Left-Over Painkillers are a Potential Source of Narcotics Abuse

A U.S. hospital study found patients recovering from breast surgery were only using a fraction of their prescribed painkillers, leaving the excess open to misuse

A study at Cleveland Clinic in the United States has found that patients recovering from breast surgery are often only using a fraction of the medication they are prescribed, raising concerns that left-over pills could lead to potential abuse.

As America faces a growing problem with opioid addiction, in many cases beginning with a prescription to painkillers, hospitals are reconsidering the best way to use narcotics to relieve pain, including for short-term use after surgery. Cleveland Clinic reviewed prescriptions after three types of surgery to treat breast cancer – it found almost half the patients used none of the medication post-surgery, leaving narcotics open to misuse.

“For years, I don’t think many surgeons realized the magnitude of the amount of narcotic pain medications that they prescribed to patients for postoperative or other pain management,” says  Stephanie Valente, DO , a surgeon with the Department of Breast Services at Cleveland Clinic. “We were surprised and disheartened to see that the prescriptions we were writing to help with postoperative pain were unknowingly contributing to dependency and abuse in America.”

Lack of clear prescribing standards for adequate post-operative pain control is a big part of the problem. The project at Cleveland Clinic’s Department of Breast Services aimed to solve this, with a goal of providing optimum pain control without excess narcotic medications.

“As a group of surgeons at a large academic institution, we wanted to see how we could standardize and improve our narcotic prescribing patterns while engaging patients in the quality improvement process,” says Dr. Valente.

Researchers reviewed prescribing data on breast surgery patients treated in 2017 to establish baseline postoperative narcotic prescribing patterns. Based on data from 100 consecutive patients, inconsistencies were found in the type and number of narcotics prescribed: Tramadol, Tylenol-3, Norco/hydrocodone and Percocet®/oxycodone prescriptions ranged from zero to 40 pills. The median number of pills varied with procedures: 15 for excisional biopsy/lumpectomy, 20 for mastectomy and 28 for mastectomy with reconstruction.

As a first step, the department educated surgeons and standardized the number of pills prescribed at 10 for excisional biopsy/lumpectomy and to 25 for mastectomy with reconstruction – both slightly below the previous median – with no reduction in the 20 pills prescribed for mastectomy.

But when doctors followed-up with 100 patients to find out how many pills they used, the median number of pills taken by patients was significantly less than what was prescribed for all procedures. The ‘average’ patient took just one pill for excisional biopsy/lumpectomy, leaving nine pills unused; three for mastectomy, leaving 17 pills unused; and 18 for mastectomy with reconstruction, leaving seven pills.

Nearly half (40 percent) of the patients reported using zero narcotics following their procedure, having a significant impact on the overall average.

“When we decided on the number of narcotics to prescribe, we were concerned that it might be too little. We were surprised how little narcotics patients took and how many patients took no narcotics at all. Many patients opt for ice and Tylenol,” says Dr. Valente.

Guided by this data, Cleveland Clinic is focusing on surgeon and patient education.

“Pain medications can have a necessary, temporary role in the management of surgical pain,” explains Dr. Valente. “Patients need to understand that there will be some degree of discomfort from surgery and know that the amount of narcotics given after surgery will not be renewed.

“At the same time, we now have a better understanding of multi-modality non-narcotic alternatives for pain management. Many breast surgery patients will be able to safely avoid all postoperative narcotics.”

The study results were presented at the 2019 annual meeting of the American Society of Breast Surgeons.

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