Opioids provide highly effective analgesia to patients with moderate or severe postoperative pain, but their use is associated with numerous adverse events (AEs) and the potential for addiction, dependence, and abuse. (1,2) At present, 60% of drug overdose deaths involve an opioid, and 91 people die every day from an opioid overdose. (3) Notably, 40% of the deaths caused by an opioid overdose involve prescription opioids. (1,4)
Opioid prescribing patterns
The opioid prescribing pattern in the United States (US) has changed in recent years, with the total number of prescriptions dispensed peaking in 2012 and declining between 2012 and 2016.5 Despite the decline, however, the national opioid prescribing rate in 2016 remains high: In 2016, 66.5 opioid prescriptions were issued per 100 persons. Although that figure marks the lowest rate in more than a decade, it still represents more than 214 million total opioid prescriptions. (5)
The rate of opioid prescribing varies widely by US region. For example, some US counties have opioid prescribing rates 7 times higher than the national rate, and approximately 25% of US counties dispense enough opioid prescriptions to supply every county resident with one. (5) In 2016, Alabama had the highest prescribing rate, and the District of Columbia had the lowest (121.0 vs 32.5 opioid prescriptions dispensed per 100 persons, respectively). (6) Figure 1 shows opioid prescribing rates by state stratified into 4 categories.
Opioids have long been regarded as the standard of care for the management of acute postoperative pain. (7) In fact, in a recent US survey of 200 surgeons, 94% of them reported that they frequently prescribe opioids to manage postoperative pain, and 91% reported that they frequently feel pressure to prescribe more opioids than are actually needed by their patients. (8) The same survey, which also included responses from 500 patients who had undergone orthopedic or soft tissue surgery, found that 1 in 10 patients became addicted to or dependent on opioids after postsurgical exposure. (8) Each year, an estimated 70 million people in the US who undergo surgery receive an opioid; thus, based on these survey findings, as many as 7 million people could potentially become addicted to or dependent on opioids annually. (8)
Management of postoperative pain
Evidence suggests that progress in managing postoperative pain has been slow and generally remains suboptimal. In a 1995 survey of 300 US hospitals, only 42% reported having an acute pain management program, with an additional 13% reporting plans to establish such a program. (9) In the same survey, which included 500 adults who had undergone surgery, 77% reported pain after surgery; of these, 80% reported experiencing moderate to extreme pain. (9) A survey of 250 surgical patients conducted in 2003 showed similar results: About 80% of patients experienced acute pain after surgery, with 86% of patients reporting moderate, severe, or extreme pain. (10) In a 2014 survey of 300 surgical patients, about 86% reported postoperative pain; of these, 75% described the pain in the immediate postoperative period as moderate or extreme, and...