How Surgery Helped Fuel the Opioid Epidemic

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Each year,
surgery puts millions of people in the United States at risk of long-term
prescription opioid use.

Sometimes, use
lasts long after the normal recovery period, a new study concluded.

This occurs
after both major and minor surgeries, leading researchers to blame other
factors for this trend.

“The reasons
for people continuing to use opioids are complicated and not always as simple
as just pain after surgery,” Dr. Chad Brummett, a study author, and director of
the pain research division in the University of Michigan Medical School’s
Department of Anesthesiology, told Healthline.

Read more: Should you take opioids
to treat pain? »

‘Persistent
opioid use’

The study, which was published April 12 in JAMA Surgery, found that about 6
percent of 36,000 adults continued to receive prescription opioids three to six
months after surgery.

The rates of
“new persistent opioid use” were similar for people who had major or minor
surgery.

This was
about 12 times more than the rate of long-term opioid use in a comparison group
of similar people who didn’t have surgery during the study period.

Researchers
also found that people who had certain conditions before surgery had a higher
risk of long-term prescription opioid use.

This
included smoking, alcohol or substance abuse disorders, depression, anxiety,
and arthritis or other chronic pain conditions.

Around 50
million surgical procedures are performed in the United States each year.

If the
study’s findings hold for all patients, it would mean that each year about 3
million people who hadn’t used opioids recently would still be receiving these drugs
months after their surgeries.

“This is an
area that we have not focused enough on and certainly merits attention, given
these high rates of new persistent use,” said Brummett.

Experts say
this study also addresses some misconceptions about prescription opioids.

“It’s a
really important study because it’s one more piece of evidence that puts to
rest this myth that people who become addicted to prescription opioids are
people who were already addicted to something else,” Dr. Anna Lembke,
psychiatrist and pain specialist at the Stanford University Medical Center,
told Healthline.

Read more: New guidelines to prevent
opioid addiction »

Fueling the epidemic

This is not
the first time that prescription pain killers have been implicated in fueling
the opioid epidemic in the United States.

A 2015 analysis published in the Annual Review of Public Health found
that since the late 1990s, sales of prescription opioids have risen in parallel
with opioid overdose deaths and opioid treatment admissions.

Opioids caused
more than 33,000 deaths in 2015, according to the Centers for Disease
Control and Prevention (CDC)
.

Half of
these deaths were due to prescription opioids, such as methadone, OxyContin, and Vicodin.

But even
after the CDC declared an opioid
epidemic
in 2011,
doctors continued for several years to prescribe a significant amount of
opioids to patients.

“It’s really
only in the last year or so that we see some plateauing and some decrease,”
said Lembke, “but not a substantial decrease.”

Two years
ago, doctors wrote about 300
million opioid prescriptions
.

People in
the United States use about 80 percent of the world’s opioid supply — yet the
country only has 5 percent of the global population.

“We have no
more need for analgesia than other high-income developed countries,” said
Lembke, “and yet we consume vast amounts of opioids.”

Read more: Treating pain in an opioid
epidemic »

Balancing risks,
benefits

The JAMA Surgery study shows that opioids
prescribed after surgery are contributing to the opioid epidemic, but that
doesn’t mean these drugs don’t have their place in medicine.

“There’s no
question that opioids are essential for the practice of modern medicine and are
vital in managing acute pain, especially moderate to severe acute pain,” Dr.
Itai Danovitch, chairman and associate professor of the Department of
Psychiatry and Behavioral Neurosciences at Cedars-Sinai Medical Center, told
Healthline.

The CDC
recommends
taking prescription
opioids for most acute pain for three days or less, with more than seven days
rarely needed.

For
long-term pain — lasting more than 30 to 90 days — opioids may not be effective.

“For most
chronic pain conditions, opioids would not be a first or even a second-line
medication,” said Brummett, “and really should be limited to very specific
situations.”

And the
downsides of opioids quickly accumulate when you are on them for months.

“There is a
lot of evidence to show that taking opioids for 90 or more days leads to lots
of risk factors and adverse medical consequences,” said Lembke. “One of which
is addiction, but there are others — depression, constipation, hormonal
imbalance, hypoxemia, accidental overdose death, and tolerance dependence
withdrawal.”

Not everyone
who uses opioids becomes addicted.

But a 2015 study found that the risk of developing an
opioid use disorder increased with both duration and dose — with duration
having the biggest effect.

Read more: Opioid epidemic and chronic
pain »

Better pain relief

There are
many points at which doctors can target the problem of long-term opioid use
after surgery.

Additional
“psychological support and education” before surgery can give patients clear
expectations about the risks and benefits of opioids, said Lembke, and may
reduce their need for opioids.

This is
especially important for people with risk factors such as mental illness or a
personal or family history of addiction.

And it means
educating doctors as well, a core mission of the Michigan
Opioid Prescribing Engagement Network
.

“We have to
retrain physicians as to how they think about opioids but also to set fair
expectations for patients about what’s to be expected,” said Brummett.

During
surgery, non-opioid pain relief may also be available.

“Localized
lidocaine infusions are just one example of innovative techniques that doctors
are coming up with now to try to minimize the use of opioids,” said Lembke.

And after
surgery, doctors can prescribe opioids in the smallest dose and duration that
works for a patient.

Surgeons
also need to be alert for problems.

“If we begin
to see patients going to two or three months of daily use, that should be a red
flag,” said Lembke. “Not for stigmatizing the patient or shaming them or
kicking them out of your practice, but for getting them additional support.”

This extra
support might come from a pain management or addiction specialist. Or from a
support group or the patient’s family physician.

Danovitch
also sees a need to break down the barriers between the physical health and
mental health systems.

“We know
that most people that struggle with chronic pain also have mental health issues
— anxiety or depression or other adversity,” he said. “To achieve optimal
health outcomes, they need to get both sets of services.”

Read more: Prescription drugs
and heroin addictions »

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