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resident Trump’s recent call to reduce opioid prescriptions by one-third over the next three years may seem like a daunting task, even unrealistic. But it’s possible to do right now — without a lot of fanfare, new regulatory rules, or torturous legislation.

The solution lies with surgeons like us. Until now, we have not really had any data to guide us when deciding how much of an opioid painkiller to prescribe when patients are discharged from the hospital after major surgery. And many with substance use disorder admit that they initially became dependent on opioids through prescriptions following medical procedures.

Research we conducted and published in the Journal of the American College of Surgeons shows how surgeons can determine an appropriate prescription. We found that many patients use less than one-third of the opioids prescribed to them, allowing unused medications to sit in a bathroom cabinet or be diverted or stolen for illicit use.

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Deaths from opioid overdoses have more than quadrupled in the past 15 years, to at least 42,000 per year, and are now the leading cause of injury-related mortality in the United States. An important contributor to this problem is the quadrupling of the number of opioids prescribed during this same time.

Our study evaluated 333 hospital inpatients discharged home after six different types of general surgery operations: bariatric procedures; operations on the stomach, liver, pancreas, and colon; and ventral hernia repair.

The most important finding from the 90 percent of survey respondents was that the number of opioid pills taken the day prior to discharge was the best predictor of the number used at home by patients. This allowed us to formulate a simple guideline for discharge opioid prescribing that would satisfy at least 85 percent of patients’ home opioid needs. If no opioids were used the day prior to discharge, none should be prescribed; if one to three opioid pills were used the day prior to discharge, 15 pills should be prescribed for five days of pain relief; and if more than four pills were used the day prior to discharge, 30 pills should be prescribed.

This guideline would apply to a variety of different surgical procedures. We found that the type of surgery patients had did not affect the number of pills they used at home. If we used this guideline instead of our standard opioid prescribing, the number of opioid pills prescribed would decrease by 40 percent.

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We know that surgeons will change their practice when shown good data. In previous studies of opioid prescribing after outpatient general surgical operations, we found out how many opioid pills patients needed after surgery and used that to formulate prescription guidelines. By simply educating the surgeons in our group at Dartmouth-Hitchcock Medical Center, we were able to cut opioid prescribing by general surgeons by more than half and still take care of patients’ pain.

There is no need to politicize or endlessly legislate this simple process that could have a meaningful impact on the opioid epidemic. We in the medical community can take action today.

Richard J. Barth is chief of general surgery and Maureen V. Hill is chief resident of general surgery at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

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  • To address surgeons… yes most can live with basically zero Rx’s a week after surgery depending on the surgery. I did myself. Long term diseases however do not apply so it’s a moot point when it comes to millions who do not have resolved pain issues. Sadly a topic never addressed.

  • I Just want to share what’s happening with opiates lately. I was seeing my doctor 4x a year last year (uncalled for) & he was feeling political pressure so sent me to pain mgmt, which is every month. So far I’ve had his 3 visits & 4 at p.m. I’ve also been drug tested all 4x at p.m. Now he tells me he needs to see me quarterly again because I’m taking a sleep aid (20 years+) & he’s supposed to drug test me too. So now 16 doctor visits & 16 drug tests per year that has been monitored just fine basically once a year most of 20+ years? I take very small amounts (15 mg extended release 2x a day) Patients like me are entirely fed up with these asinine rules being imposed. It’s expensive, needless & adds to the misery sitting in an office 16×1.5 hours each time. When will we ever get back to the reality of doctor-patient only? The number who abuse Rx’s are negligible in comparison to real patients & real doctors (I seriously don’t believe the numbers of overdoses – intentional yes most because of regulations causing excruciating pain). We need to stop making us suffer & pay the price of addicts. Most of us are very responsible just like legal gun owners. Enough is enough!

  • Your data does not support people who have lost limbs and other horrific fatalities while serving our country. Nor does it mention those of us who have orthopedic injuries as well as listening to our Orthopedist and Neurosurgeon when they said that surgery would help the crumbling joints due to osteoarthritis or injury. Then, there are those of us who were told that we needed a repeat surgery to correct the problem and the pain, which only left us with nerve damage. I, myself, am 62 and have had 11 left hip surgeries with each one being recommended by no less than 2 consultations not counting the Orthopedist who was treating me. On top of that, I have had 6 right wrist surgeries, each one more involved than the one before and each one leaving me in more agonizing pain. Let’s also add in 3 back surgeries, 2 left knee, 1 right shoulder as well as multiple broken ankles. I think I have one toe that has not been broken and the rest are working on their 2nd or 3rd fracture. Let’s also take into consideration the surgeries I have said no to and was actually admonished for doing this — those being:. My right knee needs to be replaced as well as a 4th back surgery, both of which I feel will leave me either bedridden. So sir, while I understand your comment about the amounts of pain medicine that patients need to be discharged home with, please also understand my point of view where one has little to do with the other. It would be great if the opiate limits were being set-up in this manner, but they aren’t. My pain is quite different from someone having out- patient surgery, but we are all being grouped as one. Chronic unrelenting gutwrenching pain should not be categorized with post-operative pain from a one time cholecystectomy or bunion surgery. Chronic pain patients have paid our dues, have suffered for years with uncontrolled pain, and just when we finally found the help we needed with opioids, in dosages that controlled our pain on an individual basis, enabling us to live as normal a life as possible due to our disabilities, people as yourself who most likely have never experienced this kind of pain, day in and day out, just add to the hysteria that all pain patients are going to overdose and that we need your help to make us see the light. Your opinion is not needed, is not wanted, and as I said, one has nothing in common with the other. What did cause my uncontrolled chronic pain, which was controlled before the opioid cutbacks, was doctors who I consulted, pleading for help and asking for their opinion, and I was told I needed the surgery to fix the problems that arose from the prior procedure and so on. I plan on following in the footsteps from the man in Maine, who took steps to sue his state because of the amount of medication limits that were being imposed. One day, sooner or later, the very people who are imposing these opioid limits are going to need opioids themselves or maybe for a son, daughter or mother, and they are going to see the damages that were caused when they can’t find a physician to prescribe them. Maybe then they will understand our pleas not to impose these limitations. This is a direct violation of my civil rights — withholding medication that my doctors have prescribed. Chronic pain is a legitimate diagnosis ICD-G89.4, and is no different than a diagnosis of diabetes, cardiovascular disease or emphysema. Opiates do not take it away, but it can be controlled with varying amounts. How dare treatment be withheld from me, from us, from our husbands and wives, our parents and even our children. Pain patients need to get angry and start filing lawsuits and having marches at the capital. April 7 across the nation is an important date to show this has to stop with “Don’t Punish Pain” rallies in every state.

    • To Everyone that is effected with pain like myself, after much deliberation myself I would ask that you take a step back and see if you can educate yourself and accept sll the issues at hand….
      1st of all , its clear based off reading Thousands of other pain patients like myself, WE must start trying to justify the use as well as STOP all the Drama already.
      Yes we know we hurt
      Yes time snd time again we see “ Ypu should try living with my pain “ yadda – yadda !!
      I get it …
      i feel it
      I live it daily! Yet whenever we see topics that make us afraid (ie- reducing opioids “
      Every single pain patient becomes Fearful snd starts listing their justifications as well as list surgeries ECT – just stop – please …

      As for these laws and guildlines – its clear that many of us go into protective mode – thats clear…..
      1st of all – with the new more potent opioid drugs introduced into the market over the last 10 years – anyone honest would have to admitt something much change.
      The facts are the Facts – the majority of the Patients only take 30% of those pills that where THoUGHT to be needed. SO WHY fight and jump to the issuewhen it comes down to it
      That anyone would be kept in pain because of a pill count.
      The different potencies and strength ALONE make your argument Null and viod. Take for example if a pain pt was on Hydrocodone and under the guildline should get say 15 pills – pain pts with a tolerance and a physician that knows about it Could easily JUST switch drugs to a more potent drug as one of the many Morphine substances and MGs avaliable on the market to cover them. So that places that to rest.

      Until you are ready to keep an open mind and actually admit the issue and be positive on how to maybe fix it- Its clear that the stereotypic Opioid Tolerant Chronic Pain PT will always look for something weong.
      Just like showing that you may think you understand how and what to do about building tolerance of meds esp opioids you will never admit to see the behavior that continues to be detrimental.
      We need to actually Admit and accept that we will be in Pain for our lives.
      2- unless You are Actually Unemployed – Bed ridden – or most importantly TERMINALLY ILL – on a path to death – Its a fact that Yes your pain meds should be highly restrictive !!! Patients that are in our group continue to only have one beleif and this belief is that

      1- No one could ever understand MY PAIN
      2 NO OTHeR DRUGS work besides Opioids and after awhile – MORE of them.

      3- many of us will write HUGe responses to any question or FACT posed that shows those maybe taken away and instead of dealing with the ENTIRE Group of us that have had those back surgeries- those replacements – ect
      YOU CHANgE the Response to some that is ALL about
      YOU – YOU -YOU – On and ON and ON…

      Go ahead and read any patient board and tell me tahts not true…..

      There are countries that have Opioids Illegal all together outside of a hospital or hospice…. Do those people continue LIFE – do they function – Do they die – NO !!!
      I said NO !
      They find BETTER ways to manage IT !!

      Do NOT tell me people in the 1960s and 70s couldnt function or EVEN had the idea that big pharma had to produce 80 MG orginal Oxycontin for ANYONE thats not on their Death BED to actually take and Live life ….. IT was NOT dreamed of or needed.
      That PAIN level has NOT changed nor the way people experience PAIN did … so what did ???

      Making PAIN a 6th Vital Sign !
      Rediculas !!!
      And thats coming from a 30 year Chronic pain patient myself !!!

      So instead of admitting the problem and looking for solutions to deal wuth the facts on the ground (ie- this is a epidemic that thousands of people are dying yearly to ) is unnecessary!!!

      70 % of these New Opioids should be restricted to Terminal Patients. THOSE that have a prognosis of potentially Dying – absolutely SHOULD get whatever they need and they will –

      However its clear taht so many of us are NOT allergic to non Opioid treatments and those non Opioid treatments do allow people to function – and function quite well throughout the world !!!

      I know at some point you all within our Chronic Pain Group – That I belong to will come to a point that you to will admit this and see it sooner then later .

      These comments that
      There are so many uncaring – heartless people out there tryibgbto DO YOU wrong is such B-S !!!

      You are having this view on control 2 drugs and refuse to help yourself by being able to look at the FACTS of the substance – How the substance actually work
      And most importantly being able to combine that with the facts of everyday life – YOU should be thanking people and UNDERSTAND that these same people you have an issue with are actually Caring, Processing the info and Loving you because they care so much about you staying alive number 1 and number 2 – looking for ways to fix this situation that is pulling our families apaet in one way or another…
      Unfortunately its in a

    • I totally agree. I suffer with multiple chronic pain issues on a daily . And I agree hey cover all diferentntypes of people with pain .

  • All I know is there are a lot more cold-hearted, uncaring people out there than I thought was possible. To leave a documented pain patient with no relief is taking away their quality of life. People who can’t defend themselves against so many who want to have change for the sake of people addicted to drugs and sex. They are more concerned about Aids patients. Probably because that affects so many it higher positions. People in agony don’t count and are being ignored and picked on because it’s easy to go after registered pain patients. Pick on the people that make the heroin trade possible, the CIA and US government. They make the epidemic possible by making sure farmers oversea’s have a poppy crop to grow to make a little money. There are movies made about it, but they put it on the backs of US citizens. Who is running this country.

  • Unintentional fall deaths
    Number of deaths: 33,381
    Deaths per 100,000 population: 10.4
    Don’t we then have a accidental fall crisis too by your definition? Who are you people?
    Pure horseshit. Money being made off the backs of the most vulnerable. Doctors who care more about themselves than patients, and a bored to death DEA. They need to fill up those for profit prisons somehow. I would love to see the prescription list of some of the proponents of this witch hunt.
    one day tRump will be over…….it’s all just a bad dream.

  • Living in NH, unfortunately, I have a front row seat to the toll the opioid epidemic is taking on our state. I’ve read about the efforts of Dr. Barth and DHMC and applaud them for trying to make a difference. I suggest people actually read about the various studies they’ve done before criticizing them. The studies were done in a totally logical manner and make perfect sense. Thank you Dr. Barth and DHMC!

    • How come none of these studies involved input from the pain patients and the pain physicians treating them? They asked for input from people who had no idea about chronic pain. Can’t wait to see you after a failed hip replacement!!

  • We are about to get nuked in the “opioid” war. I’ve never seen people become a flock of obedient sheep so quickly and so completely.

    The powers that be are all but taking away prescription pain medication so law enforcement will have less to contend with in circulation. Do not be so naive as to think that this “opioid” panic is for your benefit. It’s for theirs.

    One day you may find yourself in terrible, chronic pain, and in the final cruel irony, the only place to turn for help may be the streets.

    • It’s not just pain medication though.

      All controlled substance drugs have been put under the same ridiculous, unfounded restrictions…ambien, anti anxiety drugs, etc. None of this is based on fact or reality, so until the tRump team is out grandma has to pee in a cup and be treated like some criminal. Pot is legal however?????

    • And, woe to the elderly infirm who can’t even get to “the street.” This whole anti-pain relief thing has gone too far.

    • You are 100% right, Mike. Sadly, from what I have read lately, desperate people are already turning to the streets.

  • Will this get everyone off the backs of intractable and chronic pain patients and keep us from further cuts to our vital medications?

    • I’m not sure what your point is. Most never dream of medical conditions that are extremely painful and no surgery or PT applies. I believe no one is qualified to address chronic pain if they aren’t experiencing it themselves. Politicians & other government agencies decide limits regardless of any knowledge of patients’ maladies. They also do not have to follow their own laws ever. Trump is by far the most simple minded gullible easy to convince president we’ve ever had. Just because he stays far away from alcohol & cigarettes because of his brother’s early death. He sqawks about fake news but is all in on fighting opiates. Another ignorant idiot that has control over us. He & the rest know way more than medically trained doctors. All of them. It’s absurd.

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