Opioid misuse and dependence is associated
with significant morbidity and mortality. More
than 500,000 people died from opioid overdose in
2000−2015.16, 17 Unintentional drug overdoses have
become the leading cause of accidental death in
the U.S., surpassing motor vehicle-related deaths,
unintentional falls, and fatal firearm injuries.
the 33,091 opioid-related deaths in 2015, 61 percent
were attributed to prescription medications.
17 In 2011,
366,181 emergency department visits were attributed to opioid overdose, an increase from 168,379 in
2005.19 As frequent prescribers of opioids, it is essential
that surgeons recognize the morbidity and mortality associated with taking these medications. Given
that patients often receive opioid pain medications
postoperatively, these individuals may be particularly
susceptible to these harms.
The surgeon’s contribution to diversion
Opioid-related deaths and injuries have risen concurrently with opioid prescription sales, and undoubtedly,
the prescribing practices of surgeons have contributed
to this situation. Between 2007 and 2012, surgeons
wrote 9. 8 percent of opioid prescriptions in the U.S.
Although surgeons write only a fraction of all opioid
prescriptions, the average dose of opioids prescribed
postoperatively appears to be rising. Wunsch and colleagues found that the average morphine equivalent
dose prescribed after four common low-risk surgical
procedures had increased to 247 in 2014 from 219
in 2004 (p < 0.001).
20 Another factor contributing to
opioid diversion is related to individuals who misuse
prescription pain medications after receiving them
from someone they know. In 2015, 53. 7 percent of
people who misused prescription pain medication
received them from a friend or relative.
Studies suggest certain patients are at higher
risk for long-term postoperative opioid use.
22 In a
population-based study from Canada on long-term
postoperative opioid use, patients were associated
with an increased risk of opioid use at 90-days postoperatively if they met the following criteria:
•In the lower-fifth income bracket
•Have comorbidities such as diabetes
•Preoperative use of benzodiazepines, antidepressants,
Changing the preoperative dialogue
and antihypertensive medications
Genetic factors also have a strong correlation with
potential opioid addiction.
23 Preoperative screening
of patients for known risk factors offers surgeons an
opportunity to educate at-risk patients and to con-
sult specialists for recommendations regarding pain
management in the perioperative period.
Patient-centered preoperative communication is
integral to setting realistic expectations for post-operative pain, developing successful nonopioid
analgesic regimens, reducing opioid consumption
during the postoperative period, and reducing the
number of opioid pills at risk for diversion. Through
shared decision making, patients can play an active
role in determining the pain management plan
that best addresses their medical and psychological history.
Understanding risk factors that predispose patients
to opioid abuse can help surgeons to identify patients
who may require preoperative interdisciplinary consultation. Essential components of a thorough risk
assessment include a comprehensive understanding
of previous and existing mental health and substance
abuse issues, knowledge of pharmacologic treatments for substance abuse (such as methadone and
buprenorphine), and an awareness of family history of
substance abuse. High-risk patients, including those
with complex substance abuse histories, should be