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REVIEW ARTICLE/BRIEF REVIEW

The prescription opioid epidemic: an overview for

anesthesiologists L"e´pide´mie de prescription d"opio¨des: une vue d"ensemble destine´e aux anesthe´siologistes

Asim Alam, MD

David N. Juurlink, MD, PhD

Received: 12 May 2015/Revised: 23 June 2015/Accepted: 15 October 2015/Published online: 27 October 2015

?Canadian Anesthesiologists" Society 2015

Abstract

PurposeThe objectives for preparing this article were to review the historical context and epidemiology surrounding the North American prescription opioid crisis, to summarize the evidence regarding the beneÞts and harms of long-term opioid therapy for non-cancer pain, and to outline ways in which anesthesiologists may help ameliorate the problem.

SourceWe searched PubMed, Google Scholar, and

EMBASE

TM for relevant articles using various search terms, including pain, opioid epidemic, history of opioid use, perioperative care, and addiction. Related citations were further explored and searched depending on the speciÞc subtopic of interest. Principal findingsIn the 1980s and early 1990s, opioids were infrequently used for the treatment of chronic pain. Thereafter, however, physicians were gradually inculcated with the message that long-term opioid therapy was a safe and effective treatment option for patients with chronic non-cancer pain. Pharmaceutical companies supported this growing movement and employed aggressive and sometimes misleading marketing strategies for new opioid formulations. As a result, the practice of prescribing opioids ßourished in the late 1990s. The surge in prescribing opioids was accompanied by a marked increase in opioid-related morbidity and mortality. This change in practice transpired despite the absence of randomized trials showing clinically signiÞcant beneÞt from the long-term use of opioids. Subsequently, however, a large and growing body of evidence has emerged quantifying the harms associated with long-term opioid therapy. Anesthesiologists widely prescribe opioids for acute and chronic pain; yet, as a group, they may be largely unaware of the current state of this growing epidemic and what role they can play to rectify this problem. ConclusionAnesthesiologists are well positioned to take a leadership role in the management of postoperative discharge opioid therapy in an effort to curb the overutilization of opioids. Furthermore, anesthesiologists who regularly prescribe opioids for chronic pain patients should appreciate the limited evidence base for this practice and communicate the risks of opioid therapy to their patients. This article is accompanied by an editorial. Please see Can J Anesth

2016; 63: this issue.

A. Alam, MD (&)

Department of Anesthesia, Sunnybrook Health Sciences Centre,

2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada

e-mail: asim.alam@sunnybrook.ca

A. Alam, MD

Trauma, Emergency and Critical Care Program, Sunnybrook

Health Sciences Centre, Toronto, ON, Canada

A. Alam, MD

Department of Anesthesia, University of Toronto, Toronto, ON,

Canada

D. N. Juurlink, MD, PhD

Department of Medicine, University of Toronto, Toronto, ON,

Canada

D. N. Juurlink, MD, PhD

Department of Pediatrics, University of Toronto, Toronto, ON,

Canada

D. N. Juurlink, MD, PhD

Health Policy, Management and Evaluation, University of

Toronto, Toronto, ON, Canada

123

Can J Anesth/J Can Anesth (2016) 63:61-68

DOI 10.1007/s12630-015-0520-y

Re´sume´

ObjectifLes objectifs lors de la pre´paration de cet article e´taient de passer en revue le contexte historique et l'e´pide´miologie entourant la crise de prescription d'opioı¨des nord-ame´ricaine, de re´sumer les donne´es probantes concernant les avantages et les effets nocifs du traitement opioı¨de a` long terme pour les douleurs non cance´reuses, et de proposer diffe´rentes pistes aux anesthe´siologistes afin qu'ils aident a`re´soudre le proble`me. SourceNous avons effectue´ des recherches dans les bases de donne´es PubMed, Google Scholar et EMBASE TM afin d'en extraire les articles pertinents a` l'aide de diffe´rents termes de recherche, notamment douleur, e´pide´mie d'opioı¨des, histoire de l'utilisation d'opioı¨des, soins pe´riope´ratoires, et accoutumance (soit les termes anglais pain, opioid epidemic, history of opioid use, perioperative care, et addiction, respectivement). Les citations associe´es ont e´te´ recherche´es et explore´es selon leur the`me secondaire spe´cifique. Constatations principalesAu cours des anne´es 1980 et au de´but des anne´es 1990, les opioı¨des n'e´taient que rarement utilise´s pour le traitement de la douleur chronique. Par la suite toutefois, il a e´te´ progressivement inculque´ aux me´decins que le traitement opioı¨de a` long terme constituait une option de traitement se´curitaire et efficace pour les patients souffrant de douleur chronique non cance´reuse. Les compagnies pharmaceutiques appuye`rent cet essor et eurent recours a` des strate´gies commerciales agressives et parfois trompeuses pour promouvoir de nouvelles formulations opioı¨des. Ainsi, la pratique de prescrire des opioı¨des prospe´ra a` la fin des anne´es 1990. Cette monte´e des prescriptions d'opioı¨des s'accompagna d'une augmentation marque´e de la morbidite´ et de la mortalite´ lie´es aux opioı¨des. Ce changement de pratique s'e´tendit malgre´ l'absence d'e´tudes randomise´es attestant d'un avantage significatif d'un point de vue clinique quant a` l'utilisation a` long terme de ces agents. Par la suite toutefois, un corpus grandissant de donne´es probantes e´mergea, quantifiant les effets nocifs associe´s a` un traitement opioı¨de a` long terme. Les anesthe´siologistes prescrivent fre´quemment des opioı¨des pour le traitement de la douleur aigue¨ et chronique; pourtant, en tant que collectivite´, ils pourraient ne pas eˆtre pleinement conscients de l'e´tat actuel de cette crise grandissante et du ro

ˆle qu'ils peuvent jouer pour re´gler

ce proble `me.

ConclusionLes anesthe´siologistes occupent une

position privile´gie´e pour assumer un roˆle de leadership

dans la gestion des traitements opioı¨des apre`s le conge´postope´ratoire dans un effort pour ralentir la

sur-utilisation des opioı¨des. De plus, les anesthe´siologistes qui prescrivent re´gulie`rement des opioı¨des a` leurs patients de douleur chronique devraient prendre connaissance des donne´es probantes limite´es soutenant cette pratique et expliquer les risques d'un traitement opioı¨de a` leurs patients. The practice of prescribing opioids for chronic non-cancer pain has increased dramatically over the past two decades, particularly in the United States and Canada. 1-5

This has

been accompanied by a marked increase in opioid-related morbidity and mortality. 3,6-8

In Ontario, the rate of opioid-

related mortality has more than tripled since the early

1990s.

1

The majority of these deaths occur in young to

middle-aged patients, and the resulting burden of premature mortality is significant. 1,6

Even with

recognition of the problem, prescription opioid consumption has continued to increase nationally by almost 70% since 2008. 2

Canadians are among the most

prolific users of prescription opioids in the world. 9 In the United States (US), deaths from overdoses of prescription opioids quadrupled from 1999-2010 and now exceed the combined death toll from cocaine and illicit heroin overdoses. 3,10

Most of these deaths are

unintentional, although about one in five are of

‘‘undetermined"" intent.

3

The US Department of Health

and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) have declared that overdose deaths involving prescription opioids constitute an epidemic, a decree that has prompted multijurisdictional initiatives. 3

The same phenomenon—a rise in opioid

prescriptions with a corresponding increase in mortality—has been reported in both the United

Kingdom (UK) and Australia.

4,5

While primary care physicians issue most opioid

prescriptions, anesthesiologists utilize opioids regularly for anesthesia, acute postoperative pain, and the treatment of chronic pain. Herein, we detail the historical context surrounding the growth of this epidemic and create a framework for future discussion and research in the hope that anesthesiologists can make an important contribution to alleviate this problem. We searched PubMed, Google

Scholar, and EMBASE

TM to find relevant articles using various search terms, including pain, opioid epidemic, history of opioid use, perioperative care, and addiction. Related citations were also further explored and searched depending on the specific subtopic of interest.

62A. Alam, D. N. Juurlink

123

Opioids: a brief history

The use of opioids predates written history. The Sumeriansquotesdbs_dbs4.pdfusesText_7