Plastic Surgeons and the Painkiller Crisis

By Jane Farrell

Plastic surgeons are playing a part in the ongoing opioid epidemic and need to change some practices with patients, according to a professional journal.

The topic paper, in the October 2017 issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS), cited the use of opioids for pain management after surgery.

Plastic surgeons must recognize their patients’ risk of developing opioid use disorders and that the opioids they prescribe may be diverted to non-medical use, according to the article by Daniel Demsey, MD, of University of British Columbia, Vancouver, and colleagues.

“Surgeon opioid prescribing practices contribute to the opioid addiction crisis,” Demsey said. “Improvements in prescribing practices can improve patient safety.”

As is the case for other types of surgery, patients undergoing plastic and reconstructive procedures are commonly prescribed opioid medications to manage postoperative pain. In recent years, increased opioid prescribing has been closely linked to increases in opioid overdose.

“The scale of the opioid addiction epidemic is difficult to exaggerate,” according to Demsey and coauthors. They cite studies reporting that 4.7 percent of the U.S. population aberrantly used prescription opioids in 2015. In the same year, nearly 29,000 people died due to prescription opioid overdose.

Opioids prescribed after surgery contribute to the opioid crisis by exposing patients to potentially addictive medications and by contributing to the street supply of opioid drugs. Patients with previous chronic opioid use are more likely to still be taking these drugs one year after surgery. Even patients who have never taken opioids before are at risk of persistent use.

Risk factors for persistent opioid use include previous substance use disorders, mental health problems such as anxiety or depression, and low socioeconomic status. Women are also a high-risk group. Patients with chronic pain who are already taking opioids are at higher risk of complications or death after major surgery and incur higher health care costs.

Many patients don’t use all the opioid medications prescribed after surgery, with a risk that these leftover drugs will be diverted to nonmedical use by the patient or others. Most people with prescription opioid use disorder get the drugs from friends and family.

Demsey and coauthors suggest strategies for plastic surgeons to reduce the risks of persistent opioid use or diversion. Patients should be screened for risk factors for opioid use disorder; talking to patients about these risks in a nonjudgmental way may encourage them to use their pain medications cautiously. The patient’s primary care doctor should also be informed about the possible increase in risk.

For patients at risk, outcomes can be improved by referral to a transitional pain service, including development of an opioid weaning plan. Patients with known or suspected substance use disorder should be referred to an addiction specialist, preferably before surgery.

The authors said, “Elective surgery in patients with established substance use disorders should not be performed until follow-up for substance use has been arranged.”

Other strategies can help to reduce the need for opioids, including the use of combination anesthesia techniques and prescribing nonopioid pain medications after surgery. Educating patients about proper storage and disposal of opioid medications can help to reduce the risk of persistent opioid use or diversion.

“Although we cannot solve the opioid addiction crisis on our own,” Demsey said, “as plastic surgeons we can make a major contribution.”