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When is One Pill Too Many, Ten Pills Not Enough?

— June 28, 2018

When is One Pill Too Many, Ten Pills Not Enough?

Surgeon, researcher, and professor of surgery at Johns Hopkins School of Medicine in Baltimore, Marty Makary, decided that there needed to be clear-cut guidelines around how many opioid pills should be given out for each pain-inducing medical procedure.  This approach would replace the long-practiced method of dishing out however many opioids a prescriber deemed fair in a specific situation, which many believe has led to physicians overprescribing.  Overprescribing pills is one of the factors cited for causing the nation’s opioid epidemic.

Makary pooled together a group of like-minded individuals, including surgeons, nurses, patients and others, and asked them, “What should we be prescribing for such-and-such a procedure?” At first, perhaps not surprisingly, no one in the group was able to offer a definitive response.  Makary had pooled together experts in the field, but they were not able to come up with a conclusive number of pills.

It would take a couple of weeks before the group was finally able to reach a consensus regarding the number of opioids that would be best for any given scenario.  They ultimately set guidelines for twenty common procedures.

A University of Michigan study published in 2017 concluded that persistent use of opioids was “one of the most common complications after elective surgery.” Researchers reported that six percent of patients who were prescribed opioids for the first time after surgery were still taking them several months after surgery.  There are approximately 50 million surgeries in the United States each year and “there are millions who may become newly dependent,” said Chad Brummett, an associate professor of anesthesiology at the University of Michigan Medical School.

The study also pointed out that if the patients didn’t continue to refill and being to abuse the drugs, often the unused portions were stolen or taken by others close by, who then became addicts.  So, either way, having an overabundance of readily available opioids in a patient’s home was a recipe for disaster.

Photo by Jesper Aggergaard on Unsplash

“Are there better methods than opioids in the first place?” asked Dr. Lewis Nelson, chairman of emergency medicine at Rutgers New Jersey Medical School and critic of the group’s solution to identify a reasonable maximum number of opioids prescribed. “Could you put a lidocaine patch over the wound, or is there a better way to immobilize a joint?”

Legislatures in more than a dozen states across the U.S. have recently set restrictions on the number of days for which supplies of addictive painkillers can be prescribed. “States said that since physicians haven’t self-regulated, we’re going to do it for them,” Dr. Nelson said.  However, the guidelines of each state vary and sometimes vary from federal guidelines.  So, they can be confusing and still leave physicians questioning what the proper amount should be.

Nelson, who sat on the panel of the Centers for Disease Control and Prevention that developed some of the recommendations, said Makary’s approach is an “excellent idea.”  However, “It’s a lot harder than it sounds because of the large number of procedures and the diversity of patient needs,” he said.

Of course, there is a certain threshold that, when reached, physicians agree that prescribing anymore is unethical. “No one should have 50 tabs sitting in their medicine cabinet” for acute pain, Dr. Makary asserted.  The debate regarding just how many is appropriate is ongoing.


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