Opioid Stewardship in Cardiac Anesthesia Practice

Abstract

The opioid epidemic or crisis has been a burning issue since 1995, especially in the United States (US) and Canada. It is estimated that more than 600,000 people have died from opioid overdoses in these 2 countries since 1999.1Humphreys K Shover CI Andrews CM et al.Responding to the opioid crisis in North America and beyond: recommendations of the Stanford-Lancet commission.Lancet. 2022; 339: 555-604Abstract Full Text Full Text PDF Scopus (57) Google Scholar The arrival of the COVID-19 pandemic in 2020 disrupted treatment programs as well as access to life-saving medications, such as naloxone. In addition, the support mechanisms were severely impacted, leading to what can be described as the worst phase of this crisis. In the US, more than 100,000 drug overdoses were recorded—nearly 76,000 were attributed to opioids, an increase of approximately 30% over 2019, and Canada recorded a 67% increase in deaths in 2020.2Managing the opioid crisis in North America and beyond.Lancet. 2022; 399: 495Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Such was the effect of the opioid crisis that the Stanford-Lancet Commission was formed with the goals of understanding the opioid crisis, proposing solutions to the crisis domestically, and attempting to stop its spread internationally.1Humphreys K Shover CI Andrews CM et al.Responding to the opioid crisis in North America and beyond: recommendations of the Stanford-Lancet commission.Lancet. 2022; 339: 555-604Abstract Full Text Full Text PDF Scopus (57) Google Scholar In its report (which can be termed as no less than harsh), the commission attributed the origin of the crisis to be a result of weak laws and regulations and poor implementation thereof. This includes failures at the US Food and Drug Administration, which approved OxyContin, which was fraudulently described by the manufacturers as less addictive than other prescription opioids.1Humphreys K Shover CI Andrews CM et al.Responding to the opioid crisis in North America and beyond: recommendations of the Stanford-Lancet commission.Lancet. 2022; 339: 555-604Abstract Full Text Full Text PDF Scopus (57) Google Scholar The insufficient and ineffective regulation of the pharmaceutical and health care industries, in consonance with the physician community, led to a profit-driven excessive prescription of opioids. The expanded prescription of opioids for a broad range of non-cancer pain conditions, including even headaches and sprained ankle,3Delgado MK Huang Y Meisel Z et al.National variation in opioid prescribing and risk of prolonged use for opioid-naïve patients treated in the emergency department for ankle sprains.Ann Emerg Med. 2018; 72: 389-400Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 4DeVries A Koch T Wall E et al.Opioid use among adolescent patients treated for headache.J Adolesc Health. 2014; 55: 128-133Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 5Gossett TD Finney FT Hu HM et al.New persistent opioid use and associated risk factors following treatment of ankle fractures.Foot Ankle Int. 2019; 40: 1043-1051Crossref PubMed Scopus (21) Google Scholar, 6Suda KJ Zhou J Rowan SA et al.Overprescribing of opioids to adults by dentists in the US, 2011-2015.Am J Prev Med. 2020; 58: 473-486Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar as well as indiscriminate use even in conditions where the drug was not appropriate,7Taitsman JK VanLandingham A Grimm CA. Commercial influences on electronic health records and adverse effects on clinical decision-making.JAMA Intern Med. 2020; 180: 925-926Crossref PubMed Scopus (8) Google Scholar,8US Department of Justice Office of Public Affairs. Electronic health records vendor to pay $ 145 million to resolve criminal and civil investigations. Available at: https://www.justice.gov/opa/pr/electronic-health-records-vendor-pay-145-million-resolve-criminal-and-civil-investigations-0. Accessed 18 April 2022.Google Scholar has been majorly responsible for the opioid crisis. It is noticeable that the problem of the opioid crisis is not small and is likely to escalate to an even larger proportion spreading to other countries. This is so, as the pharmaceutical companies based in the US are actively expanding opioid prescribing worldwide and are using fraudulent and corrupting tactics that have now been banned in the US.1Humphreys K Shover CI Andrews CM et al.Responding to the opioid crisis in North America and beyond: recommendations of the Stanford-Lancet commission.Lancet. 2022; 339: 555-604Abstract Full Text Full Text PDF Scopus (57) Google Scholar The consumption of opioids and opioid-related hospital admissions and deaths are already increasing in other countries, mainly Europe, Australia, and South America, and are likely to affect the low-middle income countries as well. Although the genesis of the crisis is multifactorial, being one of the largest users of opioids, cardiac anesthesiologists must critically analyze the situation and put in their best efforts toward its containment. The excellent pain relief provided by opioids, along with effective control of the autonomic nervous system response, have made opioids an indispensable component of anesthesia since the early days of cardiac surgery. Furthermore, beyond a potent analgesia, owing to endorphin release, opioids reduce anxiety, cause mild sedation, and lead to a sense of well-being, often to the point of euphoria.9Fields HL. The doctor's dilemma. Opiate analgesics and chronic pain.Neuron. 2011; 69: 591-594Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar These properties of opioids score over most other analgesic medications. Over the years, the type of opioid and dosing and administration routes (regional techniques) have evolved considerably, and opioids still continue to enjoy the mainstay of cardiac anesthesia practice. The possibility that the perioperative use of opioids and continuation after discharge can be a contributory factor to the crisis is now documented. In a retrospective analysis of a large cohort of opioid-naïve patients, Brown et al10Brown CR Chen Z Khurshan F et al.Development of persistent opioid use after cardiac surgery.JAMA Cardiology. 2020; 5: 889-896Crossref PubMed Scopus (62) Google Scholar showed that 10% of patients undergoing coronary artery bypass graft and 8% of patients undergoing valve surgery who received an opioid prescription after discharge developed persistent opioid use. The patients who were prescribed more than approximately 300 mg of oral morphine equivalent at discharge had a significantly increased risk of new persistent opioid use. The potential of opioids to cause harm must not lead to overtly restrictive usage, as it would cause substantial potential harm. Every drug has a side effect, and opioids are no exception—they can be a double-edged sword when not used appropriately, effectively, and safely, leading to devastating consequences. The fear of inadequate pain relief leading to chronic pain syndrome cannot be ignored. With this backdrop, it is imperative that one should try to exploit the unique therapeutic values of opioids by allowing only supervised use. This can be achieved by opioid stewardship, which is defined as coordinated intervention designed to improve, monitor, and evaluate the use of opioids in order to support and protect human health.11Institute for Safe Medication Practices Canada. Opioid stewardship 2021. Available at: https://www.ismp-canada.org/opiod_stewardship/. Accessed 18 April 2022.Google Scholar This is not difficult, as has been shown by Germany, where the opioid prescribing rate is close to that of Canada, but there is no evident opioid crisis. This is so because in Germany the opioids are used mainly in a supervised setting, whereas in Canada, opioids are frequently prescribed to ambulatory patients.12Humphreys K Caulkins JP Felbab-Brown V. What the US and Canada can learn from other countries to combat the opioid crisis. Brookings Institute, Washington, DC2020Google Scholar Indeed, efforts toward the judicious use of opioids are already evident. For instance, Pena et al have suggested a simple ‘tailored approach that would reduce the number of unused medication in patients’ homes.13Pena JJ Chen CJ Clifford H et al.Introduction of an analgesia prescription guidelines can reduce unused opioids after cardiac surgery: A before and after cohort study.J Cardiothorac Vasc Anesth. 2021; 35: 1704-1711Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Likewise, Clarke et al have identified the patient- and surgery-related risk factors that can lead to previously opioid-naïve patients continuing to use opioids for more than 90 days after surgery.14Clarke H Soneji N Lo DT et al.Rates and risk factors for prolonged opioid use after major surgery: Population based cohort study.BMJ. 2014; 348: g1251Crossref PubMed Scopus (643) Google Scholar The risk factors identified by them included younger age, lower household income, specific comorbidities (diabetes, heart failure, pulmonary disease), use of specific drugs preoperatively (benzodiazepines, selective serotonin reuptake inhibitors, angiotensin-converting enzyme inhibitors), and open and minimal thoracic invasive procedures. Such reports can help to plan interventions to prevent progression to prolonged postoperative opioid use and, hence, strengthen the cause of opioid stewardship. Innovations in the field of pain management are required. Nowadays, low-dose fentanyl (<10 µg/Kg) anesthesia is a common practice,15Kwanten LE O'Brien B Anwar C Opioid-based anesthesia and analgesia for adult cardiac surgery: History and narrative review of literature.J Cardiothorac Vasc Anesth. 2019; 33: 808-816Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar and data on multimodal nonopioid interventions in the form of gabapentin, acetaminophen, dexmedetomidine, and ketamine are appearing in the literature.16Grant M Isada T Ruzankin P et al.Opioid-sparing cardiac anesthesia: Secondary analysis of an enhanced recovery program for cardiac surgery.Anesth Analg. 2020; 131: 1852-1861Crossref PubMed Scopus (26) Google Scholar The concept of enhanced recovery after cardiac surgery coupled with an opioid-sparing anesthetic technique can be considered an additional step toward containing the opioid crisis.17Engelman DT Ben Ali W Williams JB et al.Guidelines for perioperative care in cardiac surgery: Enhanced recovery after surgery society recommendation.JAMA Surg. 2019; 154: 755-766Crossref PubMed Scopus (385) Google Scholar The challenges of providing adequate pain relief in the era of fast-track anesthesia and enhanced recovery after cardiac surgery have been well addressed by cardiac anesthesiologists. The introduction of facial blocks, such as erector spinae plane block, serratus anterior plane block, pectoralis and intercostal blocks, in the cardiac anesthesia practice, has already demonstrated the potential to decrease the opioid dosage while providing adequate pain relief.18Macaire P Ho N Nguyen B et al.Ultrasound-guided continuous thoracic erector spinae plane block within an enhanced recovery program is associated with decreased opioid consumption and improved patient postoperative rehabilitation after open cardiac surgery-A patient-matched, controlled before- and -after study.J Cardiothorac Vasc Anesth. 2019; 33: 1659-1667PubMed Scopus (83) Google Scholar, 19Roy N Brown ML Parra MF et al.Bilateral erector spinae blocks decrease perioperative opioid use after pediatric cardiac surgery.J Cardiothorac Vasc Anesth. 2021; 35: 2082-2087Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 20Jack JM McLellan E Versyck B et al.The role of serratus anterior plane and pectoral nerves blocks in cardiac surgery, thoracic surgery and trauma: A qualitative systematic review.Anaesthesia. 2020; 75: 1372-1385Crossref PubMed Scopus (30) Google Scholar These and other multimodal nonopioid interventions need to be investigated further to find out if they have the desired effect.21Maldonado Y Mehta AR Skubas NJ. Enhanced recovery after cardiac surgery: Are more (and which) opioid-sparing interventions better?.Anesth Analg. 2020; 131: 1850-1851Crossref PubMed Scopus (4) Google Scholar Undoubtedly, the solution to the opioid crisis is not easy, and a systematic, planned approach by the politicians, regulatory and legislative bodies, the medical profession, and the healthcare system will be required in order to control this difficult problem. Although health professionals from disciplines other than cardiac anesthesia who are involved in the prescription of opioids will have to be a part of this struggle, cardiac anesthesiologists should strive to contribute their bit. In doing so, they should not lose sight of the fact that opioids are excellent analgesics and play a very important role in providing pain relief after cardiac surgery. Striking a fine balance between overprescription and reductions in opioid usage in order to meet the patient- and procedure-centered outcomes and quality of recovery should be the central theme of opioid stewardship. Some degree of self-regulation among the cardiac anesthesiologists would also further reinforce the strategy. Restricting the intraoperative doses of opioids, combining regional blocks or nonopioid analgesics, and limiting the use of fewer than 2 to 3 days in the postoperative period by adopting multimodal analgesia along with paracetamol with or without patient-controlled analgesia seems to be the answer. However, large-scale studies are urgently needed to understand the ideal technique that will address the opioid crisis without compromising the quality of pain relief to the patient. The author is the Section Editor of the Journal of Cardiothoracic and Vascular Anesthesia.