Monitored anesthesia care (MAC) is a varying type of anesthesia where an anesthesiologist is involved in a patient’s care ranging from either fully awake with ASA monitoring or a deeper level of sedation with a natural airway depending on the level of surgical stimulus and the patient’s physiological state. This chapter discusses the different levels of sedation, ASA guidelines for sedation, and associated risks and complications.

The amount of people worldwide who regularly used opioids in 2021 is staggering, and if something is not done to change the course of this epidemic, the numbers will continue to increase year over year, just as they have done over the last decade. Roughly 275 million people globally report having used drugs of any kind in the past year, an increase of almost 50 million people over the past ten years. While some of this increase was due to the 10% rise in global population over the same period, this alone cannot account for the entirety of the 22% rise in global drug use. Health-care systems around the world are being stretched beyond their capabilities to manage a population this large, and the number of people with opioid use disorder is projected to continue to increase in size over the next decade. The effects of the opioid epidemic on healthcare systems are particularly devastating in poorer and middle-income countries with less robust resources. Over the past decade the number of individuals with opioid use disorder has increased by almost 9 million, an increase of over 33%, and now affects 0.7% of the current global population.

The economic costs of the opioid epidemic include direct costs, funds that must be allocated for purchase of any and all goods and services above that which we would normally allocate for these items were there no opioid epidemic, and indirect costs arising from the need to treat health complications related to opioid misuse, the loss of worker productivity and the long-term negative impact on the children and dependents of individuals with opioid use disorder. The opioid epidemic has significantly increased the financial burden on the criminal justice system as governments must now cover the costs for increased law enforcement, the judiciary, corrections, probation services, and parole. Medical costs directly related to the treatment ofopioid use disorder include inpatient and outpatient addiction treatment, the costs for methadone, buprenorphine, and naloxone. In this chapter we look at the specific areas in which the opioid epidemic has had a very real, and very negative effect on the world economy.

While biology does play a significant role in the development of addiction, it is the environment in which we grow and develop as children and ultimately exist as adults that determines whether or not an at-risk individual will subsequently develop opioid use disorder. Race (the outward manifestation of genetics) ethnicity (cultural factors such as nationality, regional culture, ancestry, and language), religion, gender, access to economic resources, and geography all influence risk to varying degrees. Within each community different cultures have different levels of propensity for developing opioid use disorder, and, in areas where there is more mixing of different races and cultures, a person’s risk for developing opioid addiction more closely reflects the risk of the community at large and not the genetic risk of the individual. In the past, social factors such as access to economic resources and peer or family support were thought to be somewhat protective and that a biologically at-risk individual in this setting would be less likely to develop opioid use disorder, but this has not turned out to be the case.

Not all people require inpatient or residential treatment for an opioid use disorder. Instead, outpatient treatment may be appropriate for certain individuals, but must consider the person’s health, motivation, support system, and financial status. partial hospitalization and intensive outpatient programs are two outpatient treatment plans that involve regular programming and individual treatment over several weeks, whereas group and individual therapy might occur less frequently. Mutual support groups, for example 12-step groups such as Narcotics Anonymous, can be very helpful for those looking for peer support. Most recently, treatment methods such as biofeedback, acupuncture, telemedicine, and virtual reality have garnered attention as potential methods to enhance recovery from opioid use disorder.

The financial burden of the opioid epidemic can be measured in trillions of dollars. Although treatment of substance use disorders can also be expensive, multiple cost–benefit analyses have demonstrated that treating addiction is cost-effective when compared to addiction-related expenses. Inpatient treatment tends to be more expensive than outpatient, and the actual cost of treatment varies by country. In addition, insurance status can play a significant role, especially in countries that do not offer universal health care. Unfortunately, there have been multiple victims of a scheme known as body brokering, in which vulnerable individuals are exploited for their insurance benefits. Therefore, it is important to find a reputable substance abuse program before entering treatment.

Our response to the opioid epidemic has been reactionary, however preventing future addiction saves lives and money. Methods to prevent opioid misuse and addiction are frequently placed in one of three categories: universal, selective, or indicated. Universal prevention addresses an entire group of people without respect to any factors that might predispose someone to addiction. Most school-based curricula and education for prescribers fall under this category. Selective interventions are geared towards a subset of a population indentified as a higher risk for opioid use disorder, for example programs developed for children who have experienced traumatic events. Finally, indicated prevention focuses on individuals who are already using opioids but do not yet meet criteria for a clinical diagnosis of opioid use disorder. No matter the type, all strategies have the potential to postiively impact individuals and communities through reduced rates of addiction, overdose, and death.

Chronic opioid misuse puts people at significant risk for developing multiple health problems, caused either by decreased access to preventative care, exposure to blood-borne or sexually transmitted diseases or as a direct result of chronically elevated levels of exogenous opioids. People with opioid use disorder often suffer from chronic pain and mental illness at rates much higher than in the general population and are at significant risk for financial ruin, homelessness, overdose, and death. While it may not be possible to make opioid use completely safe, if we can, we should make it less dangerous. Illicit opioids are often impure and adulterated after production. They must be procured illegally and are often injected with unsterile equipment in an unsafe and unsupervised environment. All of these factors can and should be addressed as part of a comprehensive strategy to fight the opioid epidemic. Only by challenging the beliefs that underlie the stigma surrounding opioid use disorder and directly addressing the factors that contribute to the increased morbidity and mortality associated with chronic opioid misuse can we turn the tide of the epidemic.

In the late 1960s recreational drug use in the United States began to creep into the suburbs. As the children of white, middle-class Americans began to adopt this practice and the social stigmatization previously associated with recreational drug use began to fade as it became associated with protest and social rebellion in the era’s atmosphere of political unrest, these children’s parents began to demand that their government do something about it. In 1968 President Johnson formed the Bureau of Narcotics and Dangerous Drugs as the “War on Drugs” began. In the decades that followed groups like The Partnership for a Drug Free America and Drug Abuse Resistance Education sponsored media campaigns laced with anti-drug propaganda in a desperate attempt to protect the youth of America. Having had limited success parent’s organizations and government programs are now re-thinking how to create more effective drug education

The effect of individual governmental drug policies and regulations has, in many cases, been the main driving force behind the direction the opioid epidemic has taken in the United States and many countries around the world. Unfortunately these policies have sometimes had dramatically different effects than were initially intended. Changes in policy which allowed for increased availability of opioid medications had the unintended consequence of widespread opioid addiction and overdose deaths. Policies which aimed to crack down on the diversion of these medications from legitimate medical use resulted in the spike in heroin use as those people who were now addicted to opioids had to turn elsewhere. As demand for heroin surged, so too did manufacturing and sales, and as law enforcement targeted illicit heroin trafficking, cartels turned to the more potent and easier to hide synthetic opioids such as fentanyl and carfentanil. It seems that every governmental policy change or new regulation intended to stop the opioid epidemic is met with a creative solution by the people profiting to keep the opioid trade open.

All countries are facing of dearth of medical resources. As more developed countries struggle with access to specialized care, their third-world counterparts are faced with a lack of healthcare workers, equipment, medication, and medical facilities. The opioid epidemic has exacerbated this issue by placing a significant strain on healthcare infrastructure worldwide, though these effects impact people in less developed countries to a much greater degree as most areas such as this have limited resources available to begin with. As the incidence of opioid-related health issues increases, the funds and personnel necessary to address them must come from somewhere. Resources diverted in this manner negatively impact other healthcare services, reducing access to preventative treatments, increasing wait times for access to care, and increasing the already high burden on healthcare professionals. If we remain reactive instead of proactive in our approach to disease management it becomes much more expensive and ultimately impacts everyone.

When an individual has been consuming opioids for an extended period, a phenomenon known as physical dependence occurs. Because of physical dependence, when the opioids are discontinued abruptly, or the dosage is dropped significantly, the individual experiences withdrawal through the process of detoxification. Historically, people were forced to endure withdrawal symptoms without medical treatment in jail cells, drunk tanks, or compulsory treatment centers. Nowadays, withdrawal management includes education, treatment of withdrawal symptoms, and referrals for further care, which is almost always required for individuals to achieve long-term sobriety. Inpatient and residential treatment are two options for care after detoxification, and various individual factors must be considered when choosing the best type of treatment for that person.