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Strict safety protocols for prescribing opioids may have an unintended consequence: Some surgeons seem to be prescribing opioid painkillers to the spouses of patients undergoing surgery, according to a recent study led by researchers from Harvard Medical School and the Hospital for Special Surgery published in Proceedings of the National Academy of Sciences.
Patients undergoing surgery are often incapacitated in the hours and days following the procedure. This can make it difficult for them to fill a prescription for pain medicine. At the same time, there are safety protocols in place to protect patients from potential harms associated with the use of prescription painkillers, especially opioids.
In some states, regulations make it difficult for anyone other than the patient prescribed these medications to pick them up at a pharmacy.
To bypass this hurdle, some surgeons may be prescribing opioids to their surgical patients’ spouses, according to the study.
The analysis looked at nearly half a million U.S. couples who had never received a previous prescription for opioids. For couples in which one partner had surgery and picked up an opioid prescription in their own name, there was no difference in the rate of prescribing opioids to the spouse.
For couples in which the partner who had surgery did not fill an opioid prescription in their own name, rates of opioid prescription for the spouses who did not have surgery shot up sixfold on surgery days.
The number of prescriptions for that group of spouses increased from .44 prescriptions per 1,000 surgeries on the days before and after the procedure to 2.4 prescriptions per 1,000 on the day of the surgery.
“We seem to have found a situation where doctors are intentionally subverting the safety mechanisms that we have in place to ensure safe opioid prescribing,” said study author Anupam Jena, the Joseph P. Newhouse Professor of Health Care Policy in the Blavatnik Institute at HMS.
“There’s no other plausible explanation for this dramatic increase in opioid prescriptions on the day that the recipient’s partner is having surgery.”
The researchers ruled out the possibility that surgical patients’ spouses may have had some other condition that required painkillers by excluding those who had clinical encounters of their own around the time of their spouse’s surgery.
But there is some good news emerging from the analysis, Jena noted.
The researchers found no increase in side effects often reported by new opioid users among the spouses who received the inappropriate opioid prescriptions.
This suggests that they were delivering the opioids to their spouses who had surgery—the likely intended recipients of the medication.
The bad news is that those surgical patients would not receive any of the monitoring or long-term follow-up that opioid users receive to manage the risks of long-term opioid use.
“For controlled substances like opioids, you really should be prescribing to the person who is the intended recipient,” Jena said. “If you're giving the pharmacy the wrong name, then that renders that safety mechanism moot.”
In this case, the inappropriate prescriptions may be intended to help patients overcome logistical hurdles that arise from safety protocols, Jena said, but there can be dangerous consequences.
The study raises an important issue that requires attention, the authors said. If a patient cannot fill their own prescription on the day of surgery, there needs to be a mechanism that still allows the patient to receive appropriate pain management.
Some states allow such prescriptions to be filled 24 hours before the surgery, for example.
“A two-pronged approach may help reduce these risks while also improving the quality of care that patients receive,” said study author Nathan Varady of the Hospital for Special Surgery in New York.
First, surgeons should be educated about the risks involved in this prescribing pattern. And second, it would be worth examining possible solutions that would enable patients to pick up medications themselves with an appropriate prescription.
Jena and colleagues have also studied how variation in physician and hospital prescribing patterns for opioids relate to long-term complications like opioid use disorder, how these variations may include prescriptions that are not medically necessary, and how some long-term opioid users attempt to subvert limits on the number of refills they can get by seeking prescriptions for their spouses.
Authorship, funding, disclosures
Additional authors included Christopher Worsham and Antonia Chen of HMS, Eric Smith of New England Baptist Hospital, and Jaemin Woo of Brown University.
The study was supported by the National Institute on Aging (R56 AG059620) and the Agency for Health Care Research and Quality (R01 HS26753-01A1).