March 13th, 2017

“Use sparingly” was the advice Hippocrates gave in 400 B.C. about opioid medication. The recent opioid epidemic has demonstrated the consequences of ignoring this ancient caution. While our outpatient drug addiction treatment program addresses the opioid addiction after it has developed, prevention is clearly preferable.

The overprescribing of opioid medications is clearly one of the causes of the current opioid addiction epidemic. What is not clear is exactly how often the therapeutic use of opioid medications leads to addiction as well as who is most vulnerable to becoming addicted. Until those issues are clarified, a reasonable approach, supported by guidelines from the Centers for Disease Control, is to minimize exposing patients to opioids and manage pain in other ways when possible.

Using opioids for major surgery has long been standard. I was recently surprised, however, to hear from Dr. Joseph Myers, an anesthesiologist at Georgetown University Medical Center, that even in those situations, suitable alternatives may be available. Dr. Myers points out that although much of the recent focus has been on the writing of post-surgical pain prescriptions, the anesthesiologists often initiate the first contact with opioids during the surgery itself.

So much progress has been made with local anesthetics that Dr. Myers uses long-acting formulations of them and entirely avoids opioids, even for procedures like amputations. If this approach becomes more widespread, I think this would be a significant contribution to preventing opioid addiction that was inadvertently initiated by physicians.

In addition, progress is being made in changing the prescribing practices of surgeons. Most patients do not use their entire supply of pain pills following surgical procedures, and the excess is sometimes diverted to non-legitimate use. A simple solution is to prescribe fewer pills. One recent example is at Dartmouth-Hitchcock Medical Center in New Hampshire – a state hit hard by opioid addiction – where protocols were established for the number of pills to prescribe after different surgical procedures. Patients were also instructed to use non-opioid pain medications. As a result, the total amount of opioids prescribed was substantially lower than previously.

Another prescription opioid epidemic, triggered by physicians medical practices, occurred at the end of the 19th Century and was resolved by means of active intervention within the medical community. Members of the current medical community, having recognized the problem, have already begun to take steps in this direction. I believe that Hippocrates would approve.

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