Prescribed Overdose: Navigating the Overprescription Landscape of Opioids
Angela Hong
Between 1999 to 2008, a fourfold increase in prescription opioid sales was associated with a fourfold increase in opioid deaths.1 Excessive prescription practices have rendered Canada’s opioid consumption second to the USA, exposing a large number of Canadians to highly addictive opioid drugs (2). Over the past few decades, the prescription of opioids has been influenced more by tradition and dogma within the healthcare field rather than scientific evidence. Instead of following an educational model for prescribing, the tendency to overprescribe opioids relies on an experimental mindset of “that’s how I do it,” perpetuated through generations of physician trainees. The foundation of this dogma was further solidified by a 1980 New England Journal of Medicine letter, now discredited, which erroneously claimed that only 1% of people become addicted to narcotic pain medication (3). This led to the subsequent surge in aggressive advertising of opioids, including direct-to-consumer marketing. Studies indicate that a significant number of patients were prescribed excessive amounts of opioids upon surgery discharge, and the prescribing variations could not be accounted for by specific patient factors (4-5). For instance, oxycodone, a prescription pain medication, typically includes instructions to take 5-10mg as needed every 5-6 hours for pain (5) Following these guidelines could lead a patient to consume up to 90 MME (morphine mg equivalents) per day–a dose nearly double the threshold associated with a twofold increased risk of overdose ((≥50 MME/day), according to the US Centers for Disease Prevention and Control. Furthermore, a Johns Hopkins team analyzed the average number of opioids a doctor prescribes after a routine laparoscopic cholecystectomy, a gallbladder removing procedure. The findings revealed a wide range in doctors prescribing habits, with some doctors’ prescribing no opioids, while others prescribed over 50 pills (Fig 1) (4). Alarmingly, only a fifth of doctors prescribe within the best practice range (≤10 tablets) recommended by the Johns Hopkins pain specialists.
Figure 1: Distribution of surgeons based on pills prescribed following a laparoscopic cholecystectomy (4)
The implementation of the “fifth vital sign” by external authorities such as the American Pain Society, Veterans Health Administration and The Joint Commission in the 1990s became another guilty party for the rise in opioid overdoses (1,6) Becoming the first and only subjective vital sign, physicians use a patient’s self-reported pain level as a “fifth vital sign”. Hospital administrators seeking to increase patient satisfaction adopted these guidelines, and implemented patient surveys to provide feedback on the management of their pain in 2006 (1).These survey results were publicized and allowed for comparisons between hospitals, thus directly influencing the funding of hospitals. Thus, these newfound regulations encouraged the liberal use of opioids in treating patients' pain. Despite the severe risks involved, physicians may be encouraged to prescribe a generous amount of opiate-based painkillers, to increase patient satisfaction rates. In the contemporary medical landscape, many physicians have the insight to prescribe opioids judiciously, recognizing the drugs’ addictive potential. However, the consumerist mentality of patient satisfaction and pain-free expectations has permeated the field of medicine. This has lead to the prescription of opioids for soft indications such as simple procedures, back pain and chronic joint pain, rather than reserving them for persistent pain, major surgeries, second degree burns, and more (4).
Research highlights that rural US populations were more engaged with the misuse of opioids compared to their metropolitan or urban counterparts. Even after adjusting for population density, death associated with opioid analgesics remains higher in these same rural areas (7-8) Thus, rural US residents and communities may suffer a disproportionate burden from opioid misuse, with a higher proportional prescription rate in rural settings compared to metropolitan communities. Rural patients have to travel longer distances for treatment, or lack alternative pain management solutions. Since opioids must be prescribed by a physician, frequent patient consultations can take up much of a physician’s time. As patients may only manage to have one long-distance trip to the hospital facility, it is often more convenient to both the patient and physician to prescribe large amounts of opioids at once (9).
Improved education is needed for both physicians and patients on the proper role of opioids compared to other pain medications. While preventing postoperative pain should be prioritized, complete freedom from pain may be unrealistic during the recovery period. Physicians and care facilities should prioritize the health and well-being of the patient, minimizing the effects of external factors like patient pain-based satisfaction, hospital funding and profits. While better access to opioid addiction treatment is an essential part of resolving the opioid epidemic, the most effective treatment is still prevention.
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