Opioid Tactic Gone Wrong

Effort to Curb Prescriptions Instead Increases Pills

F. Perry Wilson, MD, MSCE


August 28, 2018

Hi. I'm Perry Wilson, and this is Impact Factor, your weekly commentary on the most interesting or important articles appearing in the medical literature.

This week: postoperative opioids and the unintended consequences that occur when well-intentioned government officials make seemingly reasonable policy decisions, as we look at this article appearing in JAMA Surgery.[1]


Let's go back to a simpler time: October of 2014. We're in the height of the Ebola epidemic, Taylor Swift released "1989," and no one knew what the "Internet Research Agency" was.


Also in October 2014, the US Drug Enforcement Administration (DEA) reclassified hydrocodone products to schedule II from schedule III.

The opioid epidemic, which continues to ravage the country, was on the upswing, and excessive prescription of narcotics was one of the commonly blamed culprits. By moving hydrocodone products from schedule III to schedule II, the DEA was hoping to curb its use.

The JAMA Surgery paper shows that just the opposite happened.

Researchers used insurance claims data from the Michigan Value Collaborative to identify around 22,000 patients who had undergone one of 19 common elective surgical procedures—mostly general surgery stuff, with a fair amount of ortho and ob/gyn. They then looked to see what opioid prescriptions patients filled postoperatively.

Prior to the schedule change, the average postsurgical patient filled a prescription for 371 oral morphine equivalents—about 74 5-mg Vicodin® (hydrocodone/acetaminophen) tablets. After the schedule change, when it would be more difficult to prescribe Vicodin, the average prescription increased by seven tablets. This was across the board in surgical subtypes, with the exception of bariatrics; spine surgeons prescribed 13 extra tablets after the change, cardiac surgeons 25 extra pills.


I—very much not a surgeon—was baffled. So I turned to my favorite surgeon to suss this one out for me: Niamey Wilson, MD, MSHP, chief of breast surgery at St. Francis Hospital in Hartford, Connecticut (who is also my wife).


Could it really be that all these extra pills are being prescribed because we can't call them in any more? To be honest, this seems like the most likely answer, as a pretty extensive multivariable adjustment did not reveal any other explanations. In order to avoid the hassle of writing a new script, some docs are just increasing the initial amount given postop. And this is a real problem, because excessive prescribing postoperatively may increase the potential for abuse and diversion.[2]

OK, a word of caution. This study only enrolled people who filled opioid prescriptions postoperatively. If the change in scheduling caused some physicians to abandon prescribing opioids altogether, we wouldn't see that in these data, which could seriously bias the results. But I think that is an unlikely interpretation.

No, I think more likely this is a simple case of unintended consequences and a valuable reminder that sometimes, a committee making decisions in Virginia might do well to talk to the boots on the ground first.


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