Pop quiz: “What’s the most common long-term complication after elective surgery?” Whatever you’re thinking, it’s probably not that. In fact, it’s looking more and more like the answer might well be opioid dependence.1 Surprising? Sure. But also worrisome, because there’s no doubt that surgical practices have had a hand in exacerbating the nation’s burgeoning opioid epidemic.
Prescription opioids are classic gateway drugs: nearly 75% of heroin users report previous abuse of opioids. And there’s good reason to believe prescription pain killer prescribing patterns are linked to eventual heroin usage; for instance, regions where physicians are, for whatever reason, less likely to prescribe opioids to black patients for chronic and postsurgical complaints have experienced a persistent increase in the proportion of heroin users that are white.2
There are undoubtedly several other, and probably more impactful, factors influencing the recent demographic shift among heroin users, but the link to prescribing patterns remains unassailable. And with that, connection comes culpability and responsibility.
It’s not as if we’ve done nothing to address this issue. Early in the decade, recognizing that the availability of Vicodin and OxyContin was driving people toward heroin use, those drugs were reformulated so as to be more difficult to crush, and therefore abuse, and the Centers for Disease Control and Prevention instructed physicians to prescribe the medications more judiciously.
The results were immediate and dramatic: Vicodin and OxyContin became scarce, and their price skyrocketed. Just as quickly, however, opportunistic drug cartels flooded vulnerable areas with heroin, causing its price to fall and its presence to become pervasive. Before long, Vicodin cost close to 8 times as much as heroin on the street.3 This is how epidemics happen.
Our failed attempts to control addiction by limiting street-level availability teach us that we need to intervene at an earlier point on the causal chain. Ideally, we need to start addressing these issues even before we make our first incision and, not for nothing, before our anesthesiologists put in an intravenous line.
Many practitioners are adopting a policy of mandatory pre-surgical counseling about opiate use after an operation. This can take the form of a video or iPad presentation or, better yet, a face-to-face conversation between physician and patient.
These discussions can give the patient a specific opportunity to voice and, hopefully, assuage concerns regarding postoperative pain. Just as important, it gives the surgeon a chance to set reasonable expectations for the patient’s postoperative pain and opiate requirements.