From Crisis to Consensus: Guidelines Aim to Reduce Over-Prescribing of Abused Drugs
Every day, 115 Americans are killed by opioid overdose.
That this number is so strikingly high underlines the language of ‘“epidemics” and “emergencies” in politicians’ speeches and newspaper headlines. Thousands of articles and millions of research dollars have become components of a concerted effort to understand, quantify and alleviate the opioid epidemic in the United States. Unsurprisingly, such a complex issue has myriad suggested causes and equally numerous proposed solutions, the majority of which tend to reflect political leanings as much as scientific or medical consensus. Is addiction the fault of the drug or the user? Will medical marijuana save us from the clutches of pharmaceutical heroin?
Taking a step away from the political and morality debate, there are several data-based assertions we can make about the current state of opioid use in the U.S. Between 2006 and 2015, every single adult in the country had a greater than 70 percent chance of being prescribed opioids over the course of a year. A 2015 survey showed that 90 million adults were prescribed opioid-based pain medication, and a little over 10 percent misused these drugs in some manner. In the past year, 2.1 million Americans had a diagnosed opioid abuse disorder, and that number is rising even as drug prescription rates have begun to fall in response to the crisis.
The medical field writ large has addressed the opioid epidemic with a relatively straightforward approach — fewer prescriptions, less drugs — and this attitude has affected opioid access across all specialties, from family practice to dentistry. Johns Hopkins professor of surgery Martin Makary has set out to codify this relatively vague recommendation by publishing a set of guidelines for opioid prescriptions after 20 common surgical procedures. Instead of aiming for the more ethereal “less,” Makary established a specific number of prescribed pills for each procedure based on the consensus among 30 surgeons, pain specialists, nurse practitioners, residents and even patients. These guidelines will never be hard and fast rules, since every operation and every patient is unique. Instead, the authors hope to reestablish some prescription normalcy and convention by balancing the understanding that these drugs are vitally important for postoperative patients with the visible consequences of widespread over-prescription and abuse. Importantly, the decisions reached about the 20 procedures examined are intended more as proof-of-principle than the final word for practicing physicians, and Makary believes these multidisciplinary, patient-centered consensus guidelines can become important tools in combating the opioid crisis.
Ultimately, this is a tightrope journey that will always require careful footing. Until putative miracle drugs provide opioid-level pain relief without deadly consequences, scientists and doctors must optimize the use of the drugs we have to maximize efficacy while minimizing risk — and its very public consequences.