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Overprescribing is Not the Way to Treat Pain

Recently, a generally healthy friend of mine had two small, unrelated surgeries over the course of a few months. For the first, a small operation on his hand, he received a prescription for 30 oxycodone pills. He used one the night after surgery, to make sure pain wouldn’t wake him. Over the next few days he used a few over the counter acetaminophen tablets for his modest discomfort, and then was all done. Two months later, a small suspicious lesion had to be removed from his leg by a different doctor. Again, he got 30 tablets of oxycodone. He used one the first night and continued with  acetaminophen. Problem solved.

But not really. The issue is that now this friend has 58 unnecessary oxycodone pills. Studies show that patients like him take many fewer pills than prescribed; one study of 250 patients counted 4,639 leftover pills from single prescriptions. Like many homes, my friend’s is frequently visited by friends and family members, including children, some of whom have struggled with addiction and may find those drugs tempting. It’s an invitation to misuse.

One Patient’s Pain-Control Question

The reasons for the prescription opioid crisis are many, and include false education and promotion from drug companies, reckless practices by many doctors and shockingly low availability and affordability of treatment programs for substance abuse.

Aware of the epidemic, my friend quizzed his second doctor during a follow-up appointment. Why such an oversupply of a potentially dangerous medication, since its use for acute pain increases the risk of abuse and overdose? The mildly embarrassed physician explained that since it is such a nuisance to prescribe pain medication it’s easier to give the patient extra pills to forestall requests for more. While this overprescribing might prevent a handful of patients from running out of a needed painkiller at an inopportune time, it seems like a risky practice.

Although the number of prescriptions for opioids is trending down, it is still substantially higher than it was at the start of the century. That’s why this tactic of giving more medication than is needed is so far removed from the intention of massive recent efforts to regulate and reduce the amount of prescription opioids in circulation.

New York State, for instance, has its I Stop program, which requires most physicians to check whether a patient is receiving controlled substances from other physicians before prescribing additional meds. There have also been efforts to educate doctors about opioid prescribing, both from state health departments and from the Centers for Disease Control (CDC).

One bit of good news in the battle against prescription opioid abuse is that when a doctor does prescribe controlled substances, that prescription may now receive more scrutiny. California, for example, decided to track overdose deaths and then send letters to some of the doctors who had prescribed opioids to those deceased patients within the previous year. They didn’t tell them to change their practices or that they were in trouble; they just told them their patient had died of an overdose from a drug they prescribed. Researchers studied this group, as well as a similar one of physicians who did not get letters after their patients  had died from  overdoses. The notified physicians showed a significant decrease in the amount of opioids prescribed. This intervention came too late to save some patients, but may help others in the future, and it demonstrates the positive return on a policy that works to decrease opioid prescribing.

Other Approaches to Pain Management

Now, some may quibble that 30 pills (as my friend received) is not so many. After all, for an opioid-naïve person, this amounts to being fully dosed, around the clock, for a bit more than a week. Is that the best or only approach to pain control? My friend certainly didn’t feel that way. And the CDC recommends exploring nonopioid methods to control acute pain, including over-the-counter drugs such as acetaminophen, or nonmedication methods such as ice, heat and massage. It adds that when opioids are used for acute pain, treatment should last for a maximum of three days.

One thing that neither of my friend’s doctors did was talk to him about his views on and need for pain control. In each case, they sent in the prescription to his pharmacy without discussion. A brief conversation about his individual needs could have led to a better plan: liberal use of nonpharmacologic pain control, a maximum of three days of opioids, backup use of safer over-the-counter meds and an agreement that a little pain can be a useful way to monitor recovery.

Doctors played a role in creating the opioid crisis we’re in now. We can’t stop it all by ourselves, but we can do something positive to help prevent the abuse.

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Tia Powell, M.D.

Tia Powell, M.D.

Dr. Powell is director, Montefiore Einstein Center for Bioethics and Master of Science in Bioethics. She holds the Dr. Shoshanah Trachtenberg Trackman Faculty Scholar Chair in bioethics, and is professor, epidemiology and psychiatry at Einstein.

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