What's Your Perspective?

Opioids and The Transplant Surgeon

Vinayak S. Rohan, MDVinayak S. Rohan, MD
Assistant Professor of Surgery
Medical University of South Carolina

One need only to see the statistics to realize the gravity of the current opioid epidemic; >115 people are dying of overdoses daily, equating to an economic burden of 78.5 billion dollars /year.

With more than 42,000 annual deaths attributed to opiates, a surge in the number of organs available for transplant is inevitable. In fact, there has been a 24-fold rise in organ transplants available from overdose deaths, a national tragedy earning the morose moniker of the “Grim Silver Lining.”

How did we get here?

Not surprisingly, opiates have been known to humans as long as the existence of recorded history. A reference to ‘Hulgul’ or joyplant was seen as early as 3400 BCE from Mesopotamia.

In the U.S., the 1990s saw an increase in the use of opiates for a variety of pain-control regimens, driven and pushed by pharmaceutical companies. Marketing budgets swelled to more than $200 million a year. Extended release formulations also began to appear, and doctors, nurses and pain societies advocated for these “non-addicting” opioids.

By 1994, 4 million people (2% of the population) were using prescription medications non-medically. Additionally, after JCAHO incorporated pain as the 5th vital sign, there was a doubling of the opioid abuse/misuse in one decade.

Opioids and transplant

Opiate overdose contributed to 1.1% of all donors in 2000. In 2017, it was 13.4%, an increase of 17% per year. At the same time, the discard rate for these organs is much higher than for donors from trauma, due to 56% of donors from overdose being deemed as PHS high risk (especially due to Hepatitis C.)

We in the transplant world are acutely aware of the perpetual shortage of organs with more than 100,000 people on the waiting list. Every transplant is balancing the risk with the benefit. With the advent of new Hepatitis C drugs with excellent cure rates, trials have shown the feasibility and benefit of transplanting Hepatitis C–negative patients with Hepatitis C–positive kidneys. It is time for us as a community to adopt it in wider practice and decrease the discard rates of these organs.

The other face of the coin is more humbling. We have to contemplate how we, as surgeons, have contributed to this epidemic and how our actions affect transplant outcomes.

Opioids are intended for short-term treatment of surgical pain. For far too long we have prescribed opioids without seriously considering the long-term consequences. The best predictor of misuse was the number of post-discharge prescriptions, with an additional refill increasing the misuse by 44%.

 Alarmingly, 80% of heroin users first used prescription opioids. The fact is that 67% to 92% of patients have unused opiates left with them after surgery, forming an important reservoir available for abuse.

Although the transplant rates have increased with the epidemic, outcomes have been adversely affected. Recent articles looking at the single center studies and national data have shown that graft loss and mortality are both increased in liver and kidney transplant patients who are chronic opioid users.

As we continue to focus our energies on increasing the organ utilization, the education of patients and the prescriber regarding opioid use should not be neglected. We took the easy route in treating pain; fixing the problem is not going to be pain free. A concerted effort amongst all of us is required for the development of multimodality and alternative pain control strategies in transplantation and beyond…from my perspective.

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