Bright spots emerge in the prescription opioid crisis
We’re making progress, but the gap between intention and practice reveals how far we still need to go.
Ten years after the American Academy of Orthopaedic Surgeons called for a cultural shift in opioid prescribing, bright spots are emerging. Multimodal pain management protocols at institutions like Cleveland Clinic have significantly reduced patient reliance on narcotics after major shoulder procedures. Where surgeons once routinely sent patients home with 40 or more oxycodone pills, leading physicians now prescribe a fraction the number of pills for use with breakthrough pain (no scheduled use). And, critically, patients experience better pain management and post-surgery recovery with fewer opioids.
Research on arthroscopic rotator cuff repair found that just 15% of patients using updated pain management protocols used rescue opioids in the first 48 hours after surgery. By comparison, 100% of the typical protocol patients used rescue opioids. By two weeks, none of the updated protocol patients were using opioids. It’s remarkable progress that demonstrates what’s possible.
But here’s the uncomfortable truth: these exemplary programs remain the exception, not the rule.
The Perception Gap
A recent study reveals a troubling disconnect. Orthopedic surgeons prescribed an average of 594 morphine milligram equivalents more than they perceived—equivalent to an additional 80 tablets of oxycodone. Physicians attempting to practice responsible prescribing were off by 80 pills per patient!
This isn’t about individual failing. It’s a systems problem. Discharge prescriptions were often written by residents or advanced care practitioners who may not have been aware of the attending surgeon’s intended protocol.
We’re Still Overprescribing
Despite growing awareness, surgery remains a gateway to long-term opioid use. Studies show that approximately 5-7% of previously opioid-naive patients continue filling opioid prescriptions more than three months after surgery. With over 50 million surgeries performed annually in the United States, that translates to hundreds of thousands of people at risk for chronic use and overdose.
The Promise of Upstream Prevention
When we get it right, results are dramatic. Implementation of procedure-specific guidelines in Michigan reduced new persistent opioid use. Applied nationwide, this would prevent thousands of cases of chronic opioid use every year.
What’s particularly encouraging is that reducing prescriptions doesn’t mean compromising pain control. Cleveland Clinic’s protocols have greatly reduced opioid reliance while maintaining excellent patient satisfaction. Patients receiving multimodal analgesia often report better pain control than those given traditional opioid regimens.
A Cultural Shift in Progress
Pain used to be considered a fifth vital sign requiring aggressive elimination. Now the philosophy has shifted: we treat pain, not cure it.
But cultural shifts require participation from everyone. Healthcare professionals and the system overall need updated protocols and coordination. Patients need education, expectation-setting, and support.
The gap between what should be standard of care and what is standard of care represents unfinished work. And the stakes could not be higher. Not only are patients at risk, but so are families and communities around them.
This is why we launched the Billion Pill Pledge. Learn more, sign the pledge, and join us in this important mission.