How Might Doctors Refocus Post-Operation Opioid Prescribing?

Opioid addiction is the most discussed, most concerning, and most lethal drug addiction problem in the United States today. News of opioid dependence hits media headlines weekly. It is a national public health emergency that threatens the very viability of our country.

In our efforts to reduce the opioid epidemic, a significant focus rests on opioid prescribing, an area where the medical profession has erred on the side of overprescribing for far too long. It is quite likely that many opioid addicts only become opioid addicts because they are exposed to a powerful opioid pain reliever following a medical operation or surgery of some kind. In fact, a recent research paper and news report (discussed below) published a startling revelation on this point.

The Quantity of Opioids Prescribed Is More Important than the Type of Opioid Prescribed

The research findings indicate that it is not the type of opioid prescribed to post-operation patients that increases the chances of the patient becoming addicted to that drug. Instead, it is the duration and potency at which the patient is prescribed the medication that increases the risk of addiction.

“One of the frequent myths we counter among clinicians is that some types of opioids, such as hydromorphone,
are more dangerous than others….”

Dr. Marilyn Heng, is an orthopedic surgeon in Boston and one of the study authors of “Prescription Opioid Type and the Likelihood of Prolonged Opioid Use After Orthopaedic Surgery.” She said that “One of the frequent myths we encounter among clinicians is that some types of opioids, such as hydromorphone, are more dangerous than others. Our findings demonstrate how current beliefs about the mechanism of prolonged use may be confounded.”

The research paper was published in the Journal of the American Academy of Orthopedic Surgeons. While access to the full document requires a subscription to the medical journal, the synopsis of the paper is offered to non-subscribers. It provides a concise summary of the paper’s findings.

The study examined 17,961 patients who had surgery for a significant, traumatic, musculoskeletal injury. None of the 17,961 patients had taken opioid drugs in the six months leading up to the operation. None of them had any history of opioid misuse.

The findings showed that, of the patients who stayed on opioids longer than they should have (beyond 90 days of opioid prescribing following hospital discharge), almost all such patients had been prescribed higher dosages of opioids than the patients who did not stay on opioid regimens that long.

Patients prescribed lower potency dosages of opioids following surgery typically did not refill their prescriptions. Patients prescribed higher potency dosages usually did.

The paper goes on to discuss how doctors tend to focus on the number of pills they are prescribing to patients, not the potency of those pills. That is a mistake. Again according to Dr. Heng, “Failure to account for opioid strength differences often leads to the notion that certain opioid types appear to be associated with higher odds of complications, when in fact, we are prescribing much more of the stronger drug.”

Rather than focusing on the type of drug being prescribed or how many pills are being given daily, doctors need to focus on the potency of the medicines they are prescribing and for how long they are putting their patients on those pills.

Opioid Prescribing Advice

This research reminds me of the prescribing guidelines document submitted by the Centers for Disease Control and Prevention. This document is an excellent supplement to the Journal of the AAOS research because the CDC document encourages doctors to make three, absolutely critical changes in their prescribing habits for opioids. Speaking directly to the doctors, they stated:

• Reduce the frequency with which you prescribe opioid analgesics. Only prescribe opioid painkillers to patients when absolutely necessary.
• Start with the lowest potency of opioid (dosage) possible. Do not give patients a more potent dosages dosage than what they need for basic pain relief. Err on the side of prescribing too weak an opioid versus too potent an opioid.
• Taper the patient off of the dosage as soon as possible. Do not keep patients on opioid pain relief regimens any longer than absolutely necessary.

The onset of the opioid epidemic in this country can be summed up in one sentence:

• From the late-1990s and into the mid-2000s, doctors prescribed too potent dosages of opioid pain relievers to patients for too long of a duration, creating chemical dependencies in their patients and setting millions of Americans onto the dwindling spiral of addiction in the process.

That is why it is so important for doctors to reform their prescribing habits completely and why the CDC, the organization responsible for safeguarding the health and well-being of the American people, strongly encourages doctors to do so.

Across the nation, we are already starting to see changes. Some doctors are reducing their prescribing habits. But this is not happening fast enough nor by enough physicians. Prescribing rates for opioids are still far above what those rates were at before the onset of the epidemic. We need to get those rates down immediately, or more people will die.

A More Sensible Approach to Post-Op Pain

While we cannot give medical advice, it is worth mention that opioid pain relievers are not the only method for curbing post-operation pain. Holistic and alternative methods of pain relief are almost entirely blocked out of the medical community, likely because they are not profitable for the medical and pharmaceutical industries.

Here are a dozen supplements and activities that one can take/get involved in which are useful in reducing most forms of pain:

• White Willow Bark
• Capsaicin
• Boswellia
• Turmeric
• Ginger
• Magnesium
• Valerian Root
• Cat’s Claw
• Massage Therapy
• Chiropractic Care
• Acupuncture
• Physical Therapy

Why insist on a potent, drug-based “solution” to pain that is not really a solution? To relieve pain, why not use holistic methods that have no addiction risk whatsoever? It’s time we backed off of the zealous push for opioids as being a supposed “miracle cure” for pain. Opioids are not a miracle cure for anything. It’s time we significantly reduced our nation’s consumption of opioids, and it’s time we focused on safer, non-addictive methods of pain relief.

Sources:

• https://www.usnews.com/news/health-news/articles/2019-05-14/quantity-not-type-of-opioid-matters-for-post-op-dependency
• https://journals.lww.com/jaaos/Abstract/2019/05010/Prescription_Opioid_Type_and_the_Likelihood_of.10.aspx
• https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf
• http://pennstatehershey.adam.com/content.aspx
• https://www.health.harvard.edu/pain/how-does-hot-pepper-cream-work-to-relieve-pain
• https://www.uofmhealth.org/health-library/hn-2053005
• https://www.practicalpainmanagement.com/patient/treatments/alternative/ginger-turmeric-dynamic-pain-fighting-duo
• https://www.asra.com/asra-news/article/105/oh-mg-magnesium-a-powerful-tool-in-the
• https://www.arthritis.org/living-with-arthritis/treatments/natural/supplements-herbs/guide/valerian.php
• https://www.uofmhealth.org/health-library/hn-2064008
• https://www.health.harvard.edu/alternative-and-complementary-medicine/therapeutic-massage-for-pain-relief
• https://nccih.nih.gov/health/pain/spinemanipulation.htm
• https://www.aafp.org/news/health-of-the-public/20180521acupuncture.html
• https://healthcare.utah.edu/healthfeed/postings/2016/11/pain_relief.php

Reviewed and Edited by Claire Pinelli, ICAADC, CCS, LADC, RAS, MCAP