Hard Pill to Swallow: The Role of the Perioperative Physician in the Opioid Crisis

Jordan Francke, MD, MPH

The use of opium-based substances to treat pain is not novel – its first medicinal use likely predates 3000 BC. However, in the last 25 years, an epidemic has unfolded from an explosion of misuse of both naturally occurring and synthetic opioid derivatives, resulting in over 50,000 deaths in the United States annually. Beverley A. Orser, MD, PhD, FRCPC, FRSC, professor and chair of anesthesiology and pain medicine at the University of Toronto and chair of the IARS Board of Trustees, moderated a compelling discussion of the role of perioperative physicians in mitigating this crisis during the “International Science Symposium: Role of the Anesthetist in the Opioid Crisis and the Science of Mitigation” on Saturday, May 18 at the 2024 Annual Meeting, presented by IARS and SOCCA.

The first presenter Vivianne Tawfik, MD, PhD, associate professor of anesthesiology, perioperative and pain medicine at Stanford University and IARS Trustee, shared how she utilizes murine research to answer pressing questions related to mechanisms in chronic pain pathways and possible treatments. For animal-based pain studies to be effective, Dr. Tawfik argued that they need to 1) involve more than just reflexive behaviors (e.g., a mouse lifting its paw in response to a noxious stimulus), 2) investigate sexual differences (e.g., many early studies of pain involved only male mice), 3) use a variety of approaches to confirm results, and 4) be reproducible across multiple labs.

Dr. Tawfik’s research focuses on whether pain medications can be redesigned to maximize benefits while minimizing harms. For example, she uses a mouse model that has centrally expressed µ-opioid receptors that are not expressed peripherally. Many argued that this is not biologically realistic or relevant to humans, nor an appropriate therapeutic target (e.g., it is not possible to excise peripheral µ-opioid receptors from humans). Methylnaltrexone, she asserted, is the perfect example of this research’s utility – it peripherally blocks human’s endogenous peripheral µ-opioid receptors without reversing analgesia or precipitating withdrawal centrally. Dr. Tawfik argued that drugs called allosteric modulators represent the frontier of pain medicine; they have the capacity to extend the duration of drugs at their receptors of action and reduce or neutralize their effect at unwanted receptors. 

Meredith C. B. Adams, MD, MS, FASA, FAMIA, associate professor of anesthesiology, biomedical informatics, physiology & pharmacology and public health sciences at Wake Forest University and IARS Trustee, presented slides on behalf of Chad Brummett, MD, the Bert N. LaDu Professor and senior associate chair for research at University of Michigan, who had a last-minute conflict. Dr. Adams emphasized that since 2016, synthetic opioids other than methadone have become the leading cause of death in opioid-related overdoses (https://www.cdc.gov/nchs/data/databriefs/db491.pdf). For many patients, their first contact with opioids is perioperatively, either prior to surgery or in the immediate postoperative period. Many anesthesiologists and surgical providers fear that reducing the dosages or frequencies of opioids after surgery in a typical patient will result in increased requests for refills and worse patient satisfaction, but data demonstrated by Dr. Adams show that is not supported by evidence (https://pubmed.ncbi.nlm.nih.gov/28594763/, https://pubmed.ncbi.nlm.nih.gov/29214318/).

In fact, one group in Michigan found that when stricter prescribing guidelines were implemented statewide, patient satisfaction and pain scores remained the same, while opioid consumption plummeted (https://pubmed.ncbi.nlm.nih.gov/31412184/). Dr. Adams reminded the audience of the significant overlap that exists between those with persistent postoperative opioid use and those with psychiatric comorbidities, including anxiety and mood disorders which in some chronic pain studies have been considered exclusionary criteria. It is crucial that the interaction of mental health and substance use disorders be recognized, as treating both simultaneously is likely the best opportunity patients have at regaining a meaningful quality of life.

Hance Clarke, MD, PhD, FRCPC, director of pain services and the pain research unit at the Toronto General Hospital, the knowledge translational chair for the University of Toronto Centre for the study of pain and associate professor for the department of anesthesiology and pain medicine at University of Toronto, closed out the session reviewing data on chronic pain from Canada. Dr. Clarke argued that pain is the #1 driver of disability in Canada, and also the #1 driver of inequity in healthcare and society.

Similar to the United States, most Canadian opioid-related fatal overdoses involved fentanyl and its derivatives, with roughly two-thirds involving coadministration of benzodiazepines, cocaine, or methamphetamines. Notably, one in three Canadian opioid toxicity deaths is in a patient who does not have opioid use disorder. Dr. Clarke demonstrated evidence that 56% of the opioid prescriptions written by surgeons and 74.3% of those by dentists are considered “new starts,” or patients who are opioid naïve. These represent critical targets for harm reduction by encouraging these professionals to be intentional about the quantity of opioids ordered for patients and avoid overprescribing.

To conclude the science symposium, Dr. Clarke aired a film produced by his hospital’s communication team interviewing two of his patients from his interventional pain clinic. The video displayed the poignant, toxic impacts opioid addiction has played in these patients’ lives, and how opioid-sparing interventions of nerve ablations and alternative pharmacologic modalities provided them with a renewed sense of independence, mental clarity, and hope.