Why Not Opioids?

Few topics today engender as much debate as the use of opioids in medicine and how it relates to the opioid epidemic. Proponents of opioid therapy quote a long history of use in medicine and a unique lack of a ceiling effect as reasons to continue its use. Those who believe that opioids should be minimized and eliminated whenever possible, point to the research on opioids, which shows the ever-increasing list of side effects causing complications and increased hospital length of stay. Another reason for changing the way pain is managed is changes in patient population. Concurrent chronic pain, addiction, and obesity epidemics in this country make treating pain in these patient populations more challenging and require a change in practice.

Opioids have been utilized in the treatment of pain for millennia. Prescriptions for opium have been found on tablets dating back to 2100 BC, and many ancient civilizations, including Greek, Egyptian, and Sumerian utilized it for pain. Morphine was first distilled from opium in 1803, but it was not until 1827 that Merck became the first pharmaceutical company to sell it commercially. Initially, morphine was only available as an oral formulation. When the hypodermic needle and syringe were invented in 1853, it did not take long to discover that intravenous morphine was far more potent. This led to both the increase in medication use of morphine, and also to its abuse. Addiction became such a problem that the Bayer pharmaceutical company created Heroin in 1895 as a treatment for morphine addiction. Since then, many new opioids have been invented in an attempt to minimize the side effects and maximize efficacy.

Continued research into the side effects of opioids have revealed an increasing list of complications and side effects that limit the usefulness of opioids including their effect on:

1. Pain.While opioids are given to relieve pain, they actually have a paradoxical effect of increasing sensitivity to pain after their analgesic effect wears off. This is called opioid-induced hyperalgesia, and appears to be mediated through multiple mechanisms. A second effect is opioid tolerance. This means that for every dose of opioid given, the next dose will be less effective. The combination of these two effects have been dubbed the “Sisyphus effect”, which means that using an opioid to treat pain increases the body’s sensitivity to pain. This makes opioids less and less effective at relieving pain. These effects are why chronic pain and long-term opioid use are the most common complications following surgery.
2. Breathing.The major risk factor of opioids is how they depress the body’s drive to breathe, which can lead to brain damage or death. Opioids also cause weakness of the pharyngeal (mouth and tongue) muscles, which is less well known. Use of opioids in patients with obesity and sleep apnea puts them at a much higher risk of airway obstruction. These patients may still be attempting to breathe, but not getting oxygen into their lungs. As the obesity epidemic continues to increase in this country, more and more of our patients my not be able to receive a high enough dose of opioids to manage their pain without putting them at risk for death.
3. Gastrointestinal System.Post-operative nausea and vomiting (PONV) is a common side effect of anesthesia and is the most common reason for hospital admission following outpatient surgery. Opioid-Free Anesthesia has been shown in multiple studies to reduce the risk of PONV. In addition, opioids commonly cause constipation, which if severe enough can lead to a bowel obstruction requiring hospitalization. In patients who have had bowel surgery, opioids delay return of bowel function, which the patient needs before they can be discharged home.
4. Addiction.With a nationwide prescription and elicit opioid epidemic occurring, the term opioid addiction is being used as a catch-all phrase to describe multiple problems including: opioid dependence, opioid use disorder, and opioid addiction. Long term opioid use after surgery is currently the most common complication following surgery. This is typically due to opioid dependence, rather than opioid use disorder or opioid addiction. Opioid dependence will occur to some degree in every single person who takes an opioid. Dependence simply means that as the patient takes an opioid medication, the body stops producing endogenous opioids. If the opioid is abruptly discontinued, the body will have an opioid deficiency leading to withdrawal: flu-like symptoms, rebound pain, and depression. If an opioid is taken routinely for any amount of time, it needs to be tapered down before being discontinued in order to prevent withdrawal. Studies have shown that patients are not being educated about the risk of dependence, the likelihood of withdrawal, or the need to taper the opioid before discontinuing. In addition, there are not validated tools with good predictive ability to screen for those patients who will have a harder time weaning off of opioids after surgery.
5. Miscellaneous.As more research is being done on the effects of opioids on the body, more negative side effects are being discovered including: blocking REM sleep, immune suppression through killer T cell and cortisol depression, testosterone (an analgesic hormone) suppression, osteoporosis, and increased risk of malunion after orthopedic surgery.

Opioids have a powerful analgesic effect. However, the increasing list of side effects and complications makes their risk/benefit profile increasingly undesirable and narrows the indication for their use. By substituting opioids for other analgesic medications, patients can be spared from the harm done by opioids, heal faster, and leave the hospital sooner. When an opioid is indicated after all the other options are exhausted, careful monitoring for adverse effects should be taken, the lowest dose for the shortest period of time should be used, and the patient should be adequately educated regarding the risks of taking an opioid.

Thomas Baribeault MSN CRNA

President, Society for Opioid-Free Anesthesia

The Society for Opioid-Free Anesthesia is a nonprofit organization dedicated to education and research on Opioid-Free anesthesia and post-operative pain control. Learn more here

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