Too many pain pills after surgery: When good intentions go awry

Scott Weiner, MD
Scott Weiner, MD, Contributor

As a physician with an interest in reducing opioid-related problems, I frequently hear stories from colleagues and friends about their loved ones who either struggle with opioid addiction or have even died from opioid-related overdose. My follow-up question to them is usually: “How did it begin?” Almost every time the answer is the same: the individual experienced acute pain either from a trauma or surgery, was started on opioids by a doctor, and then couldn’t quit.

My son’s baseball coach, who is not in the medical field, described it perfectly. He went in for a minor back surgery and was discharged with 60 tablets of oxycodone (the opioid medicine in Percocet and Oxycontin). For the first couple of days, he had significant pain and used the pain pills. After the pain began to subside and acetaminophen and ibuprofen were sufficient, he stopped using the oxycodone. But after discontinuing the medication, he began feeling terrible, experiencing body aches, restlessness, and insomnia. He took another oxycodone and felt better. Fortunately, he had the insight to recognize what was going on: he was withdrawing from the opioid, even after taking it for only a few days. Had he continued treating his withdrawal with oxycodone, he may have become hooked. “I dodged a bullet,” he told me.

The problem of adverse effects and unused opioids

This story, repeated time and again, is interesting in light of a recent study published in JAMA Surgery. The paper was a meta-analysis that combined the results of six previous studies investigating use of opioids by patients after seven different surgical procedures. In the era of the opioid epidemic, where we know that the vast majority of pills taken for non-medical reasons (e.g., abuse) are obtained from friends or family members, the results are staggering: 42% to 71% of the prescribed opioids went unused. Furthermore, 16% to 29% of patients experienced adverse effects directly attributed to the opioids.

Multiple government and public health agencies recommend discarding unused opioids. It’s not safe to flush them down the toilet as they can contaminate our water supply, but most police stations and now commercial pharmacies have bins where unused medications can be safely disposed. Despite this, the study discovered that only 4% to 30% planned to dispose of the medications and only 4% to 9% planned to use a safe disposal method.

Why are opioids prescribed often and in larger amounts?

A key question is why overprescribing after surgery is occurring. I believe there are two likely explanations. The first is that surgeons, appropriately, do not want their patients to suffer from pain after an operation. The second is that, in many states, it is impossible to phone in a prescription for a controlled substance (e.g. an opioid pain medication). Therefore, a patient actually has to come back to clinic to pick up a prescription, which causes inconvenience to both the patient and the prescriber. Providing a prescription for 60 or 90 pills makes sense considering this barrier. Several states are implementing ways to provide electronic prescriptions that would make the doctor’s office visit unnecessary if a refill is needed, but it will take time before most doctors can do this.

However, as the study in JAMA shows, these large amounts may be far more pills than is required. As an example, consider another intriguing study of patients being treated for an acute extremity fracture. The researchers provided patients with special pills that contained both oxycodone and a small radio transmitter that became activated in the stomach. The researchers were able to detect exactly when the opioid was taken. Patients were instructed to use up to one week of oxycodone. At follow up, the average number of pills used was eight. Most of the severe pain was gone in just three days. There was no more need for opioids than a few pills, certainly less than 15.

Here’s what you can do to protect yourself and your community

How can the public protect itself? Physicians have a duty to educate about the risks and benefits of all treatments rendered, including when prescribing opioids. That unfortunately doesn’t always occur. So here’s my advice: if you are prescribed an opioid for acute pain, including after surgery, take all of the non-opioid pain medications permitted by your doctor as instructed (e.g. acetaminophen and ibuprofen, if not contraindicated). Add the opioid if, and only if, the pain is not bearable with the other medications. And once the pain is tolerable, stop the opioid and safely dispose of it by bringing it back to your pharmacy, if they have a disposal bin, or any DEA-recommended collection site. Finally, consider having a discussion with your doctor about the number of pills you are likely to need in the first place before the prescription is written. Being informed about safely using opioids could prevent dependence, and, ultimately, save your life.

Comments:

  1. Paul

    This is such a difficult topic but I’m glad you brought up an important topic but it highlights a very difficult problem:

    “Patients were instructed to use up to one week of oxycodone. At follow up, the average number of pills used was eight.”

    So how many pills should we give after surgery? If we give 8, half of the people will have sufficient pain control half will not and may require either follow ups visits or end up in ER’s or both!

    The other problem is the out-patient surgery model that pushes patients out of the surgical center/hospital as quickly as possible to make room for the next patient in the operating room. Patients are sent home still under sedation while being given instructions for care. Then they are to sign documents that they understand their care instructions! How do the hospitals get away with this when one of the exit instructions is not to sign any legal documents?

    Quick case in point: I had my gall-bladder removed last December. I heard is should be a rather easy operation and to expect a quick recovery. My surgery was 8am Friday morning, I was out by 10am in the worst pain I can remember (this includes 2 back surgeries and a number of traumas). I was back in the ER by Sunday morning due to severe pain – I was out of pain medication and could not eat/drink/move due to the severe pain in my abdomen. I was medicated in the hospital and sent home with a script for 1 day of pain meds. Monday I showed up at the surgeons office for additional pain medication, who had put up with calls from me through the weekend.

    By Wednesday I was OK and no longer needed any pain medication (6 days). However, I have spoken to others that said this was the easiest surgery they ever had – they thought could have driven themselves home and never even used their pain medication!

    My belief is the rush to get patients out of the hospital/surgical center forces doctors to simply give all patients the same medication for the same surgery. If they had monitored my progress for a longer period of time, it would have been obvious I was struggling with pain vs my friend who was ready to get up and walk out the door.

  2. Julia Scott

    I’m glad the article mentioned the difficulty with going back to the prescribing physician for a refill. I’ve had opioids prescribed for post-op pain as well as chronic pain for an injury. Luckily for me, I don’t have the receptor or whatever that makes me feel “good” from the use of these meds. That said, I had GeneSight done a few years ago because I was having difficulty finding an antidepressant that worked longer than 2 months. As part of the study, they looked at metabolizers for analgesics. At my recent hospital stay, I gave a copy to my anesthesia team – and they were blown away, having never even known that the genetic testing was so detailed!

    Yet still, my pain management team prescribed vicodin, and then percocet (both of which are on my “maybe” list) and when my pain was still not managed well, I was made to feel that awful emotion of “drug seeking.” After my most recent surgery, this time in a hospital, my stay was longer because they had a harder time finding out what worked even though I gave them the list. It was incredibly frustrating.

    1. We need to acknowledge that serious pain reduces healing. Making people feel badly about what their body can and cannot metabolize is foolish.
    2. We need to do more genetic testing for analgesics so we can at least start from a point of usefulness.
    3. We need to reduce the push to surgical centers and get back to admitting patients post-surgery so we can manage their pain before release.
    4. We should provide the mail-in prescription return bags with every opioid script.
    5. We need a better way to provide refills. After I had a disastrous experience with a surgical center that pushed me out because they needed the bed – in spite of the fact I couldn’t keep down water, I ran out of pain meds and called the doctor, who was on vacation. Her partner had me drive 45 minutes (I had no business driving), spent 5 minutes talking to me, and then gave me 6 tylenol-3’s (which I’d already said doesn’t work for me). I felt like a junkie, and it didn’t work. Thankfully a relative visited whose son had just had wisdom teeth removed and vicodin didn’t work for him, so she gave me his meds. Within 3 days I was able to manage my pain to the point I threw out the rest of the vicodin.

    Patients shouldn’t beg for pain relief. Doctors need to be better trained on different pain options. We need a better way for refills so patients in pain who have not recovered enough to drive long distances. Lastly, we should provide safe disposal options for free.

    I used dog poop in a ziplock bag, tossed my meds in there, squished it around, and then tossed it out in the trash. Very effective but not everyone would think of that. Regardless, our current system is badly broken.

  3. William McAuliffe

    I think that anecdote about self medication of withdrawal symptoms is fishy. How did he know that taking another pill would rid himself of the discomfort.

    Iatrogenic opioid addiction generally develops slowly after long periods of use or repeated operations. The reinforcing effects of pain relief and euphoric effects are the main problems, not avoidance of withdrawal.

    • Scott Weiner, MD

      Thanks for reading the article and responding. I can only tell you that this is the experience this individual related to me. He felt miserable after stopping the med (not pain – but malaise, chills, body aches) and felt better once he took another oxycodone. This is not isolated – I have had many patients tell me similar experiences, even after a few days of opioid therapy. There is evidence that the brain changes very soon after initiation of opioids, and I can find articles that withdrawal can occur after cessation after 1 month of treatment, but no research that looks at shorter durations. Something to study!

      • Lisa Schafer-Garcia

        I’ve often felt opiates contribute to more intense pain and have mild withdraw symptoms even with short term use. No short term studies/research done? I need a project for my abnormal psychology class.

  4. Michael

    Since I reduced Tramadol pills I feel lot better, jey is to find honest physician :/

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