The Price We Pay by Marty Makary
Author:Marty Makary
Language: eng
Format: epub
Publisher: Bloomsbury Publishing
Guiding Change
The opioid crisis created an obvious opportunity to use the Improving Wisely approach to look at a surgeon’s prescribing patterns in the national data. We wanted to see which clinicians had a pattern of prescribing far too many pills after certain operations. Our analysis excluded patients with preexisting opioid use or pain syndromes. We wanted to include only patients who had not previously taken narcotics, which is an important factor that clinicians should take into account when prescribing opioids.
The analysis uncovered a stunning range in the way doctors prescribed opioids. Some doctors fell within our Johns Hopkins expert panel guideline of zero to 10 opioid tablets after, say, a prostate surgery. Other surgeons were still routinely prescribing a whopping 50 or 60 tablets to their narcotic-naïve patients.
We ran the analysis for the surgeons who did that laparoscopic gallbladder surgery that led to the creation of our expert panel. Our panel concluded that zero to 10 pills is the recommended opioid prescribing range for that operation, yet the data we looked at as a team revealed doctors that were still prescribing as recklessly as I had done, averaging 30 pills.
Someone on the team pointed to a dot on the graph that represented the surgeon averaging 45 opioid pills after the operation. “That surgeon is crazy.”
“No,” I countered. “That surgeon needs help.” We have a duty to take care of each other in medicine. “That surgeon needs to be educated as I got educated a few years ago.”
My research team repeated the analysis for many common procedures, including operations that can be managed with non-opioid alternatives. The doctor distribution graphs kept showing us the same thing: opioid prescribing patterns vary widely, even within an identical procedure. One analysis of lumpectomy operations revealed that some surgeons routinely prescribe more than 60 opioid pills. Our consensus panel of medical experts and patients recommended between zero and 10, advocating for non-opioid alternatives. Now that the data allowed us to see which doctors need help, we had a duty to help them.
We are working to apply the Improving Wisely approach to the opioid overprescribing problem. In addition to the many potential lives saved, imagine the cost of these unnecessary opioid pills being dispensed. Add to that the addiction treatment costs for the 1 in 16 patients who will become addicted. Prevention is still the best treatment.
In hopes of creating an honest conversation about the overprescribing culture, I published an account of my own overprescribing regrets and my “aha” moment when my dad had surgery. The story made the front page of USA Today6 and hundreds of doctors reached out to me to tell me that they, too, were amazed at the way medicine had embraced a culture of opioid overprescribing, oblivious to the impact. A friend from my internship days texted me. “Good piece in USA Today, remember when Dr. F required us to write for 100 opioid pills for everyone?”
Even after all the efforts to reduce overprescribing, we have a long way to go.
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