Nipping opioid use in bud before it starts
STOP Narcotics looks to dramatically lessen amount of painkillers given to surgical patients
By significantly reducing the amount of opioids prescribed, this decreases the exposure risk and potential for misuse of narcotic medication.” Dr. Luke Crawford, Western University
TORONTO — With the recognition that physician prescribing plays a significant role in Canada’s opioid crisis, a team of researchers has developed a program called STOP Narcotics to dramatically reduce the amount of the painkillers patients are given following some common operations.
In a study presented at the American College of Surgeons Clinical Congress in Boston, researchers from Western University showed that the STOP Narcotics protocol halved the amount of opioids prescribed after two types of outpatient surgery, while still adequately treating most patients’ post-operative pain.
“By significantly reducing the amount of opioids prescribed, this decreases the exposure risk and potential for misuse of narcotic medication,” said lead author Dr. Luke Hartford, a general surgery resident at the London, Ont., university.
“This also decreases excess medication available to be diverted to individuals for whom it was not intended,” he said, noting that the STOP Narcotics program includes a combination of patient and health provider education, with an emphasis on non-opioid pain control.
The study, published this week in the Journal of the American College of Surgeons, involved 416 patients at London Health Sciences Centre and St. Joseph’s Health Care, who had laparoscopic gallbladder removal or open hernia repair.
Roughly half the patients were randomly assigned either to a control group, which received a standard prescription for opioids, or to the STOP Narcotics protocol group (STOP meaning Standardization of Outpatient Procedure), which were prescribed acetaminophen and an anti-inflammatory drug to manage post-surgical pain for the first 72 hours after their operations.
Under the protocol, surgeons were instructed to write a 10-pill opioid prescription, which expired seven days after surgery. Patients were asked to fill this prescription only if they couldn’t achieve adequate pain control with the other drugs.
“Ninety per cent of the patients said that controlled their pain, they didn’t need the narcotics script filled,” said principal investigator Dr. Ken Leslie, chief of general surgery at London Health Sciences Centre.
Researchers found there was a 50 per cent reduction in the number of opioids prescribed by surgeons under the STOP Narcotics group, compared to the control group.
As well, just 45 per cent of patients in the protocol group filled their opioid prescription, compared to 95 per cent in the control group.
“So we not only decreased the amount we were prescribing in half, but we saw that (less than) half of patients were actually filling those prescriptions,” Hartford said, adding that only “a very small number” needed the opioids for additional pain control.
“We found that in our control group, as well, that even though patients were getting prescribed 20 to 30 tablets of opioid medication, they were only taking around seven of them,” he said.
That’s why the STOP Narcotics initiative has another goal: to sharply limit the amount of unused opioids diverted for recreational use.
As part of the post-surgical program, patients were asked to return leftover opioids to their pharmacy or to the hospital. The researchers found the return rate was seven per cent among those in the control group versus 23 per cent among STOP Narcotics patients.
Surgeons often say they prescribe “plenty of pills” to ensure patients have enough on hand to control their pain — but also to avoid calls to their offices for renewals, Leslie said.
But the study found that renewal rates were low: 3.5 per cent for those initially prescribed opioids and 2.5 per cent for protocol patients.
“We recognized that before STOP Narcotics, every surgeon had a different approach to pain control and that most surgeons were prescribing more narcotics than are actually needed,” said Leslie.
Dr. David Juurlink, head of clinical pharmacology and toxicology at Sunnybrook Health Sciences Centre in Toronto, said the Western study isn’t the first to show that more prudent prescribing of post-surgical opioids can be beneficial for patients, but “it’s an important topic nevertheless.”