As opioid addiction and deadly overdoses escalated into an epidemic across the U.S., thousands of surgeons continued to hand out far more pills than needed for postoperative pain relief, according to a KHN-Johns Hopkins analysis of Medicare data.
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 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, often with instructions to take one to two pills every four to six hours, as needed. The total amounts frequently 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 cardiac 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.
In sheer numbers, opioid prescribing in the U.S. peaked in 2010, but it remains among the highest in the world, according to studies and other data.
In 2016, opioids of all kinds were linked to 42,249 deaths, up from the 33,091 reported in 2015. The opioid-related death rate jumped nearly 28% from the year before, according to the CDC, and the rate of deaths involving prescription opioids increased 11%.
Yet long-ingrained and freewheeling prescribing patterns changed little over the six years analyzed. KHN and Johns Hopkins examined the prescribing habits of all U.S. surgeons who frequently perform seven common surgical procedures and found that in the first week after surgery:
- Coronary artery bypass patients operated on by the highest-prescribing 1% of surgeons filled prescriptions in 2016 that exceeded 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, with little variance from year to year. The highest-prescribing 5% of surgeons prescribed 40 to 70 pills on average.
- Some knee surgery patients took home more than 100 pills.
Those amounts — each “pill” in the analysis was the equivalent of 5 milligrams of oxycodone — are many times what is currently recommended by some physician groups to relieve acute pain, which occurs as a result of surgery, accident or injury. The analysis included only patients not prescribed opioids in the year before their operation.
“Prescribers should have known better” based on studies and other information available at the time, said Dr. Andrew Kolodny, co-director 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.
Surgeons’ prescribing habits are significant because studies show that 6% of patients who are prescribed opioids after surgery will still be taking them three to six months later, having become dependent. The likelihood of persistent use rises with the number of pills and the length of time opioids are taken during recuperation.
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.
Interactive: Look up surgeons’ opioid prescribing records
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.
But surgeons also indicated that the way they prescribe pain pills was less than intentional. It was sometimes an outgrowth of computer programs that default to preset amounts following procedures, or practice habits developed before the opioid crisis. Additionally, they blame efforts in the late 1990s and early 2000s that encouraged doctors and hospitals to consider pain as “the fifth vital sign.” A major hospital accrediting group required providers to ask patients how well their pain was treated. Pharmaceutical companies used the fifth vital sign campaign as a way to promote their opioid treatments.
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.
Indeed, 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 reevaluate her clinic’s automated prescribing program, which is set to order specific amounts of opioids.
KHN will analyze data for 2017 and subsequent years when it becomes available to follow how prescribing is changing.
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.
According to post-surgical guidelines spearheaded by Makary for his hospital last year, those surgeries should require at most 30 pills for bypass; 10 pills for minimally invasive gallbladder removal, lumpectomy, minimally invasive hysterectomy and prostatectomy; and eight pills for knee surgery. It has not yet published a guideline for open colon surgery.
The Hopkins doctors developed their own standards because of a dearth of national guidelines for post-surgical opioids. They arrived at those figures after reaching a consensus among surgeons, nurses, patients and other medical staff on how many pills were needed after particular surgeries.
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.
Brummett is also co-director of the Michigan Opioid Prescribing Engagement Network, a collaboration of physicians that makes surgery-specific recommendations, many of them in the 10- to 20-pill range.
“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 he 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.
“There are still too many 30-tablet prescriptions being written,” said Gottlieb.
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% 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 do not 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%,” 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 new analysis, KHN attempted to contact more than 50 surgeons whose 2016 numbers ranked them among the top 10 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’ 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 in the week after a heart bypass.
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 not only help track patients getting opioids but also 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, Neb., said that in her experience, opioid dependence had not been a problem.
“I can absolutely tell you I don’t have even 1% 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.
She called Johns Hopkins’ zero-to-10-pill pain-control recommendation following that procedure “miserly.”
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% 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, Ore., said she has cut back on the number of pills she gives patients since 2016, when the KHN-Johns Hopkins analysis showed that seven of her 13 opioid-naïve Medicare patients undergoing minimally invasive hysterectomies filled a prescription for opioids. 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% of lumpectomy patients in the analysis filled prescriptions, similar to hysterectomy patients.
In 2016, patients of Dr. Kimberli Cox, a surgeon in Peoria, Ariz., 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 and that 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.
Kaiser Health News (KHN) is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente. Julie Appleby can be reached at [email protected] and Elizabeth Lucas can be reached at [email protected]. On Twitter, they’re at @Julie_appleby and @eklucas.
What kind of an idiot tortured more than 90% of their patients because barely more than 5% may become dependent? What kind of sadistic barbarian says this is good?
For tens of thousands of years of evolution our species wanted to help people in pain, and were unable to do so. Now we have the ability, and some morons decide we should not.
You are the voice of reason!
If you are a physician and are persuaded by articles like this – All if can say is I am glad you are not treating me. These arguments are technically incompetent and illogical. One does not treat fraudulent statistics – Physicians treat patients. Real life Patients. This article encourages Physicians to torture patients by purposefully under prescribing absolutely necessary pain medication – an unethical act. I can understand why incompetent journalist repeat this foolishness – but it is unacceptable for a Physician to buy in to this garbage. If you cannot distinguish dependence from Addiction – turn in your medical license.
Gary stop pushing MMJ, and CBD because it doesn’t work for everyone and a lot of people still can’t get and a lot of others will get kicked out of pain management if they do. As an MD you know that opioids are fairly safe if the patient takes as prescribed, they don’t cause organ damage like a lot of other medications. As for antidepressants, Cymbalta is what is being prescribed to treat pain now and it is one of the worst meds out there with a ton of bad side effects.
Mitzy, you are correct about Cymbalta!
I was unaware of the risks of abruptly stopping and since it did not do anything to help with my pain…after a 30day trial, I just quit taking it!
I wound up in the hospital for nearly two weeks!
Re: MMj and CBD…I also agree with you.
I wonder why so many have accepted this as a reliable alternative “treatment”
without any reliable, LONG TERM studies to support such a sudden & widespread adoption.
Regardless of anyone’s personal opinion.and/or anecdotal experience…
Marijuana remains restricted by the at the federal level….even as it gets stronger and stronger…why no concern about the marijuana-naive patient?!?
and CBD is not well-regulated…many states have no idea what’s in the products!
The public worries about water purity, organic foods and clean eating, etc, etc.
yet, there’s an eagerness to ingest marijuana with little research…
I just wonder if in another 10 years, we’ll be reading about the unintentionally harmful consequences of marijuana’s widespread acceptance!
Mitzy, thank you. I agree with your comments 100%. Not only is Cymbalta frequently ineffective, with a TON of side effects to boot, but guess what – Cymbalta abuse is now RAMPANT. Junkies gonna get high, you know?
Pain relief is necessary after surgery. Pain prescriptions are not the bad guy that is fueling the opioid crisis, it’s street drugs and most of all overinflated statistics!
That 6% statistic could, no doubt, include those that already had addictive qualities. It would also mean that 94% of us do not. So, your answer is to make all chronic pain patients suffer because of the infinitesimal number of those that were either kidding themselves about their potential or lying to themselves or their Dr. This is NOT a case of a “big bad drug” swooping in to create addicts where there was none. This is a case of those who already had the potential lurking inside (addiction is a disease that comes down to biology 70% of the time) How do we know these patients had not misused other substances before this time as well? People do not want to look at themselves or reveal things that have stigma attached. Does anyone think about the bigger picture here? These are adults, not infants. To create this story that makes the patients infants in their own care creates dependency of another level altogether. This discussion smacks of blame and that is part and parcel of the addicts game. We are not helping with blame and control. We need to educate and empower.
As a pain patient of 32 years I have to disagree. I’ve been treated with opioids all these years and I’m sorry to disappoint you but I’ve never been over medicated or became an addict. Even during the era of extensive pain control I’ve only taken the bare minimum, just enough to allow me to stay out of bed and function but never pain free. I’ve had a lumpectomy with no additional prescriptions although I could have certainly used it. My gallbladder was removed and stones removed with two surgeries in two days. That one was brutal and required additional prescriptions for two weeks. I’ve had oral surgery with an infection in my upper jaw and a cadaver bone used after removing the infected section of bone and sent home with additional much needed pain meds. All of these surgeries were very painful but I was not overprescribed by any means. I’m still on the same low dose meds I was originally prescribed in 1989. I’m really ashamed of the medical community and the lack of compassion! At 61 and rapidly deteriorating I’m really afraid for my life in the current climate. Don’t lecture me, I don’t trust you!
With all due respect to the successes that surgeons accomplish in their work : the over-prescribing of opioids by surgeons as indicated in this article is mind-boggling. No wonder the crisis is kept alive, when autocratic surgeons refuse to change their prescription habits. And automated systems in their practices ?? these have still not been adjusted – or better : abolished?? Do surgeons not read or see the news?? Or do they think they are above reproach? It seems quite apparent for the logic of dire needed new laws to curb these bad habits !!
The statistics in this article are false. Surgeons are not and haven’t I over prescribed opioids. Have you had surgery? I’ve had 6 and I’ve never been given more than 30 pills that was not enough. It takes a long time to heal from some surgeries and untreated pain makes it worse and longer. Not to mention that hardly anyone gets addicted from post op prescriptions unless they already had a substance abuse issue. Right now people are screaming and crying in hospital beds for being under treated for pain and some are not given a prescription to take home. So shut up because you don’t know what you are talking about and neither does this fake new propaganda article.
CBD (cannabidiol) is already known to be able to reduce or eliminate the use of opioids. It cured my migraine. Available by prescription or outlets such as cbdMD in KY. CBD will drive Tylenol out of existence, and greatly reduce the use of NSAIDs.
Sorry but CBD and marijuana dont work for everyone. I’m glad it works for you. But it does absolutely nothing for me and I really wanted to to work and gave it months at the cost of several hundred dollars. Not only did it not help my pain I didnt get any of the other benefits it claims either.
CBD is indeed a gift from nature and it is wrong for our government to deny us its use. That doesn’t make it okay for the government to also deny us the use of opioids! I know so many people who try to use the “opioid crisis” as the foundation for their pitch to legalize cannabis. How about you preach CBD on its own merit and stop doing verbal harm to people who need opioids?
I suffer from classic migraine headaches…
including aura, nausea & sensitivities to light and smells..
Marijuana, just the SMELL, would do nothing as a cure for my symptoms…
Please realize that there is no one-size-fits-all treatment.
There are genetic differences which affect outcomes!
Your arrogance saddens me.
Still much work to be done with Dentist. Just had a crown replaced and was offered Opioids….
That’s what should happen. Opioid hysteria is largely fact impaired
This is a government conspiracy to kill off baby boomers so there are less patients overwhelming the system. They started by criminalizing patients who have so called chronic pain. Thuggish, mean, pain specialists took away from the weakest, poorest, unable to sue for malpractice, and most vulnerable elderly their only help with quality of life. Why is the VA not putting out the number of increased suicides or civilian suicides from uncontrolled pain?. Legalize marijuana now nation wide. No one ever asked the patients for their view or permission. Ive been through hell and could write a book as to what Ive seen. No one leaves the doctors office or pharmacy happy. They think deadly antidepressants is the answer for everthing.
Zoloft is not a deadly antidepressant. Paxil is.
Cannabidiol will be a better mood stabilizer than lithium, and much more anti-anxiety and antidepressant.
Cbd doesnt work for everyone and I gave it MONTHS! It did absolutely nothing for me.
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