How should painkillers be prescribed amid a nationwide opioid crisis? A new approach out of Johns Hopkins School of Medicine suggests matching dosage to specific procedures.
What’s the right painkiller prescription to send home with a patient after gallbladder surgery or a cesarean section? That question is front and center as conventional approaches to pain control in the United States have led to what some see as a culture of overprescribing, helping spur the nation’s epidemic of opioid overuse and abuse.
So surgeon Marty Makary, a researcher and a professor of surgery and health policy at Johns Hopkins School of Medicine in Baltimore, took an innovative approach toward developing guidelines: matching the right number of opioid painkillers to specific procedures. In December, he gathered a group of surgeons, nurses, patients and other leaders, asking them: “What should we be prescribing for operation X?”
“The head of the hospital’s pain services said, ‘You’re the surgeon; what do you think?’ ” recalled Makary. Makary didn’t know. Nor did the resident. And the nurse practitioner, who often is the one who most closely follows up with patients, said it varies.
“Wow,” recalls Makary of that day when they first considered appropriate limits. “We’re the experts, the heads of this and that, and we don’t know.”
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After a couple of weeks of intense discussion, Makary’s group gave its blessing to guidelines setting maximum numbers of opioid-containing pills for 20 common procedures.
Sometimes the right number of opioids is zero, concluded the group. Indeed, it recommends no opioids for patients heading home after uncomplicated labor and delivery, or cardiac catheterization, a procedure in which a thin, hollow tube is inserted into the heart through a blood vessel to check for blockages. Optimally, “no one should be given more than five or 10 opioid tablets after a cesarean section,” Makary said.
Oh, and for cardiac bypass surgery? No more than 30.
Tens of thousands of Americans are dependent upon opioid medications. Knowing that, Makary, as well as other surgeons, hospitals and organizations, are taking steps to change how they practice medicine. After all, many experts view the use of opioid prescription painkillers after surgery as a gateway to long-term use or dependence. A study published last year in the journal JAMA Surgery found persistent use of opioids was “one of the most common complications after elective surgery.”
With about 50 million surgeries in the U.S. each year, “there are millions who may become newly dependent,” said Chad Brummett, the study’s lead author and an associate professor of anesthesiology at the University of Michigan Medical School.
Still, there is debate in medical circles about just how effective recommendations and guidelines will be in stemming the epidemic.
Some experts worry that if the fight against opioids focuses only on safe prescribing at the expense of seeking alternatives, it may miss the bigger picture. “Are there better methods than opioids in the first place?” asks Lewis Nelson, chair of emergency medicine at Rutgers New Jersey Medical School. Alternatives should always be considered first, agreed Makary.
Another concern is that guidelines have carryover effects on patients with long-term pain. Advocates say all the attention around prescribing limits has made it difficult for chronic-pain patients to get the medications they need.
“It’s important for a physician to have the ability, if they feel there’s a medical necessity, to write a prescription for a longer duration,” said Steven Santos, president of the American Academy of Pain Medicine.
Legislatures in more than a dozen states have set restrictions, often on the number of days’ worth of pills prescribed for acute pain. Congress, too, is getting involved, considering legislation that would set limits on prescribing opioids for acute pain. The medical profession has also responded — with medical societies and other groups offering standards for prescribing opioids. None is meant to address the needs of chronic-pain or cancer patients.
And state rules vary. New Jersey’s says patients with acute pain should initially get no more than a five-day supply, while Massachusetts sets the cap at seven days for a patient prescribed opiates for the first time. The Centers for Disease Control and Prevention (CDC) recommends three days.
Andrew Kolodny, co-director of opioid-policy research at the Heller School for Social Policy and Management, supports guidelines but wants states to take rules further.
“I don’t think the way the states are going at this makes much sense because the issue with overprescribing was quantity, yet they’re passing laws around duration,” he said.
Instead, the laws should require that “if physicians are going to prescribe more than three days, they have to warn the patients that this is an addictive drug and that taking it every day for as little as five days may cause them to become physiologically dependent,” Kolodny said.
That would create a disincentive to prescribing more than three days’ worth of opioid painkillers, he added, and better inform patients who need a longer supply.
Rutgers’ Nelson, who sat on the CDC panel that developed recommendations, said durational rules can be effective.
“I personally think three days is enough,” Nelson said. “That doesn’t mean pain goes away in three days, but most people get better within three to five days.”
That said, Nelson called the Hopkins approach an “excellent idea” and one he has tried to follow. “It’s a lot harder than it sounds because of the large number of procedures and the diversity of patient needs,” he said.