What is the Problem?

1. The United States is in the midst of an epidemic of opioid misuse and abuse. In 2016, deaths from opioid overdoses increased to 42,249 fatalities/year (115 deaths/day) – more than the number of deaths from motor vehicle accidents (37,461).^1,2 In addition, over 11.5 million adults report misusing prescriptions opioids,³ and these patients frequently transition to heroin use.⁴
2. The opioid epidemic is driven by opioid prescribing by physicians, which quadrupled from 1999-2010.⁵ During this time, opioid abuse and deaths from opioid overdoses increased dramatically.^1,4

1. Surgeons as suppliers
   1. Surgeons play a key role in the opioid epidemic. Surgeons provide 10% of all opioid prescriptions.⁶
2. Surgeons overprescribe
   1. There are no evidence-based guidelines to inform surgical opioid prescribing and surgeons frequently prescribe far too much opioid.^7,8
   2. 72% of opioids prescribed to patients after elective surgery go unused.⁹
   3. The majority of patients undergoing abdominal operations report consuming 15 tablets or fewer of prescription opioids to manage postoperative pain.¹⁰
3. Opioids prescribed after surgery may lead to adverse effects such as persistent opioid use or diversion.
   1. Risk of developing chronic opioid use after surgery: Among opioid-naïve patients undergoing common surgical procedures, 6-10% continue filling opioid prescriptions 3-6 months after surgery.^11,12
   2. Risks of unused prescription opioids: Unused prescription opioids are frequently diverted to people who misuse them. Among patients who misuse prescription opioids, over 50% obtained them for free from a friend or relative.¹³

1. Use existing, procedure-specific evidence of patient opioid consumption to guide prescription size.¹⁴
   1. When opioid prescriptions are reduced using evidence-based prescribing guidelines from patient-reported consumption data, patients do not request more refills, nor do they report worse pain scores.⁷
   2. Prescribing larger quantities of opioids for the initial postoperative prescription is not associated with a decreased frequency of refills. Regardless of the quantity of the initial postoperative opioid prescription, 9% of patients require an opioid prescription refill.¹⁵
2. Screen patients for preoperative opioid use, as this may increase pain control requirements and place them at risk for surgical and opioid-related complications.^16-18
3. Counsel patients about safe opioid use and disposal
   1. Patients must be aware that the risk of transitioning to chronic opioid use after surgery is 6-10%.^11,12
   2. Patients should be provided with normative data on opioid consumption: “Most patients require less than 15 tablets of pain medication for this operation.”¹⁰
   3. Patients should be explicitly instructed to use non-opioid analgesics first for pain control, such as acetaminophen and ibuprofen, with opioids used only for breakthrough pain.¹⁹
   4. Surgeons must ensure patients have reasonable expectations for postoperative pain control:¹⁹ “Most patients have moderate pain after surgery. You should be able to walk and do light activity, but may be sore for a few days. This will gradually get better.”
   5. Patients should be counseled on the risks of unused prescription opioids,^13,20 and explicitly instructed on how to safely dispose of any unused medication.^21,22
4. Examples of prescriptions we should be writing:

Fig 1. Michigan Surgical Quality Collaborative opioid prescribing recommendations. Recommendations were based on patient-reported data from MSQC and published studies. Recommended amounts meet or exceed self-reported use of 75% of patients.¹⁴

1. Cochrane systematic review: 7 studies, 422 participants²³
   1. Has some opioid-sparing effect, in general, no major differences in postoperative pain when compared with placebo
   2. at high doses can cause intraoperative hypotension/bradycardia
   3. Larger, more high-quality studies are needed

1. Using lower peritoneal pressures (5-7 mmHg compared to 12-15mmHg) shown in randomized trials to result in less shoulder tip pain, lower pain scores, less opioid consumption (likely from decreased abdominal wall stretch)²⁴
2. Coupling low-pressure pneumoperitoneum with deep neuromuscular blockade results in lowered pressure requirements²⁵
3. Per European Association for Endoscopic Surgery clinical practice guidelines for laparoscopy, use lowest possible pressures to permit visualization²⁶

1. Intraoperative ketamine or PCA (some institutions may not be able to use PCA)
2. Systematic reviews found that patients who received ketamine took less opioid (especially abdominal, thoracic, and orthopedic surgery, less so head and neck/dental surgery)^27,28
3. Patients also reported better pain scores than placebo, and had decreased PONV
4. Side effects: rare increased neuropsychiatric effects, but not sedation

1. IV lidocaine can be administered intra- and/or postoperatively in order to decrease postoperative pain
   1. Reductions in pain, nausea, ileus duration, opioid requirement, and length of hospital stay seen in meta-analyses for abdominal surgery^29-32
   2. No difference between IV lidocaine and epidural in open colectomy³³
   3. Strength of evidence varies by procedure (best evidence in abdominal surgery, long-term benefit in breast surgery compared to placebo, but not short-term, mixed evidence in genitourinary, gynecologic operations)³⁴
   4. No clear mechanistic explanations, although reduction in opioid requirements may underlie benefits
      1. Lidocaine and other local anesthetics shown to be anti-inflammatory in preclinical models³⁵
   5. Toxicity exceedingly rare, as described infusion rates do not result in toxic levels; effects may include tinnitus, cardiac dysrhythmias³⁶

1. Magnesium may potentiate analgesics (such as lidocaine or morphine) but also facilitates neuromuscular blockade
2. Has shown to reduce opioid consumption and/or pain scores for selected procedures in randomized trials (laparoscopic gynecologic surgeries, lap chole) ^37,38
3. No convincing evidence of superiority over placebo on meta-analysis³⁹

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2. National Highway Traffic Safety Administration. Traffic Safety Facts Annual Report. 2018; https://cdan.nhtsa.gov/tsftables/National%20Statistics.pdf. Accessed March 27, 2018.
3. Center for Behavioral Health Statistics and Quality. 2015 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration, Rockville, MD. 2016. https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.htm. Accessed March 22, 2017.
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9. Hill MV, McMahon ML, Stucke RS, Barth RJJ. Wide Variation and Excessive Dosage of Opioid Prescriptions for Common General Surgical Procedures. Annals of surgery. 2017;265(4):709-714.
10. Feinberg AE, Chesney TR, Srikandarajah S, Acuna SA, McLeod RS, Best Practice in Surgery G. Opioid Use After Discharge in Postoperative Patients: A Systematic Review. Annals of surgery. 2017.
11. Lee JS, Hu HM, Edelman AL, et al. New Persistent Opioid Use Among Patients With Cancer After Curative-Intent Surgery. J Clin Oncol. 2017;35(36):4042-4049.
12. Brummett CM, Waljee JF, Goesling J, et al. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. 2017;152(6):e170504.
13. Jones CM, Paulozzi LJ, Mack KA. Sources of prescription opioid pain relievers by frequency of past-year nonmedical use United States, 2008-2011. JAMA Intern Med. 2014;174(5):802-803.
14. Michigan Opioid Prescribing Engagement Network. Opioid Prescribing Recommendations for Surgery. https://opioidprescribing.info/. Accessed March 27, 2018.
15. Sekhri S, Arora NS, Cottrell H, et al. Probability of Opioid Prescription Refilling After Surgery: Does Initial Prescription Dose Matter? Annals of Surgery. 2017;Publish Ahead of Print.
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18. Waljee JF, Cron DC, Steiger RM, Zhong L, Englesbe MJ, Brummett CM. Effect of Preoperative Opioid Exposure on Healthcare Utilization and Expenditures Following Elective Abdominal Surgery. Annals of surgery. 2017;265(4):715-721.
19. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17(2):131-157.
20. Kennedy-Hendricks A, Gielen A, McDonald E, McGinty EE, Shields W, Barry CL. Medication Sharing, Storage, and Disposal Practices for Opioid Medications Among US Adults. JAMA Intern Med. 2016;176(7):1027-1029.
21. Drug Enforcement Administration. Controlled Substance Public Disposal Locations Search Utility. https://apps.deadiversion.usdoj.gov/pubdispsearch. Accessed March 27, 2018.
22. Food and Drug Administration. Disposal of Unused Medicines: What You Should Know. https://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm. Accessed March 27, 2018.
23. Jessen Lundorf L, Korvenius Nedergaard H, Moller AM. Perioperative dexmedetomidine for acute pain after abdominal surgery in adults. The Cochrane database of systematic reviews. 2016;2:Cd010358.
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25. Koo BW, Oh AY, Seo KS, Han JW, Han HS, Yoon YS. Randomized Clinical Trial of Moderate Versus Deep Neuromuscular Block for Low-Pressure Pneumoperitoneum During Laparoscopic Cholecystectomy. World J Surg. 2016;40(12):2898-2903.
26. Neudecker J, Sauerland S, Neugebauer E, et al. The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery. Surgical Endoscopy. 2002;16(7):1121-1143.
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28. Bell RF, Dahl JB, Moore RA, Kalso E. Perioperative ketamine for acute postoperative pain. The Cochrane database of systematic reviews. 2006(1):Cd004603.
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37. Sousa AM, Rosado GM, Neto Jde S, Guimaraes GM, Ashmawi HA. Magnesium sulfate improves postoperative analgesia in laparoscopic gynecologic surgeries: a double-blind randomized controlled trial. Journal of clinical anesthesia. 2016;34:379-384.
38. Mentes O, Harlak A, Yigit T, et al. Effect of intraoperative magnesium sulphate infusion on pain relief after laparoscopic cholecystectomy. Acta Anaesthesiol Scand. 2008;52(10):1353-1359.
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