On Babies, Bath Water and Opioids
The “opioid crisis” occupies a substantial part of our professional and political milieu. We are besieged by headlines in media of all types reporting on the evils of opioid analgesics. There is no shortage of individuals, professional societies and government agencies ready to step to the plate with guidelines, rules and regulations designed, it seems, to virtually eliminate these drugs and to hog-tie providers who are trying to care for patients.
Unfortunately, physicians have been labeled as perpetrators because we allegedly write opioid prescriptions willy-nilly. We are now living in a Big Brother–like world where the states’ prescription drug databases monitor everyone’s activities, where family practitioners hesitate to write a prescription for hydrocodone for acute injuries, and where pain specialists have become the only providers “worthy” of dealing with opioids. As a surgeon, I’d like to propose that our community take a step back from this climate of fear and retribution, and think for a moment like the scientists we are supposed to be.
First, opioids have legitimate uses. Having been on the receiving end of the scalpel (no minimally invasive procedures for me, unfortunately!) several times, I can assure you that acetaminophen, nonsteroidal anti-inflammatory drugs, local anesthetics and tramadol do not cut the muster when one’s spine, retroperitoneum or pelvis has been violated—and that includes the post-discharge period. Severe pain does not promote good recovery from major surgery, and we all know the reasons why (e.g., it limits mobility, hinders pulmonary toilet and facilitates deep venous thrombosis). In the haste to make noticeable headway on the number of opioid-related overdoses and deaths, the knee-jerk response has been to release the “opioid police” to hover over all, to confiscate drugs and to take names while forgetting and/or ignoring real-world experience. Trust me, mass abdominal closure with #2 polypropylene hurts.
Second, we have been guilty of prescribing too many opioids. I learned early in my own practice, and have read in scattered studies, that our patients do not use nearly the amount of postoperative analgesics as we have believed. I recall a report showing that just 15 pills would have met the pain relief needs of 88% of postoperative general surgery inpatients upon discharge. The days of 90, 60 and even 30 dispensing are long gone. I chopped my prescriptions to three or four days’ worth early on and hardly heard a peep from my patients. Besides, significant pain beyond this time should behoove the surgeon to be certain that all is well and recovery is proceeding as expected rather than triggering a new prescription. If we all followed this practice, how much excess supply would be eliminated?
Third, as trained scientists, we should question authors who speak and report beneath apocalyptic headlines and who fill their narratives with gloom-and-doom statistics. Is there a problem? Certainly. Is there scientifically correct study and reporting of it? Certainly not. We should no sooner accept poor science—incorrect study design, mismatched comparison groups, misleading cause and effect, etc.—than we would take a patient to the OR without the proper evaluation and preparation. (See General Surgery News, May 6, 2019 [web-only edition], “Opioid Overdose Now Leads to More Deaths Than Motor Vehicle Accidents” for an insightful discussion of opioid “data.”) It’s time to call out these practices and to direct the discussion toward honest and meaningful data: Where do the data come from? Are we comparing apples with apples? Are we even actually measuring what we presume to measure?
Finally, abused opioids come from several sources. Physicians prescribe them and injudicious prescribing can contribute to abuse, but so do prescription forgery, “doctor shopping,” drug diversion and theft, illegal manufacturing for importation, and failure to properly destroy unused medications. Given the size of the illegal drug market in the United States, it seems naive to assume that legitimate prescriptions account for most of the abused opioids (although the numbers in the article cited above would give one pause) or that restricting or limiting prescribing will make the problems disappear. There is plenty of blame to spread around, even ignoring the issue of demand—from a societal and social standpoint, perhaps the most crucial one of all and perhaps the most ignored.
Do not mistake my remarks as disrespect for the opioid misuse issue or as callous disregard for its victims. The issue is real, the victims are our fellow human beings, and no one should trivialize either. I’m merely suggesting that we return to rational thought in our approach. Prescribe fewer opioids at a time, but let’s also insist on scientific collection of meaningful data, retaining the right to use our hard-earned clinical judgment without outside interference or blanket retribution and a multipronged approach to managing the opioid problem.
In my practice, I had a single rule: Do the right thing for each individual patient, and everything else (quality, outcomes, reputation, referrals, finances) will take care of itself. The corollary to this is that whenever the rule ceases to be true, it is time to find another line of work. Although I can no longer see patients, I can still work in the periphery of clinical medicine. Since I finished residency in 1982, there has been a sea of changes and the landscape is very different from my first days as a solo practitioner. However, my reading of today’s environment leads me to believe that my single rule remains true. And for this issue, we should not allow poor science, sensationalism, headline grabbers and glory seekers, and a minority of miscreants to get in the way of doing the right thing. In other words, don’t throw the baby out with the bath water.
Dr. Murphy is a surgeon in Conway, Ark.