The Opioid Epidemic and New Legislation in Massachusetts: Time For a Culture Change in Surgery?

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Between 1999 and 2008, the rate of overdose deaths from prescription opioid pain relievers (OPR) in the United States increased 4-fold.1 This alarming increase in OPR-related death rate was paralleled by a simultaneous increase in the sales of OPR, and also an increase in the rate of admissions for opioid use disorder treatment nationally. Since then, the OPR overdose epidemic continued to worsen, with unintentional drug overdose now becoming the leading cause of accidental death in the United States, killing more Americans than motor vehicle crashes or firearms. Prescription opioids account for the greatest number of drug-related deaths in the United States: of 47,055 drug overdose deaths in 2014, 18,893 were related to OPR and 10,574 to heroin.2 Among individuals who have used an OPR for a nonmedical reason, 69% report getting the medication from a friend or relative, the majority of whom received the original prescriptions from a single physician.1,2
Massachusetts has been hit particularly hard by the opioid epidemic. In 2013, poisoning and overdoses were the leading cause of injury in the state, accounting for 37% of deaths, compared with falls and motor vehicle crashes that accounted for 20% and 11% of injury deaths, respectively.3 Examination of this trend reveals the driving role opioids have played in these trends: from 2009 to 2013, the rate of opioid overdoses in Massachusetts increased from 9.6 per 100,000 people to 14.2 per 100,000 people.4 In addition to the death toll, for every opioid overdose death in Massachusetts, there were twice as many hospitalizations and 4 times as many emergency room visits for nonfatal opioid overdose, resulting in a substantial burden on the healthcare system.5
In response to the opioid epidemic, Massachusetts Governor Baker proposed a comprehensive legislation in late 2015. After multiple revisions, The STEP Act, an act relative to Substance use, Treatment, Education, and Prevention, was signed into effect in March 2016. The law detailed several components focused on OPR prescription. Table 1 illustrates some of the key parts of the law that surgeons in Massachusetts not only need to understand but also need to legally abide by.
Although it is likely too early to fully understand the new opioid law in Massachusetts, interpret its mandates, or even get a sense of the degree to which it will be strictly enforced, 1 thing is now clear: our current approach to acute perioperative pain relief, as surgeons, needs to change. The predominant opioid-centric habits and traditions of OPR prescriptions in surgical fields have partially contributed to the epidemic, and a culture change in perioperative pain management is needed. Such a change will not be fast or easy and will require funds and resources, as it will probably affect multiple aspects of the surgical patient care that we cannot yet fathom, including current surgical and clinic workflow, patient expectations for perioperative pain, and the patient's care satisfaction. Patient-centered outcomes including patients’ perception of the quality of care they receive [eg, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores] might be negatively affected by limiting OPR use unless patients’ expectations are addressed and managed a priori. Several experts understandably debate the misconception that prescribing more opioids creates better patient satisfaction, but the message remains clear either way: preoperative empathetic discussions with the patients to optimize their coping mechanisms and the design of pathways for pain management that are not opioid-centric are both essential.
The Massachusetts General Hospital (MGH) is one of the 2 major hospitals of Partners Healthcare, the largest private employer and the biggest healthcare provider in the Boston Metropolitan area, serving more than a third of its population.
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