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Doctors can change opioid prescribing habits, but progress comes in small doses

Julie Appleby and Elizabeth Lucas

Kaiser Health News via AP

When they started practicing medicine, most surgeons say, there was little or no information about just how many pain pills patients needed after specific procedures.

As a result, patients often were sent home with the equivalent of handfuls of powerful and addictive medications. Then the opioid crisis hit, along with studies showing one possible side effect of surgery is long-term dependence on pain pills. These findings prompted some medical centers and groups of physicians to establish surgery-specific guidelines.

But questions remained: Would anyone pay attention to the guidelines and would smaller amounts be sufficient to control patients’ pain?

Yes, appears to be the answer to both — in some measure — according to a study that encompassed nearly 12,000 patients in 43 hospitals across Michigan. The researchers published details of their work in a letter Wednesday in the New England Journal of Medicine.

Seven months after specific guidelines for certain operations were issued in October 2017, surgeons reduced by nearly one-third the number of pills they prescribed patients, with no reported drop in patient satisfaction or increase in reported pain, according to the research.

“We’re not trying to deny patients narcotics,” said Dr. Joceline Vu, one of the paper’s authors and a general surgery resident at the University of Michigan. “But there’s an acceptable level where people are still happy and still have their pain under control, but we have dropped the number to a minimum.”

Overall, doctors prescribed eight fewer pills per patient — from 26 to 18 — across nine common surgical procedures, including hernia repair, appendectomy and hysterectomy, based on guidelines from the Michigan Opioid Prescribing Engagement Network (Michigan OPEN), a collaboration of hospitals, doctors and insurers.

Patients also reported taking fewer pills, dropping from 12 to nine on average across those procedures, possibly because they were prescribed fewer in the first place.

Still, while researchers say the study offers considerable reason for encouragement, it illustrates how hard it is to change prescribing habits. In May 2018, at the study’s conclusion, the average number of pills prescribed exceeded the most up-to-date recommendations for all nine procedures.

And that’s in Michigan, where there has been a concerted push to change prescribing habits. Most states don’t have such a broad effort ongoing.

“There is a misconception that this is all fixed,” said Dr. Chad Brummett, co-director of Michigan OPEN and one of the researchers on this study. “I do think people are still overprescribing. Definitely.”

The guidelines come amid ongoing concern about the opioid crisis and a continued examination of the role prescription drugs played in its escalation.

The likelihood of persistent opioid use rises with the number of pills and the length of time opioids are taken during recuperation from surgery. But there’s another avenue of concern. When doctors write scripts with a generous number of pills, the chance that patients won’t take them all increases, along with the potential for the unused pills to make their way from medicine cabinets to the street, or to fall into the hands of other family members.

“That can be a bigger concern for many of us,” said Vu. “It seems that in surgery, for whatever reason, we wrote prescriptions for a lot more opioids than people actually needed.”

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