by Michelle Andrews
I recently hobbled to the drugstore to pick up painkillers after minor outpatient knee surgery, only to discover that the pharmacist hadn’t yet filled the prescription. My doctor’s order of 90 generic Percocet exceeded the number my insurer would approve, he said. I left a short time later with a bottle containing a smaller number.
When I got home and opened the package to take a pill, I discovered that there were 42 inside.
Talk about using a shotgun to kill a mosquito. I was stiff and sore after the orthopedist fished out a couple of loose pieces of bone and cartilage from my left knee. But on a pain scale of 0 to 10, I was a 4, tops. I probably could have gotten by with a much less potent drug than a painkiller like Percocet, which contains a combination of the opioid oxycodone and the pain reliever acetaminophen, the active ingredient found in over-the-counter Tylenol.
When I went in for my follow-up appointment a week after surgery, I asked my orthopedist about those 90 pills.
“If you had real surgery, like a knee replacement, you wouldn’t think it was so many,” he said. He told me the electronic prescribing system sets the default at 90. So when he types in a prescription for Percocet, that is the quantity the system orders.
Such standard orders can be overridden, but that is an extra step for a busy physician and takes time.
As public health officials grapple with how to slow the growing opioid epidemic — which claims 91 lives each day, according to federal statistics — the over-prescription of narcotics after even minor surgery is coming under new scrutiny.
While patients today are often given opioids to manage postoperative pain, a large supply of pills may open the door to opioid misuse, either by the patients themselves or others in the family or community who can access the leftovers.
Post-surgical prescriptions for 45, 60 or 90 pills are “incredibly common,” says Dr. Chad Brummett, an anesthesiologist and pain physician at the University of Michigan Medical School.
Last year, the Centers for Disease Control and Prevention released a general guideline saying that clinicians who prescribe opioids to treat acute pain should use the lowest effective dose and limit the duration to no longer than seven days.
But more detailed guidance is necessary, clinicians say.
“There really aren’t clear guidelines, especially for surgery and dentistry,” Brummett says. “It’s often based on what their chief resident taught them along the way or an event in their career that made them prescribe a certain amount.”
Or, as in my case, an automated program that makes prescribing more pills simpler than prescribing fewer.
Brummett is co-director of a Michigan program that has released recommendations for post-surgical opioid prescribing for a growing list of procedures.
To determine the extent to which surgery may lead to longer-term opioid use, Brummett and his colleagues examined the insurance claims of more than 36,000 adults who had surgery in 2013 or 2014 for which they received an opioid prescription. None of the patients had prescriptions for opioids during the prior year.
The study, published online in JAMA Surgery in June, found that three to six months after surgery, roughly 6 percent of patients were still using opioids, having filled at least one new prescription for the drug. The figures were similar whether they had major or minor surgery. By comparison, the rate of opioid use for a control group that did not have surgery was just 0.4 percent.
Some insurers and state regulators have stepped in to limit opioid prescriptions. Insurers routinely monitor doctors’ prescribing patterns and limit the quantity of pills or the dosage of opioid prescriptions.
At least two dozen states have passed laws or rules in just the past few years aimed at regulating the use of opioids.
Last year in my state of New York, Gov. Andrew Cuomo signed legislation that reduced the initial opioid prescription limit for acute pain from 30 days to no more than a seven-day supply.
As my experience demonstrated, however, a seven-day limit (those 42 pills in my case) can still result in patients receiving many more pills than they need. (For those who find themselves in a similar situation with excess pills, there is a safe and proper way to dispose of them.)
Still, some worry that all this focus on overprescribing may scare physicians away from prescribing opioids at all, even when appropriate.
“That’s my concern, that people are so afraid of things and taking it to such an extreme that patient care suffers,” says Dr. Edward Michna, an anesthesiologist and pain management physician at Brigham and Women’s Hospital in Boston. Michna is on the board of the American Pain Society, a research and education group for pain management professionals. Michna has been a paid consultant to numerous pharmaceutical companies, some of which manufacture narcotics.
But other doctors say that one of the reasons doctors call in orders for lots of pills is convenience.
“When you land on the front lines, you hear, ‘I like to write for 30 or 60 pills because that way they won’t call in the middle of the night’ ” for a refill, says Dr. Martin Makary, a professor of surgery and health policy at Johns Hopkins School of Medicine.
Makary is spearheading a consortium of Hopkins clinicians and patients that provides specific guidelines for post-surgical opioid use. The program, part of a larger effort to identify areas of overtreatment in health care, also identifies outlier prescribers nationwide to encourage them to change their prescribing habits.
The Hopkins group doesn’t have an opioid recommendation for my surgery. The closest procedure on their website is arthroscopic surgery to partially remove a torn piece of cartilage in the knee called the meniscus. The post-surgical opioid recommendation following that surgery: 12 tablets.
by Michelle Andrews