On Patient Safety: Limiting Opioid Exposure - We Can Do Our Part

Field: Medicine (Health Sciences)

One of my patients recently returned to my clinic for his 3-week postsurgical check rather upbeat. “That leg pain has been gone since surgery,” he said. “My back is stiff, but I stopped taking those pain meds you gave me. I didn’t even take half of what you gave me.” Not too long ago, I would have congratulated the patient on his recovery and instructed him to keep the leftover pills in his medicine cabinet in case he had a future flare up of pain. While this may seem reasonable, I no longer make that suggestion. The opioid crisis is taking its toll in the United States. Drug-overdose deaths recently surpassed the number of deaths from motor-vehicle accidents [8]. Opioid-overdose deaths from 2002 to 2015 have increased nearly three-fold [5]. The leading cause of opioid overdose deaths from 2000 to 2015 was common prescription opioids [1], and more people died from hydrocodone and oxycodone than from heroin overdoses [1]. As an orthopaedic surgeon, I had always thought that this was an issue that really didn’t affect me, since I felt like I was not contributing to the problem. I have always considered myself stingy with narcotics, especially for a spine surgeon. I generally do not prescribe narcotic medications for reasons other than acute postsurgical pain. I also generally try not to prescribe narcotic pain medications beyond 3 months after spine surgery, I discuss this with patients up front so that their expectations are set before surgery, and when I anticipate challenges in this area, I try to coordinate pain management with their primary care or pain physicians before surgery. I try to help those patients who are habituated to high-dose narcotics to reduce their doses in advance of elective procedures. Admittedly, some patients do ask for pain medications for longer than 3 months; some patients who undergo especially complex reconstructions (or who have particularly long histories of pain-medication use) may be on narcotic analgesics for 6 months under my supervision. But most have discontinued their narcotics by 3 months, and many of them do so within the first few weeks. As content as I was in my approach to narcotic management, I’ve recently learned I could be doing better. As physicians, we need to be mindful of how much opioid medication we prescribe, as well as consider what happens to the analgesics we prescribe that go unused by the initial recipient of the prescription. Since 2000, 75% of heroin addicts got started with prescription medication [4]. The greater the exposure to opioids, the greater the likelihood that the individual will continue to take them for the long-term. A recent study demonstrated that among patients prescribed 1 day’s worth of opioid medication, 6% were still taking them 1 year later. When that 1-day prescription was increased to 6 days, 12% of those patients are still taking opioids 1 year later. And when the opioid was given for 12 days, 24% of those patients are still taking them at 1 year [2]. Clearly, there is a dose-response risk with these medications. As surgeons who prescribe these medications after surgery, we can most definitely make a difference. In a recent Clinical Orthopaedics and Related Research® editorial, Leopold and Beadling noted that “we should write smaller prescriptions for shorter periods of time, think twice before using long-acting opioid medications in narcotic-naïve patients, and help our patients to set realistic expectations about pain after surgery” [3]. By taking those steps, we could decrease the opioid exposure, and potentially reduce the likelihood of addiction and overdose in the general population. It’s important to note that some of that exposure may paradoxically come through our patients who did well after surgery—those who didn’t finish the prescriptions we gave them. What happens to those leftover opioids? According to the 2013-2014 National Survey on Drug use and Health, 75% of recreational opioid users obtain them from nonprescription sources such as medications from the medicine cabinets of friends and family members [6, 7]. We should ask those patients with excess narcotic analgesics to bring the pills to the office so they can be safely discarded. Our patients want to do this. Many hospitals have started drop-box programs through which patients can discard any unused medications. Dr. Vivek Prachand, Chief Quality Officer at the University of Chicago Medical Center, told me in an interview that in 2017 more than 2000 pounds of narcotic medication was voluntarily returned. If patients are unable to bring them into the clinic or hospital, we can educate patients on how to discard of the excess medications themselves. Initiatives with a drug-disposal locator tool on their website like AWARxE® (https://nabp.pharmacy/initiatives/awarxe/) can enable patients to find the nearest drop box. But the onus can’t just be on patients. We need to reduce the number of extra pills our patients have by prescribing more thoughtfully after surgery. Dr. Megan Conti Mica, a hand and upper-extremity surgeon at the University of Chicago Medical Center, has spearheaded a quality-improvement initiative there since 2016. She shared with me in an interview that some 60% of narcotics prescribed after orthopaedic surgery at that center went unused, and we prescribed more than twice the needed amount. It’s no wonder there was (literally) a ton of excess opioids out there. If that’s the case, surely we can prescribe less. Do all orthopaedic surgical procedures really require opioids? For certain procedures, we probably shouldn’t prescribe any opioids at all. No one disputes the need to treat pain appropriately, but one of the big (unsaid) sticking factors of prescribing pain medication in smaller amounts is the convenience factor. Will this affect patient convenience? Yes. If we prescribe less, does that mean patients will have to come in more frequently for refills? Probably. Because at least for now, these controlled medications cannot be electronically prescribed or telephoned to the pharmacy (they require a hard-copy signature), does that mean arrangements will have to be made so the patient can physically receive these prescriptions more often? Yes. However, in the big picture, it seems like a small trade-off. With 66.5 opioid prescriptions per 100 persons in the United States [1], surely, we (patients and physicians) can put up with some inconvenience to reduce the societal exposure to narcotics. The opioid crisis is being fought on several fronts, and while we, as orthopaedic surgeons, will not singlehandedly resolve the issue, we are part of the solution. Ultimately, a culture change is needed to resolve this complex opioid situation, and all physicians are a part of that culture change. As orthopaedic surgeons, we can certainly do more.