While much of the discussion pertaining to the opioid epidemic in the anesthesia/pain communities surrounds reducing opioid exposure or new drug or interventional targets for the treatment of pain, it is worthwhile to view the epidemic through the lenses of both public health and that of the addiction medicine practitioner.

Public Health

While opioid use disorder (OUD) is not the second or even third most common substance use disorder (SUD), (alcohol use disorder makes up about 80% of SUDs nationally), the primary and unique issue with opioids is their potential for lethality. With the recent addition of fentanyl and its more potent derivatives to both illicit heroin and what appear to be prescription medications purchased from non-medical sources, a rising number of deaths have been reported.¹ While legal bodies, including the Drug Enforcement Agency (DEA), continue to crack down on illicit drug dealing, the number of sources in East Asia and other areas continue to present a challenge.²

Any epidemic is by definition a public health crisis. Drug overdose rates in America progressively increased from 1999-2017 before dipping slightly in 2018 but increased again in 2019. This past year, nearly 71,000 Americans died from a drug overdose with more than 50,000 involving opioids and 36,500 involving synthetic opioids, a 4.6% increase from 2018.³ Worse yet, the first four months of 2020 have seen a dramatic rise in overdoses and overdose deaths compared to 2019. Drug overdoses were up 40% from May 2019 to May 2020 likely secondary to decreased employment, increased stress, and increased isolation among Americans due to the COVID-19 pandemic.⁴ There have also been increasing levels of multiple psychiatric problems including depression, anxiety, and post-traumatic stress disorder.⁵ With no clear end to the pandemic in sight, all of these numbers are, unfortunately, likely to further escalate.

---

Be empathetic. Many of these patients have dealt with SUDs for extended periods and are terrified of withdrawal, pain, or relapse.

---

Increased emphasis and awareness of the epidemic from the public health standpoint has brought controlled substance prescribing into focus. Prescription drug monitoring programs and increased awareness among prescribers has resulted in a substantial decrease in opioid prescribing since its peak nearly ten years ago.⁶ This significant prescribing reduction has led to less pills in circulation, decreasing rates of diversion, and diminished overall access to use of opioids for non-medical purposes.

From a harm reduction standpoint, several strategies are in play: 1) roughly 400 syringe exchange programs with sterile injecting equipment now exist in 33 states;⁷ 2) access to intranasal naloxone has expanded substantially;⁸ and 3) the steadily increasing number of drug courts has allowed many with SUDs to avoid incarceration for minor drug offenses and instead seek treatment.⁹ Expansion of access to medication treatment for opioid use disorder (MOUD) has certainly helped; opioid treatment programs (ie, “methadone clinics”) have grown in quantity,¹⁰ as has access to the other two FDA-approved medications for OUD, buprenorphine and naltrexone. The pandemic-induced increased use of telemedicine for provider coverage, recovery coaches, and support groups continues to engage patients in treatment outside of the typical physician office. Many are anecdotally finding increases in attendance when individual or group therapy is done remotely.

Unfortunately, despite these improvements, SUD patients remain vastly underserved. In 2018, less than 13% of those with a likely substance use disorder received treatment.¹ In addition, the incidence of mental health disorders in the United States has also continued to increase, likely contributing to the use of illicit substances for self-medication.¹

Addiction Medicine

As we encounter SUDs in our own anesthesiology and pain clinical practices, there is value to understanding the addiction medicine approach to these patients.

When a patient presents to the office of an addiction practitioner, their motivation for doing so is often very different than the typical patient presenting to an operating room or a pain clinic. SUDs are defined not by the quantity of substance used but by the maladaptive and pathological behaviors induced by their use. SUD may result in social, familial, occupational, or legal ramifications and it is often these consequences that motivate (or require) the patient to seek assistance.¹¹ Many patients have co-occurring or substance-induced psychiatric comorbidities which require treatment.¹¹

The primary focus of most addiction providers is initially to reduce harm and manage symptoms, not to “cure” or “fix” the patient or the addiction. According to the American Society of Addiction Medicine (ASAM), addiction is a chronic, relapsing and remitting disease state like diabetes or hypertension.¹² For OUD treatment, addiction practitioners use medications, lifestyle changes, and psychological therapies to improve chronic symptoms, reduce future harm, or improve quality of life. With increasing SUD severity, patients are sent to varying levels of supportive treatment. This stratification is known as the ASAM Patient Placement Criteria and ranges from early intervention (Level 0.5) to weekly/monthly outpatient care (Level 1), up to medically managed intensive inpatient services (Level 4).¹³

Unlike opioid and alcohol use disorders, not all SUDs have FDA-approved medications available for treatment. Traditional psychosocial interventions such as 12-step facilitation, relapse prevention strategies, motivational interviewing, contingency management, cognitive-behavioral therapy, family therapy, and partner therapy are the only options and must be employed as recovery support.¹⁴

Briefly: What You Can Do

1. Be empathetic. Many of these patients have dealt with SUDs for extended periods and are terrified of withdrawal, pain, or relapse, any of which can occur around the time of surgery or a pain exacerbation. 
2. Address expectations of level of pain and the associated treatment strategies as early as possible. Reassure the SUD patient that they will be treated appropriately. The utilization of MOUD in the perioperative setting and pain clinic are out of the scope of this article, but evidence-based recommendations from ASRA and multiple other societies are coming. 
3. If the patient has a primary addiction provider, ensure good communication, collaboration, and discharge planning with that provider as indicated. 
4. If the patient is demonstrating signs of addiction and specifically OUD, you can evaluate them using the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria:¹⁵ https://www.asam.org/docs/default-source/education-docs/dsm-5-dx-oud-8-28-2017.pdf. If positive, consider referral to treatment if locally available.  ( https://www.samhsa.gov/medication-assisted-treatment/practitioner-program-data/treatment-practitioner-locator)

Sudheer Potru, DO, is the director at the Complex Pain and High-Risk Opioid Clinic at the Atlanta VA Medical Center and an assistant professor in the Department of Anesthesiology at the Emory School of Medicine.

References

1. Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results From the 2018 National Survey on Drug Use and Health. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2018. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf
2. Peck G. UN agency warns of fentanyl production threat in SE Asia. ABC News. https://abcnews.go.com/International/wireStory/agency-warns-fentanyl-production-threat-se-asia-70741748. Published May 19, 2020. Accessed August 10, 2020.
3. Ahmad FB, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. Published 2020. Accessed August 10, 2020.
4. Alter A, Yeager C. The consequences of COVID-19 on the overdose epidemic: overdoses are increasing. Overdose Detection Mapping Application Program. http://www.odmap.org/Content/docs/news/2020/ODMAP-Report-May-2020.pdf. Published May 13, 2020. Accessed August 10, 2020.
5. Vindegaard N, Benros M. COVID-19 pandemic and mental health consequences: systemic review of the current evidence. Brain Behav Immun. 2020;89:531-42. https://doi.org/10.1016/j.bbi.2020.05.048
6. American Medical Association. Opioid task force 2020 progress report. https://www.ama-assn.org/system/files/2020-07/opioid-task-force-progress-report.pdf. Accessed August 10, 2020.
7. SEP Locations. Tacoma, WA: North American Syringe Exchange Network. Available at: https://www.nasen.org/map/. Accessed August 10, 2020.
8. Substance Abuse and Mental Health Services Administration. Expansion of naloxone in the prevention of opioid overdose FAQs. https://www.samhsa.gov/sites/default/files/programs_campaigns/medication_assisted/expansion-of-naloxone-faq.pdf. Accessed August 10, 2020.
9. Valentino T. Fact file: drug court expansion. Psychiatry & Behavioral Health Learning Network. https://www.psychcongress.com/article/policy/fact-file-drug-court-expansion. Published August 5, 2016. Accessed August 10, 2020.
10. Vestal C. Long stigmatized, methadone clinics multiply in some states. The Pew Charitable Trusts. https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2018/10/31/long-stigmatized-methadone-clinics-multiply-in-some-states. Published October 31, 2018. Accessed August 10, 2020.
11. McLellan AT, Alterman AI, Metzger DS, et al. Similarity of outcome predictors across opiate, cocaine, and alcohol treatments: role of treatment services. In: Marlatt GA, VandenBos GR. Addictive Behaviors: Readings on Etiology, Prevention, and Treatment. Washington, DC: American Psychological Association; 1997. https://doi.org/10.1037/10248-028
12. American Society of Addiction Medicine. Definition of addiction. https://www.asam.org/docs/default-source/quality-science/asam's-2019-definition-of-addiction-(1).pdf?sfvrsn=b8b64fc2_2. Published September 15, 2019. Accessed August 10, 2020.
13. American Society of Addiction Medicine. About the ASAM criteria. https://www.asam.org/asam-criteria/about. Accessed August 10, 2020.
14. Jhanjee S. Evidence based psychosocial interventions in substance use. Indian J Psychol Med. 2014;36(2):112-8. https://doi.org/10.4103/0253-7176.130960
15. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). 2013. Washington, DC.