As a surgical resident, the single most common prescription I write is for an opioid. While opioids are a very effective way to treat our patients’ pain after surgery, they are also at the center of an exploding public health crisis. Annual overdose deaths are at their highest rate ever and millions of American’s have a substance use disorder involving prescription opioids. It’s against that backdrop that I’ve found myself asking: what role do I, as a surgeon, play in addressing this epidemic?
One of the first issues we face as opioid prescribers is the problem of excessive prescribing. Up to 92% of opioids prescribed after surgery go unused.1 This results in millions of leftover pills available for diversion. At our own institution, we launched a small pilot project with a simple goal: to prescribe better simply by asking patients how much medication they took after surgery. We started with laparoscopic cholecystectomy, and the results were eye-opening. While the median prescription size was 50 tablets of Norco®, patients reported a median use of 6 tablets.
We used these data to implement prescribing recommendations that suggested 15 tablets for laparoscopic cholecystectomy.2 In the first 200 patients treated under the new recommendations, median prescription size fell to 15 tablets, but patients reported no increase in postoperative pain, and there was no increase requests for prescription refills. Across these 200 patients, we estimate that roughly 7000 excess pills were kept out of the community.
Since that initial pilot, we’ve continued to collect data on patient use across a wide range of common surgical procedures. The prescribing recommendations based on these data are available for free at http://opioidprescribing.info. As we continue to learn more about opioid use after surgery, we hope to further refine these guidelines and expand them to other surgical subspecialties.
Evidence-based opioid prescribing is an important first step in the surgeon’s role as a prescriber. However, this is still only a “one size fits all” solution. Next steps will likely need to involve individual patient characteristics to improve prescribing. For example, we know that older patients tend to use fewer opioids, smokers tend to use more opioids, and patients who use fewer pills the day before discharge use fewer pills at home.3 Therefore, if I treat a 22-year-old smoker still taking oxycodone at discharge, she may need a larger prescription than the 76-year-old non-smoker who is only taking Tylenol by discharge. This is an area where clinical decision-making aids – which most electronic medical record platforms support – have the potential to make a significant impact.
Lastly, patient counseling plays a critical role in these efforts. Central to this is the importance of setting patient expectations for pain after surgery. During our pilot project, a number of patients told me they were under the impression that they were supposed to finish their entire prescription, just like they would with antibiotics. Others were planning to save the leftover pills for other ailments, such as headaches or insomnia. Not only do we now counsel patients about safe opioid usage, we even use the data we’ve collected to counsel patients – for example, “we’ve found that most patients who undergo this procedure use 5-10 pills.” This type of statement takes mere seconds, yet anchors patients’ outlook for their recovery. We also provide patients with a website to help them locate opioid disposal sites around our state: http://michigan-open.org/takebackmap.
Pain is an integral part of surgical practice – we inflict pain in the short-term in order to cure in the long-term. It is certainly our job to effectively manage our patients’ pain. However, it is also our job to do so in a safe and evidence-based way. Over the last several months, I’ve been excited to see the transformation that is taking place. Providers at all levels are changing their practice to make their patients safer. By improving the quality of the care we provide to our individual patients, surgeons will play a central role in turning the tide on an epidemic that affects millions.
- Bicket MC, Long JJ, Pronovost PJ, Alexander GC, Wu CL. Prescription Opioid Analgesics Commonly Unused After Surgery: A Systematic Review. JAMA Surg. 2017.
- Howard R, Waljee J, Brummett C, Englesbe M, Lee J. Reduction in Opioid Prescribing Through Evidence-Based Prescribing Guidelines. JAMA Surg. 2018;153(3):285-287.
- Hill MV, Stucke RS, Billmeier SE, Kelly JL, Barth RJ, Jr. Guideline for Discharge Opioid Prescriptions after Inpatient General Surgical Procedures. J Am Coll Surg. 2017.