by Kevin Schofield

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This weekend’s read is a look at how U.S. surgeons have historically over-prescribed opioids to their patients to manage postoperative pain, and how that practice is changing for the better. Over the past several years, we have heard much about how pharmaceutical companies, such as Purdue, have aggressively marketed opioids to doctors, including downplaying their addictive properties, to increase sales. Those efforts largely succeeded and have led to an epidemic of people addicted to opioids — some of whom moved on to illicit street drugs, such as fentanyl, after their prescriptions ran out.

Over-prescribing opioids brings three risks. First, as mentioned above, it can lead to addiction: constant cravings for more opioids and physical withdrawal if deprived of the drug. Second, opioid users can develop resistance: Over time, they need higher doses to achieve the same effect. Third, there can be “diversion”: Unused pills can end up in the hands of family members or friends, who in turn can start taking them and end up addicted.

Some doctors prescribe opioids to manage chronic pain symptoms for people who are in constant pain due to the aftereffects of an injury or the impact of years of hard physical labor. But other uses are intended to be short-term, including for managing postoperative pain that is expected to fade after a few days or perhaps weeks. But the customary prescribing practices for U.S. surgeons, encouraged by opioid manufacturers and for many years unmonitored by regulatory agencies, led to opioid prescriptions for many patients with mild pain where non-opioid medications that don’t carry the same risks would have worked just as well, as well as prescriptions that provided medicine for longer than the pain was expected to last. These practices have led to more addiction and more diversion of leftover medication into the wrong hands.

The over-prescribing of opioids is not limited to the United States, but data shows that as far back as 2013 to 2015, U.S. surgeons prescribed opioids more often than their European counterparts and provided more doses in those prescriptions. In the late 2010s, however, as the extent of the problem became clear, many surgeons began to rein in their use of opioids for their patients. Between 2016 and 2022, there was a 36% decrease in the number of prescriptions and a 46% decrease in the average number of doses included in a prescription — together accounting for a 66% decrease in the total amount of opioid doses prescribed. That’s very good news.

Across the board, all surgical specialties reduced both the frequency with which they prescribed opioids and the number of doses they provided — but some specialists were doing much more over-prescribing than others. The biggest culprit in over-prescribing opioids was the community of orthopedic surgeons, which in 2016 issued over 45% of all the prescriptions. Orthopedic surgeons also tended to prescribe more doses, with the result that nearly 55% of all opioid doses that year were prescribed by them. Along with them, OB/GYNs (who perform cesarean-section births) and general surgeons each issued about 15% of all opioid prescriptions — so together, these three specialties account for three-quarters of all postoperative opioid prescriptions. Since all surgical specialties decreased their use of opioids between 2016 and 2022, the share attributable to each specialty didn’t change much, but overall, the impact is huge: an almost two-thirds drop in the quantity of opioid doses being prescribed by surgeons. 

An interesting side note: In the first six months of 2020, the number of opioid prescriptions by surgeons plummeted and then went back to its previous level. This is almost certainly because in the early days of the pandemic, most elective surgery was canceled. At the same time, the number of doses prescribed went up (and then back down), most likely because doctors worried about their patients’ ability to get prescriptions filled. These sorts of short-term anomalies are now showing up everywhere in research papers in health care, but also in other fields of study, such as economics and transportation. It seems likely that for the foreseeable future most studies that cover 2020–2022 will need to explain away these kinds of inconsistencies in their data.

Sadly, we have not yet solved the problem of opioid over-prescription despite the recent progress. U.S. surgeons still prescribe addictive opioids more often than their European counterparts, and they prescribe more doses — more than even the guidelines suggest. And while the surgeons are making progress in curtailing their own bad behavior, there is still the separate problem of doctors over-prescribing opioids for long-term chronic pain — a topic for another day.

Opioid Prescribing by US Surgeons, 2016-2022

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📸 Featured image via tong patong/Shutterstock.com.

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