The Surgeons' Remarkable Mea Culpa (acknowledgement of fault)

In the current issue (April 2017) of the Annals of Surgery, the authors come together to shine a light not only on the opioid epidemic, but their contributing role. While we have all heard doctors admit to the general role that physicians have played in fueling the crisis, its almost unheard of for physicians to stand up publicly and take responsibility for their part. Blame the lawyers or hubris or just professional defensiveness, its is sadly all too rare to witness physicians admit their systematic contribution to America's opioid epidemic. Kudos to the surgeons. Its an admirable step. We are counting on your colleagues to follow your lead.

Dr. Keith Lillemoe says in the introductory piece:

Although most of these drugs (opioids) are prescribed with the best of intentions, as most of us have been schooled that “pain is the 5th vital sign,” it is clear that we as surgeons are contributing to this crisis.
— Lillemoe, Keith, Annals of Surgery, Volume 265, April 2017

Evidence just keeps pouring in that even short-term exposures to prescription opioids can lead to long-term use.  Just this week (March, 17, 2017), the CDC published research on the dramatic increase in the probability of using prescription pain pills a year or three years after the first prescription.  The difference between a 3 and 10 day initial prescription results in an almost 5x probability of using a year later, as you can see from the chart below:

As the term of the initial prescription moves to the right from 3 to 10 days, the chance of continuing use of prescription opioids increases from ~6% to more than 25%.

As the term of the initial prescription moves to the right from 3 to 10 days, the chance of continuing use of prescription opioids increases from ~6% to more than 25%.

What is so remarkable about this graph, is that it only includes data on patients' prescription opioid use. With no access to data on patients' access to illicit pain pills or street drugs like heroin, these numbers almost certainly underestimate the impact of longer term prescriptions.

And the range of initial prescriptions is massive.  In another study in the Annals of Surgery this month, authors find that while many surgeries result in a prescription of no opioids, some patients are prescribed as much as four! months' supply. Most patients are prescribed less than a month's supply, but few end up taking their medication for that length of time.

Hill, Maureen V.; McMahon, Michelle L.; Stucke, Ryland S.; Barth, Richard J. Jr., Annals of Surgery. 265(4):709-714, April 2017.

Hill, Maureen V.; McMahon, Michelle L.; Stucke, Ryland S.; Barth, Richard J. Jr., Annals of Surgery. 265(4):709-714, April 2017.

As the authors note:

Overprescribing opioids would be acceptable if the cost of opioid prescriptions to individual patients and the cost to society were negligible. However, the current epidemic of deaths from opioid overdose, largely fueled by diversion of prescription opioids, makes it clear that the cost to society is not negligible, and must be considered when prescribing opioids for individual patients.
— Hill, et al

Hill, et al should win an award for understatement.  To suggest that the cost to society of over-prescribing opioids is "not negligible", rivals Crick and Watson when they reported on the discovery of DNA and noted that "This structure has novel features which are of considerable biological interest." 

Waljee, et al, are more clear in their description of surgeons as the "Gatekeepers" to the opioid crisis:

Deaths attributable to prescription opioids are a leading cause of accidental death in the United States, and have increased 5-fold over the last decade. Given the societal impact of opioid abuse and dependence, the unmeasured burden related to lost productivity and wages is substantially higher. Moreover, excess opioids that remain unconsumed are an opportunity for individuals to develop opioid dependence, and a pathway to substance abuse. Surgeons contribute to the excess of prescription opioids in our communities daily, and increase prevalence of opioid-dependent individuals. As such, we have a critical responsibility and opportunity to develop appropriate prescribing practices.
— Waljee, Jennifer F. MD, et al, Annals of Surgery, April 2017

In a previous blog post, MATClinics defends physicians' right to use their own situationally specific judgement in prescribing.  Hopefully, with better guidance, standards, and most importantly, a sense of the consequences of over-prescription, those same physicians will begin to show more restraint.