By David Heitz
For most common surgeries, a two-week supply of opioids – tops — is plenty to get most patients past the serious discomfort phase.
That’s the conclusion of research published this week in the Journal of the American Medical Association Surgery, or JAMA Surgery.
The research went on to say that many who undergo these common surgeries, for everything from women’s health procedures to appendectomies, aren’t getting quite enough pills, in fact.
Current prescription writing habits for opioid medications after surgeries may be too restrictive?
That’s the conclusion.
“Governmental efforts limiting the length of initial prescriptions of opioid pain medication, typically to fewer than seven days, have recently been passed in several states, including New York and Massachusetts,” the authors argue. “Prescription drug monitoring programs have also become increasingly common despite a lack of evidence regarding appropriate duration of prescriptions of opioid pain medication or the efficacy of such legislation.” (1)
Dr. Rebecca Scully led the team of researchers from Brigham and Women’s hospital in the original investigation.
Could too few pills when needed lead to addiction?
Many would jump at the chance to argue that prescription drug monitoring programs would be much more effective if doctors actually had time to check them.
But in truth, many of those dependent on opioids long have said that running out of a pain pill supply while still in pain (and being unable to get refills) is what led them to search for opioids illicitly.
Indeed, as painkiller prescriptions have gone done in the U.S., heroin deaths have gone up. Those who get a taste of the opioid and like it and will seek it out regardless of obstacles put in their path.
While nobody ever sets out to find it, addiction will find you really fast if it wants to – especially if you like opioids.
The massive analysis in the JAMA study of more than 200,000 people, all military veterans, who had surgeries from 2006 to 2014, concluded:
“Although a (seven)-day limit on initial opioid prescription appears to be adequate for many common general surgery and gynecologic procedures, for patients undergoing orthopedic and neurosurgical interventions, a (seven)-day limit may be inappropriately restrictive and place an undue burden on patients and clinicians.”
Show of hands: How many people reading this story right now received far more than that after their last surgical procedure?
That’s what we thought.
Doctors face challenges when it comes to dosing
The study may seem like just one more example of how a schizophrenic view among the medical establishment is resulting in off-target dosing.
In fact, that’s also the entire reason the authors performed the research: To find that optimum target.
For doctors, prescribing opioids is complicated by the fact that pain is subjective. There also are not enough quality, non-opioid pain relief alternatives. At least, not enough alternatives that are widely available to all health care consumers.
The paper determined the optimal prescribing target to be, on average:
Four to nine days for general surgery procedures; four to 13 days for women’s health procedures; six to 15 days for musculoskeletal procedures.
“Orthopedic procedures appeared to be associated with the highest refill rates and the highest median length of initial prescriptions, which is in line with previous work that showed that chronic use of postoperative opioid medications was higher after orthopedic and neurosurgical procedures,” the authors concluded.
Why patient expectations need to change
In an editorial published alongside the study, a researcher from University of Chicago medicine said the paper represents a step in the right direction.
“Any effort that reduces excessing prescription of opioid pain medications is welcome,” Dr. Selwyn O. Rogers declared. (2)
“The authors found a marked variation in the timing and frequency of requests for narcotic prescriptions among postoperative patients who had undergone various operations,” Rogers continued.
“We hope the days of writing a prescription for 60 tablets of acetaminophen and oxycodone hydrochloride (Percocet) to discourage follow-up telephone calls for refills are gone.
“We are living in the midst of an ongoing opioid crisis.”
In this new era of “value-based care” – a buzz term born from Obamacare – patients can wind up hitting doctors in the pocketbook if they leave his or her office unhappy.
So, doctors are incentivized to keep their patients happy. And most patients believe pain should never have to occur in this day and age.
They really do believe that.
“It is key to remember the importance of setting expectations in the interpretation of pain,” the doctor warns. “Unfortunately, we have reached a point that 100 percent elimination of pain has become not only the goal but the expectation.
If a surgeon allows a patient to expect a pain-free recovery, he or she will see refill requests increase. Alternatives to narcotics should be recommended and incorporated as the foundation of pain management.”
The author suggests doctors warn patients that opioids may make them feel itchy, sick to their stomachs, even induce nightmares. All of this on top of the costly and uncomfortable burden of addiction.
“We should do our part to alleviate this burden on our patients,” Rogers concludes.
Study’s limitations mask true extent of opioid epidemic
The study has many limitations, beginning with it being limited to a military population.
However, the sample came from Tricare, not the VA, and there are notable differences. Explain the authors:
“The TRICARE insurance program covers more than 9 million beneficiaries, including members of the Department of Defense, dependents, retirees, and those with medical disabilities. Only 20 percent of covered individuals are active members of the U.S. military.
“The TRICARE insurance program is not involved in the delivery of health care in combat zones, and beneficiaries are not obligated to receive care in the Veterans Affairs system.”
We also have no way of knowing about people who seek out medications illegally after surgeries.
The study doesn’t tell us whether some medications aren’t getting used and instead are being passed along later.
Recent studies have shown us that many people do withhold their leftover opioid medications, and even offer them up to friends and family now and then.
While such practices may sound like a nice way to help a friend avoid a doctor’s visit, this is exactly how opioids end up in the wrong hands. In fact, research has shown this happens about 70 percent of the time.
Finally, we don’t know exactly how co-prescribing non-addictive NSAIDs may also lower recovery times and result in the fewer opioids being needed.
More research into alternative pain treatments needed
Alternative pain treatment methods such as Exparel were excluded from the study.
“Specific procedural approaches and techniques as well as intraoperative anesthesia adjuncts may also affect postoperative pain control,” the authors wrote.
The study ends with a huge caveat that may well describe many people who are vulnerable to opioid addiction.
“Critically, further work is needed to better identify the 10 percent to 30 percent of patients who will require more intensive pain management to better tailor postoperative pain regimens to these individuals.”
That means that as many as one in three people who undergo these common surgeries will not find relief with that two-week supply.
That still is a very large number in light of the nation’s opioid epidemic. It underscores the urgent need for effective, accessible alternatives to opioids for pain management.
1. Scully, R. et al. (2017, Sept. 27). Defining optimal length of opioid pain medication prescription after common surgical procedures. JAMA Surgery. Retrieved Sept. 28, 2017, from http://jamanetwork.com/journals/jamasurgery/fullarticle/2654949
2. Rogers, S. (2017, Sept. 27). Addressing variability in opioid prescribing. JAMA Surgery. Retrieved Sept. 28, 2017, from http://jamanetwork.com/journals/jamasurgery/article-abstract/2654943