Nearly 40 percent of the outpatient prescriptions that surgeons write are for opioids, a prescrib- ing rate second only to that of pain medicine
specialists ( 49 percent).
2 As a result, surgeons are
uniquely positioned to address the opioid epidemic.
Up to 10 percent of opioid-naive patients (specifically
those who are not receiving chronic opioid therapy on
a daily basis) who receive a postoperative narcotic prescription require opioids to control pain symptoms at
one year from surgery.
3 Notably, data suggest that surgeons vastly overprescribe narcotics after procedures,
with unused pills inevitably stored in patients’ medicine
cabinets where they can be accessed by anyone for
4 Improper disposal of medications is a major source of opioids among individuals
who abuse them, a practice known as diversion.
Despite the ubiquity of pain among the ill and
injured, education regarding optimal opioid prescribing practices has historically been little more than
an afterthought in medical school and surgical residency curricula. According to a 2016 article in the
New England Journal of Medicine, “...many physicians
admit that they are not confident about how to prescribe opioids safely, how to detect abuse or emerging
addiction, or even how to discuss these issues with
5 Filling this educational gap is perhaps
one of the greatest obstacles surgeons face in terms
of addressing the opioid epidemic. Not only must the
surgical community develop a better understanding of the magnitude of the opioid epidemic, but it
is essential that surgeons assume responsibility for
safely and appropriately prescribing these powerful medications. Because surgeons are central to the
genesis and management of surgical pain, it is our
professional duty to be responsible stewards of opioids and to play a key role in crafting the medical
community’s response to the opioid epidemic.
Similar to the multimodal approach that has
proven efficacious to manage pain, the health care
community must adopt a multifaceted approach to
ensure that we are addressing the biological, psycho-
logical, and social factors that contribute to the opioid
6 We anticipate that heightened awareness
will inform opioid prescribing practices for surgeons,
and that targeted patient education will lead to more
responsible use and disposal of opioids.
Opioid stewardship, in the form of surgeon-led
preoperative discussions, may be a powerful tool in
reducing the immense societal costs of the opioid
epidemic. In this article, the authors discuss several strategies surgeons can use in the preoperative
period to facilitate more effective communication
with patients regarding risk assessment, expectations
for pain management, and the harms associated with
Defining the problem
Despite recent efforts to develop multimodal analgesic
regimens to control perioperative pain symptoms,
opioids remain the most common pain relievers
patients use in the postoperative period. Ideally,
opioid analgesics are one aspect of multimodal post-operative analgesic regimens. However, opioids are
often used independently.
7 In patients with pain symptoms refractory to nonopioid treatments, opioids can
greatly alleviate pain symptoms and significantly
improve quality of life. However, like any medical
treatment, opioids carry a risk. Even moderate opioid
use, as recommended after successive operations,
can result in misuse, addiction, and diversion.
8, 9 Prolonged postoperative opioid use is associated with
increased morbidity, poor quality of life, increased
risk of traumatic injury, cardiac events, and delayed
10-15 Notably, surgical patients who
suffer from opioid-related complications accrue
greater hospital costs, higher readmission rates, and
longer hospital lengths of stay.
The art of communication is the language of leadership.