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Opioid Prescribing: New Guidelines for Massachusetts Physicians 

May 29, 2015  |  Falmouth Enterprise

Dr. Michael Bihari

Several weeks ago, the Boston Globe published the results of a poll conducted by the Globe and the Harvard School of Public Health that gauged awareness and concerns about opioid medication abuse in Massachusetts and nationally. Two of the poll questions dealt with prescribing of opioid medications:

“During the past 2 years, have you taken any strong prescription painkillers, such as Percocet, OxyContin, or Vicodin, prescribed by a doctor for you to use for more than a few days, or not?” For both the state and nationally, one out of five people answered yes.

“Before or while you were taking these strong prescription painkillers, did you and your doctor talk about the risk of prescription painkiller addiction, or haven’t you talked about that?” Nationally, 61 percent said “yes, talked about the risk” while in Massachusetts 36 percent answered yes and 61 percent said “no, did not talk about the risk.” These figures may indicate that we are not doing the best we can to educate physicians and patients about the dangers of long-term use or misuse of opioid medications.

Enter the Massachusetts Medical Society

Founded in 1781, the Massachusetts Medical Society (MMS) is the oldest continuously operating medical society in the country. MMS, which publishes the New England Journal of Medicine, has more than 24,000 physicians and student members and functions as an advocate for patients and physicians in the state.

Last week MMS announced plans to initiate a campaign to educate physicians and other healthcare professionals, and the public, about the safe and responsible prescribing and management of opioids.  According to the Society’s President Dennis M. Dimitri, MD, “Physicians must step forward immediately to do everything we can to help bring this devastating problem under control. There is no more important public health issue today than the opioid epidemic.”

The MMS website indicates that the campaign will have three components; a set of guidelines to help physicians make the right decisions for their patients; free education resources for prescribers, including the Society’s Pain Management courses (such as Managing Pain Without Overusing Opioids); and a program to educate the public about proper storage and disposal of medications.  

The MMS Guidelines

An outline of the MMS guidelines can be found on the organization’s website. 

MMS has developed separate guidelines for the treatment of acute and chronic pain; the guidelines for the management of chronic pain apply to patients who receive opioid medications for more than a 90-day period. The guidelines do not apply to patients with cancer, patients in hospice or palliative care, and  people being treated in hospitals and nursing homes. 

MMS assumes that their guidelines will mostly be used by primary care physicians (internists and family physicians) who are the most frequent prescribers of opioid medications: “We recognize that this document creates opioid prescribing guidelines that have general applicability and are most relevant in primary care.” 

The MMS is working with appropriate specialists and specialty organizations to review opioid prescribing issues and guidelines unique to that specialty.  The Society recommends that physicians practicing in the state should review existing guidelines for their individual specialties (such as orthopedic surgery, emergency medicine, OB/GYN, and others). 

Orthopedic Surgeons

In an introduction to an article - The Opioid Epidemic: Impact on Orthopaedic Surgery - published in the May 2015 issue of the Journal of the American Academy of Orthopaedic Surgeons, the author stated that, “Orthopaedic surgeons are the third highest prescribers of opioid prescriptions among physicians in the United States. Thus, it is important for orthopaedic surgeons to understand the detrimental effects of opioid abuse on individuals and society…” Read the full article. 

The article also states that, “Orthopaedic patients can experience a tremendous amount of pain with acute injuries and chronic conditions, and following surgery the treatment plan may involve opioid prescriptions for relief of discomfort.” The American Academy of Orthopaedic Surgeons (AAOS) does not currently have guidelines for the appropriate use of opioid pain medication.

At their annual national meeting in 2014, the AAOS held a symposium -  Managing Surgical Pain in the Opioid Epidemic Era - during which expert panelists shared strategies for reducing opioid prescriptions.

Noting that the pills of the opioid epidemic “aren’t stolen, they are physician-prescribed,” symposium speakers made no effort to sugarcoat the problem of opioid overprescription, abuse, and addiction. Several of the presenters offered strategies for providing humane and effective pain management to patients while blunting the risk of abuse.

Some Interesting Statistics

In a recent study of patients who were prescribed opioids after outpatient orthopedic surgery, almost half of the patients used less than five pills from the average of 30 pills that were dispensed. On average, 19 pills per patient were unused.

According to a study looking at the use of narcotic painkillers in the U.S. and The Netherlands, “American patients are prescribed significantly more inpatient and outpatient narcotic pain medication than Dutch patients” after surgical treatment of hip fractures. 85 percent of American and 58 percent of Dutch patients were prescribed narcotic painkillers during hospitalization. After discharge from the hospital, 77% of American and none of the Dutch patients were prescribed narcotics. 

Vicodin, the most widely used opioid pain medication and the most frequently prescribed medication for people with Medicare, is a combination of hydrocodone and acetaminophen (Tylenol). The U.S. consumes most of the world’s supply of hydrocodone. On a yearly basis we consume more than 60,400 pounds of the drug compared to slightly more than 7 pounds for the UK, France, Germany, and Italy combined.

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