The opioid epidemic in the United States is as serious as ever. Although the sharp increase in opioid overdose deaths over the past decade is largely attributed to Increase in fentanyl distributed through drug cartels., a surprising number are due to recipes. In fact, the Estimates from the Centers for Disease Control and Prevention that 45 people died every day in 2021 from a prescription opioid overdose, about a fifth of all opioid-related deaths.
Some efforts to curb opioid prescribing have shown promise, including prescription drug monitoring programspromotion of alternative pain relievers, provider education and inform prescribing doctors when their patients die from opioid overdoses. But there is one medical specialty for which opioids remain a crucial part of most patients' treatment plan: surgery. Almost all patients discharged after surgery leave the hospital in significant pain, which is why surgeons prescribe more opioids than almost any other specialty.
However, most patients do not use all of the opioids they are prescribed after surgery. That leaves excess pills in circulation and helps fuel the epidemic. If we could get surgeons to prescribe only the number of pills that patients need for their own use, this could greatly reduce the number of surplus pills available for diversion and misuse among patients, their families, and members of their families. communities. This, in turn, could reduce addiction and overdoses.
Minimizing the frequency with which a surgery patient ends up on additional opioids would not solve the crisis, but it is part of the solution and it is achievable.
Changing the behavior of prescribers is difficult. They are set in their ways, rooted in a strong belief that what they do is best for their patients. Furthermore, they strongly resist attempts to limit their freedom to decide what is best. Our research team looked to the behavioral sciences for ways to incentivize providers to prescribe according to best practices, while leaving them complete autonomy to choose what they think is best.
Conventional strategies to curb opioid overprescription assume that surgeons are rational actors who, as long as they are informed about patients' needs and motivated to address them, will act to maximize patients' well-being. If that were the case, simply educating doctors about the dangers of overprescribing might be enough.
However, numerous studies in experimental psychology and behavioral economics have shown that people are highly selective in the information they focus on and are more socially minded than traditional models of rational self-interest would predict.
This knowledge from behavioral sciences provides promising avenues to reduce overprescribing of opioids by surgeons. For example, one group of researchers discovered that set default opioid amount in the electronic medical records system to match the amount patients actually use, substantially reduces the amount of opioids prescribed. Apparently, busy surgeons tended to go with the flow when prescribing: presumably because the predetermined number of pills became a salient reference point, was easier to introduce, and suggested a norm of correct behavior.
Surgeons, like other human beings, are social animals strongly motivated to adhere to norms of good behavior endorsed by their peers. We took advantage of this for our recent studya randomized trial to test two simple interventions in 19 Northern California hospitals for one year.
In one version, the emails informed surgeons that they had prescribed more pills than other surgeons in their health system had prescribed for the same procedure. This message highlighted “descriptive” norms of actual behavior. In a second, simpler version, whenever a surgeon prescribed amounts of opioids that exceeded the recommended amounts for the procedure he had performed, we sent the doctor an email notification informing him or her. This intervention highlighted “precautionary” norms of ideal behavior.
Surprisingly, both social norms interventions had exactly the same impact on prescribing. Subsequent patients were approximately 25% less likely to receive an opioid prescription that exceeded the recommended amount. This resulted in around 42,000 fewer pills in the community for the 26,000 patients in the intervention group.
Imagine how many fewer pills would be prescribed if this were expanded nationwide, given that more than 50 million inpatient surgical procedures are performed each year in the U.S. Surely this would lead to millions, if not tens of millions, of opioid pills will circulate less throughout the country. United States every year.
Affordable solutions based on evidence about human behavior can be powerful tools in our campaign against opioid addiction. Sometimes a simple touch—a change to the electronic health system's default settings or an automated email to surgeons—can have a huge effect on prescribing decisions with life-or-death consequences.
Zachary Wagner is a health economist at USC and Rand. Craig R. Fox is a professor of psychology and medicine at UCLA and president of the Behavioral decision making area in it UCLA Anderson School of Management.
