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March 23, 2017

Gawande: One change you can make right now to fight the opioid crisis

Daily Briefing

    As the opioid-misuse epidemic rages, it's time for surgeons to embrace modernized prescribing practices for the highly addictive drugs, Atul Gawande writes in Annals of Surgery.

    Gawande, a renowned surgeon and author from Brigham and Women's Hospital, says taking advantage of e-prescribing is an easy way for surgeons to make a positive impact on the opioid crisis, which according to Gawande, killed more than 30,000 Americans in 2015.

    Gawande says such a shift among surgeons would be important for two main reasons:

    • Research suggests patients who see surgeons are significantly more likely than the general population to use opioids chronically; and
    • Research "suggests that surgeons are unwittingly enablers of addiction."

    For the latter point, Gawande cites a study which suggests 3 to 10 percent of patients who receive opioids for the first time following surgery are still on the drugs a year later. Moreover, Gawande writes that surgeons could be indirectly contributing to the epidemic since research shows that they frequently write prescriptions for more pills than their patients need—and many people who misuse opioids obtain them through friends and family with excess pills.

    Gawande: Surgeons have a responsibility to treat patient's pain—and stem the opioid epidemic

    According to Gawande, surgeons need to find a way to both treat their patients' pain and "help stem the tide of drug overdose deaths." Research suggests that modernized prescribing practices can help surgeons address both goals, Gawande writes. Such practices include:

    • Informing patients that opioids will help control their pain but not eliminate it;
    • Use of non-opioid alternatives for procedures associated with only mild pain;
    • Querying prescription monitoring databases to confirm that a patient is not receiving opioids through other clinicians;
    • Giving patients clear disposal instructions; and
    • Prescribing the fewest number of required pills.

    "This last [recommendation] is, of course, the trickiest part," Gawande writes. One of the reasons that surgeons may so frequently prescribe too many pills, Gawande explains, is because they "have generally lacked data to guide [their] opioid supply decisions," such as the ideal number of pills for a partial mastectomy. He calls on "research agencies [to] support calculation of this information for all types of operations."

    Moreover, according to Gawande, surgeons also face a system that encourages them to prescribe more than necessary because "patients stranded with an insufficient supply for their pain have no straightforward way to get a refill without a written prescription."

    How Dartmouth-Hitchcock dramatically cut opioid prescription for some surgeries

    A step forward with e-prescribing

    While acknowledging these difficulties, Gawande posits  e-prescribing systems could serve as an immediately implementable solution. According to Gawande, e-prescribing systems can help because they:

    • Prevent duplicate or forged prescriptions using advanced security protocols;
    • Reduce dosing errors;
    • Reference prescription monitoring databases;
    • Simplify the prescription-writing process for doctors; and
    • Enable surgeons to write smaller prescriptions because they can call in refills as needed.

    This technology is widely available, with 81 percent of pharmacies equipped to receive electronic prescriptions and more than 90 percent of physicians using EHRs which can usually be equipped for e-prescribing controlled substances, Gawande writes. Even so, just 8 percent of physicians work in practices that have that capability in place and use it. 

    Surgeons shouldn't wait for new regulations to change their prescribing habits, Gawande concludes. "We cannot sit idly by," he writes. "We surgeons turn out to be suppliers of the excess prescription opiates fueling addiction and death by overdose. We have to change that. And we now know how we can" (Gawande, Annals of Surgery, April 2017; Minemyer, Fierce Healthcare, 3/17).

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