Knee replacement. Cancer surgeries. Organ transplants. Worldwide, tens of millions of elective surgeries have been postponed because of the coronavirus. Public health officials have had to balance patients’ urgent need for treatment against the very real danger of potentially immune-compromised individuals being exposed to the virus in a hospital setting, and the need to reserve hospital capacity for COVID-19 patients.
But the decision to postpone these so-called elective surgeries may have severe consequences—including deepening the opioid crisis. Based on what we already know about the connection between preoperative pain management and opioid dependency, the coronavirus pandemic is creating a perfect storm.
Before the virus hit, we had hardly even begun to grapple with the opioid crisis. And now, the coronavirus crisis risks sending millions more people down the road to medication dependency.
When most people hear the word “elective,” they typically assume that means “cosmetic.” But in hospital terms, an elective surgery is simply any surgery that’s scheduled—in other words, not an emergency. In most cases, these are not cosmetic procedures; they are urgently needed surgeries to deal with serious medical issues. And right now, all kinds of procedures, including cancer surgeries, organ transplants, and other lifesaving treatments, have been postponed. Some hospitals have started scheduling elective surgeries again, but the very real risk of a second wave of coronavirus cases could put these patients at risk once more.
The population potentially at risk is enormous: In a typical year, 51 million people have inpatient surgery, whether elective or emergency, and over 80% of them are prescribed opioids after surgery—even when the surgery was low risk. Most patients with upcoming surgeries are prescribed opioids to manage their pain while awaiting treatment. For example, opioids are commonly prescribed for hip, knee, and shoulder surgeries; for neurosurgical and orthopedic spine patients (including people suffering from chronic back pain); for colorectal surgeries, including tumor removals; and for thoracic, head, and neck cancer patients.
Delaying surgery means patients will be taking these medications for longer before they’re treated, greatly increasing the odds that they’ll become dependent. Even patients who’ve never used opioids before surgery have a 10% chance of becoming dependent. But patients who’ve been using opioids to manage pain before surgery have a 70% chance of remaining on opioids years later. Cancer patients who need chemotherapy after their surgeries are also at a higher risk of long-term opioid use.
Right now, the risk of long-term dependence is likely even higher, because of the severe anxiety associated with delaying cancer treatment in particular. Anxiety and catastrophizing tend to make pain harder to manage. And if patients are prescribed benzodiazepines, such as Valium, Ativan, or Xanax, for anxiety, their risk is compounded. The risks associated with benzodiazepines (or “benzos”) aren’t as well known as the risks of opioid use, but there is a significant risk of long-term dependency even for new users of these medications. People who use both opioids and benzodiazepines at the same time are at risk of respiratory depression and even death. And even if patients escape those severe consequences, benzodiazepines are also known to make opioids stronger—potentially setting off a vicious, even deadly, cycle.
Patients whose surgeries have been delayed urgently need support throughout the period they’re using opioids, including pre-surgery and eventually post-surgery. They need evidence-based solutions that will help them manage their pain. For some patients, injections have enormous potential as a highly focused way to block pain receptors. For others, physical therapy or mindfulness practices can help manage pain and anxiety. A growing body of evidence shows that mindfulness can reduce chronic pain, and it’s also proven to have a significant positive impact on depression and quality of life issues. Cognitive behavioral therapy has also been proven to be effective at treating anxiety, depression, and chronic pain.
In many cases, with evidence-based interventions like these, patients can manage their postsurgical pain with non-opioid medications. (Lucid Lane offers telehealth counseling services for people with medication and substance dependence and other mental health disorders, and could benefit financially from some of the treatments described in this article.)
Opioids do have a role to play in pain management, including the management of chronic pain. But even after years of headlines over the opioid crisis, these drugs remain worryingly overprescribed and undermonitored. One study of post-surgery prescriptions from 2011–2016 found little change during the period, despite increasing awareness of the long-term risks of even a short period of opioid use. Doctors and surgeons still need more training in both how to manage pain and how to help patients safely taper off these medications once their surgeries have been performed. Patients need support to ensure that circumstances beyond their control don’t send them down the path to a lifelong struggle with chemical dependency.
The COVID-19 crisis has created a host of unprecedented challenges for us as a society. We’re struggling with record unemployment, political unrest over the question of when and how to reopen businesses, and deep, painful questions over racial divisions. But another crisis is looming behind all these urgent problems—a crisis that, if we do not face it head on, could also be with us for years to come.
Without strong, evidence-based support for patients awaiting surgery, the COVID-19 crisis risks creating an enormous new wave of the opioid crisis. These patients are in pain. They need our help to manage that pain without creating a dependency problem that could haunt them for the rest of their lives.
Adnan Asar is CEO of Lucid Lane*, founding chief technology officer of Livongo, and former global head of technology at Shutterfly.
The views expressed here are the author’s own and not those of Battery Ventures or of any person or organization affiliated or doing business with Battery Ventures. Further, the information herein is not intended for use by any current or potential investor in any investment fund affiliated with Battery Ventures.
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