Breaking News
November 20, 2018 - Towards finding a druggable cancer target
November 20, 2018 - Ultragenyx Announces Intent to Submit New Drug Application to U.S. FDA for UX007 for the Treatment of Long-chain Fatty Acid Oxidation Disorders in Mid-2019
November 20, 2018 - Cooling ‘brains on fire’ to treat Parkinson’s
November 20, 2018 - Less pollution could increase the average lifespan of Copenhageners by an entire year in 2040
November 20, 2018 - Abramson Cancer Center becomes the 28th member institution of National Comprehensive Cancer Network
November 20, 2018 - The plug and play time-resolved spectrometer from PicoQuant
November 20, 2018 - Breakthrough technology offers new hope to people with glaucoma, retinitis and macular degeneration
November 20, 2018 - New report highlights key focus areas to help cancer screening realize its full potential
November 20, 2018 - International experts to discuss strategies to maintain spatial orientation in old age
November 20, 2018 - Scientists discover new inhibitor that decreases lung inflammation
November 20, 2018 - Participation project calls for relaxing research ban on germline interventions
November 20, 2018 - Karyopharm’s Selinexor Receives Fast Track Designation from FDA for the Treatment of Patients with Relapsed or Refractory Diffuse Large B-cell Lymphoma
November 20, 2018 - Arthritis by the Numbers: Book of Trusted Facts & Figures
November 20, 2018 - Drug homing method helps rethink Parkinson’s
November 20, 2018 - AHF commends the passage of global AIDS funding in the House, calls for swift approval
November 20, 2018 - The search for new psychiatric disorder treatments
November 20, 2018 - New research offers hope for simpler way to diagnose and treat cancer
November 20, 2018 - Study sheds light on the infection mechanism of influenza virus
November 20, 2018 - Storage failures of eggs and embryos gain a new perspective
November 20, 2018 - Buyers of short-term health plans: Wise or shortsighted?
November 20, 2018 - Study indicates that frogs in virus-exposed groups breed at young age
November 20, 2018 - FDA Alerts Health Care Professionals and Patients Not To Use Sterile Drug Products from Pharm D Solutions
November 20, 2018 - Asthma may contribute to childhood obesity epidemic
November 20, 2018 - Researchers to explore the enigmatic role of unstructured protein in regulating circadian function
November 20, 2018 - Many patients with adenomas do not receive colonoscopy within recommended time frame
November 20, 2018 - Drug used to treat PTSD does not reduce suicidal thinking, may worsen nightmares and insomnia
November 20, 2018 - In-person social contact may offer protection against depression and PTSD symptoms
November 20, 2018 - Routine HCV testing in correctional facilities can best identify and treat disease, say researchers
November 20, 2018 - Molecular DNA analysis could facilitate more accurate prognosis, treatment of aggressive brain tumors
November 20, 2018 - Breast Cancer Recurrence Rate Not Up With Autologous Fat Transfer
November 20, 2018 - Beta 2 Microglobulin (B2M) Tumor Marker Test: MedlinePlus Lab Test Information
November 20, 2018 - Could bariatric surgery make men more virile?
November 20, 2018 - Urine test to check if patients take their medications will save the NHS money, say researchers
November 20, 2018 - Study reveals impact of residual inflammatory risk on clinical outcomes after PCI
November 20, 2018 - RNAi therapy shown to alleviate preeclampsia
November 20, 2018 - Replacement of dysfunctional microglia has therapeutic potential for neurodegenerative diseases
November 20, 2018 - Forming 3D Neuronal Models of the Brain
November 20, 2018 - Shoulder ultrasounds could be used to predict diabetes
November 20, 2018 - SGLT2 Inhibitors for Diabetes Linked to Increased Risk for Amputation
November 20, 2018 - Stem cell transplant cements Arizona men’s father-son bond
November 20, 2018 - Scientists try to develop portable systems that can quickly produce biologics on demand
November 20, 2018 - Automating Data Capture and Image Analysis in Continuous Experiments
November 20, 2018 - New drug shows promise for treating people with peanut allergy
November 20, 2018 - Researchers develop novel mouse model to study immunomodulatory therapies
November 20, 2018 - “Britain must not go backward on antibiotic controls to appease US trade deals” – Jim Moseley, CEO of Red Tractor
November 20, 2018 - Widespread errors in ‘proofreading’ cause inherited blindness
November 20, 2018 - Reaping the benefits of living longer
November 20, 2018 - New Program Hopes to Make Early Detection and Treatment of ALS a Reality
November 19, 2018 - Artificial bone-like substance mimics the way real bone grows at atomic level
November 19, 2018 - FDA Grants Orphan Drug Designation To RGX-181 Gene Therapy For The Treatment Of CLN2 Form Of Batten Disease
November 19, 2018 - Systemic mastocytosis – Genetics Home Reference
November 19, 2018 - Eye trauma secondary to falls in older adults increasing
November 19, 2018 - Empowering women in India to improve their health: A Q&A
November 19, 2018 - Researchers have trained a computer to analyze breast cancer images and classify tumors
November 19, 2018 - New glucose binding molecule could be key to better metabolic control for diabetics
November 19, 2018 - Biologists uncover novel genetic control of lipid maintenance and its potential connection to lifespan
November 19, 2018 - Warmer winters may set scene for higher rates of violent crimes
November 19, 2018 - Personalized program of physical exercise effective in reversing functional decline in the elderly
November 19, 2018 - Acacia Pharma Resubmits Barhemsys New Drug Application
November 19, 2018 - PDL1 (Immunotherapy) Tests: MedlinePlus Lab Test Information
November 19, 2018 - Transforming pregnancy research with a smartphone app
November 19, 2018 - Stanford Medicine magazine explores how digital technology is changing health care
November 19, 2018 - Vision impairments may increase risk of falls in older adults
November 19, 2018 - Concomitant use of sleeping pills and opioids found to prevalent among people with Alzheimer’s disease
November 19, 2018 - Marijuana prevention programs should focus on promoting mental wellbeing of youth
November 19, 2018 - New report calls for greater awareness and emphasis on scale and impact of atrial fibrillation
November 19, 2018 - In throes of turkey salmonella outbreak, don’t invite illness to your table
November 19, 2018 - UK health policies should be redesigned to become more accessible for men
November 19, 2018 - Short Interpregnancy Intervals Tied to Adverse Outcome Risk
November 19, 2018 - New mothers’ breastfeeding pain can affect infant health
November 19, 2018 - Stanford Medicine magazine reports on ways digital technology is transforming health care | News Center
November 19, 2018 - Human drugs alter cricket personality
November 19, 2018 - Insilico Medicine to introduce ‘Cure a disease in a year’ program at Biodata World Congress 2018
November 19, 2018 - Experts debate over whether gut or brain is more important in regulating appetite
November 19, 2018 - Playing on fear and fun, hospitals follow pharma in direct-to-consumer advertising
November 19, 2018 - 2PG Company receives grant to develop sensitive, low-cost molecular diagnostic tests for tuberculosis
November 19, 2018 - Low-Carb Diets May Work By Boosting Calorie Burn
November 19, 2018 - Key molecule responsible for learning and memory discovered
November 19, 2018 - New blood test developed for early diagnosis of ovarian cancer
November 19, 2018 - Researchers identify molecule to fight myotubular myopathy
An ingrown toenail not the same as a bypass

An ingrown toenail not the same as a bypass

image_pdfDownload PDFimage_print

What’s the right painkiller prescription to send home with a patient after gallbladder surgery or a cesarean section?

That question is front and center as conventional approaches to pain control in the United States have led to what some see as a culture of overprescribing, helping spur the nation’s epidemic of opioid overuse and abuse.

The answer isn’t clear-cut.

Surgeon Marty Makary wondered why and what could be done.

So, Makary, a researcher and a professor of surgery and health policy at Johns Hopkins School of Medicine in Baltimore, took an innovative approach toward developing guidelines: matching the right number of opioid painkillers to specific procedures.

After all, most doctors usually make this decision based on one-size-fits-all recommendations, or what they learned long ago in med school.

Even Makary admitted that for most of his career he “gave [painkillers] out like candy.”

In December, he gathered a group of surgeons, nurses, patients and other leaders, asking them: What should we be prescribing for operation X?”

The answer was illuminating.

“The head of the hospital’s pain services said, ‘You’re the surgeon, what do you think?'” recalled Makary.

Makary didn’t know. Nor did the resident. And the nurse practitioner, who often is the one who most closely follows up with patients, said it varies.

“Wow,” recalls Makary of that day when they first considered appropriate limits. “We’re the experts, the heads of this and that, and we don’t know.”

After a quick couple of weeks of intense discussion, Makary’s group reached consensus and gave its blessing to guidelines setting maximum numbers of opioid-containing pills for 20 different common surgical situations, from relatively minor procedures to coronary bypass surgery.

“We’re in a crisis,” said Makary, explaining why the group didn’t go a more traditional route and publish its findings in a medical journal first, which could take months.

Sometimes the right number of opioids is zero, concluded the group.

Indeed, it recommends no opioids for patients heading home after uncomplicated labor and delivery, or after cardiac catheterization, a procedure in which a thin, hollow tube is inserted into the heart through a blood vessel to check for blockages.

For certain types of knee surgery, such as arthroscopic meniscectomy, the guidelines recommend no more than 12 pills upon discharge, while a patient going home after an open hysterectomy could require as many as 20.

Optimally, “no one should be given more than five or 10 opioid tablets after a cesarean section,” Makary said.

Oh, and for cardiac bypass surgery? No more than 30 pills.

Tens of thousands of Americans are dependent upon opioid medications. An increasing number are dying from overdoses, both from prescription medication and street drugs.

Knowing that, Makary, as well as other surgeons, hospitals and organizations, are taking steps to change how they practice medicine.

After all, many experts view the use of opioid prescription painkillers after surgery as a gateway to long-term use or dependence. A study published last year in the journal JAMA Surgery found that persistent use of opioids was “one of the most common complications after elective surgery.”

In that study, University of Michigan researchers found that 6 percent of people who had never taken opioids but received them after surgery were still taking the medications three to six months later.

With about 50 million surgeries that occur in the U.S. each year, “there are millions who may become newly dependent,” said Chad Brummett, the study’s lead author and an associate professor of anesthesiology at the University of Michigan Medical School.

Smokers, and those diagnosed with certain conditions such as depression, anxiety or chronic pain before their operations, were most at risk of long-term use.

Each refill or additional week of use makes for a greater risk of misuse, other studies have shown.

Additional research points to another reason for concern. If patients don’t take all the pills they are prescribed following an operation, those pills can be stolen or diverted to other people, who then run the risk of becoming dependent.

Still, there is debate in medical circles about just how effective recommendations and guidelines will be in stemming the epidemic.

For one thing, some experts worry that if the fight against opioids focuses only on safe prescribing at the expense of seeking alternatives, it may miss the bigger picture.

“Are there better methods than opioids in the first place?” asks Lewis Nelson, chair of emergency medicine at Rutgers New Jersey Medical School. “Could you put a lidocaine patch over the wound or is there a better way to immobilize a joint?”

Studies have shown that sometimes a combination of ibuprofen and acetaminophen can be just as good as or better than opioids.

Alternatives should always be considered first, agreed Makary.

Another concern is that guidelines for prescribing relief — even those aimed at short-duration, acute pain, such as that following surgery — have carryover effects on patients with long-term pain. Advocates say all the attention around prescribing limits have made it difficult for chronic pain patients to get the medications they need.

Some people even apply these concerns to recommendations about the treatment of acute pain.

“It’s important for a physician to have the ability, if they feel there’s a medical necessity, to write a prescription for a longer duration,” said Steven Santos, president of the American Academy of Pain Medicine. “It’s challenging to lump all patients into one basket.”

A Different Focus: Duration

Lawmakers — desperate to address overdose problems that are destroying families and communities — have gone where they usually don’t: setting specific rules for doctors.

Legislatures in more than a dozen states, including New Jersey, Massachusetts and New York, have set restrictions, often on the number of days’ worth of pills prescribed for acute pain.

“States said that since physicians haven’t self-regulated, we’re going to do it for them,” said Nelson at Rutgers.

Congress, too, is getting involved, holding a flurry of hearings this spring, and considering legislation that would, among other things, set limits on prescribing opioids for acute pain. The recently passed federal spending bill includes $3 billion in new funding to help states and local governments with opioid prevention, treatment and law enforcement efforts.

To be sure, the medical profession has also responded to the crisis — with medical societies and other expert groups offering a growing number of standards for prescribing opioids.

Some are fairly generic, recommending the lowest dose for the shortest period of time for acute pain. Some are more prescriptive.

None is meant to address the needs of chronic pain patients or those with cancer.

And state rules vary. New Jersey’s, for example, says patients with acute pain should, initially, get no more than a five-day supply, while Massachusetts sets the cap at seven days for a patient prescribed opiates for the first time.

The Centers for Disease Control and Prevention recommends three days.

Makary and some other experts say that, while well-intentioned, such durational rules are too blunt.

A day’s worth of pills can vary, depending on how often the doctor instructs patients to take them. Under many of the state rules, patients could still head home with more than 50 pills.

“No one should have 50 tabs sitting in their medicine cabinet” for acute pain, said Makary.

Andrew Kolodny, co-director of opioid policy research at the Heller School for Social Policy and Management, supports guidelines but wants states to take their rules a step further.

“I don’t think the way the states are going at this makes much sense because the issue with overprescribing was quantity, yet they’re passing laws around duration,” he said.

Instead, the laws should require that “if physicians are going to prescribe more than three days, they have to warn the patients that this is an addictive drug and that taking it every day for as little as five days may cause them to become physiologically dependent,” Kolodny said.

That would create a disincentive to prescribing more than three days’ worth of opioid painkillers, he added, and lead to more informed patients among those who need a longer supply.

Rutgers’ Nelson, who sat on the CDC panel that developed recommendations, said durational rules — like those adopted by the states — can be effective.

“I personally think three days is enough,” said Nelson. “That doesn’t mean pain goes away in three days, but most people get better within three to five days.”

That said, Nelson called the Hopkins’ approach an “excellent idea” and one he has tried to do. “It’s a lot harder than it sounds because of the large number of procedures and the diversity of patient needs,” he said.

To get around overprescribing — or setting one-size-fits-all guidelines — physicians at Dartmouth-Hitchcock Medical Center have a developed their own data-based approach.

Dr. Richard Barth, the chief of general surgery at Dartmouth, and colleagues studied 333 patients discharged from the hospital following six common surgeries that included bariatric procedures; operations on the stomach, liver, colon and pancreas; and hernia repair.

Surveying the patients, they asked how many opioid pills they went home with, how many they actually took, how many went unused and how much pain they experienced.

The data helped them land on a way to recommend a specific number of pills. “If they took none the day before discharge, then over 85 percent of patients did not take any when they went home,” said Barth.

Dartmouth-Hitchcock now uses that data as a recommended starting point for physicians.

Under the guidelines, patients taking no opioid pain pills the day before discharge go home with none. Those who take one to three pills get 15, an amount Barth’s study found satisfied 85 percent of patients, and those who took four or more get 30 pills.

“We came out with a very easy to implement and remember guideline,” said Barth. “We actually called patients and asked them how many [pills] they used. That’s what differentiates us from other places.”

Brummett, at Michigan, says the Opioid Prescribing Engagement Network, a collaboration of hospitals, insurers, physicians and others in his state, has used similar data methods to come up with procedure-specific guidelines.

“We’ve taken a data-driven approach,” he said. “We believe patient-reported outcomes are a better way to guide than expert consensus.”

For his part, Makary admitted it is harder to develop guidelines like those at Hopkins and Dartmouth, but he said the effort is vital.

“It’s mind-boggling to me” that so many opioid-prescribing guidelines do not specify the procedure, said Makary. “An ingrown toenail is not the same as cardiac bypass surgery.”

Julie Appleby: [email protected], @Julie_Appleby

Kaiser Health NewsThis article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Tagged with:

About author

Related Articles