By David J Samuels, MD, Facility Medical Director TeamHealth Anesthesiology, Select Physicians Surgery Center, Tampa, Florida.
In 2016, Surgeon General, Vivek Murthy, MD, sent a letter to every physician in the United States enlisting our commitment to help end the opioid epidemic. He stated that the crisis was born from a “path of good intentions.” For decades, physicians were encouraged by various pain organizations, government agencies and big pharma to be more aggressive about treating pain. Dr. Murthy highlighted routine surgery as a potential gateway for opioid use disorder. Recent literature demonstrated that 6-8 percent of patients remain on opioids more than 90 days after major or minor surgery. Should anesthesiologists be concerned about our contribution to the initiation of opioid tolerance during surgery?
I recently removed fentanyl (and all opioids) from my general anesthesia practice to mitigate opioid-induced deaths from respiratory depression known as “dead-in-bed” syndrome. A feature of the non-opioid general anesthetic is that patients utilize fewer opioids in the recovery room. The scientific evidence for acute opioid-induced hyperalgesia (paradoxical increased pain) is decades old, but its clinical significance has been difficult to prove. That even a small dose of intraoperative opioid can lead to more than double the opioid requirement in the recovery room might be explained by opioid-induced hyperalgesia. Additionally, the decreased nausea and vomiting rate leads to earlier home readiness.
Some of the non-opioid medications in the regimen improved chronic pain issues unrelated to the surgical procedure. Might this technique also lead to less opioid dependence after surgery?
Most anesthesiologists today consider fentanyl integral to all anesthetics, despite the lack of scientific studies. The fentanyl story is a remarkable one. It was synthesized by Dr. Paul Janssen in the 1960s to be a highly potent, more powerful and safer morphine analog. The Food and Drug Administration (FDA) did not initially approve fentanyl due to the misgivings of the distinguished anesthesiologist, Dr. Robert Dripps, who felt it was too potent and would lead to many abuse problems. Eventually, it was approved in a combination form to deter abuse, then subsequently approved alone. In the 1980s, anesthesiologists readily adopted it due to its cardiac stability and rapid onset and offset. In the 1990s, big pharma produced it in patches, lollipops and sprays. In the 2000s, the illicit drug cartels adopted it due to its addiction potential as it is 50 times more potent than heroin. Recently, a 23-year-old in recovery from opioid addiction overdosed one month after receiving fentanyl during his surgery. Cases like this have led to four states legislating the rights of patients to sign a non-opioid directive. Dr. Dripps’ concern about fentanyl leading to abuse proved to be prescient.
As the TeamHealth facility medical director at an ear nose and throat ambulatory surgery center, I standardized the non-opioid technique during surgery. Our anesthesiology care team utilizes combinations of multimodal, non-opioid agents including preoperative acetaminophen and gabapentin and intraoperative N-methyl D-aspartate (NMDA) blockers, sodium channel blockers, glucocorticoids, Nonsteroidal Anti-inflammatory Drugs (NSAIDs), alpha 2 blockers, histamine blockers, beta blockers and inhalational agents to interrupt the various junctions along the pain pathway. Our intraoperative success treating more than 3,000 patients will now be leveraged to include the post-operative period with an education program called NOPE! (non-opioid perioperative engagement). Evidence shows collaborative preoperative patient education can lead to improved health outcomes. Prior to surgery we will educate our patients on expectations concerning pain and its management. They will learn the efficacy of non-opioid pharmacologic agents such as magnesium, gabapentin, ibuprofen and acetaminophen as first line treatment. By avoiding opioids, our patients are spared their adverse effects including nausea, vomiting, constipation and dysphoria which many consider worse than the underlying pain. The patient’s endogenous opioid system (beta-endorphins) remains intact by avoiding the adverse effect of prescription opioids.
The primary aim is to improve function and quality of recovery while eliminating adverse effects of opioid therapy. Many of our surgeons have decreased their prescription opioid pill count from 50 pills to five, saving tens of thousands of opioid pills from the community medicine cabinet, often diverted for abuse. On many occasions we keep opioid-naïve patients, opioid-naïve. We can indeed make a difference in the opioid epidemic by eliminating potent opioids during surgery.