Blog: Should anesthesia clinicians discuss the risks of perioperative opioid exposure with patients in the preanesthesia interview?

By Jonathan Markley, DO, Chief of Anesthesia, NAPA

Anesthesia clinicians play an important role in patient education, which in turn drives patient safety and satisfaction. There is no question that educated patients are safer patients, particularly when it comes to the risk of opioid abuse. Yet when we review perioperative risks with patients, the risk of chronic opioid use after a surgical procedure is often overlooked.

Communicating with patients is a vital part of an anesthesia clinician’s responsibility in the continuum of care. Recognizing our pivotal position in the patient experience, in the preanesthesia interview we typically use our discretion to discuss the most common—and sometimes even uncommon—perioperative risks. For example, it’s common practice to alert patients to the possibility of post-operative nausea and vomiting, which has an overall risk of 30%. Sometimes we mention very rare risks associated with specific procedures, such as postoperative visual loss after spine surgery, which has a low overall risk of only 0.02%. Since new data suggests that one in 20 opioid-naïve patients will become chronic opioid users, after even a minor procedure, this topic must now be uniformly included in our preanesthesia interview protocol. A preoperative risk discussion could alert our patients to this risk and suggest mitigation strategies, offering our patients a safer perioperative journey.

Defining the Risk
In June 2017, the Journal of the American Medical Association published a study titled “New Persistent Opioid Use after Minor and Major Surgical Procedures in US Adults.” This watershed research shined a light on the previously unrecognized risk that after surgery, opioid-naive patients have a very high incidence of developing into chronic opioid users. Examining a large cohort of 36,177 privately insured patients, in which 29,068 (80.3%) had minor procedures and 7,109 (19.7%) had major procedures, the study found that 6% of all patients continued to use opioids 90 days after surgery. A disturbing outcome uncovered in this study was that even minor surgeries led to a high incidence of chronic opioid use.

When we couple this data with the fact that 70,237 Americans died from opioid use in 2018—more than the total of US soldiers who died during the entire Vietnam war, and add to this the knowledge that 80% of heroin users started with prescription opioids, it’s clear that our primum non nocere medical directive to “first, do no harm” obliges anesthesia clinicians to alert their patients to this risk when they present for surgery.

Discussing Strategies to Minimize Opioids
Educating our patients with the facts about opioid abuse and related deaths, along with strategies to minimize opioid consumption, gives anesthesiologists and CRNA’s a powerful first step in preventing harm. There are several alternatives to opioid techniques that can be discussed before surgery:

1. Pharmacologically, a focus on administering acetaminophen and NSAIDS at scheduled intervals around the clock, instead of PRN (as needed), has been shown to decrease opioid consumption up to 30-50%.
2. Non-pharmacologic solutions also play a strong role, such as teaching patients to apply ice packs to the affected area, guided imagery, and free soul meditation techniques.
3. Teaching patients the 0-10 pain scoring system, with guidelines to only use non-opioid medications for a score of 6 or less, can deter the use of opioids for pain that is less than severe.
4. Informing patients that they do not need to take all the opioid pills prescribed to them when they are not in severe pain will also reduce unnecessary opioid use.
5. Instructing patients to destroy or remove any leftover opioids after the pain has subsided will help prevent diversion of prescribed pills to family, friends, or household employees; patients should be told that they can safely dispose of extra medications at local pharmacies.
6. Most importantly however, we can draw attention to the risk of perioperative opioid exposure.

Discussing Realistic Expectations
As the old Buddhist saying popularized by Haruki Murakami goes, “Pain is inevitable, suffering is optional.” Through education and non-pharmacologic solutions, anesthesia clinicians can help minimize the suffering that patients may experience with the physical pain that can follow surgery. By discussing with patients that some level of pain can be a normal part of the healing process, we can give them realistic and reasonable pain expectations for the postoperative period. We can also suggest or offer extra counseling and interventions for patients who are identified as being at the highest risk of becoming chronic opioid users. Known attributes of high-risk patients are mental health disorders, anxiety, depression, tobacco and/or alcohol use, a history of substance abuse, anxiety, and other preoperative pain disorders (i.e. back pain, neck pain, arthritis, and centralized pain conditions).

Our commitment to improve patient safety and enhance patient satisfaction compels us to protect our patients from the dangers of opioids by regularly adding a full discussion of opioid risk and control measures to the preanesthesia interview. For NAPA clinicians, this is one more way that we can create exceptional patient experiences, every day.

…educated patients are safer patients, particularly when it comes to the risk of opioid abuse. Share on X