Substance misuse is “one of the most pressing public health crises of our time” according to US Surgeon General Vivek H Murthy, in his November 2016 report on alcohol, drugs and health, Facing Addiction in America. Describing the nature of the medical community’s response to the country’s substance misuse crisis as a “moral test for America”, his report aimed to set out a road-map for “parents, families, educators, healthcare professionals, public policy makers, researchers, and all community members” to help address substance abuse. In this special report, Spinal News International interviews Sanjog Pangarkar, a pain management specialist from the West Los Angeles Veterans Affairs (VA) Medical Center, Los Angeles, USA, about his experiences with the VA’s successful Opioid Safety Initiative, which, according to research published in Pain, has resulted in significantly lower rates of opioid prescription among VA physicians over a two-year period.
In 2014, 28,647 deaths from overdose involving some kind of opioid were reported in the USA—the highest number ever recorded by the Centers for Disease Control at the time. This increased to 33,091 in 2015. According to the Surgeon General’s report, 12.5 million people reported their misuse of prescribed opioid pain relievers to the Center for Behavioral Health Statistics and Quality.
Surgery is rarely a perfect solution to back pain, with patients frequently prescribed opioid pain relief to treat chronic post-procedural pain. A number of prominent medical societies, including the North American Spine Society (NASS), signed a letter to the US Congress calling for urgent political action on the growing opioid crisis. The letter asks that Congress “provide[s] the maximum possible allocation” for grant programmes under the Comprehensive Addiction and Recovery Act, as well as for front-line prevention and treatment efforts.
Extending far beyond the USA, recent research published in BMC Psychiatry showed past-year rates of pain relief abuse in Europe to be only slightly lower than in the USA. Using data from 2,032 youths and 20,035 adults collected as part of the European Union Medicine Study, researchers found that those with a prescription for opioid pain relievers were eight times more likely to move on to recreational use of opioids.
In August 2016, Steven J Sack, president of the American Medical Association, issued an open letter to the country’s physicians, emphasising the importance of their role in both exacerbating and addressing the crisis. Stack asserted that physicians “are on the front lines of an opioid epidemic that is crippling communities across the country”. They must, he wrote, “accept and embrace our professional responsibility to treat our patients’ pain without worsening the current crisis.”
The USA is in the midst of an opioid misuse crisis, with rates of misuse in Europe and the rest of the world rising. How is surgery—spinal in particular—contributing to this problem?
Over the past decade, the number of spinal surgeries performed has steadily increased, and we have seen a concurrent rise in the number of patients requiring chronic pain care afterward. Opioids were a common tool used for managing chronic pain in this population, which is one of the reasons we have found ourselves in this crisis.
However, the problem is not unique to spine surgery as Eric Sun and his colleagues recently pointed out.1 They found an increased requirement for opioids after total knee replacement, total hip replacement, open cholecystectomy and simple mastectomy as well. I think that as our understanding of the causes of chronic pain improves, we will be able to offer treatments other than opioids.
What can make patients particularly vulnerable to the development of opioid misuse problems following surgery?
There are several factors that predict the development of chronic post-surgical pain requiring opioids, including emotional overload, preoperative pain at the operative site, other chronic preoperative pain (eg. headache), acute postoperative pain, and comorbid stress symptoms such as anxiety and disturbed sleep.2 Additionally, preoperative use of opioids increases the risk of chronic post-surgical pain by a relative risk of two.3
Having said that, patients experiencing significant postoperative pain (increased duration or severity) may also be at higher risk for developing chronic pain, which is why we recommend appropriate post-surgical pain care. Lastly, if a patient has a history of opioid abuse or misuse, post-surgical pain and treatments such as opioids could trigger a relapse. For that population, careful pre-surgical planning with a pain or addiction specialist should be considered.
How can surgeons address already-existing opioid dependence?
In patients that already have opioid dependence, careful pre- and postoperative pain planning should take place between the surgeon and pain or addiction specialist. Collaboration between providers is key, including postoperative rehabilitation, which is critically important for success in these patients.
I certainly do not think having a history of opioid dependence should prevent a needed surgery from taking place, but I would suggest that the surgeon and patient review informed decision making and post-surgical expectations. Education is key, along with appropriate contingency planning in the event of a difficult recovery (eg. referral to specialists, including mental health or addiction). Lastly, weaning patients down to the lowest dose of opioid prior to surgery may help in the perioperative period and improve overall safety.
What alternative options to opioid prescription—for low back pain generally and post-surgical back pain—are currently available?
There are a number of options available for post-surgical low back pain (and low back pain) other than opioids. These include adjunctive medications, including anti-convulsants and anti-depressants that address pain related to nerve injury, as well as many commonly performed interventional pain procedures.
Integrative approaches—which were historically referred to as complementary and alternative medicine—are also being used more commonly, including acupuncture, hypnosis, holistic nursing, cognitive behavioural therapy (CBT), and mindfulness-based stress reduction (MBSR). We also continue to use conventional treatments post-surgery, including early mobilisation with physical therapy and appropriate regional anaesthesia techniques. Having a multimodal and multidisciplinary approach to this patient population improves outcomes for the vast majority of those suffering from chronic pain and disability.
How is the VA pain management programme approaching opioid prescription?
The VA is a national leader in improving pain care while reducing morbidity for our nation’s veterans that are taking opioid medications for pain. The Opioid Safety Initiative (OSI) was rolled out to all VA facilities in 2013. The OSI identifies patients at high risk for adverse events related to opioids and benzodiazepines. This initiative has significantly reduced the number of opioids dispensed and put in place policies that ensure safe prescribing by providers. At the same time, the VA has offered many integrative therapies that offer patients an alternative to opioids, including yoga, acupuncture, chiropractic care and Tai Chi.
In cases where opioids are felt to be necessary in providing adequate relief, patients and families are provided Naloxone Rescue Kits (OEND) that help in the event of an accidental overdose at home. We have also instituted an informed consent process for long-term opioids that educates patients on the risks and benefits of taking these medications chronically. Patients are provided the pamphlet “Taking Opioids Responsibly” as part of this consent process, which promotes mutual decision making and ensures patients are aware of risks and benefits.
Additionally, the VA has started an academic detailing programme that educates providers on appropriate pain management therapies, opioid safety, and available resources within the system. The SCAN ECHO programme also allows primary care clinicians to discuss patient care with pain specialists via video teleconferencing equipment, allowing access to specialty care in rural areas that do not have pain providers readily available. Electronic consultation is also available to help with questions that do not require in-person specialty consultation.
Other tools have also been provided to VA clinicians, including pain dashboards that provide valuable information on patients taking opioids, including labs, urine toxicology screens, and information from state prescription drug monitoring programmes.
NASS recently signed a letter asking the US Congress to allocate sufficient funding to aid opioid misuse programmes. Do you think that there is a need for more funding?
Absolutely! Providing funding for opioid misuse programmes helps patients that have inadvertently become addicted to regain control of their lives and possibly return to gainful employment.
These programmes also help lower the direct and indirect costs associated with the legal system, law enforcement, and emergency medical services that are taxed as a result of this epidemic.
How can physicians at smaller centres help to prevent opioid misuse among surgical patients?
In cases where a patient may already be taking opioids, communication between the surgeon and pain specialist prior to surgery may help mitigate post-operative pain issues and improve outcome. Ensuring that appropriate and timely consultation after surgery may further reduce the development of chronic pain in these patients.
Systems that look at integrative or adjunctive therapies, screening for mental health conditions, and prescription of opioids for the shortest duration necessary may also improve outcomes.
Are there any upcoming developments—drug, device or otherwise—that you think could be game-changers for pain management?
I am not aware of any singular technique, drug or device that serves as a game-changer in pain management, but the use of regional anaesthesia and certain long acting anaesthetics for wound closure may help improve outcomes in the perioperative period. New minimally invasive approaches to surgery may also help reduce tissue damage and speed up recovery, thereby reducing the incidence of chronic pain post-surgery.