by Marty Makary
We ran the analysis for the surgeons who did that laparoscopic gallbladder surgery that led to the creation of our expert panel. Our panel concluded that zero to 10 pills is the recommended opioid prescribing range for that operation, yet the data we looked at as a team revealed doctors that were still prescribing as recklessly as I had done, averaging 30 pills.
Someone on the team pointed to a dot on the graph that represented the surgeon averaging 45 opioid pills after the operation. “That surgeon is crazy.”
“No,” I countered. “That surgeon needs help.” We have a duty to take care of each other in medicine. “That surgeon needs to be educated as I got educated a few years ago.”
My research team repeated the analysis for many common procedures, including operations that can be managed with non-opioid alternatives. The doctor distribution graphs kept showing us the same thing: opioid prescribing patterns vary widely, even within an identical procedure. One analysis of lumpectomy operations revealed that some surgeons routinely prescribe more than 60 opioid pills. Our consensus panel of medical experts and patients recommended between zero and 10, advocating for non-opioid alternatives. Now that the data allowed us to see which doctors need help, we had a duty to help them.
We are working to apply the Improving Wisely approach to the opioid overprescribing problem. In addition to the many potential lives saved, imagine the cost of these unnecessary opioid pills being dispensed. Add to that the addiction treatment costs for the 1 in 16 patients who will become addicted. Prevention is still the best treatment.
In hopes of creating an honest conversation about the overprescribing culture, I published an account of my own overprescribing regrets and my “aha” moment when my dad had surgery. The story made the front page of USA Today6 and hundreds of doctors reached out to me to tell me that they, too, were amazed at the way medicine had embraced a culture of opioid overprescribing, oblivious to the impact. A friend from my internship days texted me. “Good piece in USA Today, remember when Dr. F required us to write for 100 opioid pills for everyone?”
Even after all the efforts to reduce overprescribing, we have a long way to go. I was asked to give a speech at a medical conference in Lebanon and offered to give a talk about the opioid epidemic. The conference organizers told me, “That’s a uniquely American problem. We don’t have that problem here because we prescribe opioids sparingly.” Most doctors worldwide reserve opioids for the classic indications—like terminal cancer, burns, and major surgery. I felt a bit ashamed, but it was true. The opioid crisis was unique to American medicine.
There are concrete things we can do to address this crisis. We can start by changing perverse financial incentives. It is difficult to find doctors interested in carefully managing a patient’s pain medications because doing so pays so little. A doctor might get only $50 for a 30-minute visit. That might not even cover overhead. Our reimbursement system should value expert advice and counseling on pain management. Moreover, pain specialists should be paid not just for doing procedures, but for their time managing pain.
We also need insurance companies to change. Ironically, acetaminophen and NSAIDs (nonsteroidal anti-inflammatory drugs) are over-the-counter medicines and thus rarely covered by insurance. But the insurers do cover narcotic painkillers. As I’ve talked to my patients, I’ve come to believe that one simple solution is that all non-opioid pain meds should be fully covered after surgery with no copay or deductible. Those who think that the $10 to $20 price for a bottle of NSAIDs is a not a barrier to patients buying them should meet some of my poor patients from inner-city Baltimore. I have had patients buy heroin to manage their surgical pain because it cost less than their copay.
Finally, patients should inquire about having a nerve block when they have a painful procedure. It’s well established that when nerve blocks are injected in a surgical area or nerve root, patients require fewer pain pills. Hopefully, someday, physicians will be able to manage local pain with local therapy rather than systemic therapy, which has collateral damage.
I’m shocked that no one in politics has requested to review the analyzed national Medicare data for surgeons’ prescribing patterns by procedure in narcotic-naïve patients. I tried to get the attention of members of Congress who have high rates of addiction in their home districts. I told them I can show them the specific doctors who are prescribing too many of the pills. But they respond with hot air and no action. But after a lot of persistence, a breakthrough. I presented the data to Medicare leaders Kim Brandt, Kate Goodrich, Paul Mango, and others who decided to do something about it. They launched an initiative to send opioid prescribing reports to outlier high prescribers, showing surgeons where they stood on the bell curve. The reports were specific to a procedure and used data on narcotic-naive patients so there would be no reason for pushback that one surgeon’s patients were “different.” We had a valid way to measure where the opioid faucet is still pouring out, and finally Medicare was on top of it. At the same time, a grant from the Laura and John Arnold Foundation to my Hopkins research team allowed us to expand the project beyond what Medicare could do and also launched a national program to lower opioid prescribing defaults in electronic health records. This project, called the SOLVE collaborative (SolveTheCrisis.org), resets opioid e-prescribing defaults from sky-high legacy numbers, like a 30-day supply, to a consensus amount that is much lower and specific to the procedure performed. For many procedures, that default number is now 5, 10, or zero.
If ever there was a practice pattern of overtreating patients, it is the way we prescribe opioids. Using data to identify prescribing patterns and changing incentives to reward pain management best practices are far less expensive than rehab. Engaging doctors who overprescribe, as I did, can have a broad impact. Treatment for opioid addiction is essential, but we should remember that preventing addiction is even better. To address the opioid crisis, we need to take away the matches, not just put out the fires.
CHAPTER 10
Overtreated Patients like Me
It had been a long, grueling day of surgery. After driving home and trudging through the front door, I turned on the news and flopped onto the couch. There I lay, horizontal and half asleep, until something caught my attention. I heard the anchor announce breaking news of a medical study that found some heartburn medications like Nexium increased the chance of stroke and kidney failure. What? I sat straight up. Not only did I frequently prescribe the heartburn medication Nexium, but I was taking it myself.
I jumped off the couch and listened carefully to the broadcast. I pulled out my computer and hunted down the study to learn more. Ironically, the research came from Johns Hopkins.1
My gosh, is this true? I called my friend Dr. Tony Kalloo, head of gastroenterology at Johns Hopkins, who acknowledged the new findings of the study and the risks of Nexium. I told him I’d swing by his office in the morning to talk more. I hung up the phone, walked to my medicine cabinet, and glared into the soul of my orange plastic bottle of Nexium tablets. Just a moment ago I had considered it my friend. Et tu, Nexi?
My love affair with Nexium began when I told my primary care doctor that I sometimes get heartburn when I perform long operations. He wrote me a prescription for Nexium, a medication I had known personally for years and prescribed to thousands of patients after surgery. I told patients it was safe and would perfectly cure their heartburn the majority of the time.
When I started taking Nexium myself, it did exactly that—it cured me, affirming my belief that it worked wonders. I didn’t like the $40 copay I had each month, but luckily, my insurance company paid the bulk of the expense. It shelled out $120 each month for the medication. Life seemed good. Until this new study came out.
The day after the study hit the nightly news, I walked into Dr. Kalloo’s office. He’s a good friend, a jovial man from Trinidad. “It’s over between me and Nexium,” I told him. “Now what do I take instead?”
He laughed hard and long, then gained enough composure to look
at me. “Marty, there’s this thing called lifestyle modification.” He paused with a big smile, then asked sarcastically, “Maybe you’ve heard of it?”
Oh, gee, I thought, there is a natural way to cure heartburn that I learned in medical school and then stored deep in the attic of my brain. Let me see if I can remember what it involves: (1) No eating before bedtime, (2) No eating between meals, and (3) No processed foods.
The thought of monitoring and changing my eating habits was already making me tired. I felt betrayed by those who taught me Nexium was perfectly safe. I reluctantly agreed to try the lifestyle modification protocol. I stopped eating a bowl of cereal before going to bed. I removed the jar of peppermint patties I had been dipping into at my front office desk. And I stopped buying processed foods altogether in favor of whole foods.
It worked perfectly. My heartburn was cured, this time without medication. With little effort, I had successfully avoided the risks of a drug, cut out the daily routine of popping a pill, and saved a lot of money for me and all the people paying premiums to my health insurance plan. In total, I saved myself $480 a year, and I saved my insurance plan $1,440. Sure, the nonprocessed foods cost more, but net-net I came out on top. And I felt great. My own experience was a powerful lesson—getting off lifestyle medications can improve health and lower medical costs.
But was my story a one-off anecdote or a viable step in solving our health care cost crisis?
Consider this simple fact: Last year, physicians prescribed a record 4.5 billion medications.2 That’s about double the number we prescribed just a decade ago. Did the incidence of disease double in the last ten years? Of course not. Most of the doubling represents pills that could be avoided with lifestyle changes or more judicious prescribing. More than half of Americans are now on four or more medications, according to Consumer Reports.3 As if that’s not shocking enough, my research team published a study showing the average person on Medicare is on twelve medications.4
I learned many things in medical school, but overtreatment was not on the syllabus. Both the doctors prescribing and the patients demanding these medications have a role to play in reversing the dangerous and costly trend. A quick message to all people who walk into a doctor’s office demanding an antibiotic for a viral infection or Nexium for heartburn: please stop putting pressure on doctors to prescribe something.
My experience taking Nexium reminded me how ingrained in our culture pill popping has become. The medicalization of ordinary life is so widespread it’s hard to avoid. As a physician, my experience writing prescriptions for too many opioids after surgery reminds me how doctors can also do better with our prescribing.
In medical school, a practical topic like the hazards of too much medical care took a back seat to all the rote memorization and regurgitation of facts. We learned Latin just for the sake of knowledge, but the traditionalists who designed my extensive medical education left out some of the most important parts of being a good doctor: effective communication and self-awareness. Moreover, they did not teach an important caveat to everything in our medical textbooks and journal articles: the risks of medications and procedures are understated because of publication bias (a tendency to publish only good results) and the lack of studies evaluating long-term consequences.
Second Tour of Duty
As if lightning never strikes twice, I went in for my next routine annual checkup with my primary care doctor. (If I can be honest, as a doctor it feels weird to be a patient. Doctors tend to be skeptical and explore extreme alternatives to what our own doctors recommend.) During this visit, my doctor told me I have high cholesterol and that I should start taking a statin, a common drug used for lowering cholesterol numbers. With the trashed Nexium bottle still fresh in my mind, I was reluctant to take a statin.
To be honest, I didn’t like the idea of taking any medication, let alone one with well-known side effects. But every cardiologist I grabbed in the hospital hallways told me “Statins save lives.” I read the leading studies myself and couldn’t deny the survival benefit. But one cardiologist I respect thought the survival benefit was limited to a subgroup of people who took them and that it was due to the anti-inflammatory effect of statins rather than their cholesterol-lowering effect. That made sense, but regardless, the data made it clear that statins save lives. I reluctantly took the medication daily for three months.
But then the multicultural part of me came out. I realized that all the studies were done predominantly with Anglo subjects, not people like me.
I recalled that everyone in my family lives long and that family history was the biggest determinant of heart disease. I also realized that no one in my family had heart disease or had ever had a heart attack. My grandma Fifi, back in Egypt, was almost 100 years old and had never had a heart issue. I called an uncle, a Cairo cardiologist and the go-to doctor for my extended family, and asked for Fifi’s cholesterol numbers. He took my numbers and said they were the same as those of my grandma and grandpa and everyone else in the family.
When I started to tell him my doctor recommended I start a statin, he interrupted. “No, you don’t need to take it.” He also took the opportunity to say that U.S. doctors are well known in the international cardiology community to overmedicate, overstent, and overtreat. He pointed out that one popular statin medication in the United States was banned in the UK because of its side effects, and he commented that Americans are on way too many meds.
I went back to my personal primary care doctor and explained to him that my family history contains zero heart disease and that everyone in my family lives into their nineties with the same cholesterol profile as mine. I told him if my cholesterol numbers were good enough for Fifi, they were good enough for me. His humble response impressed me. He thanked me for doing the research and said based on my family history, he wouldn’t recommend the statin medication.
My doctor had also checked several new science markers of heart disease risk: my LP(a) level, ApoB level, and my hs-CRP, all of which were good. Finally, we agreed that if my calcium score was zero, I would not take any meds. It was. My wallet and I were off the hook.
For the three months I took statins every day, who was paying for them? It wasn’t just me, it was everyone else insured by my health insurance company. The insurance company sets premiums based on what they pay out each year. If I had not stopped my unnecessary Nexium and statin medications, the total cost passed along to everyone paying insurance premiums would have been approximately $30,000 over the next ten years. For people wondering why insurance premiums are going up, one of the leading drivers is the doubling of prescription medications our country has witnessed over the last decade.
One Last Round
By the time I went back to my doctor the following year, the fact that I had been on two unnecessary medications over the last few years was water under the bridge. This time I went to him for something that was real. I had developed back pain from standing in the operation room doing pancreas islet transplant operations for six to ten hours at a stretch. I had two spine surgeons evaluate me for the pain. One told me to do physical therapy, and the other offered to do surgery.
Around that time, Steve Kerr, coach of the Golden State Warriors basketball team, missed most of his team’s playoff games for health reasons. Oh my, I thought. He must have something serious. Well, he did, but it was not a virus or heart attack—it was the endemic problem of too much medical care.
He had been disabled by one of his back operations for chronic pain. His words sent chills down my spine. “I can tell you, if you’re listening out there, stay away from back surgery,” Kerr said. “I can say that from the bottom of my heart. Rehab, rehab, rehab. Don’t let anyone get in there.” Stanford spine surgeon Dr. Robert Aptekar called what Kerr said “good advice.”5
After talking to more spine surgeons about my back problem, I was amazed by how many of them told me the same thing Coach Kerr had said. My physical therapist worked wonders and I never had spine surgery. I
didn’t need it.
In this chapter, I’ve discussed only my personal experience. But overtreatment is pervasive in health care. A detailed report released by 21 Washington State physicians who are part of the nonprofit Washington Health Alliance found that 45% of Washington State health care services were unnecessary. In total, they found that 600,000 patients in Washington underwent medical services they didn’t need, costing an estimated $282 million in one year.6 Topping the list were frequent screenings and tests deemed irrelevant to care, such as unnecessary lab tests routinely performed before minor surgery.
In recent years, a plethora of studies have shown that doctors have been overtesting, overmedicating, and overoperating. If there’s one theme I’ve observed in medical journals over the last few years, it’s a massive rollback of broad recommendations. Studies in the New England Journal of Medicine have challenged surgical dogma on when we should be doing knee replacement, appendicitis, and thyroid surgeries. Many of these surgeon-authors point out that we have been overdoing them.7
There’s also the psychological harm to patients who get spooked by a screening test that simply captures normal variants of the human body. I’ve seen patients tormented with anxiety thinking that they are carrying a time bomb inside them and doing everything to avoid living with regret if they develop cancer. A needless scare can consume people with emotional trauma, affecting mental health.
Don’t Forget the Bill
Who paid for Coach Steve Kerr’s back operations? We all did. His most recent operation probably cost more than $200,000, if you include the complications. In contrast, my physical therapy sessions cost $85 each. Just like the medications I was taking that I didn’t need, his surgery was paid for by his insurance company, which then sets premiums based on what they pay out each year.