The Heroin Epidemic in America: A Surgeon's Perspective

Abstract

Background:

The United States is currently experiencing a heroin epidemic. Recent reports have demonstrated a three-fold increase in heroin use among Americans since 2007 with a shift in demographics to more women and white Americans. Furthermore, there has been a correlation between the recent opioid epidemic and an increase in heroin abuse. Much has been written about epidemiology and prevention of heroin abuse, but little has been dedicated to the surgical implications, complications, and resource utilization.

Discussion:

This article focuses on the surgical problems encountered from heroin abuse and how to manage them in a constant effort to improve morbidity and mortality for these heroin abusers.

Recent reports from the U.S. Centers for Disease Control and Prevention (CDC) found that more than half a million Americans used heroin in 2013, representing a nearly three-fold increase since 2007 [1]. With increased stringency in prescribing practices for pharmaceutical opioids, the biggest surge in heroin use is among a demographic that has historically had lower average rates of heroin abuse: women and white Americans [2,3]. Given the recent recognition of the opioid epidemic, increases in heroin abuse have been shown to be something healthcare providers have become aware of and inadvertently contributed to via prescribing practices [3]. In 2012, it was estimated that 2.1 million Americans suffered from substance abuse disorders related to prescription drug abuse with an estimated 467,000 of these individuals abusing heroin—many of whom started with prescription opioids [4,5]. Although causality cannot be proven, it can be inferred that this heroin epidemic is the direct result of an increase in the abuse of prescribed opioids for analgesia because the number of opioid prescriptions has quadrupled since 1991 and 72% of prescribed opioid pills go unused after surgery [6].

In 2011, intravenous drug use-related infections resulted in 1.25 million visits to U.S. emergency departments, a 100% increase from 2004 [7]. The market dominance of black tar heroin, the popularity of skin-popping, and the combination of heroin with other illicit drugs have resulted in the dramatic emergence of Clostridium and other bacterial infections among heroin abusers [7]. Abscesses, septic thrombophlebitis, and necrotizing soft tissue infections (NTSIs) are some of the various surgical diseases related to heroin injection and are increasingly common.

Whereas much of the current literature focuses on epidemiology and antimicrobial therapy, little has been written on the complications and surgical management of heroin-related infections. This review highlights the changing demographics of heroin abuse in the United States, describes the severe infectious complications related to heroin injection, and defines the role of the acute care surgeon in the battle against heroin-related morbidity and mortality.

Epidemiology and Progression to Heroin Abuse

Ubiquitous for centuries and in various cultures, opium, and now heroin, was once a drug of young, poor, inner-city male minorities yet now has become a popular drug of choice for older, wealthier white men and women in smaller cities and suburban areas [8]. According to the CDC, heroin use has increased in nearly every demographic when comparing survey data from the years 2002–2004 and 2011–2013 with an overall increase in prevalence of 62.5% since 2004 [8]. Although it is still more likely that a male making less than $20,000 per year, without medical insurance, or on Medicaid is more likely to abuse heroin, it is important to recognize this is not the demographic for heroin abuse that is increasing most rapidly in America. Greatest increases in heroin use include females, non-Hispanic whites, persons aged 18–25, and those with an annual income of $20,000 to $49,999 [5]. The CDC reports that a 2.25:1 distribution of males to females remains [8], although a recent study demonstrated 52% of current heroin users are actually females [2,9].

Not only have the demographics of heroin abuse undergone dramatic changes in the United States, there have also been shifts in the geographic distribution of its use. Historically, heroin was used most commonly in low-income urban areas during the 1960s and 1970s. However, over the last several decades there has been a shift by approximately 75% to smaller metropolitan and non-urban areas [9]. It was reported in 1971 that 15% of American soldiers in Vietnam abused heroin, which created great political uproar when President Nixon created the Drug Enforcement Administration (DEA) in 1973 [10,11]. Although only approximately 5% of those males who returned from the Vietnam War continued opioid abuse, it is speculated that this, in addition to increased use of opioids in response to chronic post-traumatic stress disorder, was the genesis of heroin abuse in the United States [10,11]. Although it was not until the mid-1980s that the use of opioids for better, long-term pain control became widespread, it was only in the last 10 years that the prevalence of heroin abuse has increased dramatically, culminating in the current epidemic [12,13].

One of the major contributors to the recent increases in heroin addiction and shift in demographics was the approval of the extended-release opioid, OxyContin^® (Purdue Pharma, Stamford, CT) by the Food and Drug Administration (FDA) in 1995 [14]. However, prescription opioid use of hydrocodone and oxycodone has increased astronomically and with it an acute surge in opioid-related morbidity and mortality including more emergency department visits, neonatal abstinence syndrome, and a reported 900% increase in individuals seeking treatment for opioid addiction [9,14]. In 2014, 75% of drug addicts who completed a demographic survey stated they used prescription opioids to treat a painful condition before becoming addicted and switching to heroin, which is a stark contrast to trends of the 1970s showing heroin as the first opioid of abuse [9]. Epidemiologic data have shown that drug abusers have transitioned their addictions from prescription opioids to heroin. In fact, one report stated that more than 80% of novice heroin addicts became dependent on prescribed opioids by misusing prescription painkillers [2,9,15].

Access to prescription opioids has become so difficult that it has been estimated that taking prescription opioids increases the likelihood of transitioning to heroin 40-fold [15]. However, many factors contribute to this progression. Heroin is particularly addictive because of its high lipid solubility that allows it to cross the blood-brain barrier within 15–20 seconds, providing euphoria almost immediately and more quickly than prescription opioids with the effect lasting 4 to 5 hours [15]. These characteristics coupled with its lower cost and higher attainability makes it a more viable option than prescription opioids [3,9,16]. According to the DEA, the mean price per milligram of pure U.S. heroin has decreased from $4.36 per milligram-pure in 1990 to $1.07 per milligram-pure by 2000, making it readily accessible [16]. In a 2014 survey of people receiving treatment for opioid addiction, 94% said they chose to use heroin because prescription opioids were “far more expensive and harder to obtain” [16].

One of the added risks of street heroin is that it contains an estimated 7%–10% to a maximum of 20% pure heroin with the remainder comprising filler substances such as sugar, caffeine, ephedrine, aspirin, cement, chalk, and most notably, acetaminophen [17]. More recently, heroin is starting to be cut with other prescription opioids such as fentanyl, making it potentially more dangerous and putting users at a substantially higher risk for overdose [2,18]. Whereas overdose and contamination of illicit drugs is a risk to individuals abusing these drugs, route of administration puts heroin users at risk for skin and soft tissue abscesses, infectious vasculitis, necrotizing infections, transmission of human immunodeficiency virus (HIV), hepatitis, sexually transmitted infections, and blood-borne diseases [17]. Many of these complications require surgical interventions to correct.

Surgical Implications and Management from Heroin Abuse

Skin and soft tissue infections

Although overdose and mortality remain a major focus of heroin abuse in the United States, the resource utilization and healthcare costs of other complications related to heroin abuse must also be considered. Heroin abusers frequently develop skin and soft tissue infections (SSTIs) such as cellulitis and abscesses from use of dirty injection equipment [19 –22]. One recent study found that one-third of all intravenous drug users had experienced some form of an SSTI [19,22]. Other studies suggest a rate of abscess formation anywhere from 22%–65% among heroin addicts [23 –25]. Another study demonstrated that 40% of intravenous drug users who sought emergency department care for an SSTI were admitted and 25% of those admitted required surgical intervention [19,26]. Skin and soft tissue infections, especially abscesses, are associated with inexperience [27], subcutaneous or intramuscular injecting known as skin popping [22], speed balling (the injection of heroin plus cocaine) [28,29], and the use of black tar heroin [19,30 –32]. Additionally, the failure to disinfect the skin or dirty needle use by heroin abusers can further lead to SSTIs [13,19,20].

Even though abscesses are not often complex to manage, the high incidence of SSTIs among heroin abusers results in costly implications for cities with large abuse populations [19]. Studies from urban public hospitals have demonstrated SSTIs are one of the most common reasons for seeking emergency department and inpatient treatment by intravenous drug users, with heroin abuse being the most common culprit [19,20,33 –35]. One recent study estimated more than 106,000 hospital admissions and a total cost of $193.8 million for injection drug-related SSTIs in the United States over a four-year period [19,36], a number that has likely increased since that time. Most intravenous drug users admitted with SSTIs are either uninsured or rely on Medicare/Medicaid, with heroin abusers and subsequent overdoses tending toward longer and more costly hospitalizations [19,36,37]. The nature of hospitalization costs stems from multifaceted care required for these patients including need for intravenous antibiotic agents, withdrawal symptoms, wound care, concomitant comorbidities, and specific disposition need because of lack of trustworthiness [38,39]. Because of the potent addictive properties of heroin, these patients frequently develop multiple SSTIs resulting in multiple hospitalizations making their overall care even more complicated and costly.

Skin and soft tissue infections from heroin injection usually present in one of two forms: cellulitis or abscess. Initial treatment typically begins with administration of intravenous antibiotic agents with empiric coverage for common bacterial strains of Staphylococcus aureus, community-acquired methicillin-resistant Staphylococcus areus (MRSA) strains, group A β-hemolytic Streptococcus, and other Streptococcus species [37,40 –43]. Community-acquired MRSA has become particularly prevalent among intravenous drug users, especially given the discovery of new strains of MRSA in which panton-valentine leukocidin is upregulated resulting in a much more aggressive form of the bacteria and a more acute presentation [44,45]. Anaerobic bacteria are also concerning, including Clostridium species, because these infections can lead to NTSI, which has potential to become severe and life-threatening if not treated promptly [40]. If Clostridium species is suspected with or without NTSI, then clindamycin is indicated for mitigating toxin production associated with gram-positive bacteria and spores from Clostridium species [40]. Once cultures are available, antibiotic therapy can be tailored according to sensitivities.

Incision and drainage (I&D) remains the mainstay of treatment for intravenous drug abscesses [40,46]. Traditionally, diagnosis is made after obtaining a medical history and performing a physical examination [47,48]. Unfortunately, physical examination has been shown to be associated with a fair to poor inter-rater reliability in identifying abscess and its severity [48 –50]. Given that heroin users utilize blood vessels for injection, pseudoaneurysms may be misdiagnosed as abscesses on physical examination [51]. The limited utility of a physical examination to diagnosis of an abscess may necessitate the use of adjunct procedures to help in this process. Although computed tomography (CT) can be utilized, point-of-care ultrasound has been shown to provide accurate differentiation of an abscess prior to I&D, ruling out potential underlying vascular or neoplastic lesions that can mimic abscesses prior to the procedure [48,51,52]. Furthermore, it is imperative for the surgeon to ensure that no foreign body, such as a needle, remains in the abscess cavity prior to I&D. Given the possibility of concurrent infections such as HIV or hepatis in this population, the surgeon must make sure to protect him/herself. Often a simple radiograph can confirm this finding. Once the diagnosis of an abscess is made, the decision of whether I&D can be performed at the bedside or in the operating room is made. If the abscess is in a sensitive area or deep within soft tissue or NTSI cannot be excluded by physical examination, I&D should be performed in the operating room.

Septic thrombophlebitis

Thrombophlebitis is the inflammation of a vein associated with venous thrombosis [53]. This disease process occurs frequently in heroin users because of the repetitive use of veins for injection. As favorite sites are used repeatedly, risk of developing an infection and subsequent septic thrombophlebitis increases substantially, particularly if the heroin is contaminated [53]. Unfortunately, the incidence of septic thrombophlebitis remains unclear [53]. Furthermore, as superficial veins become more difficult to access, heroin users will turn their attention to deeper veins, such as the proximal saphenous, dorsal penile, and femoral veins, in order to access the venous circulation [54]. Several studies suggest the groin is the preferred site for drug injection in up to 45%–58% of cases because these injection sites are easily hidden [49,55,56]. Using groin veins may result in propagated septic thrombophlebitis in deep veins, creating a more challenging problem for the patient and the surgeon leading to additional complications such as septic pulmonary emboli [57].

Whenever a patient presents with a warm, erythematous extremity commonly with a palpable painful cord, the differential diagnosis should include septic thrombophlebitis and superficial, non-infected thrombophlebitis. This diagnosis is usually made clinically because non-infected thrombophlebitis usually presents with pain and skin discoloration localized directly over the affected vein [53]. Septic thrombophlebitis, however, usually involves a much more diffuse area of affected skin [53]. Furthermore, fever, swelling, and purulent drainage are present in anywhere from 9%–44% of patients with septic thrombophlebitis [53,58].

Once the diagnosis is established, treatment must include strategies to provide for symptomatic relief, limitation of thrombosis extension, and reduction in the risk of pulmonary embolism formation [53]. Non-steroidal anti-inflammatory medications, extremity elevation, and warm compression are often the first-line therapies [53]. Anticoagulants such as unfractionated heparin, low molecular weight heparin, fondaparinux, and warfarin are used to prevent thrombophlebitis extension, especially if the thrombosis is in a deep venous system [53,59]. Some have advocated for the use of topically applied anticoagulants, such as heparin cream or epicutaneous warfarin, however, this remains controversial [53]. If septic thrombophlebitis is identified, then culturing the purulent fluid (if present) and administration of antibiotic agents is indicated [39,53,54]. If non-surgical management with antibiotic agents, elevation, compression, and pain relief fails, these patients can become ill from persistent or recurrent bacteremia, endocarditis, or septic pulmonary and neurologic emboli. One study suggested a failure rate of non-surgical management as high as 43.5% [39]. If non-surgical management does not yield improvement within a day, more aggressive surgical options are mandated.

Surgical treatment for septic thrombophlebitis is often dependent upon location. If the vein involved is superficial, then simple local excision is usually the treatment of choice [53]. However, if the septic thrombus is located in the femoral vein or great saphenous vein, more aggressive surgery may be required. If the thrombus is in the saphenous system, ligation and excision of the saphenous vein may be required [53,55,60]. Infected thrombus in the femoral vein (or other deep vein) may require surgical thrombectomy or even a venous bypass [39,55,60]. Although these procedures are possible, the overall outcomes are usually not optimal and may result in chronic venous insufficiency, chronic edema, and pain with use because of venous sclerosis [39,55,60] These surgical interventions, although imperfect, can be life-saving in the critically ill because of continued bacterial showering of the septic thrombophlebitis [39,60].

Mycotic pseudoaneurysms

Another rare but life-threatening complication of injection heroin abuse is that of mycotic pseudoaneurysm formation. These aneurysms result from the bacterial infection of an arterial wall secondary to intra-arterial or peri-arterial injection of the drug [55,61]. Inexperienced users may inject via arterial rather than subcutaneous routes to achieve a quicker high, which can increase the incidence of pseudoaneurysm formation [55]. The resulting bacterial infection causes either recurrent episodes of bacteremia or weakness in the arterial wall [55]. Eventual weakness of the arterial wall results in pseudoaneurysm formation and the potential for arterial rupture and life-threatening hemorrhage [55]. Repetitive use of a vessel combined with impurities within the heroin itself can weaken the vessel wall resulting in pseudoaneurysm formation and if infection develops, a mycotic pseudoaneurysm will ensue [55,61].

The prevalence of mycotic aneurysm formation among intravenous drug users is low at 0.03% annually [55]. Nonetheless, it requires a high index of suspicion based on the patient's history because it can often be misdiagnosed as an abscess resulting in simple I&D causing inadvertent rupture and life-threatening hemorrhage [46,55]. The majority of mycotic pseudoaneurysms form in the femoral artery because heroin users can easily mistake the artery for femoral vein, or if both vessels are missed altogether [31,62]. Other common sites include the brachial and radial arteries. Seventy-five percent of patients with a mycotic pseudoaneurysm present with a pulsatile mass [46,63]. Other symptoms include extremity ischemia such as pallor, decreased temperature, and diminished or absent distal pulses [46]. Patients may also have neurologic sequela secondary to compression on local nerves from the pseudoaneurysm itself, cellulitis with pain, or ongoing bleeding from the injection site after drug injection [46]. Duplex ultrasonography is usually the first-line imaging to confirm the diagnosis [55]. If unsuccessful, angiography can be used to confirm the presence of a pseudoaneurysm further [46,55].

Once the diagnosis is made, surgical intervention is required. Non-operative management utilizing antibiotics, elevation, and compression is rarely beneficial in this clinical scenario [55]. Furthermore, because pseudoaneurysms are often infected, embolization will not result in resolution of the infectious portion of the process. The mainstay of treatment is surgical ligation of the aneurysm followed by excision and debridement of surrounding tissues [46,55,62,64]. Controversy exists as to whether or not revascularization is necessary after ligation of the aneurysm [55]. Prosthetic grafts often result in further infection or occlusion within the presence of an infected field, even if the graft is placed in the extra-anatomic position [55]. Furthermore, finding a suitable autologous graft is almost impossible in intravenous drug users because the majority of veins are sclerosed [55]. If a viable vein is found, there is still risk of further infection when the graft is placed in the infected field [55]. A recent study examined 277 cases of mycotic pseudoaneuysm from intravenous drug abusers, 72% of whom were managed with ligation and excision alone and 28% of whom had immediate or delayed re-vascularization [55,65]. The amputation rates between the two groups were similar (6.5% in the non-revascularized group and 9% in the re-vascularized group) and the infected or occluded graft rate was 26.9% [65]. On the basis of this study, simple ligation with excision and antibiotic agents should be considered as first-line surgical therapy for these drug injection-induced mycotic pseudoaneurysms [55]. Amputation is appropriate if the infectious process is severe and the patient is too ill to undergo post-ligation re-vascularization in the presence of a cold extremity [55].

Necrotizing soft tissue infection

Necrotizing soft tissue infection, although rare, requires prompt recognition and aggressive management in all patients including those abusing heroin. Necrotizing soft tissue infection is characterized by extensive and rapid progression of cellulitis with fascial and subcutaneous necrosis caused by rapid bacterial propagation. Mortality remains high, anywhere from 6%–76% despite recent progress in treatment modalities [66,67]. Although classic risk factors include diabetes mellitus, advanced age, obesity, liver disease, malignancy, alcoholism, and other immunosuppressive disorders, there is an increased incidence among intravenous drug users in the United States [66,68]. One recent study suggested that almost half (45.8%) of all new cases of NSTI are because of intravenous drug abuse [40,68]. Although studies have not identified specifically the incidence related solely to heroin abuse, it can be assumed that this number accounts for the majority of cases given the scarcity of illicit injectable drugs and the recent substantial increase in heroin abusers in the last several years.

One of the major contributors to NSTI (and all infectious processes from heroin abuse) is the quantity of contaminants within the heroin itself. One urban study found that 68% of street heroin samples and 89% of the confiscated material for injection was contaminated with various pathogens including Clostridium sp., gram-negative bacteria, and fungi [40,69]. Another study demonstrated similar results with 61% of heroin samples containing 1.6 × 102 – 3.7 × 104 organisms per gram [40,61]. These findings clearly illustrate why many heroin users suffer substantial, life-threatening infectious complications. Combining risk of infection with possible development of vascular sclerosis, many heroin users resort to skin popping, which provides a warm and relatively hypoxic medium in which NTSIs flourish [27,30].

Although NSTI is often polymicrobial, recent literature has shown a link between black tar heroin and Clostridium sp. infections [31,70]. Black tar heroin is a crude, unpurified derivative of the opium poppy smuggled from Mexico into the United States [30]. Considering the crude preparation and potential for adulteration, bacterial contamination of black tar heroin is inevitable [30]. Unlike most bacteria, which are killed by brief heating to temperatures of 72°C or greater, clostridia spores, often found in black tar heroin, are resistant to heating making bacterial spore injection more common among these drug abusers [22,30,54,71]. Necrotizing soft tissue infections caused by black tar heroin are often more aggressive with rapid spread, resulting primarily from Clostridium sp., compared with other (non-heroin–related) infectious causes of NSTI, which result in both streptococcal species or polymicrobial infection [30,31].

Necrotizing soft tissue infection requires aggressive and timely surgical debridement to prevent rapid progression [72]. However, it may be difficult to distinguish NSTI from simple cellulitis or abscess because initial signs and symptoms are non-specific including erythema, pain, edema, fever, crepitus, and induration. These vague initial signs and symptoms often result in diagnostic challenges [31,68,70]. Physicians should always evaluate and have a high suspicion for NSTI in patients presenting with a history of intravenous drug use. When NSTI is suspected, urgent surgical intervention is warranted because survival is improved by aggressive resuscitation and debridement [31]. Furthermore, rapid administration of antibiotic agents or antitoxins (in cases concerning for Clostridium infection) has been suggested and shows improvement in overall outcomes [73 –75]. Surgical intervention necessitates excision of all dead and infected muscle, fascia, skin, and soft tissue that often results in large and complex wounds. Patients should receive a second-look operation after aggressive resuscitation and often will require multiple debridements given the aggressive nature of the bacterial infection, which will continue to propagate until all infected tissue is removed. In severe cases, amputation may be mandated as a life-saving procedure.

Once the infection is controlled, additional surgical resources will be required to help close extensive wounds. Patients with NSTI will frequently require daily dressing changes, or alternatively, the use of negative pressure wound therapy (NPWT), which has been shown to decrease toxin absorbance, preserve residual tissue, and facilitate the formation of a healthy wound bed, all of which are paramount for future reconstruction [76 –79]. Negative-pressure wound therapy is a safe option once the wound is clear of infection and may also assist in decreasing narcotic use for pain, because the NPWT dressings require less frequent dressing changes [79]. When the wound bed is ready, closure of the wound via local rotational or advancement flap or skin grafting is frequently required. For patients requiring amputation, additional rehabilitation and prosthetics may be required before the patient can be discharged home. Necrotizing soft tissue infection resulting from heroin abuse not only results in substantial morbidity (and mortality) for the patient, but also extensive healthcare resource utilization and costs.

Additional infectious surgical implications

In addition to SSTIs and NSTIs, the intravenous injection of heroin can result in bacteremia leading to severe sepsis, endocarditis, and hematogenous osteomyelitis [19,80,81]. Osteomyelitis can result from hematogenous spread of the bacteria without the signs or symptoms of an SSTI [19,27]. Infectious endocarditis (IE) is becoming more common among heroin abusers usually requiring hospitalization for intravenous antibiotic administration [19]. In cases in which the endocarditis is severe, cardiac surgery may be required to debride or replace infected valves [82 –84]. Furthermore, IE can result in septic embolization to the lungs, spleen, central nervous system, and other organs resulting in additional morbidity [85,86]. Patients with IE generally have long complex hospitalizations further complicated by one or more of the complications listed previously.

One of the rare complications from heroin abuse is that of avascular femoral head necrosis [87]. Few publications exist pertaining to this pathophysiology and it remains unclear how the systemic effects of heroin can cause osteonecrosis of the femoral head. One thought is that it develops secondary to thrombophlebitis resulting from intravenous injection [88]. Direct injection of heroin into the femoral vein can result in emboli dispersing directly to the vasculature of the femoral head ultimately leading to ischemia and subsequent necrosis [87,88]. Others suggest the mechanism may be the result of microvascular damage and apoptosis caused by the intravenous injection of the heroin [89,90]. Regardless of the mechanism, these patients often require arthroplasty because many with this syndrome are not diagnosed until late in the course [90].

Another rare complication from heroin abuse that has surfaced recently is that of injection anthrax. Although there does not appear to be any reported cases in the United States, there have been a small number of cases reported throughout various European countries [91]. Injection anthrax is caused by Bacillus anthracis, a gram-positive, spore-forming, encapsulated bacterium that forms endotoxins [91,92]. Just as with Clostridium sp., this bacterium is a contaminant of heroin. Given that the spores are resistant to heat, both bacterium and spores end up within the systemic circulation [91]. Primary clinical differentiation between anthrax and other types of sepsis or phlegmon is nearly impossible, therefore, it is important to have a high level of suspicion because early diagnosis is a decisive factor in successful treatment as the infection is life threatening [91]. Blood cultures should be obtained for diagnosis, often reported as positive for Bacillus anthracis within one to three hours of culturing [91]. Serology and real-time polymerase chain reaction can also be used to confirm the diagnosis within a few hours of presentation [91]. Timely antibiotic initiation is the most important prognostic factor in treatment of anthrax, which should be administered as quickly as possible after patient presentation, making empiric coverage an important aspect to their care [91]. Injection anthrax from heroin often will necessitate surgical debridement because of NSTI [91]. Albeit rare, injection anthrax should be on the differential with heroin use-associated infections given the mortality can be as high as 30% [91].

Conclusions

Heroin abuse has recently taken on epidemic proportions in the United States with more people dying of heroin overdoses and more healthcare resources being expended because of the many comorbidities and surgical interventions these patients acquire from continued intravenous drug abuse [4,93]. Surgeons must have the ability to diagnose many of these heroin-related surgical complications in a timely fashion because urgent operative intervention can often be life-saving. Furthermore, surgeons must have a good understanding of the surgical intervention that must be undertaken in this patient population to produce good outcomes. Finally, because prevention is always better, surgeons should be cognizant of their post-operative opioid prescribing habits and try to minimize their use, creating the potential for less heroin abuse.

Footnotes

Acknowledgments

We would like to thank Mattie M. Henry, M.D., for help with reviewing the manuscript.

Author Disclosure Statement

There are no conflicts of interest or financial interests to disclose for any of the contributing authors.

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