By Bob Kronemyer

Originally published by our sister publication, Pain Medicine News

A recently formed advisory group of the Anesthesia Patient Safety Foundation (APSF) aims to expand understanding and explore methods of prevention and mitigation of opioid harms in perioperative patients.

“In 1995, the American Pain Society instituted the ‘pain as the fifth vital sign’ campaign, based on quality improvement guidelines published the previous year in JAMA [1995;274(23):1874-1880],” said Ken Johnson, MD, an acute pain specialist, and a professor and the vice chair of research in anesthesiology at the University of Utah, in Salt Lake City. “Industry and health resources rallied in response and made opioid pain medicine widely available. This led to opioid overconsumption, adverse events and a rise in opioid-related harms.”

As a result, he said, the pendulum of opioid prescription directives has swung over the past five years from liberal treatment of pain to rigorous restriction to slow the rise in opioid-related deaths, as embodied by guideline recommendations from the CDC (see cover story, upper left) that opioid prescriptions be regulated and the drugs less frequently prescribed.

“This policy has driven many people to find their opioids elsewhere, where sources are unregulated—hence, opioid-related harm has increased,” said Johnson, who is a member of the APSF advisory group tasked with informing the board of directors on 10 safety priorities—one of which is opioid-related harms in the perioperative period. The group comprises scientists, researchers, physicians, other clinicians and industry leaders.

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Johnson would like epidemiology experts in opioid use to take a fresh look at benchmarking opioid harms from perioperative opioid administration. “That is a time in which many patients are introduced to opioids,” he said. “In the context of recent guidelines restricting opioid prescriptions, areas to explore include the new incidence of opioid use disorder [OUD], opioid misuse, opioid addiction, chronic opioid use and opioid-related deaths that stem from starting opioids in the perioperative period. Answers to these questions are important to understand when formulating effective interventions that address the recent rise in opioid harm.”

Overdose deaths top the list in opioid-related harms, with more than 100,000 deaths recorded in the United States in the 12-month period ending in April 2021—the most ever in any similar period.

According to the Drug Enforcement Administration, opioid-related deaths are being fueled, in part, by illicit fentanyl. Even a tiny amount, like a grain of salt, of illicit fentanyl can be fatal to an adult. The drug also can be pressed into counterfeit pills, yet the drug is rarely disclosed to buyers and sometimes dealers.

The second and third leading opioid-related harms are OUD and the need for chronic opioids, respectively, he said.

Johnson noted that to effectively reduce opioid-related harms in the perioperative period, a multipronged approach will likely be required, for example, promoting better patient education about the potential harm of opioids. “It is important that patients be engaged from the moment they consider having surgery,” he said. Patients would benefit from an education campaign that focuses on opioid alternatives, duration of and proper opioid use, pain management expectations, and the dangers of opioids.

Another approach may be with opioid disposal. “It should also be very easy for a patient to dispose of their opioids,” Johnson said. “We need enhanced resources for opioid disposal in a safe place, so they are not lying around.”

As more surgery is performed on an outpatient basis, patients are being sent home after procedures associated with significant postoperative pain, such as total joint replacement. “This trend warrants exploration of innovative devices that monitor hemoglobin oxygenation saturation and alert providers and/or family members of worrisome trends in oxygenation,” Johnson said.

Other approaches to minimize opioid-related harms may include more research into opioid reversal, opioid–drug interactions and educating perioperative clinicians how to reduce or eliminate opioid use.

Leveraging techniques developed for artificial intelligence may be another useful tool to analyzing large data sets of patient demographics, clinical history and behavioral phenotypes to identify patients at risk for opioid-related harms.

“Beyond the perioperative setting, there are, of course, important patient care access points that deserve attention in addressing opioid harm,” Johnson said, noting that numerous clinical investigators with expertise in chronic pain and opioid addiction have stated that although opioid prescription limits were implemented with good intentions, “they have caused as much or more harm than the original mandate to treat pain as the fifth vital sign.”

Patients with OUD require attention and are best served by a multidisciplinary approach to their care, which includes behavioral medicine, physician opioid prescribers, psychologists and occupational therapists “to help manage the addiction and steer patients through a very difficult time,” Johnson said. “Thought leaders in addiction medicine have suggested that controlling the prescription opioid floodgates without attention to these other areas has been very harmful.”

Johnson said there must be a hard look at policy that regulates opioid prescriptions to patients who are addicted, in the context of recent harm, notably, rising rates of death by suicide and opioids.

“Opioid prescription limitations are trying to help, but they have a ceiling effect,” he said. “Chronic pain and opioid addiction experts argue that restricting opioid prescriptions is misguided because it removes or substantially limits access for vulnerable people to the healthcare resources they need. These people end up either alone or feed their addiction from illicit sources. They lose access to the help they need.”

To truly help someone with OUD, “addiction experts have advocated for clinician–patient interaction that allows for enough time to establish a reasonable rapport of trust,” Johnson said. “Unfortunately, the infrastructure is not in place to allow clinicians to do that. They neither have adequate time nor reasonable compensation to provide compassionate, multidisciplinary care and the visit frequency that can make an impact.”

To effectively wean people from opioids, clinicians need flexibility in opioid prescribing practices to maintain patient engagement, provide boundaries and minimize the risk for opioid-related death.

“APSF is committed to action to advance perioperative patient safety and welcomes input from a diverse group of professional experts, such as the advisory group,” Johnson said.



Johnson is an equity partner of Respiration AI.