Colorectal Surgery and the Opioid Epidemic: Opioid Stewardship and Safe Prescribing Practices

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Quality Assessment and Safety Committee and Author Dissclosures

Introduction

The opioid epidemic in the United States began following an increase in opioid prescribing starting in the 1990s. It has claimed over 750,000 lives since 1999, including 46,802 drug overdose deaths in the United States in 2018.[1], [2] The amount of opioids prescribed in the United States remains higher than any other country in the world.[3] The overall economic burden of opioid use in the United States is estimated to amount to $78.5 billion dollars per year,[4] including the cost of healthcare, addiction treatment, lost productivity and criminal justice system expenses.

Learning Objectives

​Upon completion of this content, participants should be able to:
  • Demonstrate an understanding on how perioperative opioid prescribing contributes to the opioid epidemic.
  • Identify and manage patients at higher risk for developing opioid use disorders.
  • Locate federal and state opioid-related legislation.
  • Identify methods for decreasing opioid use in the perioperative period.
  • Develop safe prescribing practices.

The Role of the Surgeon as Prescriber 

Perioperative opioid use plays a major role in the opioid epidemic. Opioids are prescribed following approximately 80% of surgical procedures.[5] Approximately 6% of opioid-naïve patients prescribed opioids after minor surgical procedures will still be using opioids 3-6 months later.[6] Twenty seven percent of chronic opioid users received their original prescription after surgery[7] and are at substantially increased risk of opioid dependence and opioid use disorder.[8] Prescription opioids may also serve as a gateway to injection drug use, with 79.5% of heroin users reporting having used prescription opioids prior to heroin.[9] In addition, the majority of opioids prescribed following surgery (67-92%) go unused, which can serve as a reservoir for diversion.[10] Sixty percent of users of nonmedical opioids report getting their pills from family or friends.[11]

Opioid Legislation 

In October 2017, the Opioid Epidemic was declared a National Emergency. One year later, the federal SUPPORT for Patients and Communities Act (HR 6) was signed. This bill authorized $3.3 billion of federal spending over 10 years. It aims to increase access to opioid treatment within Medicare and Medicaid, expand non-opioid treatment options, reduce overprescribing, and identify opioid best practices. The bill has a provision that requires the Department of Health and Human Services to study and report to Congress on the impact of federal and state laws and regulations that limit the length, quantity or dosage of opioid prescriptions.
 
In response to the opioid epidemic, states have enacted several different kinds of legislation to combat the opioid epidemic: https://www.cdc.gov/phlp/publications/topic/prescription.html
  1. Time and dosage limits to opioid prescribing – Many states have set limits to the length or number of doses of opioid prescriptions, ranging from 3-14 days. There are often exceptions for treatment of chronic pain, end-of-life care, substance use disorder treatment, and even physician judgement. Thus far, these opioid-prescriQAS-Opioid-State-Chart.jpgbing limits have resulted in only modest reductions in opioid prescribing.[16]
  2. Physical examination requirements – Many states require that a physical exam be performed prior to prescription of a controlled substance.  This is done to limit refills being given over the phone. In the setting of the opioid epidemic, these limits have often been waived.
  3. Prescription Drug Monitoring Programs (PDMP)  – These state-run programs collect and distribute data regarding federally controlled substances. PDMPs generally use an online database to prevent overprescribing of opioids by prescribers. As of May 2020, all states now have PDMPs in place, although the design of PDMPs differs among states.

Perioperative Practices to Decrease Opioid Use

Patient Education

Surgeons should address pain control and symptom management during the preoperative visit by setting realistic expectations of pain or discomfort following an operation. Surgeons should discuss the side effects of opioids including the risks of physiologic dependence, addiction, and overdose, and the importance of multimodal anesthesia and non-pharmacologic treatments. The American College of Surgeons offers the following brochure to assist with talking to patients about opioids preoperatively: Safe and Effective Pain Control After Surgery

Multimodal Pain Management

In addition to the potential for addiction and abuse, perioperative opioid use is associated with complications including nausea, vomiting, ileus, confusion and respiratory depression. These opioid-related adverse events have been shown to occur in 23.9% of colorectal surgery cases,[17] and their incidence has been shown to increase costs and length of stay following surgery.[18] The ASCRS clinical practice guidelines for enhanced recovery in colorectal surgery strongly recommends multimodal opioid-sparing anesthesia for all patients starting before the induction of anesthesia and continuing through to the outpatient setting.[19] Multimodal pain management strategies within an Enhanced Recovery After Surgery (ERAS) perioperative protocol in colorectal surgery have been associated with decreased inpatient opioid use, accompanied with decreased opioid related adverse events, earlier return of bowel function and decreased postoperative length of stay.[19] Medication regimens include the use of oral acetaminophen, oral gabapentin, and intravenous ketorolac, given immediately before the operation and in the postoperative period. Regional anesthetic techniques including transversus abdominis plane blocks have been used to reduce opioid use as well. However, the benefits of multimodal ERAS postoperative pain management has not yet been clearly shown to decrease opioid prescriptions at discharge, decrease the incidence of persistent opioid use or decrease opioid-related overdoses.[20] Recently, studies have shown that standardized protocols—including patient education and multimodal pain management—can successfully reduce the need  for opioid prescriptions following outpatient anorectal surgery.[21], [22]

Determining Safe Prescribing Practices

There are currently no national guidelines for postoperative opioid prescribing. However, several state-run agencies have successfully implemented evidence-based guidelines for opioid prescribing, resulting in decreased opioid prescriptions associated with non-inferior patient pain and satisfaction scores.[23], [24]

The Michigan Opioid Prescribing Engagement Network (OPEN) Opioid Treatment and Prescribing Guidelines[25]

  • Non-opioid therapies should be encouraged as a primary management of acute pain
  • Non-pharmacologic therapies should be encouraged (ice, physical therapy)
  • Short-acting opioids should be prescribed for no more than a 3-5 day course
  • Fentanyl and long-acting opioids such as oxycontin should NOT be prescribed to opioid-naïve patients
  • Michigan OPEN Procedure-Specific Prescribing Recommendations: According to these guidelines, 0-10 oxycodone tablets (or equivalent) should be prescribed for a laparoscopic colectomy, and 1-15 pills should be given for an open colectomy, ileostomy/colostomy creation, ileostomy/colostomy closure, or open small bowel resection.

Bree Collaborative and Washington State Agency Medical Directors' Group Prescribing Opioids for Postoperative Pain - Supplemental Guidance[26]

For procedures with medium term recovery (including laparoscopic colectomy)
  • Prescribe non-opioid analgesics and non-pharmacologic therapies as first-line therapy
  • Prescribe < 7 days of short-acting opioids for severe pain.  Prescribe the lowest effective dose strength
  • For those exceptional cases that warrant >7 days of opioid treatment, the patient should taper off opioids within 6 weeks of surgery.

Additional Resources 

The Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services provides a directory of opioid treatment programs:
https://dpt2.samhsa.gov/treatment/directory.aspx
 
Reducing excess opioids in the community is of great importance, as most opioids go unused and diversion is one of the most common ways that opioids are obtained for illicit use. A resource to locate a safe public disposal location in your area can be found here: Controlled Substance Public Disposal Locations

Conclusion

The opioid epidemic demands an informed, responsible approach by colorectal surgeons to reduce the risk of opioid prescribing while providing the best perioperative care for our patients.

Selected References

  1. Wilson N, Kariisa M, Seth P, Smith Ht, Davis NL. Drug and Opioid-Involved Overdose Deaths - United States, 2017-2018. MMWR Morb Mortal Wkly Rep 2020;69:290-7.
  2. ​Control CfD. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: National Center for Health Statistics, 2020.
  3. Board UNINC. Report of the International Narcotics Control Board for 2019, 2018.
  4. Florence CS, Zhou C, Luo F, Xu L. The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013. Med Care 2016;54:901-6.
  5. Wunsch H, Wijeysundera DN, Passarella MA, Neuman MD. Opioids Prescribed After Low-Risk Surgical Procedures in the United States, 2004-2012. JAMA 2016;315:1654-7.
  6. Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, Bohnert ASB, Kheterpal S, Nallamothu BK. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg 2017;152:e170504.
  7. Callinan CE, Neuman MD, Lacy KE, Gabison C, Ashburn MA. The Initiation of Chronic Opioids: A Survey of Chronic Pain Patients. J Pain 2017;18:360-5.
  8. Kaye AD, Jones MR, Kaye AM, Ripoll JG, Jones DE, Galan V, Beakley BD, Calixto F, Bolden JL, Urman RD, Manchikanti L. Prescription Opioid Abuse in Chronic Pain: An Updated Review of Opioid Abuse Predictors and Strategies to Curb Opioid Abuse (Part 2). Pain Physician 2017;20:S111-S33.
  9. Ruan X, Bydalek K, Kaye AD. Emergency Visits for Prescription Opioid Overdose. Clin J Pain 2016;32:459.
  10. Bicket MC, Long JJ, Pronovost PJ, Alexander GC, Wu CL. Prescription Opioid Analgesics Commonly Unused After Surgery: A Systematic Review. JAMA Surg 2017;152:1066-71.
  11. Jones CM, Paulozzi LJ, Mack KA. Sources of prescription opioid pain relievers by frequency of past-year nonmedical use United States, 2008-2011. JAMA Intern Med 2014;174:802-3.
  12. Burcher KM, Suprun A, Smith A. Risk Factors for Opioid Use Disorders in Adult Postsurgical Patients. Cureus 2018;10:e2611.
  13. Hilliard PE, Waljee J, Moser S, Metz L, Mathis M, Goesling J, Cron D, Clauw DJ, Englesbe M, Abecasis G, Brummett CM. Prevalence of Preoperative Opioid Use and Characteristics Associated With Opioid Use Among Patients Presenting for Surgery. JAMA Surg 2018;153:929-37.
  14. Cron DC, Englesbe MJ, Bolton CJ, Joseph MT, Carrier KL, Moser SE, Waljee JF, Hilliard PE, Kheterpal S, Brummett CM. Preoperative Opioid Use is Independently Associated With Increased Costs and Worse Outcomes After Major Abdominal Surgery. Ann Surg 2017;265:695-701.
  15. O'Brien SJ, Chen RC, Stephen VT, Jorden J, Farmer R, Manek S, Schmidt M, Pan J, Rai SN, Galandiuk S. Preoperative Opioid Prescription Is Associated With Major Complications in Patients With Crohn's Disease Undergoing Elective Ileocolic Resection. Dis Colon Rectum 2020;63:1090-101.
  16. Chua KP, Kimmel L, Brummett CM. Disappointing Early Results From Opioid Prescribing Limits for Acute Pain. JAMA Surg 2020.
  17. Homsi J, Brovman EY, Rao N, Whang EE, Urman RD. The Association Between Potential Opioid-Related Adverse Drug Events and Outcomes in Colorectal Surgery. J Laparoendosc Adv Surg Tech A 2019;29:1436-45.
  18. Shafi S, Collinsworth AW, Copeland LA, Ogola GO, Qiu T, Kouznetsova M, Liao IC, Mears N, Pham AT, Wan GJ, Masica AL. Association of Opioid-Related Adverse Drug Events With Clinical and Cost Outcomes Among Surgical Patients in a Large Integrated Health Care Delivery System. JAMA Surg 2018.
  19. Carmichael JC, Keller DS, Baldini G, Bordeianou L, Weiss E, Lee L, Boutros M, McClane J, Feldman LS, Steele SR. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2017;60:761-84.
  20. Echeverria-Villalobos M, Stoicea N, Todeschini AB, Fiorda-Diaz J, Uribe AA, Weaver T, Bergese SD. Enhanced Recovery After Surgery (ERAS): A Perspective Review of Postoperative Pain Management Under ERAS Pathways and Its Role on Opioid Crisis in the United States. Clin J Pain 2020;36:219-26.
  21. Hartford LB, Murphy PB, Gray DK, Maciver A, Clarke CFM, Allen LJ, Garcia-Ochoa C, Leslie KA, Van Koughnett JAM. The Standardization of Outpatient Procedure (STOP) Narcotics after anorectal surgery: a prospective non-inferiority study to reduce opioid use. Tech Coloproctol 2020;24:563-71.
  22. Ivatury SJ, Swarup A, Wilson MZ, Wilson LR. Prospective Evaluation of a Standardized Opioid Reduction Protocol after Anorectal Surgery. J Surg Res 2020;256:564-9.
  23. Louie CE, Kelly JL, Barth RJ, Jr. Association of Decreased Postsurgical Opioid Prescribing With Patients' Satisfaction With Surgeons. JAMA Surg 2019;154:1049-54.
  24. Vu JV, Howard RA, Gunaseelan V, Brummett CM, Waljee JF, Englesbe MJ. Statewide Implementation of Postoperative Opioid Prescribing Guidelines. N Engl J Med 2019;381:680-2.
  25. Network MOPaE. Opioid Prescribing Recommedations for Surgery, 2020.
  26. Group DRBCaWSMD. Prescribing Opioids for Postoperative Pain - Supplemental Guidance, 2018.
  27. Scarborough JE, Schumacher J, Kent KC, Heise CP, Greenberg CC. Associations of Specific Postoperative Complications With Outcomes After Elective Colon Resection: A Procedure-Targeted Approach Toward Surgical Quality Improvement. JAMA Surg 2017;152:e164681.
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