Standard Opioid Dosages for Postoperative Pain?

Study Sets Ideals For Opioid Use in General Surgery – Pain Medicine News – 12/1/2016

At the end of summer 2016, when it had become apparent that the number of opioid overdoses across the country could hit a new record this year, Surgeon General Vice Adm. Vivek Murthy, MD, MBA, Standard Opioid Dosages for Postoperative Pain?

For surgeons, whose opioid prescribing rates are, at 37%, among the highest of all specialists, this is a challenging task: There are few data on how to meet the acute pain needs of patients in the office without adding to the abundance of excess pills that are driving the opioid epidemic.

By now, we know that prescribed pills are NOT driving the “opioid epidemic” (see Manipulating Truth About Overdose Deaths), but this publication aimed at doctors continues spreading this false narrative.
In the current anti-opioid climate, it would seem to be good news that most patients take fewer opioid pain pills than prescribed after surgery.

Instead, this careful handling of opioids is classified as “misuse” because the prescription is written to take more and, from the doctor’s side, it’s labeled “overprescribing”.

But a study reported in the Annals of Surgery this fall provides new information that may help surgeons achieve a balance between overprescribing opioids and undertreating patients’ pain (2016 Sep 14. [Epub ahead of print]).

The study’s lead author:  Richard J. Barth, MD,

  • professor of surgery at Geisel School of Medicine
  • chief of general surgeryat Dartmouth-Hitchcock Medical Center.

Dr. Barth and his colleagues analyzed opioid prescription rates and usage for five common outpatient general surgery procedures at their hospital. They found that overprescribing of opioids was rampant: 72% of prescribed pills went unused after surgery.

When any amount of unused pills is considered overprescribing, this can be avoided only when the number prescribed is coincidentally exactly the number needed.

Patients will request repeated opioid prescriptions as long as their pain requires it, and their pain is unlikely to end exactly when a prescription does. This makes leftover pills almost a certainty.

Of these unused pills, most were not disposed of appropriately. Fewer than 10% of patients followed the FDA guidelines for getting rid of excess pills.

Based on their findings, Dr. Barth and his colleagues calculated an “ideal number” of opioid pills to be prescribed for each patient undergoing each of these procedures, the first recommendation of this type in the general surgery literature.

This is where Dr. Barth’s ideas become truly ridiculous and dangerous to any surgical patients. 

Without knowing anything about the patients’ general health situation or past history, he diagnoses their postsurgical pain and determines the correct treatment dosages from afar.

One pill was considered to be the analgesic equivalent of 5 mg of oxycodone.

They recommend

  • 5 pills per patient for partial mastectomy; 
  • 10 for partial mastectomy with sentinel lymph node biopsy; and
  • 15 for laparoscopic cholecystectomy, laparoscopic inguinal hernia repair and open inguinal hernia repair.

It frightens me to think that a doctor might treat (or be mandated to treat) my pain restricted by these standards based on some theoretical “average patient” (with one testicle and one breast).

Neither I nor anyone else can possibly know that in advance whether these doses will be enough.

This flawed reasoning comes from a misuse of statistics. Statistics from studies of populations ONLY apply to populations, NOT to individuals

These amounts would satisfy 80% of patients’ opioid requirements with the initial prescription and reduce the number of opioid pills prescribed to 43% of the current number, the investigators said. In their study of 642 patients, this formula would have cut the number of total pills prescribed from 17,167 to 7,360.

“We felt that satisfying 80% of patients’ opioid requirements with the initial prescription was reasonable,” Dr. Barth said.

I can’t believe this doctor believes it’s OK to deliberately allow 20% of patients to suffer unnecessary pain after surgery.

Is this what “medicine” has come to as a result of being wrongly blamed for the opioid overdose crisis?

The researchers tracked 642 patients who underwent the five most common outpatient procedures at an academic medical center in 2015.

Patients with a history of opioid abuse and those with postoperative complications, who are likely to require additional opioids, were excluded.

Ninety percent of the patients were prescribed opioids after surgery.

The opioid prescription rate ranged from 73.7% for partial mastectomy patients to 100% for laparoscopic inguinal hernia repair and open inguinal hernia repair patients.

Telephone surveys with 127 patients after surgery revealed that patients used around 25% of the pills prescribed to them.

Why were only 127 (<20%) out of 642 surveyed? Why were the other 80% excluded?

The 127 patients in this survey are not nearly enough to be the entire evidence base for new restrictive policies.

  • Patients who underwent partial mastectomy had the lowest use rate, consuming only 14.7% of the pills prescribed.
  • The highest use was among laparoscopic cholecystectomy patients at 32.7%.
  • Patients who underwent partial mastectomy with sentinel lymph node biopsy and open inguinal hernia repair reported taking 25.7% and 31.1% of prescribed pills, respectively.
  • A total of 3,545 pills were prescribed to the 127 patients surveyed; 2,527 were unused.
  • Of the 10.3 million Americans who have reported abusing prescription opioids in their lifetime, only 20% said they were the legitimate recipients of the initial prescription.

The remainder were misused from family or friends, or diverted from the legal to the illegal market

This is, in part, why the surgeon general asked physicians to take the lead in ending the opioid crisis.

The campaign focuses on chronic pain but emphasizes that long-term opioid use often begins with treatment of acute pain

There has never been strong evidence-based information about optimal dosing for pain management for patients after surgery, said Shirin Towfigh, MD, a hernia surgeon in Beverly Hills, Calif., who no longer prescribes opioids for acute pain in her opioid-naive patients.

I would be curious to hear how many people are willing to have hernia surgeries without opioids for pain relief afterward. Certainly not I!

There are real concerns, however, about undertreating patient pain by cutting down on opioid prescriptions.

Below the article continues with a saner, more compassionate view:

Alex B. Haynes, MD,

  • assistant professor of surgery at Harvard Medical School
  • attending surgeon at Massachusetts General Hospital

agreed that too many opioid pills are being prescribed, and, in many cases, nonnarcotic pain medication may be enough or nearly enough for some these procedures.

But he is concerned that the authors’ benchmark of achieving ample pain control in 80% of patients could subject the remaining 20% to suffering.

“At the end of the day, as the surgeon, my primary obligation is to the patient in front of me and ensuring that patient has adequate pain control after their operation,” Dr. Haynes said. “While there are indeed societal trade-offs to that, to me the first and most important thing is providing adequate pain control for my patient.”

Surgeons often have to guess how much medication a person needs and add a buffer amount to reduce the risk that the patient will be in pain at home without access to medication, Dr. Haynes said.

The problem of overprescribing also has been reported in patients undergoing upper extremity surgery and dental procedures.

Opioid overdose is the leading cause of injury-related death in the United States, surpassing for the first time motor vehicle accidents.

This erroneous statistic is the latest to be hyped by the media – see Manipulating Truth About Overdose Deaths

Deaths secondary to prescription overdose have quadrupled in the last 15 years, and now reach almost 19,000 per year.

The median number of pills prescribed by individual providers for a particular operation varied by a factor of three.

This is absolutely normal and expected.

Dr. Barth should know very well that individuals cannot all be expected to benefit equally from a given medication.

Opioids have notoriously variable effects on individuals due to a wide variety of factors, from genetic problems with their metabolism to cross tolerance with other drugs.

Any suggestion to impose a standard for postoperative opioid doses is dangerous for all surgery patients.

Because of the infinite variety of surgical outcomes and inter-patient variability in opioid response, this is not a medically sound idea (nor is it backed up by scientific evidence).

Shoddy surveys like this only cloud the issue by confusing lofty ideals with the realities of healthcare for unique individuals.

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