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Circling the Dome

New Guidelines for Prescribing Opioids

A Johns Hopkins expert panel of health care providers and patients has announced what is, to their knowledge, the nation’s first set of operation-specific opioid prescribing guidelines.

The guidelines are based on the premise that opioid prescribing limits should be based on the operation performed rather than a blanket approach. The ranges offered for each of 20 common operations generally call for reductions from the current rates of opioid prescription, and the researchers say that patients themselves favor using less of the drugs than physicians often prescribe.

“Prescriptions for pain meds after surgery should be tailored to the operation and a patient’s needs and goals, but the hope is that these guidelines will help reset ‘defaults’ that have been dangerously high for too long,” says Martin Makary, professor of surgery, health policy expert and senior author of the guidelines, which were published in the Journal of the American College of Surgeons. The guidelines were reached through a process of consensus involving 30 surgeons, pain specialists, outpatient surgical nurse practitioners, surgical residents, patients and pharmacists.

The prescribing limits are designed to help prevent patients from receiving unnecessary opioid pills after surgery—a common way in which some people are introduced to opioids and later become addicted, with data showing that an estimated one in 16 surgical patients eventually becomes a long-term user, says Makary. The guidelines are already being used to educate Johns Hopkins residents and surgeons, and to replace the current e-prescribing defaults that appear in prescribing systems.

Makary says the magnitude of the overprescribing problem can be best summarized in recent data showing that half of surgical patients who are not even taking opioids in the hospital the day before they go home are still given an opioid prescription.

Some organizations do offer guidelines for overall pain management but do not provide procedure-specific guidance for postoperative pain management and do not focus on patients receiving opioids for the first time, says Makary. “We should not be using the same opioid guideline for an open-chest operation that we use for a lumpectomy,” he says.