opioid prescriptions have increased dramatically in
the U.S. from 76 million in 1991 to 219 million in 2011,
and the number of opioid prescriptions sometimes
eclipses a state’s population.
3, 4 More opioids are consumed per capita in the U.S. than in any other country.
As surgeons, we manage acute postoperative pain with
opioids in both opioid-naive and opioid-dependent populations. Consequently, surgeons can be considered
the gatekeepers of the opioid epidemic and thus have
a duty to develop responsible prescribing practices and
This article summarizes the scope of the opioid
crisis and describes the recent changes to federal and
state regulations governing opioid prescribing practices. It also offers several brief profiles that illustrate
how individual surgeons are mitigating the effects of
the opioid crisis through research and advocacy.
Scope of the problem
The Centers for Disease Control and Prevention (CDC)
organizes opioids into the following four categories:
•Natural opioid analgesics/semi-synthetic opioid analgesics, including morphine, codeine, oxycodone,
hydrocodone, hydromorphone, and oxymorphone
•Synthetic opioid analgesics, such as tramadol and
From 2014 to 2015, overdose deaths from synthetic
opioid analgesics in the U.S. increased 72 percent,
and heroin overdose deaths increased 21 percent.
Overall, opioids accounted for 33,091 deaths in the
U.S. in 2015—the equivalent of 91 people per day
dying from opioid-related causes, or quadruple the
number of people who were dying from opioid-related
causes in 1999.2, 7, 8 The rise in the number of opioid-
related deaths coincides with a fourfold increase in
the number of prescription opioids sold in the U.S.
As of 2011, drug poisonings and overdoses have surpassed motor vehicle crashes as the leading cause
of unintentional injury deaths in the U.S.
9 In 2014,
5. 9 deaths per 100,000 Americans were due to opioid
analgesic overdoses, while 10. 8 deaths per 100,000
were from motor vehicle-related injuries and 10. 3 per
100,000 were firearm-related.
9 To combat the growing death toll of the opioid epidemic, it is necessary
to understand not only the scope, but also the origins of the crisis.
Chronic opioid use often begins with acute pain.
The American Pain Society publicized the idea of
measuring pain as a vital sign in the 1990s. The U.S.
Department of Veterans Affairs (VA) and other health
care systems, networks, and institutions quickly
adopted this recommendation.
10, 11 In 2001, the Joint
Commission on Accreditation of Healthcare Organizations (now The Joint Commission) included the
concept of pain as the “fifth vital sign” in an example
of how to implement Standard RI. 1. 2. 8 in The Comprehensive Accreditation Manual for Hospitals, which states
that “patients have the right to appropriate assessment and management of pain.”
12 The societal shift
toward treating pain more vigorously was noticed by
pharmaceutical companies, which then aggressively
marketed pain-relieving opioids to both physicians
13 Sadly, the heightened focus on pain
management coincided with a rise in both opioid prescriptions and overdoses.
4 As opioid deaths rose, states
implemented prescription drug monitoring programs
(PDMPs) and regulated pain management clinics to
curb abnormal prescribing practices and to shut down
so-called pill mills.
Despite efforts to reduce prescription opioid
misuse, many Americans continue to take them for
nonmedical reasons. Unable to obtain opioids from
physicians, patients turn to what are referred to as
diverted prescription opioids or illicitly produced
opioids. According to 2008–2011 data from the U.S.
National Survey on Drug Use and Health, diverted
opioids are often freely given to users from friends or
family ( 54 percent), stolen or purchased from friends