Overprescription of Opioids as a Determinant of the Crisis

Prescription opioids intended for analgesic use may also act as vehicles for drug addiction. Opioids are powerful drugs often prescribed in a perioperative setting to relieve severe pain.1,2 Although postoperative opioid use has been a common practice over the last few decades, their addictive nature has not always been known.2-4 In effect, seemingly well-intended physicians, pharmaceutical companies, and other stakeholders created the foundation for a severe crisis in which many individuals became addicted to prescription opioids.

Widespread use of opioids began in the 1980s when precautionary measures in prescribing this medication were abolished. Based on research findings at the time, it became a common belief that opioids were only addictive when used recreationally.2,4 In contrast to studies from the 1980s whose results were likely over-interpreted and suffered from discrepancies in sample sizes and analytical methods, modern studies on opioid usage have confirmed their addictive nature.2 Moreover, physicians’ inexperience relating to pain management–a novel field at the time–and the monetary incentive for pharmaceutical companies lead to the acceptance of these false claims, especially in the United States and Canada.2,5 As a result, opioid-mediated analgesia became a common practice for treating surgical pain with over 80% of patients receiving opioids after low-risk surgery.6 Consequently, opioid prescribing has quadrupled since 1999 and has risen in parallel with the number of opioid-induced overdoses. In 2017, more people in the United States died from opioid overdose than from HIV or AIDS.3 This data emphasizes the severity of this crisis and the need for immediate action.

Even if opioid use follows physician recommendations, they may cause adverse effects in many organ systems; constipation, sleep-disordered breathing, increased risk of cardiovascular events, and neurotoxicity represent just a few possible outcomes.7 More specifically, for neurocognitive outcomes, recent evidence also supports that pharmacological interventions may act as a trigger for cognitive impairment, especially in elderly patients with altered baseline cognition and co-morbid conditions.8 Recent studies like these shed new light on possible disadvantages of opioid therapy, which previous studies have not addressed. Perioperative care teams now face the challenge of optimizing pain management while reducing opioid use in the hospital and after discharge. Although there is evidence to support the use of alternative methods of pain management, such as hypnosis and cognitive behavioural therapy, the effectiveness of these novel approaches remains unclear.9,10 Despite these challenges, precautionary measures have emerged as an effective method to reduce the overprescribing of opioids. In recent years, patients are typically assessed for a history of substance use disorder, a mental health diagnosis, or concomitant prescription to assess their risk of developing an addiction before gaining access to pain pharmacotherapy.11

Ultimately, a widespread health crisis is among us. A collective effort will be needed to undo some of the decisions that have led us here, specifically, those relating to opioid prescribing practices.

References

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  11. Jan Klimas PD. Strategies to Identify Patient Risks of Prescription Opioid Addiction When Initiating Opioids for Pain [Internet]. JAMA Network Open. JAMA Network; 2019 [cited 2020Dec19]. Available from: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2732338
Denise Sabac