HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Reprinted by permission of Otolaryngol Head Neck Surg. 2018; 158(5):817-827.

State of the Art Review

Otolaryngology– Head and Neck Surgery 2018, Vol. 158(5) 817–827 American Academy of Otolaryngology–Head and Neck

Opioid Stewardship in Otolaryngology: State of the Art Review

Surgery Foundation 2018 Reprints and permission:

sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599818757999 http://otojournal.org

John D. Cramer, MD 1 , Brad Wisler, MD 2 , and Christopher J. Gouveia, MD 3

History of the Opioid Crisis: How Did We Get Here? The United States is in the midst of an opioid epidemic that has been building for several decades. In the 1990s, pain was elevated to the ‘‘fifth vital sign’’ by the American Pain Society. 1 This coincided with a shift in medical provider attitudes toward eliminating all pain, relaxation in regula- tions for opioid prescribing, and aggressive marketing by pharmaceutical companies. 2 As a result, opioid prescribing skyrocketed. Between 1991 and 2011, opioid prescriptions nearly tripled in the United States, rising from 76 million to 219 million. 3,4 This number of prescriptions is enough to supply every adult in the United States with 5 mg of hydro- codone every 6 hours for 45 days. 5 Sadly, this coincided with dramatic increases in opioid dependence and opioid- related deaths. 6 Opiates are now responsible for greater than 30,000 deaths each year, more than motor vehicle accidents 7 or the number of deaths during the height of the human immunodeficiency virus epidemic. 8 In response to this public health crisis, the president declared the opioid epi- demic a public health crisis on October 26, 2017. 9 As surgeons, otolaryngologists are active participants in the opioid epidemic and are in a unique position to institute change. Surgeons have the second highest rate of opioid prescribing (37% of all prescriptions written) after only pain medicine specialists (49% of all prescriptions written). 10 Despite the frequency with which surgeons prescribe opioids, many underappreciate the risks of developing chronic opioid use after short-term prescriptions. 11 Up to 1 Department of Otolaryngology–Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA 2 Department of Anesthesiology, United States Air Force, Wright Patterson Air Force Base, Dayton, Ohio, USA 3 Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA Corresponding Author: John D. Cramer, MD, Department of Otolaryngology–Head and Neck Surgery, University of Pittsburgh Medical Center, 203 Lothrop Street, Suite 519, Pittsburgh, PA 15213, USA. Email: cramerj5@upmc.edu Otolaryngologists’ Role in the Opioid Epidemic

No sponsorships or competing interests have been disclosed for this article.

Abstract Objective. The United States is facing an epidemic of opioid addiction. Deaths from opioid overdose have quadrupled in the past 15 years and now surpass annual deaths during the height of the human immunodeficiency virus epidemic. There is a link between opioid prescriptions after surgery, opioid misuse, opioid diversion, and use of other drugs of abuse. As surgeons, otolaryngologists contribute to this crisis. Our objective is to outline the risk of abuse from opioids in the management of acute postoperative pain in otolaryngology–head and neck surgery (OHNS) and strate- gies to avoid misuse. Review Methods. We conducted a review of the literature on the rate of opioid abuse after surgery, methods of safe opioid use, and strategies to minimize the dangers of opioids. Conclusions. Otolaryngologists have a responsibility to treat pain. This begins preoperatively by discussing perioperative pain control and developing a personalized pain control plan. Patients should be aware that opioids carry significant risks of adverse events and abuse. Perioperative use of mul- timodal nonopioid agents enables pain control and avoid- ance of opioids in many otolaryngologic cases. When this approach is inadequate, opioids should be used in short duration under close surveillance. Institutional standards for opioid prescribing after common procedures can minimize misuse. Implications for Practice. Otolaryngologists need to acknowl- edge the potential harm that opioids cause. It is essential that we evaluate our practices to ensure that opioids are used responsibly. Furthermore, opioid stewardship should become a priority in otolaryngology. Data Sources. PubMed/MEDLINE.

Keywords otolaryngology, head and neck surgery, pain, postoperative pain, opioids, narcotics, analgesics

Received November 13, 2017; revised December 21, 2017; accepted January 18, 2018.

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