President's Column: If You Are Not Part of the Solution...

Keith S. Naunheim, MD, President

STS News, Spring 2018 -- There are many longstanding issues afflicting our cardiothoracic surgical specialty, including threats to reimbursement, liability issues, and burdensome regulation. The profession has addressed and continues to address these issues; however, just recently, a chronic but previously unrecognized danger to the specialty and our patients was identified—the national epidemic of opioid abuse.

The opioid epidemic is a real phenomenon with devastating consequences in the US. The number of overall deaths from overdoses has more than doubled in the last decade, peaking at about 64,000 fatalities in 2016 and exceeding the deaths from traffic accidents or gun violence. Fully, two-thirds of those deaths were related to opioid overdose. The etiology of this problem is multifactorial and involves many health care players. Pharmaceutical companies intentionally downplayed the addiction risk of new pain medications while engaging in morally indefensible sales and distribution practices. In the 1990s, the American Pain Society, funded by the same pharmaceutical companies, touted pain as “the fifth vital sign,” insisting on visual pain scales with aggressive management that included narcotics. The Joint Commission published a pain management guideline in 2001 encouraging this pain management strategy, and in fact published a continuing education booklet (again funded by drug companies) citing studies suggesting “there is no evidence that addiction is a significant issue when persons are given opioids for pain control.” The Federation of State Medical Boards called for the punishment of doctors who inadequately treated patients’ pain, while simultaneously accepting pharmaceutical company money to produce drug prescribing guidelines. Hospitals implemented patient satisfaction scores specifically addressing inadequate pain management issues and threatened to downgrade physicians’ performance assessment for poor scores. Even the US legal system was involved, with physicians found financially liable for inadequate pain management practices (Bergman v. Chin).

Despite these facts, it is the physician community that has been vilified by the media for wanton and irresponsible prescribing practices. While it is true that there are unscrupulous doctors at “pill mills” who are guilty of unethical practices, it is also true that a portion of the blame could be assigned to responsible and caring physicians misled by the above-mentioned authorities and institutions. This group includes cardiothoracic surgeons who, for decades, have utilized thoracotomy incisions to achieve intrathoracic access. This approach produces a combination of muscular, skeletal, mesothelial, and neuropathic pain, which arguably makes thoracotomy the most painful incision one can undertake, both with regard to the immediate postoperative period and in the long term. A paper presented in January at the STS Annual Meeting reported that 14% of patients undergoing thoracoscopy or open thoracotomy were still filling opiate prescriptions 6 months after surgery. As surgeons, we need to be conscious of such results and take action directly addressing the issue of post-thoracotomy narcotic usage.

As surgeons, we need to … take action directly addressing the issue of postthoracotomy narcotic usage.

STS recognizes its role and that of its members in confronting this ongoing epidemic. Our first action is to better understand the current state of practice and, therefore, the Society has undertaken an electronic member survey requesting specific information regarding the routine practice of opioid administration and prescription following cardiothoracic surgery. Information regarding standard dosage, number of pills, and duration of treatment has been requested both from surgeons and associated providers who have been asked to participate (physician assistants, advanced practice nurses, anesthesiologists). This information will help form the foundation for the Society’s response to this nationwide problem. It is hoped that the results of this survey will help STS identify best practices and then issue expert clinical opinion regarding optimal perioperative utilization of both opioid medication and nonnarcotic pain control methods and medications. 

In addition, the Society will undertake ongoing education initiatives to help guide the membership in future practice. This will include emphasis of ERATS (Enhanced Recovery After Thoracic Surgery) protocols, a topic that was highlighted at the recent Fort Lauderdale meeting (see page 8 for information on how to access a related video roundtable and podcast). ERATS also will be addressed specifically at the upcoming STS Critical Care Conference in October, and it is expected that next year’s Annual Meeting in San Diego will highlight the issue of perioperative pain management and responsible perioperative opioid utilization in breakout sessions.

It is unrealistic to expect that cardiothoracic surgeons will be able to forgo narcotic medication completely given the nature of our operative incisions. However, both you the members and our patients can and should expect the Society to help guide practitioners in the measured and judicious approach to opioid usage in both inpatient and outpatient arenas. Such an approach will help minimize the risk of addiction for our patients and help address the ongoing epidemic.

It seems that this scourge caught most of America flat-footed in 2017, and our specialty was no exception. But now I believe we all recognize that the problem exists and it is one in which cardiothoracic surgeons have unwittingly played a role, however unintended. Yes, we have a problem, but now we pledge that—together—we will become part of the solution.