It's Time to Adopt Electronic Prescriptions for Opioids

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We are running out of ways to emphasize how dire the opioid overdose crisis has become. In 2015, United States drug overdose deaths exceeded 50,000; 30,000 involved opioids.1 There were more deaths from opioid overdose than not only from motor vehicle accidents, but also than from HIV/AIDS at the peak of the epidemic in 1995.2
The role of surgeons is important for 2 reasons. First, we are likely to encounter many patients on chronic opioids. Older estimates suggest 5% of the general population use opioids chronically.3 Cron et al4 found that patients seeing surgeons may have significantly higher rates of use, with 21% of general surgery patients at the University of Michigan Medical Center using opioids at home prior to surgery.
Second, emerging evidence suggests that surgeons are unwittingly enablers of addiction, abuse, and overdosage. Waljee et al5 cite administrative data suggesting that 3% to 10% of opioid-naive patients who receive narcotic prescriptions for low-risk surgery continue to take narcotics up to a year later. Moreover, the vast majority of prescription opiate abusers receive the drugs they use through diversion, most often from family members who have excess pills.6 And, as Hill et al7 document, surgeons frequently supply a large excess of pills, with 72% of narcotics prescribed for 5 outpatient procedures going unused. One hundred seventeen of 127 patients they tracked had excess pills; three-quarters retained the pills instead of disposing them. Cauley et al8 also found, in data from the National Inpatient Sample, that rates of postoperative opioid overdosage among patients undergoing inpatient surgery doubled over the last decade. Surgeons are proving to likely be a significant source of the opioid supply fueling the current epidemic.
As a profession that inflicts pain as a necessary part of the care we provide, we have a responsibility to treat our patients’ pain effectively and appropriately. But we also have a clear responsibility to help stem the tide of drug overdose deaths. Hill et al7 and Haytham et al9 detail prescribing practices with evidence of significant benefit. They include:
This last is, of course, the trickiest part. Hill et al usefully document how many opioid pills would be adequate to meet the needs of 80% of patients undergoing 5 procedures. For example, after partial mastectomy, 5 pills are sufficient; after lap chole or inguinal hernia, 15 are. These quantities are markedly lower than surgeons usually prescribe.7
One reason surgeons prescribe more is that we have generally lacked data to guide our opioid supply decisions—research agencies should support calculation of this information for all types of operations. Another reason, however, is that surgeons may often intentionally overprescribe narcotic pain relievers to meet the needs of 99% of patients (if not 100%). Why? Because, under federal regulations, patients stranded with an insufficient supply for their pain have no straightforward way to get a refill without a written prescription.10
I once had a patient arrive home out of state after surgery only to find he’d been inadvertently discharged without his script for pain medication. By then, he was miserable with pain. His pharmacy would not accept an emergency prescription by phone. A family member therefore had to drive back to the hospital 2 hours in the middle of the night to pick up a written prescription. It is the kind of experience patients and surgeons are both eager to avoid.
In 2010, however, the U.S. Drug Enforcement Agency issued regulations permitting electronic prescribing for controlled substances.11 Such systems have numerous advantages: they prevent duplicate and forged prescriptions by using 2-factor authentication; reduce dosing errors; cross-reference prescription monitoring program databases; and simplify the prescription process for doctors and patients.
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