The Opioid Crisis: From an Anesthesiologist’s Lens!

Introduction

Conventionally, opioids have been the cornerstone of moderate-to-severe post-surgical pain and have been the most sought-after singular agents and vital components of multi-modal analgesia. Furthermore, for decades, they have played a key role in balanced anaesthesia and for control of nociception and haemodynamics. The concept of pain, perceived as the fifth vital sign, led to an exponential rise in the use of opioids.

The challenge

The last decade has witnessed an alarming spike in opioid-related deaths and adverse events in developed nations. What is further distressing is that about 20 per cent of these patients were naive to opioids. The opioid crisis the world is undergoing seems to be iatrogenic and to originate from liberal prescriptions.

Factors that contributed to their exponential rise in several countries were hospital policies directing clinicians to give high priority to opioid use in pain management¹ , massive rise in post-discharge prescription opioids for indefinite periods, even for low-risk procedures, and their easy, unrestricted availability in developed countries.²

Moreover, many centres continue to use opioids for non-cancer pain.^3,4

Last few years have witnessed increasing harm associated with opioid usage, including overdosage, death and their abuse potential.

In sharp contrast, the situation in India and many developing countries is not iatrogenic but more at the community level. Nevertheless, caution needs to be exercised at the level of the practitioners and hospital policies in the developing countries like India as well. Developing world, including India is undergoing a demographic transition leading to an alarming increase in the obese and the elderly. Anaesthesiologists are having to encounter a significant number of patients with obesity and elderly for procedural sedation, surgery and perioperative care.

The medical implications of routine perioperative opioid usage with this background can be alarming. The obesity epidemic has come with an ever-rising prevalence of obstructive sleep apnoea (OSA). Exponential trends in obesity parallel the increasing prevalence of OSA. It is estimated that up to 20% of middle-aged adults suffer from OSA. However, it is feared that about 80% of the female population and up to 93% of the male population have sub-clinical OSA that remains undiagnosed. Because of epidemic trends observed in the obese and geriatric populations, caution needs to be exercised with opioid prescriptions. In the last decade, sleep-related disorders have attracted considerable attention from anaesthesiologists from a perioperative outcome perspective. Though the impact of obesity is multi-dimensional, its implications for airway architecture and upper airway function are of prime importance to the anaesthesiologist and have been widely substantiated in the existing literature.⁵

OSA is a disorder characterised by an increase in oropharyngeal soft tissues that periodically block the airway during sleep. It can be expected that obesity and OSA, owing to an increase in soft tissue mass, have been closely linked.^4,5 Use of opioids in patients with obesity and more so morbid obesity can be detrimental to immediate and even post discharge outcomes. Some of the most common and dreaded opioid-related adverse drug events include those related to the airway as the opioids have a significant impact on the airway and respiratory system, causing a condition known as “opioid-induced respiratory depression” (OIRD) and “airway-related adverse events” (ARAE). These can be life threatening and contribute significantly to morbidity and mortality in the perioperative period. This can further extend hospital stay, and add strain to the healthcare system. Obese and the elderly are particularly vulnerable to these adverse events.^6-10 The other adverse events include opioid-induced hyperalgesia (OIH), the association of mu receptor activation, and cancer progression. However, this lacks any high-level evidence.^11-14

The anaesthesiologist and perioperative caregiver must be mindful of these facts, as they directly influence perioperative adverse events, patient safety and hospital stay . Rising trends in obesity are more in the higher BMI segments, implying a greater increase in patients who have BMI > 50kg/m2 (Grade V and VI obesity). These are more vulnerable to airway-related adverse events.^4,5 Use of opioids in them as a part of pain management strategy impacts patient outcome and directly influences the utilisation of healthcare resources.

The solution

There has been a continuous endeavour to look for alternatives, safe, non-opioid pain management strategies. The concept of opioid-free analgesia (OFA) has emerged as a promising strategy to treat post-surgical pain and is even more pertinent, given evolving demographic trends. Several non-opioid regimens that have different modes of action have been suggested. OFA techniques have emerged as an up-and-coming alternative to opioid-based analgesia, more so for the high-risk and high BMI groups. OFA most commonly uses regional analgesia for post-surgical pain in combination with paracetamol and other opioid-sparing adjuvants, wherever feasible.^6,7 Most logically, the definition of OFA could be revised to include opioid-restricted or opioid-sparing techniques.^12-14

Most clinicians do resort to some form of opioid, whatever the minimal dose, in the postoperative period. The impact of opioids encompasses a wide range of clinical and non-clinical scenarios extending outside of operation theatres. Hence, OFA involves the anaesthesiologists, surgeons, physicians, and nurses. There is no ideal opioid-sparing or opioid-free technique. Each component is chosen with great caution, adverse events, and dose while addressing the vulnerable group. Since opioid-related adverse drug reactions are dose-dependent, a lot can be handled by using a carefully titrated dose to achieve the desired effect. Extreme caution should be exercised while co-administering other sedatives.^15,16 In the developed world, it is reported that only a minor portion of prescribed opioid medications are used by the patient at the time of discharge, and their medications are left in an unmonitored environment that could potentially contribute to opioid abuse.^17-18 In the Indian scenario, this is more applicable to patients with chronic or cancer pain. About 10% of patients with chronic conditions continue to use opioids. The possibility of the patient becoming a chronic user exponentially increases after the third postoperative day.¹⁹

The duration of opioid use, rather than the dose, is more closely associated with opioid misuse.^20,21 To minimise the incidence of opioid-related adverse drug events, it is suggested that instant-release formulations (and not slow-release preparations) be preferred in the perioperative environment, further enabling their safer titration and optimal pain relief in both high-risk and opioid-naïve patients.²²

In healthcare facilities where it is the norm to prescribe opioids after discharge, it is pertinent to educate all clinicians, paramedics, and family members involved in perioperative pain management to ensure curative procedures and patient-specific opioid prescription guidelines. Hospitals could initiate monitoring of post-discharge opioid use and safe drug disposal. A comprehensive approach to address and pre-empt the opioid crisis in our current practice is needed.^20-25

It is time for a rational and patient-centric approach to perioperative pain management. Perioperative opioid-sparing or opioid-free analgesia using a multi-modal approach using local anaesthetics and regional analgesia when appropriate is strongly advocated. Judicious use of opioids can be reserved for breakthrough pain.

It is vital to train the first responders and caregivers of patients on chronic opioid therapy and the use of naloxone for the management of opioid overdose. Primary caregivers and other physicians should be able to identify red-flag signs in patients’ psychosocial and behavioural patterns. Preoperative opioid use, depression, a history of substance abuse, preoperative pain, and tobacco use should alert caregivers to the risk of tolerance, misuse, and abuse of opioids. Pain management strategies in the perioperative period need strict monitoring. Nevertheless, all physicians and nurses must understand the importance of opioid titration and evaluate any need for and duration of post-discharge analgesia. It is recommended to set up a multi-disciplinary transitional pain service to reduce the risk of opioid misuse in high-risk patients. Instead of uniformly focusing on an “opioid-free plan” for every surgical patient and compromising on the patient’s optimised comfort and early functional recovery, we should emphasise strict checks applicable at various timelines during a patient’s surgical journey to identify and avoid misuse of opioids.

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