Johns Hopkins panel creates guidelines for prescribing opioids after common surgeries

Johns Hopkins Hospital is recommending its doctors give patients far fewer opioids following surgery than they have in the past, after a panel including doctors, nurses and patients looked at the prescribing habits of physicians.

The panel developed guidelines for how much opioids doctors should prescribe for patients after 20 specific surgeries, such as hysterectomy and breast surgery, saying there is no broad brush formula for pain treatment with opioids.

It is the latest effort by the medical community to reduce the amount of opioids prescribed to patients. Some of the nation’s epidemic of opioid addiction and overdoses has been traced to doctors generally prescribing more of the painkillers than patients need.

Hopkins doctors hope the guidelines, published Tuesday in the Journal of the American College of Surgeons, spurs more action by surgical associations and hospitals across the country to reduce the prescribing of opioids.

“Our feeling is we shouldn’t just be using draconian, one-size-fits all prescribing,” said Dr. Martin Makary, a professor of surgery and health policy expert at the Johns Hopkins University School of Medicine and the study’s senior author. “Everyone is different. Opioid prescribing should fall within a best practices range and currently we don’t do very well with that. Our hope is that this represents a first step in better understanding how we can treat pain better.”

For years, doctors prescribed one-size-fits-all painkiller prescriptions for patients. Everyone was sent home with essentially the same bottle of pills regardless of the procedure.

Ideally, Makary said, the nation’s different surgical associations would come up with guidelines for all doctors to follow. But Johns Hopkins isn’t waiting and plans to lead by example.

The Baltimore hospital will begin teaching doctors in its residency program the new guidelines developed by the panel. The hospital’s electronic medical system also will default to the new prescribing guidelines. Currently, the system suggests a 30-day supply for surgeries, defaults that have been “dangerously high” for too long, Makary said.

The guidelines cover 20 common surgeries, including breast surgery, thoracic surgery, orthopedic surgery and cardiac surgery, among others such as open hysterectomies and cochlear implants. The panel was made up of 30 surgeons, pain specialists, outpatient surgical nurse practitioners, surgical residents, patients, and pharmacists.

The panel recommended one to 15 opioid pills for 11 of the 20 procedures, 16 to 20 tablets for six of the 20 procedures, and no opioid tablets for three of the 20 procedures.

Orthopedic surgery procedures needed the most opioid painkillers and otolaryngology (ear, nose and throat) procedures the fewest.

The dosages are just guidelines and doctors can adjust prescriptions based on the condition of each patient.

Reducing how much opioids are prescribed is critical because one in 16 surgical patients eventually become long-term drug users, Makary said. Half of patients who don’t need opioids in the hospital after a surgery are sent home with a prescription anyway, he said.

The panel found that patients typically were not comfortable using all the drugs their doctors prescribed. Other research has found that 70 percent to 80 percent of opioid pills prescribed to patients are never used, Makary said.

Makary said there is a place for opioids for patients with debilitating pain. But there are other ways to fight pain, he said, including less addictive drugs, such as ibuprofen and using anesthetic and blockers directly at the pain site.

“We don’t just need treatment and rehab facilities,” Makary said. “We shouldn’t just be cleaning up the floor, but we should be turning off the spigot of overprescribing that doctors did with good intention, but bad science.”

Dr. Heidi Overton, a surgery resident at Johns Hopkins who worked on the study, said the creation of the guidelines lets the medical community play a role in a problem they unknowingly helped create.

“This work reflects that surgeons want to be a part of the solution,” she said.

The American College of Surgeons has not issued guidelines, but said it soon will release a patient education brochure “to help surgeons facilitate a dialog with their patients on postoperative pain relief.”

Other researchers around the country also have developed similar guidelines.

Dartmouth Hitchcock Medical Center researchers recently suggested guidelines be made based on the amount of opioids a patient was taking the day before being discharged from the hospital. The Dartmouth study findings were published in the Journal of the American College of Surgeons.

They recommended no pills for patients who took no opioids the day before they left the hospital; 15 pills for those who took one to three pills and 30 pills for those who took four or more pills. The researchers said the type of operation did not matter.

University of Michigan researchers recently recommended reducing opioid prescription guidelines for the weight loss surgery known as a sleeve gastrectomy and several other surgeries. Their findings were also published in the Journal of The American College of Surgeons.

They recommended reducing the number of pills after sleeve gastrectomy from 89 to 58. Hernia was reduced from 37 pills to 21; appendectomy, 35 to 17 pills.

amcdaniels@baltsun.com

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UPDATES:

4:20 p.m. August 28: This story has been updated to correct that it was a sleeve gastrectomy that University of Michigan researchers recommended reducing the number of pain pills to 58 from 89.

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