have suffered such devastating circumstances. We have reached a critical point of this national anguish. It is not just limited to loss of life at the scene. The suffering encompasses victims whose cardiac function remains, yet they are brain dead from lack of oxygen. Current bystander CPR recommends hands-only chest compressions for unconscious victims, while rescue breathing has fallen off the algorithm. It takes critical minutes for the police or EMS squad to arrive, which is a potential missed chance for survival if a bystander is unprepared.

Overdose-related brain death remains the single most significant increase in etiology leading to organ donation over the past 20 years. I had the education to have naloxone immediately available and CPR skills to achieve the best possible outcome – skills that anyone can learn. There is a dire need and an interest in the community to be prepared to respond to opioid overdoses in the home or public spaces. The time is overdue to boldly address the critical need and develop policies through multiagency involvement. Naloxone must be universally available with rapid public education on how to rescue an opioid overdose victim. Through ASA, anesthesiologists are uniquely positioned to be ambassadors to lead initiatives to mitigate the loss of life and limit injury due to an opioid overdose.

– Bonnie Milas, MD

The opioid epidemic

The American public is under threat by the opioid epidemic. The number of overdose deaths increased from 38,329 in 2010 to 70,237 in 2017, followed by a small decrease in 2018 to 67,367 and a significant increase to 70,980 in 2019 (asamonitor.pub/3jZ31ON; asamonitor.pub/376D78r). As a result, people are more likely to die from accidental opioid overdoses (one in 98 odds) than in car crashes (one in 106 odds) (asamonitor.pub/2SU8lqP). In addition, the U.S. COVID-19 epidemic has been accompanied by an increase in substance use with serious consequences (JAMA September 2020).

The increasing use of illegal substances such as heroin, cocaine, methamphetamine, and benzodiazepines, and widespread use of high doses of prescription opioids for acute and chronic pain have increased opioid-related overdose deaths. In addition to the direct patient consequences, there is an indirect effect on family members through drug sharing, accidental overdose, or deliberate self-harm. The U.S. government approved $7 billion in funding, an increase of more than $200 million, for opioid efforts and initiatives across the government for 2021 (asamonitor.pub/3nZ1X03).

Combating the problem

ASA understands this public emergency and is actively combatting the opioid crisis. ASA engages in efforts to increase patient access to better pain management through multimodal analgesia, multidisciplinary care, insurance coverage of non-opioid therapies, physician education, safe and effective opioid prescribing, secure storage and disposal of opioids, and research on pain and non-opioid alternatives. ASA partnered with Premier, Inc., and launched The Safer Post-Operative Pain Management: Reducing Opioid-Related Harm Pilot, which specifically focused on reducing opioid use in the inpatient setting. Preliminary data showed positive results, and ASA is currently in the planning process for a second expanded pilot. The society is also collaborating with the American Academy of Orthopedic Surgeons (AAOS). They have reached a consensus on the maximum for opioid dose and prescription duration for various procedures and developed a pain alleviation toolkit to treat acute pain. In April 2018, ASA co-sponsored the 7th annual National Rx Drug Abuse & Heroin Summit in Atlanta, involving federal and state agencies, payers, patient advocates, and health care professionals. Plans are already in place for the ASA's prominent role in the 2021 Summit. ASA's best practice recommendations have been mirrored by public policies, such as the U.S. Department of Health and Human Services (HHS) Pain Management Best Practices Interagency Task Force.

Public education

In 2017, HHS launched the following initiatives to combat the opioid epidemic (asamonitor.pub/2H31HvN):

  1. Improving access to treatment and rehabilitation

  2. Increasing access to life-saving opioid overdose reversal drugs, such as naloxone

  3. Expanding public health surveillance of opioid use

  4. Supporting pain and addiction research

  5. Promoting pain management programs and practices among caregivers.

ASA's COTEP believes that at least three of these initiatives (1,2,5) could be further promoted as a public action campaign and has begun work on an awareness and education project called Revive.

Following the Sandy Hook Elementary School shooting in December 2012, the American College of Surgeon's Committee on Trauma formed a task force. It published the Hartford Consensus to reduce mortality and improve survival following mass shootings and other intentional acts of mass violence (asamonitor.pub/372HGAx). This “Stop the Bleed” campaign involved training the public to take life-saving action regardless of the situation or cause of severe bleeding until professional help arrives.

The “Stop the Bleed” campaign may serve as a useful model for the Revive project to reduce overdose-related deaths, promote multimodal analgesia care, improve general knowledge on pain and analgesic use, and advocate widespread use of naloxone as an emergency resuscitation measure. The Revive project may also provide another opportunity for ASA to demonstrate its leadership as dedicated advocates of patient safety and multi-disciplinary collaboration with national medical organizations and regulatory agencies.

Opioid naloxone reversal

Naloxone is an opioid antagonist that is used to temporarily reverse the effects of an opioid overdose by restoring respiration and consciousness. Naloxone has an excellent safety profile and, when given in time, can save lives. Therefore, increasing the availability and targeted distribution of naloxone should be a critical component of any effort to reduce opioid-related overdose deaths and, combined with rescue breathing maneuvers, will improve survival and reduce permanent injury due to opioid overdose. In nearly all states, individuals who want to be prepared to respond with naloxone can go to a pharmacy or their community health department and receive basic instruction with a dose of naloxone under a “standing order,” i.e., without a patient-specific prescription. Rescue breathing and basic airway maneuvers are often not included in the education, which provides another opportunity for ASA's involvement.

Public advocacy

During the past year, overdose-related death rates have not declined, but rather increased in some regions. The number of lives lost each year surpasses the total number of deaths during the entire Vietnam War. This epidemic is hitting every state, county, town, and neighborhood. Every demographic and socio-economic subset has victims. There is a critical need for a grassroots movement, and ASA members already have the knowledge to respond and educate. As COTEP develops the initial elements of the Revive program over the coming months, consider what role you could play as an ASA member and, more importantly, as a member of society at large. It would not require additional time or expense, but rather engagement. Reach out by speaking with those in your community, on the soccer fields, or in the mailroom of your apartment complex and schools in your neighborhood. Lean into a conversation and add what you know about opioids, substance use, overdose, naloxone, and basic life support, especially naloxone and rescue breathing. ASA members are beacons of information. These conversations will go a long way to dispel the stigma surrounding substance use. There will be a website and educational materials to which you can direct individuals. It might not feel natural at first to insert yourself into conversing about this complicated topic, yet it flows more easily with practice. In later stages of the project, there may be opportunities with ASA and your local drug and alcohol commission should a more expanded role be sought.

Recommendations:

  1. Develop public and professional educational materials (e.g., videos, podcasts, printed materials, infographics)

  2. Create a communication strategy for state- and local-level distribution of information

  3. Support and develop policy and regulation on opioid use reduction and rescue with federal and state agencies

  4. Create a consensus statement involving national health care organizations, colleges, societies, emergency medical response units, and regulatory bodies

  5. Develop and lead the national efforts to disseminate information

  6. Lead multi-organizational efforts to develop public emergency access to naloxone rescue kits to be located near public defibrillators

Take the time to pick up a dose of naloxone, gloves, and a face shield or collapsible face mask and carry them. It is an unsettling feeling to be at the scene of an overdose, knowing you should have been prepared, but you are not ready because you never thought you would be in that situation.

Naloxone is available at all pharmacies, it is covered by nearly all insurance carriers, and is free at most county health departments.