Opioids in vascular surgery: A call to action

The opioid epidemic has created increasing (and overdue) scrutiny of perioperative pain management. A growing body of evidence implicates elective procedures performed on opioid-naïve patients as a gateway to dependence, sometimes with fatal consequences. Unused pills from filled prescriptions often wind up in the hands of people other than the patient for whom they were prescribed, expanding the danger of over-prescribing to a circle of people surrounding or downstream from the intended recipient.

Several initiatives have been implemented to stem the tide of over-prescribing, addiction, overdoses, and deaths. New, opioid-free approaches to perioperative pain management have arisen to avoid opioid prescriptions when possible. Databases that track prescriptions by patient allow providers to identify drug-seeking behavior, which they were previously blind to without these resources. Community programs to take back unused medications, many of which are surgeon-initiated, are also helping to keep pills out of the hands of people who might obtain pain medicine without a prescription through theft or illegal resale. ¹ State and local governments are engaging in the fight against the opioid crisis through litigation against manufacturers, increased regulatory oversight (including prescription limits with penalties for providers), and programs to support identification and rescue from overdoses. ² These initiatives have already had an impact in several geographic areas across medical and surgical specialties.^2,3

Vascular surgery, however, faces several unique challenges to successful implementation of strategies to reduce opioid prescription and abuse. Patients with vascular disease include a wide spectrum of diagnoses, anatomic disease distributions, and procedures. Some vascular procedures have clear parallels to outpatient surgical procedures in other specialties, where initiatives to reduce opioid prescribing, including enhanced recovery after surgery, have been implemented and subsequently proven successful.^3,4 Examples include endocrine and laparoscopic surgery, ³ where the operations are usually performed on an outpatient basis and the patient is often expected to make a complete recovery with potential for cure. Analogous circumstances in vascular disease include many carotid, aortic, and varicose vein procedures. Rather than reinventing the wheel, vascular specialists might consider adapting programs from other specialties that have proven effective for reducing opioid use, thereby sparing themselves from having to learn from the same mistakes previously made by others.

More challenging, however, are scenarios where patients present with chronic pain caused by chronic disease processes, and long-term management, rather than cure, is required. Many vascular specialists meet these patients under circumstances that are challenging irrespective of the opioid issue, often after multiple treatment interventions have failed over time. Examples of patients who might fall into this category include those with rest pain from chronic limb-threatening ischemia or Buerger’s disease. Unlike other elective procedures, where the pain is primarily procedure-related and expected to resolve with time, these patients require a long-term pain management strategy, where the timeline is undefined and may last for the rest of the patient’s life. Vascular specialists need to be comfortable initiating a conversation with these patients about pain medication and proactive in communicating the plan to other members of the patient’s care team (including primary care physicians and pain specialists, ⁵ both of whom are increasingly overwhelmed by the number of patients requiring chronic pain management and the increased regulatory oversight). Because vascular specialists may not see patients as regularly as their primary care physicians, it is important for all parties to be aware of the pain management strategy, including what prescriptions have been issued and expectations regarding who will provide refills. Reluctance to treat pain due to concerns about risk of overdose, liability, or regulatory oversight must be balanced against the individual needs of patients with chronic pain, so that these patients are not abandoned.

In this issue of Vascular Medicine, the analysis by Colton and colleagues provides an important first step toward smarter pain management through thoughtful and selective opioid use in patients with vascular disease, with a critical look at prescribing patterns. ⁶ Several key observations support the notion that there is plenty of room for improvement. Refills were seldom required, and patients indicating that they had more pills than necessary outnumbered those who reported receiving less than they needed by more than double. ⁵ These findings suggest that restraint and reduction are appropriate for the majority of patients, and that vascular specialists are contributing to the pool of excess narcotic pills that continues to take a toll on our patients, families, and communities.

Vascular specialists need to engage in reducing the variability in opioid prescribing patterns through structured approaches, such as the departmental guidelines developed and implemented by Colton and colleagues at the University of Vermont in response to their study results. Further steps should include structured education and training for vascular providers and trainees on appropriate prescribing practices, team-based strategies for patients with chronic pain who require surgery, and upfront communication with patients and families about pain management (including opioids) when any procedure is scheduled.

Consider the results of Colton et al.’s study a call to action; it is time for vascular specialists to join the fight against the opioid epidemic.