A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.
The grayish white zippered sheet being laid on the patient stretcher was the first clue.
It was the middle of a busy day at the hospital. I had been taking care of several patients for their elective surgeries in the operating room (OR) when the overhead paging system chirped: “Code Blue ER, ETA 2 minutes.” I walked over to the emergency department (ED), expecting to hear about an elderly patient who had suffered a stroke or heart attack, but instead was faced with an unresponsive overdose patient.
That’s when that grayish zippered sheet started to make sense. The team was already preparing the body bag. “How many this week?” I asked. “Lost count,” was the reply.
The patient was a 44-year-old woman with a history of fentanyl and heroin abuse who was brought in with the EMTs already performing CPR on her. After 45 minutes of trying to save her life, the fight ended.
As a physician anesthesiologist, I use the opioid fentanyl every single day at work, and on almost every patient. Fentanyl has been a constant in my anesthesia practice as one of the most potent pain medicines used intravenously during surgery, as it has for almost every patient going under general anesthesia in this country and most of the world. Yet, when used illegally on the street in a variety of forms (lollipops, powder, pills, spiked blotting paper, patch), it is also one of the biggest culprits in the opioid epidemic facing this country.
South Florida, where I live, is one of many communities right in the middle of the opioid epidemic. In 2017 alone, there have been an estimated 2,300 to 2,500 opioid-related deaths in just three counties, one of which is where I work, and even these numbers may be an underestimate. Day after day, overdose victims are brought into emergency departments and morgues across the three counties. No one can keep up.
The opioid epidemic originated in the late 1990s. In 1999, the Veterans Health Administration launched the “Pain as a 5th Vital Sign” initiative to ensure their patients’ pain was being adequately treated. Then, other groups joined in this effort to see that pain was treated appropriately. Additionally, patient satisfaction surveys, used to determine hospital reimbursement rates, added pain-related questions to their survey.
The outcome could have been predicted. There was a surge in opioid prescriptions, and following that, opioid overdoses and deaths. Since 2000, there has been a 200 percent increase in overdose deaths related to opioids. Once this was realized, steps were taken to correct it.
In 2016, the Centers for Medicare and Medicaid Services (CMS) reviewed the data and revised the survey questions pertaining to pain management to reflect more on how pain was addressed, rather than what the patient perceived his/her pain level to be during hospitalization. Physicians were no longer incentivized to get patients’ pain levels to an unattainable zero and therefore began to use less medication.
A step in the right direction, but now the pendulum has swung in the opposite direction. A nationwide opioid shortage.
After I complete my paperwork on the previously mentioned overdose patient in the ED, I head back to the OR to prepare for my next patient, who will be receiving general anesthesia for a routine laparoscopic appendectomy. As I remove the medications from the dispensing machine, I am careful to ration the minimum amount of fentanyl possible because we have a limited quantity available in my hospital. This is because we are also in the midst of a nationwide opioid shortage and my hospital, like many others in the country, is severely restricting the use of intravenous fentanyl.
How is this possible? On one hand, this drug is rampant on the streets in its illegally produced forms. On the other hand, there is a real shortage in the hospitals where it is so desperately needed during surgery. The answer lies in a long and tortuous history.
In 2017, the Drug Enforcement Administration (DEA) cut U.S. opioid production by 20 percent, as compared to the previous year. Under federal law, the DEA sets production quotas for manufacturers of controlled substances, including opioids. As the U.S. lawmakers and regulators looked for ways to tackle the opioid epidemic, the DEA proposed this cut to limit the supply of opioids to combat the cycle of abuse, addiction, and overdose. In 2017 the agency reduced the amount of almost every Schedule II opioid medication by 25 percent or more. In November 2017, the DEA announced plans to further reduce opioid production in the U.S. by another 20 percent in 2018, despite concerns from three drug manufacturers that the reduced supply of opioids was “insufficient to provide for the estimated medical, scientific and industrial needs of the United States.”
There we have the reason why hospitals across the country are struggling with the shortage. But what about the reason why this was undertaken in the first place? Has this cut in production been sufficient to stop or even reduce the opioid epidemic? The number of patients overdosing on these power painkillers suggests otherwise. For all the reduction in legal fentanyl production and availability in the U.S., illegally produced fentanyl and it’s 100 times more potent analog, carfentanil, is readily and cheaply available on the illegal market. Therein lies the irony: not enough fentanyl to provide analgesia for surgery in the hospitals but more than enough available on the streets to kill.
Addressing pain without contributing to an epidemic
For physician anesthesiologists across the country, we now face an interesting challenge: we are actively involved in the fight to combat the opioid epidemic, yet we have a responsibility to our patients to address their pain in the perioperative period. In my own hospital, we are taking a multi-pronged approach to tackle this problem:
1. Perioperative multi-modal therapy. We are reducing opioid use during and after surgery and combining different non-opioid pain medications with regional blocks to reduce our patients’ exposure to highly addictive opioids.
2. Patient education. Pain management during and after surgery is based on adequate pre-operative preparation and management of expectations. In the pre-operative interview, we stress the fact that “Surgery is not pain-free. Our goal is for the pain to be bearable, not zero.”
3. Nursing education. Pre- and post-operatively, nursing staff repeat the message that surgery is not pain-free to further manage patient expectations about pain levels. The same nurses proactively ask patients if their pain is appropriately being managed any time they are in the patient’s room. Previously, the nursing staff was only asking about pain around the time of the next scheduled dose of pain medicine. We found this simple change in practice improved our pain scores.
We hope this approach will reduce the risk of dependency and addiction for our patients. What happens with the illegal drugs flooding the streets remains to be seen.
Asha Padmanabhan is an anesthesiologist.
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