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to be assessed at the same time as vital signs are taken.
The pain assessment shall be noted in the patient's
chart in a manner consistent with other vital signs."
The convergence of expert opinion, some supportive
literature, legislation, and accreditation of health care
facilities set in motion an unfortunate series of events
that resulted in the current crisis of opioid addiction
and the epidemic of death from opioid overdose.
Patients with conditions that were not traditionally
associated with significant pain were being asked
pain scores. For example, patients with pneumonia
were receiving significant amounts of opioids because
of "elevated pain scores", even though the cough
suppression and respiratory depression associated
with opioids is highly undesirable in this condition.
Recovery room nurses were aiming for pain scores
of zero. Physicians who were reluctant to prescribe
additional opioids, even when faced with patients
displaying obvious drug seeking behavior, were
disciplined by the health care system. Patient satisfaction
surveys and 360-degree workplace evaluations that
had physicians evaluated by non-physicians only added
more fuel to the fire. Experienced physicians who were
concerned about overprescription and overuse of opioids
were often unheeded.
The potential for opioids to cause widespread addiction
is well-recognized, but was ignored. An opioid addiction
epidemic in China had been the cause of two opium wars
in previous centuries between China and Britain. China
has since been able to successfully control the widespread
opioid addiction problems of the past.
Countries that did not designate pain as a vital sign and
did not make pain management a condition for health
care accreditation did not experience an opioid epidemic.
The Joint Commission has now reversed its stance on
pain as the fifth vital sign. Too late for many current
opioid addicts, who trace the origin of their opioid

addiction back to legitimate prescriptions or exposure
to opioids.5 To successfully reduce the incidence of
addiction we must take our role as stewards for opioid
medications seriously.

Methods to prevent the development
of opioid addiction
Non-pharmacological methods
Non-pharmacological methods to distract the nervous
system from noxious afferent impulses are of major
importance. The patient education video produced by
the California Society of Anesthesiology (CSA) entitled
"Managing Your Pain After Surgery" is an excellent
tool to educate patients about what they should expect
after surgery. It clearly explains that they should expect
some pain after surgery and that there are many ways
to control pain other than pills. These include cold or
hot compresses, resting, doing rehabilitative exercises
such as stretching and walking, occupational and
physical therapy, acupuncture, massage, music therapy,
and distractions like watching a movie. The CSA video
frankly discusses that opioids can be extremely addictive.
In light of the current addiction epidemic, full disclosure
of this topic is vital when obtaining consent for an
operation.

Non-opioid analgesics
When pharmacological means of pain control are
required, we need to increase the use of non-opioid
modalities like nerve blocks, spinal and epidural
anesthesia, alpha-2 agonists like dexmedetomidine,
acetaminophen, ketorolac, and other non-steroidal
analgesics, as well as adjuvants like IV lidocaine,
gabapentin, magnesium, and ketamine. Ketamine is a
powerful analgesic drug, but unfortunately also has a
significant potential for developing addiction.6
We should try to limit the opioids we administer intraoperatively to avoid the opioid paradox -whereby the

Annual Publication 2019 | 73

Vital Times 2019

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