Surgeons as Part of the Solution: Changing the Culture of Opioid Prescribing

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In this pointed research letter, Thiels et al report that the amount of postoperative opioid prescribing in their institution has recently decreased, perhaps due to more recent awareness of the opioid epidemic among patients and providers. View this unprecedented opioid epidemic across the nation, 3 important concepts are key for our understanding, as surgeons, of this epidemic, our role in it, and how we can be part of the solution.
Opioid Diversion: The data reflect that surgeons are realizing more and more the role that opioid pills’ diversion plays into the opioid epidemic. Recent data suggest that only 20% of substance abuse patients obtained their opioid pills through a prescribing physician, while 65% obtained/took them from a friend or relative.1 The even more staggering statistic is that 82% of these friends/relatives were prescribed the pills through a single physician;1 this is what is defined as diversion of unused opioid pills. We as surgeons need to acknowledge that the days of prescribing a large number of opioid pills, “just in case” and to “avoid that phone call in the evening or weekend” asking for pain medication refills, are simply gone. Some patients might legitimately require more pain medications, but we cannot afford prescribing extra amount of opioid pills to our patients anymore.
Surgical Culture: Legislation like that passed in Massachusetts and other states and guidelines on opioid prescribing are all helpful. However, at the core of the solution (or our role as surgeons in the solution) is changing the prevalent culture of opioid prescribing.2 In the report by Thiels et al, the mere awareness of the scope of the problem led to a statistically significant decrease in opioid prescription in most of the surgical procedures in the authors’ institution. Changing the prevalent culture requires that surgeons understand 3 main issues: 1) we need to set the patients’ pain expectations as early as possible, whether in the clinic or emergency room—the goal is tolerable pain, not zero pain, 2) alternatives to opioids not only exist but are efficacious— multimodal pain management is essential, and medications such as acetaminophen, ibuprofen and gabapentin are even more effective than opioids in certain situations, and 3) we should prescribe the necessary number of opioid medications only along with clear patient instructions on how to dispose of extra pills.
Standardization: The degree of variation in the amount of opioid being prescribed for similar patients and similar procedures is clear. Procedure-specific guidelines and protocols recommending a limited and set number of pills to be prescribed are needed, and several institutions are making progress in that domain. Policy-makers need to know that surgeons were perhaps part of the problem in the past, but they are now part of the solution.
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