Doctors can stop the opioid crisis by not over-prescribing | Marty Makary

For most of my surgical career, I gave out opioids like candy. My colleagues and I were unaware that about 1 in 16 patients become chronic users, according to new research by doctors at the University of Michigan. Even more alarming, research shows that relapse rates after opioid addiction treatment could be as high as 91 percent. In addition to expanding treatment, it’s time we address the root of the problem — overprescribing.

My own aha moment came recently after my father had gallbladder surgery and recovered comfortably at home with a single ibuprofen tablet. Wow. It directly contradicted my residency training 15 years ago, when I was taught to give every surgical patient a prescription for 30-90 opioid tablets upon discharge. Some of my mentors told me that overprescribing prevents late night phone calls asking for more. The medical community at that time ingrained in all of us that opioids were not addictive and urged liberal prescribing. So that’s exactly what we did.

Too many Americans are leaving the hospital with bottles full of opioid tablets they don’t need.

We need to take away the matches, not put out the fires.

My colleagues at Johns Hopkins and I have used data to identify the average number of opioids a doctor prescribes after a routine C-section, excluding patients with pre-existing opioid use or pain syndromes. The range is stunning. Some doctors fall within what Johns Hopkins specialists call “best practices range,” averaging three to 10 opioid tablets after C-section. Others still average 30 or 60 tablets.

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We have repeated the analysis for many minor procedures, including operations that can be managed with non-opioid alternatives alone. The doctor distribution graphs keep showing us the same thing: There is wide variation in opioid prescribing today.

By allowing the data to tell us which doctors are outliers, we can identify who we can help and offer them expert guidance. Hospitals should be rewarded rather than penalized financially for adopting these programs.

Second, we need to address distortions in rating systems. The question “How often did the hospital staff do everything they could to help you with your pain?” is a measuring stick by which all U.S. hospitals are rated, creating a perverse incentive to generously distribute opioids. While many doctors reserve opioids for conditions such as terminal cancer, burns and major surgery, the classic indications for opioids have been broadened to now include things such as backaches and very minor procedures. We need to change the quality metrics in health care so doctors can practice sound medicine.

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Third, we need to change several perverse financial incentives. It is very difficult to find doctors interested in carefully managing a patient’s pain medications because doing so pays so little (as little as $50 for a 30-minute visit). Our reimbursement system should value expert advice and counseling on pain management.

Ironically, acetaminophen and NSAIDs (non-steroidal anti-inflammatory drugs) are over-the-counter meds and thus rarely covered by insurance, yet opioids are. Those who think $10-$30 for a bottle of NSAIDs is not a barrier should meet some of my poor patients from inner-city Baltimore. All non-opioid pain meds should be covered after surgery with no co-pay or deductible.

Finally, payers should give doctors more incentive to do nerve block procedures. It’s well established that when patients are injected with anesthetics in surgical areas or root nerves, they need fewer pain pills.

Using data to identify overprescribing patterns and changing incentives to reward best practices is far less expensive than addiction rehabilitation. Engaging with rather than blaming doctors who overprescribe, as I did, can have a dramatic impact.

While opioid treatment is an important priority, we should remember that the most effective treatment is still prevention.

Dr. Marty Makary is a professor of surgery and health policy at the Johns Hopkins School of Medicine in Baltimore and an adviser to Practicing Wisely.