Editorial  |   February 2020
Opioids. Opioids!! Opioids???
Author Affiliations
  • Steven L. Shafer, M.D.
    Editor-in-Chief, ASA Monitor
Article Information
Pain Medicine / Pharmacology / Editorial / Opioid
Editorial   |   February 2020
Opioids. Opioids!! Opioids???
ASA Monitor 2 2020, Vol.84, 4-5.
ASA Monitor 2 2020, Vol.84, 4-5.
Thank God for the mu opioid receptor! This receptor mediates the most profoundly merciful balm to the most afflicted among us. No pain is refractory to the mu opioid receptor’s ability to dull its sharp edges and ease the suffering soul. If only the actions of the mu opioid receptor stopped there. Unfortunately, the mu opioid receptor is associated with side effects ranging from mild (ileus, urinary retention, itching, hyperalgesia) to respiratory depression, apnea, coma and death. Even worse, the pharmaceutical ligands for the mu opioid receptor are among the most addictive substances on earth.
Why does this receptor even exist? What survival advantage is conferred by a receptor that mediates profound analgesia accompanied by life-threatening apnea? Is there any setting where profound analgesia and apnea might be desirable?
7 Comments
February 7, 2020
Wilhelmina Korevaar
Associate Professor of Anesthesiology, Volunteer Faculty UCF College of Medicine
Thank you!
Thank you for your timely, well-written, thoughtful and entertaining editorial. You captured my imagination with the opening query and explanation of why we are born with mu receptors. You carried us along the read about opiate risks, including addiction. And you ended with a direction forward we can all embrace. I applaud especially your injection of reality - opiates are an integral part of modern anesthesiology - while proposing a sensible solution through expeditious tailored cessation of use.
February 7, 2020
Donald Kilpatrick
VHA
Assuming credible leadership
Once again, ASA (Dr. Shafer) defers responsibility for opioid exposure and its potential long-term dependency to others: "Ensure that our patients stop taking opioids shortly AFTER [emphasis added] surgery." I routinely administer opioid-free and opioid-sparing anesthetics to patients at a level 1 complexity VHA facility. This not for marketing! My experience: opioids are NOT an essential component of modern anesthesia for most patients, but a pharmacologic crutch for those unwilling to expand their anesthetic toolboxes. ASA will never provide credible leadership on this important issue without assuming leadership by example.

RESPONSE FROM THE EDITOR
I appreciate the enthusiasm of Dr. Kilpatrick for opioid-free anesthesia. I often avoid opioids as well, preferring low doses of ketamine, magnesium, NSAIDs, avoidance of nicotinic antagonists (e.g., inhaled anesthetics) and lots of sodium channel blockade. Opioid-free anesthesia is currently the subject of discussion, reflection and debate within our specialty. A few days ago, Kefraoui and colleagues published the protocol for an upcoming meta-analysis on the subject (see BMJ Open; 2020:10:e035443).

I refer Dr. Kilpatrick to an excellent pro/con debate that appeared in the April 2019 issue of the European Journal of Anaesthesiology. Dr. Patricia Lavand'homme, arguing for opioid-free anesthesia, notes that the evidence for opioid-free anesthesia comprises hypothetical benefits, small studies and case reports. Conversely, Drs. Kirk and Rathmell assert we aren’t ready for opioid-free anesthesia based on nearly identical observations. It makes for fun reading, as the authors of the pro and con positions reach nearly identical conclusions: great idea, worthy goal, not there yet. I also refer Dr. Kilpatrick to the excellent editorial "Rational Perioperative Opioid Management in the Era of the Opioid Crisis" by Drs. Kharasch, Avram and Clark, which appeared online a few days ago. Dr. Kharasch and colleagues point out that "a link between persistent postoperative opioid use and specific approaches to intraoperative or even early postoperative opioid administration has yet to be demonstrated." The authors caution us to "avoid making surgical patients pay with unnecessary suffering for the opioid overprescribing sins of others."

Lastly, I caution against drawing broad conclusions from personal clinical experience. Generalizable knowledge can only come from systematic investigation. I absolutely believe Dr. Kilpatrick's assertion that he capably gives anesthesia without opioids, and I applaud him for it. However, we have the tools of science to support our clinical practice, and we should not replace science with assertions of truth based on personal experience. - SLS

February 7, 2020
C. Philip Larson
Geffin School of Medicine at UCLA
One solution not a panacea
While Dr. Kilpatrick makes an important contribution, there is no one solution for the opiate issue. Steve is on the right track with his comments. As a society, we need to think creatively about how to eliminate the demand, since preventing access to opiates is virtually impossible. Steve's comments about carfentanil are scary and should mobilize not only physicians and nurses but all health care organizations to address what can be done at the local, state and national level. It is everyone's problem!
February 7, 2020
Adam Rubinstein
Henry Ford Allegiance Health
Cogent summary
A brilliant analysis on the quixotic nature of opiates and our responsibilities as physicians to lead the discussion and, more importantly, to initiate action to alleviate the suffering caused by these miracle substances. Untold numbers of individuals and families have been inexorably scarred or destroyed as a result of the consequences of opiate addiction. And when considered in the context of media frenzy pandemics such as the "coronavirus," the destructive nature of opiate addiction is many magnitudes greater. But how does one eliminate substances that have both illicit economic value and are easy to synthesize and distribute? That's the multi-billion dollar question - though as healers we should be doing our part to reduce the exposure, provide alternative pain modalities and, importantly, ensure and provide access for detoxification and recovery. Sadly, the research in non-addictive, alternative pathway pain compounds has been relatively slow, and few tangible products have come to fruition. Consequently, we need to be the standard bearers for research and innovation while we continue to press on the sociological and political fronts.
February 7, 2020
John Hsu
Presbyterian Hospital
It has been 20 years
Dr. Shafer has written eloquently about opioids and the crisis. The opioid crisis is 20 years old, and government policies have taken us from pain as the 5th vital sign to the uncontrolled access of controlled substances and full circle to severe limitations on opioid access. 770,000 people have died since 1999 (CDC2020). Why hasn’t it gotten better?

Recent focus on simply limiting opioids is not prudent because it is similar to treating symptoms of disease rather than the cause. It can lead to other problems, as we have seen with the second (heroin up 500%), third (fentanyl up 1,000%) and now the fourth wave of drug overdoses (amphetamines up 22%). Pain is difficult to treat. There are many reasons for it, while 62% take opioids appropriately and 38% take opioids for reasons not indicated (DOJ2019). Can we morally hold opioids from patients who take opioids appropriately?

Recent focus on narcan, a 60-year-old drug for those already overdosed, and suboxone, a 45-year-old drug for those already addicted, does not represent prevention of the opioid crisis. Only 10% of addicts receive or seek treatment with these drugs, so how will we deal with other 90% of abusers and addicts?

Promoting other pills or limited opioid access without cognitive behavioral therapy, harm-reduction policies and prevention of underlying causes is not thorough care. Consider the 3.3 billion unused pills entering our communities every year and the recent report out of Boston Medical Center that only 1.3% of patients who overdosed on prescription opioids had an active opioid prescription. Reducing diversion is direct treatment while limiting access is indirect with unintended consequences. We have Omnicell/Pyxis devices for hospitals and fewer overdose deaths than patients at home with an easy-to-bypass child-resistant cap without secure storage, safe disposal or active controlled dispensing. Recently departed FDA commissioner Dr. Scott Gottlieb promoted secure storage and disposal solutions. One solution, the iPill, won an FDA innovation challenge.

As anesthesiologists, we balance treating pain with opioids and the risk of side effects. We treat abuse, dependency, addiction, constipation, pruritus, nausea and vomiting but surprisingly no one treats respiratory depression, the most deadly side effect. Narcan treats respiratory depression but also negates any treatment of pain with mu receptor blockage. We are perioperative physicians and experts in opioid physiology and pharmacology. We are great in doing studies. Can we apply our expertise to bring a solution together to address the opioid crisis?
February 8, 2020
Rita Guttersen
Froedtert Hospital and the Medical College of Wisconsin
Opioids.Opioids!! Opioids??!
This was a great editorial on our complex relationship with opioids. While some believe that opioids are not an essential part of postoperative pain management, I do enough cases on a daily basis to believe that, unfortunately, it absolutely is. We can realistically decrease usage by various multi-modal pain management modalities, but taking it off completely from our postoperative pharmacopeia is a losing proposition.

Addressing patients' expectations before surgeries might also do a great deal to help in terms of realistic pain management goals. Help them understand what we can and cannot do.

I do believe that patients need a good dose of reality regarding expectations for pain management after surgery. They need to realize that there will be some amount of pain they will have to go through.

Correct me if I am wrong, but why is it that other developed countries don't have the same opioid crisis we have in the U.S.? What are we missing? Are they better with multi-modal techniques? Do they have a more stoic population/better expectations? Or do they have a health care delivery system that does not rely on patient satisfactory surveys that would lead a provider to be at the whim of a certain patient?

Complex relationship with opioids, indeed!

RESPONSE FROM THE EDITOR

Dr. Guttersen points out the elephant in the room: why is this problem so much worse in the U.S.? I refer Dr. Guttersen to Burden et al., Opioid Utilization and Perception of Pain Control in Hospitalized Patients: A Cross-Sectional Study of 11 Sites in 8 Countries. J Hosp Med. 2019; 14:737-745. The authors conclude that “physicians in the U.S. may prescribe opioids more frequently during patients’ hospitalizations and at discharge than their colleagues in other countries, and patients have different beliefs and expectations about pain control.” This may partly explain why the problem is so much worse in the U.S.

The Burden article does not discuss intraoperative opioids, and I have not been able to find any references about the relative use of intraoperative opioids in other countries. However, we can draw some inference from the experience at the Department of Anesthesiology at St. Gallen Hospital in Switzerland. For almost 20 years, every patient requiring general anesthesia has received propofol/remifentanil total intravenous anesthesia – more than 150,000 patients. There is no evidence of an increased incidence of opioid dependence in the population served by St. Gallen. The nearly uniform use of remifentanil in their patients, without any evidence of increased postoperative dependence, is consistent with the hypothesis that intraoperative opioid use does not contribute to postoperative opioid dependence. - SLS
February 10, 2020
M. Lilian
Lankenau Medical Center
Best synopsis of 'opioid crisis'
Dr. Shafer's wise and compassionate editorial in this issue of the Monitor is the best synopsis I’ve seen regarding the “opioid crisis.”
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