“Three to take or throw”, “Four to Fill or Flush” – how we can wean off prescribing opioids for acute outpatient pain
Unlike other drug crises, 80% of opioid addiction starts with a pill prescribed by a physician or dentist. 76 Billion pills, it seems, prescribed in the 6 years that led to 100,000 deaths. The late 1990’s ushered in a perfect storm for prescribing: humanitarian good will, the desire to correct pain treatment inequities (that persist), the rise of the HMO and “patient as customer”, and a giant push from pharma accompanied by overt and covert teaching that “opioids aren’t addictive if you’re really in pain.”
We know more now. We know 10-15% of people are susceptible to addictive highs beyond pain relief due to genetic speed of metabolism. We know 5.8% of young adults who got opioids for wisdom tooth removal are addicted within a year, compared to 0.4% who did not. Most importantly, we know that for most outpatient injuries and surgeries, OPIOIDS ARE INFERIOR TO OVER THE COUNTER CARE. It is time to wean ourselves off of writing for opioids. Considering risk, efficacy, and why we prescribe, we can change our habits of writing opioids for acute outpatient pain. We know enough now to stop.
What do we know about risk?
The first consideration must be our oath to do no harm. As an extremely homogenous procedure, oral surgery is a great model for pain relief research. A compelling argument that ANY exposure increases the risk of addiction comes Schroeder et al, who found that 5.8% of youth prescribed opioids for this procedure were diagnosed with Opioid Use Disorder (OUD) by the end of the year. Of age matched young adults without an opioid prescription, only 0.4%.(1) The risk factor most associated with opioid addiction was that someone prescribed them opioids. A compelling argument that this risk is unnecessary? Opioids are prescribed 37 times more in the US than England for the same procedures.
The new findings “even for surgical pain, home opioids are a risk for addiction” holds up for other procedures. Risks for addiction were 5.1 times higher after knee replacement, 3.6 times higher for open gallbladder surgery, and 1.28 times higher after C-section. Typically, more opioids are prescribed for knee replacements than gallbladders than C-sections. If addiction were a moral failing, it’s odd that there is such correlation between medical prescribing habits and weakness of character. Instead, it's a simple linear relationship: the more opioids you're prescribed, the greater the chance of addiction.
In addition to the inherent tolerance to the medication, a complex genetic array of drug metabolism that can make opioids ineffective, or hyper-intense. While I was grateful for codeine and fentanyl after various fracture-associated misadventures, at home pills made me foggy and nauseated. I have questioned others about the appeal. “Percocet made me feel great!” said a friend in recovery. “The drugs made me feel energized, happy, and totally unselfconscious. As they hit, they made me feel cool.” The ultra-rapid metabolizers get a rush. The ultra-slow metabolizers get nauseated, or often don’t even get pain relief. Without insight to our patients' genetics, we’re introducing some to a craving they would never had had.
What do we now know about efficacy?
Potentially because of the variation of opioid metabolism, most studies don’t show a benefit for home opioids. For 4th molar extractions, multiple studies showed ibuprofen superior to Tylenol with codeine.
For pediatric fractures, ibuprofen was at least as good for pain relief.(2-4) For carpal tunnel release,(5) hand surgeries,(6, 7) and even general surgeries from gallbladder removal to robotic prostatectomy,(8) over-the-counter was sufficient or superior. The only difference, in fact, was opioid side effects.
With the exception of the pediatric fracture studies, most of this research was published in the last two years. Few family practitioners, emergency doctors, or surgeons would have reason to know this. The question is, now that you do, WHAT do you do?
Why do we write for opioids anyway?
In one of the earliest examples of big data, Porter and Jick published a letter to the editor of the New England Journal of Medicine in 1980 evaluating addiction to in-hospital opioids. In their read of the Boston Hospital’s data, addiction at discharge was fractional.
That’s important: AT DISCHARGE. There was no follow up. This letter was billed as a “landmark study” cited to assuage the fears of addiction when Purdue pharma launched OxyContin. It was a part of the PowerPoints residents absorbed with their lasagna lunches post call.
Because of the confluence of the societal factors in the late ’90s noted above, scrips for outpatient opioids soared. Writing a scrip for oxycodone showed you cared and believed they hurt. Soon, patients demanded “the good stuff”, and the hassle of writing refill prescriptions pushed docs to writing for bigger numbers of pills. Even when unused, the “stuff” was too good to throw away just in case, and ended up in medicine cabinets. Over 80% of opioids used recreationally by patients who become addicted were prescribed for a medical use, and given by friends or family.
How do we stop?
While there are some surveys of prescribing practices and use, the actual opioid NEED for various acute maladies and patients is undetermined. As studies for opioid-sparing regimens proliferate, a few models are emerging. Hallway et al found that the most important part of opioid reduction or elimination comes from coaching. Priming patients that usually ibuprofen and Tylenol were sufficient worked. They used a “rescue” prescription of around 5 tablets, and found that most patients either used all or none. (To avoid the implied promise of “rescue”, perhaps a “Three to Try or Throw” or “Four to Fill or Flush” scrip with stern safe disposal instructions would be better. And yes, the FDA advocates flushing.))
Understanding the duration of pain, the maximal duration of pain, and how to plan in advance gives patients control. An Opioid-Free Pain Plan includes advocating for long acting lidocaine, taking magnesium early for anti-inflammatory effects, maximizing over the counter options, and planning for distraction, social interaction, and pleasant surprises BEFORE surgery. After surgery or injury, ice and specific frequencies of mechanical massage inhibit pain, and optimizing sleep is critical. Above all, planning for pain emphasizes that pain is expected yet manageable.
Going cold turkey on the prescription habit will be hard. In Japan they don’t give home opioids for knee repair surgery at all – but we can’t keep patients as long as they do. A dose or two of opioids could help some patients sleep past their kidney stone, hip, or femur fracture once discharged. Some patients can’t take or get no benefit from ibuprofen. Sometimes there’s no time to coach, or plan, or discuss the virtues of vibration or ice or magnesium. Sometimes your patient is the board chairman’s relative.
In the scrum of assigning blame, many fault physicians in capital letters. In one forum I was told of COURSE opioids are addictive, we should know EVERYTHING about a drug before we prescribe it… I argued there is simply too much to know, that we trust our lecturers, that this is why there are pharma laws. We didn’t know then. We trusted what we were taught. We wanted to help. We had to satisfy patients. As I responded I realized that the possible defense a decade ago is no longer true. We do know. We must do no harm. The time for acute outpatient opioid prescribing – for fractures, for dental work, for hand, gallbladder, and so many more surgeries and injuries - is over.
Caveats and disclosures: My opinions are only related to putting acute-use opioids in outpatient circulation for opioid-naiive patients. Chronic patients often come to the ED only when they’ve tried everything, and chronic pain patients (sickle cell, Ehlers Danlos) have a lifetime of learning what to try. When they show up, help them.
Three years ago a device I made for needle pain helped someone in recovery avoid opioids after surgery. I went full time to research the new science of oscillatory motor strain and pain perception, and I still make and sell medical devices. I acknowledge my preachy point of view is easier to maintain without the discomfort of fatigue on call at 3AM. Even before I quit practicing, however, I had already begun arguing emergency patients out of home opioids. It was often hard, and I sometimes capitulated.
My ex-best friend died of an opioid overdose almost 30 years ago. Angry at her addiction, I had given up on her, and I was wrong. I also spent the last fifteen years of my medical practice globally extolling the virtues of intranasal fentanyl and “staying ahead of the pain”. While my training in the 90’s predisposed me as an opioid acolyte, a mission to eliminate pain runs headlong against “First do no harm”. I still advocate for morphine, fentanyl, ketamine - whatever it takes - in the hospital, in hospice, and for those on stable doses living with chronic pain. The evidence still supports that opioids for trauma don’t lead to addiction. Morphine in the first 24 hours of major trauma and burns is inversely proportional to PTSD, prolonged pain, and decreased function. This is not a screed to get rid of the tools to eliminate suffering in the most severe of times. This is a manifesto to re-educate with new up-to-the minute science: not only are opioids not safe for outpatient acute use, they’re not even effective. Three to try or throw? Four to fill or flush? Um, Actually, ibuprofen is better? Our move.
1 Schroeder AR, Dehghan M, Newman TB, Bentley JP, Park KT. Association of Opioid Prescriptions From Dental Clinicians for US Adolescents and Young Adults With Subsequent Opioid Use and Abuse. JAMA internal medicine. 2018 Dec 3.
2 Clark E, Plint AC, Correll R, Gaboury I, Passi B. A randomized, controlled trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children with musculoskeletal trauma. Pediatrics. 2007 Mar;119(3):460-7.
3 Drendel AL, Gorelick MH, Weisman SJ, Lyon R, Brousseau DC, Kim MK. A randomized clinical trial of ibuprofen versus acetaminophen with codeine for acute pediatric arm fracture pain. Annals of emergency medicine. 2009 Oct;54(4):553-60.
4 Friday JH, Kanegaye JT, McCaslin I, Zheng A, Harley JR. Ibuprofen provides analgesia equivalent to acetaminophen-codeine in the treatment of acute pain in children with extremity injuries: a randomized clinical trial. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2009 Aug;16(8):711-6.
5 Ilyas AM, Miller AJ, Graham JG, Matzon JL. Pain Management After Carpal Tunnel Release Surgery: A Prospective Randomized Double-Blinded Trial Comparing Acetaminophen, Ibuprofen, and Oxycodone. The Journal of hand surgery. 2018 Oct;43(10):913-9.
6 Ilyas AM, Miller AJ, Graham JG, Matzon JL. A Prospective, Randomized, Double-Blinded Trial Comparing Acetaminophen, Ibuprofen, and Oxycodone for Pain Management After Hand Surgery. Orthopedics. 2019 Mar 1;42(2):110-5.
7 Weinheimer K, Michelotti B, Silver J, Taylor K, Payatakes A. A Prospective, Randomized, Double-Blinded Controlled Trial Comparing Ibuprofen and Acetaminophen Versus Hydrocodone and Acetaminophen for Soft Tissue Hand Procedures. The Journal of hand surgery. 2019 May;44(5):387-93.
8 Hallway A, Vu J, Lee J, et al. Patient Satisfaction and Pain Control Using an Opioid-Sparing Postoperative Pathway. Journal of the American College of Surgeons. 2019 Apr 26.
9 Daniels SD, Garvey KD, Collins JE, Matzkin EG. Patient Satisfaction With Nonopioid Pain Management Following Arthroscopic Partial Meniscectomy and/or Chondroplasty. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2019 Jun;35(6):1641-7.
10 Resnick CM, Calabrese CE, Afshar S, Padwa BL. Do Oral and Maxillofacial Surgeons Over-Prescribe Opioids After Extraction of Asymptomatic Third Molars? Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons. 2019 Jul;77(7):1332-6.
11 Scully RE, Schoenfeld AJ, Jiang W, et al. Defining Optimal Length of Opioid Pain Medication Prescription After Common Surgical Procedures. JAMA surgery. 2018 Jan 1;153(1):37-43.
12 Suda KJ, Durkin MJ, Calip GS, et al. Comparison of Opioid Prescribing by Dentists in the United States and England. JAMA network open. 2019 May 3;2(5):e194303.