Many doctors wrote prescriptions for dozens of opioid tablets after surgeries—even for operations that cause most patients relatively little pain, according to the analysis, done in collaboration with researchers at Johns Hopkins Bloomberg School of Public Health. It examined almost 350,000 prescriptions written for patients operated on by nearly 20,000 surgeons from 2011 to 2016—the latest year for which data are available.
Some surgeons wrote prescriptions for more than 100 opioid pills in the week following the surgery. The total amounts often exceeded current guidelines from several academic medical centers, which call for zero to 10 pills for many of the procedures in the analysis, and up to 30 for coronary bypass surgery.
While hundreds of state and local lawsuits have been filed against opioid manufacturers, claiming they engaged in aggressive and misleading marketing of these addictive drugs, the role of physicians in contributing to a national tragedy has received less scrutiny. Research shows that a significant portion of people who become addicted to opioids started with a prescription after surgery.
- Coronary artery bypass patients operated on by the highest-prescribing 1 percent of surgeons filled prescriptions in 2016 exceeding an average of 105 opioid pills.
- Patients undergoing a far less painful procedure—a lumpectomy to remove a breast tumor—were given an average of 26 pills in 2016 the week after surgery. The highest-prescribing 5 percent of surgeons prescribed 40 to 70 pills on average.
- Some knee surgery patients took home more than 100 pills in the week following their surgery.
“Prescribers should have known better” based on studies and other information available at the time, said Andrew Kolodny, codirector of opioid policy research at Brandeis University and director of the advocacy group Physicians for Responsible Opioid Prescribing.
While the dataset included only prescriptions written for patients on Medicare, the findings may well understate the depth of the problem, since doctors are more hesitant to give older patients the powerful painkillers because of their sedating side effects.
Also, unused pills in medicine cabinets can make their way onto the street.
Dr. Marty Makary, a surgical oncologist at Johns Hopkins, admits that he, too, once handed out opioids liberally. Now he is marshaling a campaign to get surgeons to use these powerful painkillers more consciously and sparingly.
“I think there’s an ‘aha’ moment that many of us in medicine have had or need to have,” he said.
But old habits are hard to kick.
KHN contacted dozens of the surgeons who topped the ranks of opioid prescribers in the 2016 database. They hailed from small, community hospitals as well as major academic medical centers. The majority declined to comment, some bristling when questioned.
Some of those surgeons were critical of the analysis, saying it didn’t take into account certain essential factors. For example, it was not possible to determine whether patients had complications or needed higher amounts of pain medication for another reason. And some surgeons had only a handful of patients who filled prescriptions, making for a small sample size.
Makary, who oversaw the analysis of the Medicare dataset, said that, while opioid prescribing is slowly dropping, to date many surgeons have not paid enough attention to the problem or responded with sufficient urgency.
Dr. Audrey Garrett, an oncologic surgeon in Oregon, said she was “surprised” to hear that she was among the top tier of prescribers. She said she planned to re-evaluate her clinic’s automated prescribing program, which is set to order specific amounts of opioids.
Prescribing Patterns Highlight What’s at Stake
The analysis examined prescribing habits after seven common procedures: coronary artery bypass, minimally invasive gallbladder removal, lumpectomy, meniscectomy (which removes part of a torn meniscus in the knee), minimally invasive hysterectomy, open colectomy, and prostatectomy.Across the board, the analysis showed that physicians gave a large number of narcotics when fewer pills or alternative medications, including over-the-counter pain relief tablets, could be equally effective, according to recent guidelines from Makary and other academic researchers.
On average, from 2011 to 2016, Medicare patients in the analysis took home 48 pills in the week following coronary artery bypass; 31 following laparoscopic gallbladder removal; 28 after a lumpectomy; 41 after meniscectomy; 34 after minimally invasive hysterectomy; 34 after open colon surgery; and 33 after prostatectomy.
Hoping to reduce overprescribing, Makary is preparing to send letters next month to surgeons around the country who are among the highest opioid prescribers under a grant he received from the Arnold Foundation, a nonprofit group whose focus includes drug price issues. (Kaiser Health News also received funding from the Arnold Foundation.)
Even if the prescription numbers have fallen since 2016, the amounts given today are likely still excessive.
“When prescribing may have been five to 20 times too high, even a reduction that is quite meaningful still likely reflects overprescribing,” said Dr. Chad Brummett, an anesthesiologist and associate professor at the University of Michigan.
“Reducing unnecessary exposure is key to reducing the risk of new addiction,” said former Food and Drug Administration Commissioner Scott Gottlieb. In August 2018, when Gottlieb was at the agency’s helm, it commissioned a report from the National Academy of Sciences on how best to set opioid prescribing guidelines for acute pain from specific conditions or surgical procedures. Its findings are expected later this year.
Healers Sowing Disease?
Naturally, surgeons rankle at the idea that they played a role in the opioid epidemic. But studies raise serious concerns.Transplant surgeon Dr. Michael Engelsbe, director of the Michigan Surgical Quality Collaborative, points to the study showing 6 percent of post-op patients who get opioids for pain develop long-term dependence. That means a surgeon who does 300 operations a year paves the way for 18 newly dependent people, he said.
Many patients don’t need the amounts prescribed.
Intermountain Healthcare, a not-for-profit system of hospitals, clinics, and doctors in Utah, began surveying patients two years ago to find out how much of their prescribed supply of opioids they actually took following surgery.
“Globally, we were overprescribing by 50 percent,” said Dr. David Hasleton, senior medical director.
But Intermountain approached individual doctors carefully. “If you go to a prescriber to say, ‘You are overprescribing,’ it never goes well. A common reaction is, ‘Your data is wrong’ or ‘My patients are different than his,’” said Hasleton.
For the analysis, KHN attempted to contact more than 50 surgeons whose 2016 numbers ranked them among the top prescribers in each surgical category.
One who did agree to speak was Dr. Daniel J. Waters, who 13 years ago had his chest cut open to remove a tumor, an operation technically similar to what he does for a living: coronary artery bypass.
“So I have both the doctor perspective and the patient perspective,” said Waters, who practices in Mason City, Iowa.
In 2016, Waters’s Medicare bypass patients who filled their prescriptions took home an average of nearly 157 pills each, according to the KHN-Johns Hopkins analysis.
“When I went home from the hospital, 30 would not have been enough,” said Waters of the number recommended by the Hopkins team for that surgery.
But he said he has recently curbed his prescribing to 84 pills.
Nationally, the average prescription filled for a coronary artery bypass was 49 pills in 2016 and had changed little since 2011, the analysis shows.
Others who spoke with KHN said they had developed the habit of prescribing copiously—sometimes giving out multiple opioid prescriptions—because they didn’t want patients to get stuck far from the office or over a weekend with pain, or because they were trying to avoid calls from dissatisfied, hurting patients.
In the KHN-Johns Hopkins data, the seven patients of Dr. Antonio Santillan-Gomez who filled opioid prescriptions after minimally invasive hysterectomies in 2016 received an average of 77 pills each.
A gynecologic oncologist, Santillan-Gomez said: “I’m in San Antonio, and some of my patients come from Laredo or Corpus Christi, so they would have to drive two to three hours for a prescription.”
Still, he said, since e-prescribing of opioids became more widespread in the past few years, he and other surgeons in his group have limited prescriptions to 20 to 30 pills and encouraged patients to take Tylenol or other over-the-counter medications if they run out. E-prescribing can help track patients getting opioids and reduce the problem of patients having to drive back to the office to get a written prescription.
Dr. Janet Grange, a breast surgeon in Omaha, Nebraska, said that in her experience, opioid dependence had not been a problem.
“I can absolutely tell you I don’t have even 1 percent who become long-term opioid users,” said Grange.
The analysis showed that Grange had 12 opioid-naïve Medicare patients who had a lumpectomy in 2016. Eight of them filled prescriptions for an average of 47 pills per patient.
The Pendulum Swings
Some of the higher-prescribing surgeons in the KHN-Johns Hopkins analysis reflected on their potential contribution to a national catastrophe and are changing their practice.“That is a shocking number,” said oncologist Garrett, speaking of the finding that 6 percent of patients who go home with opioids will become dependent. “If it’s true, it’s something we need to educate physicians on much earlier in their medical careers.”
Garrett, in Eugene, Oregon, said she has cut back on the number of pills she gives patients since 2016. The KHN-Johns Hopkins analysis showed that seven of her 13 opioid-naïve Medicare patients undergoing minimally invasive hysterectomies filled a prescription for opioids in 2016. Those patients took home an average of 76 pills each.
Johns Hopkins guidelines call for no more than 10 opioid pills following this procedure, while Brummett’s Michigan network recommends no more than 15.
Surgeon and researcher Dr. Richard Barth, once a heavy prescriber himself, said that his own experience convinced him that physicians’ preconceptions about how much pain relief is needed are often way off.
The analysis showed his lumpectomy patients in 2013 filled an average of 33 pills in the week after surgery. By 2016, that average had dropped to seven pills. Many patients, he said, can do just fine after lumpectomy with over-the-counter medications—and often no opioids at all.
The key, he said, is to set patients’ expectations upfront.
“I tell them it’s OK to have a little discomfort, that we’re not trying to get to zero pain,” said Barth, who is chief of general surgery at Dartmouth-Hitchcock Medical Center and has published extensively on opioid prescribing.
After lumpectomy, “what I recommend is Tylenol and ibuprofen for at least a few days and to use the opioids only if the discomfort isn’t relieved by those.”
Indeed, the data analysis showed that a significant number of patients given prescriptions for opioids never filled them because they don’t need that level of pain relief.
Between 2011 and 2016, for example, only 62 percent of lumpectomy patients in the analysis filled prescriptions, similar to hysterectomy patients.
In 2016, patients of Dr. Kimberli Cox, a surgeon in Peoria, Arizona, were prescribed about 59 pills in the week following lumpectomy, well above the recommendations from both Johns Hopkins and others.
But the KHN-Johns Hopkins analysis of that year’s data shows that half of her patients never filled a painkiller prescription—a fact she acknowledges has changed her thinking.
“I am now starting to prescribe less because many patients say, ‘You gave me too many’ or ‘I didn’t fill it,” she said.
