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Study: Mayo Clinic overprescribing opioids after surgery

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An internal study has found that 80 percent of opioid prescriptions after surgery at Mayo Clinic exceeded new guidelines, raising red flags as opioid deaths have become an epidemic across the country.

The new study, published today in Annals of Surgery, a medical journal, examined the records of more than 7,000 Mayo patients in Minnesota, Florida and Arizona between January 2013 and December 2015, a period that precedes the new guidelines. The findings highlight the nation's ongoing struggle to balance pain relief with overprescription, which has been linked to addiction and deaths.

The Centers for Disease Control and Prevention reports that opioid prescriptions and the number of related deaths has quadrupled since 2000. More than 90 people per day died from prescription opioid or heroin overdose in 2015.

"In light of the opioid epidemic, physicians across the country know overprescribing is a problem, and they know there is an opportunity to improve," said Dr. Elizabeth Habermann, senior author of the study and scientific director of surgical outcomes research in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. "This is the first step in determining what is optimal for certain surgeries and, eventually, the individual patient."

The lead author of the study is Cornelius Thiels, a general surgery resident in the Mayo Clinic School of Graduate Medical Education. While he examined data from Mayo's three largest campuses, the information revealed varying degrees of concern.

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Patients at Rochester's campus median prescription equaled 40 pills of oxycodone, while Arizona and Florida campus' medians were 50 and 60, respectively. The overall median of 50 pills of five milligram oxycodone is nearly twice the maximum recommended amount in Minnesota's new draft guidelines, which is 27 pills.

'Pain is very subjective'

Mayo researchers say the difficulty in prescribing opioids is due to a lack of evidence-based guidelines.

"For the last two decades, there had been such a focus at the national level on ensuring patients have no pain," said Dr. Robert Cima, a co-author who works as a colorectal surgeon and chairman of surgical quality at Mayo's Rochester campus. "That causes overprescribing and, now, we're seeing the negative effects of that.

"Because pain is very subjective, it makes it challenging."

Mayo researchers also compared prescription ranges within each of the 25 surgeries. They found a "wide variation," even after controlling for individual factors.

Study authors say that shows room for improvement — and have already begun using the new data to develop a tiered approach based on specific surgeries — but they also argue that Minnesota's draft guidelines aren't appropriate for all cases.

"For some of the procedures, the guideline is probably appropriate and we have an opportunity to reduce the amount prescribed," Dr. Habermann said. "For some of the more painful procedures, in orthopedics, for example, the draft guideline is likely too low."

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Recommendations for prescribers

The new guidelines come from the Minnesota Department of Human Services, which created the Opioid Prescribing Work Group in 2015 to address inappropriate prescribing behavior among health care providers.

The work group has created a draft of recommendations for prescribers. Some of those recommendations include:

• Provide documentation of the patient's presentation of pain and diminished physical function.

• Know the status of your patient's risk factors for opioid-related harm. Consider any relevant risk factors not already documented in the patient's record.

• Prescribers should check the Prescription Monitoring Program (PMP) whenever prescribing an opioid for acute pain.

• Avoid prescribing more than a three day supply or 20 pills of low-dose, short-acting opioids. Limit the entire prescription to 100 morphine milligram equivalents (MME) (not 100 MME per day).

• Avoid prescribing opioids to patients with a history of substance use disorder, and to those with an active addiction. Maximize appropriate non-opioid therapies.

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• Avoid prescribing opioids for fibromyalgia; headache, including migraine; uncomplicated back and neck pain; and uncomplicated musculoskeletal pain.

Mayo researchers acknowledge that opioid reform is necessary, but they contend that some responsibility falls on the patients, who must "adjust expectations on appropriate levels of pain after surgery."

"We actively support patients, but they also need to be educated that some discomfort is part of the process," Dr. Cima said. "We want patients to be comfortable enough to function, but taking away all the pain isn't an appropriate part of recovery."

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