What Opioid Crisis? Not My Job

Oftentimes in human discourse, when a controversial topic is discussed, there is a natural tendency for the proponent of an argument to avoid offending the audience, for fear of being labeled as prejudiced, or even a “shamer.” Nowhere is this truer than a discussion of health, medicine and body weight. In a day when some patients now hand “please don’t weigh me unless medically necessary” cards to their healthcare providers, it is not difficult to understand how fraught with difficulty a discussion of weight and health has become. At the risk of suffering the very consequences I warn against, I’ll ignore the blowback that I expect to receive and speak what appears to me to be obvious: A high body mass index can make receiving anesthesia in any form riskier for the patient and practitioner alike. And no amount of spin can change that, for the medical literature is rife with evidence of the risks that a high BMI can pose to patients in general, and anesthetized patients in particular.

Postoperative pain management in 2025 remains solidly rooted in opioid-dependent regimens, despite the availability of new multimodal, opioid-sparing protocols and strategies. Nationally, the opioid crisis continues to claim lives, with 130 deaths per day and economic costs ranging from $80 billion to $100 billion annually. The Drug Enforcement Administration is spending billions to monitor prescriptions, pharmacies and patient data through the Prescription Drug Monitoring Program, aiming to curb fraud and abuse and hold outliers accountable. Recently, the U.S. Senate passed the NOPAIN Act, which provides funding for opioid-sparing protocols.

However, one missing piece in this equation is any meaningful buy-in from the American Society of Anesthesiologists (ASA), hospital administrations, chief medical officers and anesthesia departments. During my brief tenure as a locum tenes hospital anesthesiologist, I was shocked to note that there was no dedicated ‘acute pain service’ or even a system or resources to train, buy equipment and add pharmaceuticals to the formulary to set one up. My efforts to initiate such a service were met with a solid wall of resistance at all levels, and it was probably held against me as trying to upset their apple cart and their solidly opioid-dependent stable status quo.

Given the scale of the opioid crisis and its widespread devastation, the ASA failed to take a leadership role. Ideally, it would have focused on compiling research, developing protocols and creating actionable models to establish an acute pain service in every hospital, ambulatory surgery center and hospital outpatient department. To date, no such effort has been made.

Instead, the ASA continues to focus on airways and various other topics at its annual meetings—issues that, while important, are far less pressing in the context of the opioid crisis.

Hospitals are often bureaucratic, with endless committees and red tape. In my experience, hospital administrations are unmotivated to allocate resources, train staff or disrupt their existing systems to implement new, opioid-sparing protocols. There should be some regulatory pressure on the administration to commit to this cause of implementing opioid-sparing regimens as a rule.

As anesthesiologists, we bear the responsibility of leading this change. The newer opioid-sparing regimens require us to update our skills in ultrasound-guided blocks, catheters, pumps and nonopioid medications. Unfortunately, many of us remain unaware of the latest therapies because we are too comfortable with the easy, default option of opioids. The disconnect is staggering: As anesthesiologists, we are central to minimizing opioid use in the perioperative period, yet we often view our role as completed once we drop a narcotized patient in the recovery room and prescribe more opioids for the recovery period. The consequences of this approach—on patients, their families and society—are devastating, yet too often viewed as someone else’s problem.

It behooves us all to take this opioid crisis seriously for what it is and take on the challenge to upgrade our skills, upgrade our basic concepts and make a concerted effort to get away from our total reliance on opioids as our go-to comfort zone in all cases. A lot of opioid-sparing techniques exist today, for both inpatient and outpatient settings. Read up on them, get trained in new techniques and get your organizations to make that switch. It is unconscionable to ignore the severe consequences of our outdated practices. Waiting for the ASA to take the lead is futile—we must act now.

Dayal is an anesthesiologist in Germantown, Md. He reported no relevant financial disclosures.

Editor’s note: The views expressed in this commentary belong to the author and do not necessarily reflect those of the publication.