What's the right painkiller prescription to send home with a patient after gallbladder surgery or a cesarean section?
That question is front and center as conventional approaches to pain control in the United States have led to what some see as a culture of overprescribing, helping spur the nation's epidemic of opioid overuse and abuse.
The answer isn't clear-cut.
Surgeon Marty Makary wondered why and what could be done.
So, Makary, a researcher and a professor of surgery and health policy at Johns Hopkins School of Medicine in Baltimore, took an innovative approach toward developing guidelines: matching the right number of opioid painkillers to specific procedures.
After all, most doctors usually make this decision based on one-size-fits-all recommendations, or what they learned long ago in med school.
Even Makary admitted that for most of his career he "gave (painkillers) out like candy."
In December, he gathered a group of surgeons, nurses, patients and other leaders, asking them: What should we be prescribing for operation X?"
The answer was illuminating.
"The head of the hospital's pain services said, 'You're the surgeon, what do you think?'" recalled Makary.
Makary didn't know. Nor did the resident. And the nurse practitioner, who often is the one who most closely follows up with patients, said it varies.
"Wow," recalls Makary of that day when they first considered appropriate limits. "We're the experts, the heads of this and that, and we don't know."
After a quick couple of weeks of intense discussion, Makary's group reached consensus and gave its blessing to guidelines setting maximum numbers of opioid-containing pills for 20 different common surgical situations, from relatively minor procedures to coronary bypass surgery.
"We're in a crisis," said Makary, explaining why the group didn't go a more traditional route and publish its findings in a medical journal first, which could take months.
Sometimes the right number of opioids is zero, concluded the group.
Indeed, it recommends no opioids for patients heading home after uncomplicated labor and delivery, or after cardiac catheterization, a procedure in which a thin, hollow tube is inserted into the heart through a blood vessel to check for blockages.
For certain types of knee surgery, such as arthroscopic meniscectomy, the guidelines recommend no more than 12 pills upon discharge, while a patient going home after an open hysterectomy could require as many as 20.
Optimally, "no one should be given more than five or 10 opioid tablets after a cesarean section," Makary said.
Oh, and for cardiac bypass surgery? No more than 30 pills.
