American Society of Anesthesiologists Annual Meeting Review
Recent CDC Guidelines and FDA Action on the Opioid Epidemic in the US, Asokumar Buvanendran, MD, Anita Gupta, DO, PharmD
By Sophie R. Pestieau, MD
Children's National Health System
One of the keynote lectures of this year’s ASA Annual Meeting covered the current opioid epidemic, a topic of high importance for not only all the anesthesia providers in the US and around the world, but, all the healthcare providers and patients as well. This one-hour session was led by two fantastic speakers: Asokumar Buvanendran, MD from Rush University Medical Center, and Anita Gupta, DO, PharmD from Drexel University Medical College.
Dr. Buvanendran opened the session by discussing the recent Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for chronic pain. The CDC published these guidelines in March 2016 with the purpose to provide recommendations for prescribing opioids for patients 18 years of age and older in primary care settings. These guidelines focus on the use of opioids in treating chronic pain (pain lasting longer than 3 months or past the time of normal tissue healing), other than pain resultant from active cancer treatment, palliative care, and end-of-life care. Recommendations are grouped in three areas:
- Determining when to initiate or continue opioids for chronic (non-cancer) pain
As per the guidelines, non-pharmacologic and non-opioid therapy are a preferred option as and when possible. Clinicians should consider opioids only if expected benefits for both pain and function are anticipated to outweigh the risks, and if opioids are used, they should be combined with non-pharmacologic and non-opioid therapies. Treatment goal should be identified and opioids should be continued only if there’s a clear evidence of improvement in a patient’s pain and function.
- Opioid selection, dosage, and duration
When starting opioids, a provider should prescribe immediate-release instead of extended-release/long-acting opioids. Long-term opioid use often begins with therapy initiated for the treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and in no greater quantity than needed for the expected duration of pain severe enough to require opioids. Studies have shown discrepancy between the number of pills prescribed for acute pain, and what is actually taken by patients. A supply of three days or less will often be sufficient, and more than seven days will rarely be needed. Benefits and harms should be evaluated within 1 to 4 weeks and at least every three months thereafter.
- Assessing risk and addressing harms of opioid use
Utilizing urine drug testing as a tool may be helpful in assessing appropriate use of prescribed medications as well as to assess for simultaneous use of other controlled or illicit drugs by a patient. Urine drug testing may be done before initiating opioid therapy and can be repeated annually or more frequently as indicated. Clinicians are encouraged to avoid prescribing opioids and benzodiazepines concurrently. Considering offering naloxone when there is an increase risk for opioid overdose, or concurrent benzodiazepine use.
He concluded by addressing the “Red Flags for Prescribing” which are a series of screening tools developed by the US Drug Enforcement Administration (DEA) in collaboration with pertinent medical societies including the ASA, to consider prior to prescribing opioids. Examples of Red Flags discussed during this presentation include:
- Patients declining physical exam,
- Declining permission to obtain medical records or to undergo diagnostic tests;
- Patients exhibiting conduct suggesting abuse or withdrawal.
- Unexplained dose escalation,
- Non-adherence to the treatment plan,
- Alternate route of administration, i.e. injecting or inhaling oral formulations;
- Seeking medications from non-coordinated sites of care (ER, clinics, etc.).
ASA co-chair of the committee on opioid abuse and member of the US Food and Drug Administration (FDA), Anita Gupta, DO, PharmD from Drexel University Medical College, started by reminding the audience that fatal overdoses from opioid hit record levels in 2014. She presented the FDA opioid action plan in response to the opioid crisis, which includes: preventing prescription drug abuse, treating addiction, and saving lives from overdose. For example, in 2014 the FDA approved the Evzio autoinjector, designed to deliver naloxone outside of a healthcare setting. Similarly, in 2015 Narcan nasal spray was released as the 1st FDA approved nasal spray version of naloxone. The FDA also recently approved several products with features likely to reduce their abuse. Dr. Gupta also addressed the ASA initiatives on the opioid crisis. Some examples of some of these initiatives include:
- An Ad-Hoc Committee on Prescription Opioid Abuse in March 2016.
- Developing a wallet sized card to help families identify the signs and symptoms and how to respond to an opioid overdose, in collaboration with the Office of National Drug Control Policy,
- The ASA’s initiatives to increase physician education via an online portal and CME modules,
- Recommendations to physicians to register and use state Prescription Drug Monitoring Program (PDMP).
She concluded this presentation by listing future initiatives to address the prescription overdose epidemic: identify models of care of opioid therapy, enhance collaboration between the ASA and public/private organizations, policy development, improved research, etc.
The topic and presentations sparked a lively and engaging discussion and pertinent comments from the audience in regards to the role of the anesthesiologist in the OR, highlighting the need for an increased emphasis on minimizing use of opioids intra-operatively, when appropriate, utilizing multimodal analgesia and regional anesthesia. And that as perioperative physicians, our role is crucial in preventing the opioid epidemic from spreading. Finally, some appropriately raised the question about medical students’ education on pain and opioid prescribing, and whether this information was adequately being included on board examination.
Overall, this was an a pertinent, engaging and informative session that may be familiar to us as anesthesiologists but raises the important issue of our role as anesthesiologists in actively helping curb this opioid crisis, afflicting our nation.