How Many Opioid Pills Do You Need After Surgery?

With heightened addiction concerns, doctors are working to rein in prescriptions of pain relievers like oxycodone and hydrocodone.

When Mark Greenberg had arthroscopic knee surgery in 2017 he was surprised he got a prescription for 50 pills of the pain reliever Percocet from a fellow doctor. Percocet contains oxycodone, an opioid commonly used to treat pain but has a high risk of addiction.

“I never filled the prescription,” says Dr. Greenberg says, a pain management physician in Ashland, Ore. “I certainly didn’t need any pain medications for a relatively painless surgical procedure.”

The pain specialist says he can see how some patients getting such a procedure might need 10 or 15 pills to get them through the first couple of days. But he found 50 excessive.

The opioid epidemic kills on average 115 Americans a day, according to the Centers for Disease Control and Prevention. About 40% of overdose deaths in the U.S. involve a prescription opioid.

Emergency room doctors, dentists and outpatient physicians are curbing prescriptions. And surgeons are rethinking their own prescription practices.

Mark Lockett used to routinely send his patients receiving partial mastectomies home with 30 pills of oxycodone. The South Carolina surgeon changed that approach two months ago and now typically gives such patients 10.

“As a surgeon, I didn’t realize how many of my patients who were never on opioids continued on opioids after surgeries that I had done on them,” says Dr. Lockett, an associate professor of surgery at the Medical University of South Carolina in Charleston. “We heavily overprescribe, not intentionally, but because we don’t want patients to hurt, and what we do hurts.”

Many of Dr. Lockett’s fellow surgeons at his medical school have cut in half or more the amount of opioids given to patients undergoing common procedures such as knee replacements and hysterectomies.

Dr. Lockett’s efforts began after he attended an educational session at the University of Michigan, where experts have formed the Opioid Prescribing Engagement Network (OPEN), a group working to prevent the overprescription of opioids for acute care, or short-term treatment for a severe injury. The group focuses on surgery and dentistry.

The organization unveiled data-driven recommendations on the appropriate number of opioids to prescribe for 14 common procedures, such as gall bladder and colon removals, in October.

“We have so many opioids in our community,” says Chad Brummett, an associate professor of anesthesiology at the University of Michigan and co-director of OPEN. “Drawing back to where that person got the prescription is not easy in many cases. You can assume more than half are for chronic pain conditions. But we think acute care is the most important opportunity for prevention.”

Dr. Brummett says studies have found that between 6% and 13% of patients not using opioids before surgery use them persistently three to six months later. But it’s a continuing area of research, and experts aren’t entirely clear on how many patients who first receive an opioid prescription after surgery become dependent or addicted to them.

In one study, Dr. Brummett and colleagues found that about 6% of patients who received opioids for a minor or major surgical procedure became new persistent users, defined as getting at least one opioid prescription 90 to 180 days after their procedure. They published their study in JAMA Surgery in June.

Those with mood disorders, alcohol and substance abuse disorders and chronic pain disorders showed a higher chance of becoming a persistent user. Smokers also faced a higher risk.

Doctors also worry about what happens with unused opioids. Experts say unused pills can end up in the hands of adolescents, family members or friends or on the black market.

Mark Christopher Bicket, an assistant professor of anesthesiology and pain medicine at the Johns Hopkins University School of Medicine, published a review article in November in JAMA Surgery looking at six studies to determine how often opioids prescribed for pain go unused.

“We were fairly surprised to see across the board what we would consider very high rates of leftover opioid medications,” Dr. Bicket says. The rates ranged from 42% to 71%.

“These medications are often unsafely stored and not disposed of in recommended ways,” he says. Some hospitals and pharmacies collect them, among other methods.

Richard Barth, a professor of surgery and chief of general surgery at the Geisel School of Medicine at Dartmouth in Hanover, N.H., and his team came up with guidelines for prescribing opioids for five different procedures. They educated residents, nurses and other physicians on the guidelines. Opioid prescriptions had dropped by 53% four months later. They published their findings in the journal Annals of Surgery in 2017.

Dr. Barth says he know that opioids prescribed to postsurgical patients are just one factor of the opioid epidemic. But it’s one doctors can easily fix.

“I’m just trying to do my part as a physician to responsibly prescribe opioids,” he says. “I think if you do that, then fewer people are going to become longtime opioid users. It’s those people that go back to their family practitioners and keep demanding more opioids.”

Dartmouth doctors are encouraging patients to bring back unused opioids and depositing them in a dropbox installed in the pharmacy this month.

Surgeons have also started emphasizing to patients how using high doses of a combination of ibuprofen (Motrin or Advil) and acetaminophen (Tylenol) is just as or more effective in relieving acute pain following surgery, he says.

This article was originally published in the The Wall Street Journal.