Two years ago, weight-loss surgeons at Roper St. Francis sent all of their patients home with a prescription for an opioid painkiller. This year, they have written only three. 

That's because the bariatric surgery unit at the hospital system has been working hard to create a new list of pain management policies in an attempt to bring down the number of potentially addictive prescriptions they write.

Those prescriptions are thought to be at the root of the painkiller epidemic.

The hospital system is "engineering" new ways to treat surgery patients' pain, said Dr. Jeffrey Frohock, an anesthesiologist tasked with reducing opioid prescriptions across Roper St. Francis.

In bariatric, or weight-loss, surgery, the physician must inflate the abdomen with gas in order to be able to see to do the surgery. That is the most common source of pain in these patients.

Bariatric surgeon Dr. Bryan Thomas said the key has been to prepare patients for that pain, and manage it before it becomes unbearable. 

"It's easier to keep up with it than catch up," Thomas said.

Roper St. Francis' effort is one example of how the state's hospitals are trying to bring down their opioid prescription rates.

Across the state, that same goal has been a policy focus. Gov. Henry McMaster's opioid study committee asked insurers and medical groups to work on the issue. 

During a visit to Roper St. Francis on Friday, Attorney General Alan Wilson said he was searching for ways to play a role. He asked the Roper physicians for marching orders. 

Frohock said patients are warming to the idea of trying different options, like less addictive painkillers or a nerve block, he said.

"We didn’t have a great option to give them in the past," Frohock said. "We now do."

One study released this year by the American College of Surgeons showed bariatric surgery patients are prescribed a high rate of opioids compared to other common types of surgery. 

The same study showed any patient who is assigned an opioid prescription after an operation is at an increased risk of becoming a chronic user at a 3- to 7-percent rate.

Chronic opioid use is the most common complication after elective surgery, research has shown. Said another way, optional surgeries can lead to dependence on the pain medication patients are sent home with.

Patients often use only a fraction of the opioids they're given. This creates a problem because excess pills are left around the house and can be misused in the future by the patient or someone else.

Roper St. Francis is not alone in its attempts. The Medical University of South Carolina's obstetrics group, for instance, nixed their oxycodone prescriptions for many of their patients, a spokeswoman said.

Another example: MUSC's surgeons cut their opioid prescriptions by 37 percent for pediatric hernias, which are not uncommon.

Health insurance companies have found their own ways of changing how they pay for pain medication. Cigna dropped Oxycontin, manufactured by Purdue Pharma, in the beginning of this year. Tennessee's BlueCross BlueShield association will blacklist the drug in the beginning of 2019.

There is a divide between how physicians approach the topic. Some feel there should not be restrictions on their ability to prescribe medications, and patients with serious pain issues are being sidelined. 

"There is no correlation between the number of prescriptions written and a state’s death rate by opioid overdose," two local physicians wrote in a recent opinion piece in The Post and Courier

New numbers released from the S.C. Department of Health and Environmental Control show a shift from deaths from overdose of prescription drugs to illicit ones. 

Statewide overdoses involving the powerful synthetic drug fentanyl increased by 432 percent between 2014 and 2017. In total, 758 people in South Carolina died from an opioid overdose in 2017, compared to 616 the year before. 

The attorney general said lawyers are prosecuting cases involving illegal drugs. But Wilson still wants to see more physicians cutting down on their opioid prescriptions.

"We need to attack the cause of the epidemic, not the symptom," Wilson said. "By the time you're prosecuting something, you're treating the symptom."

Frohock said Roper St. Francis has been reigning in its opioid use little by little. His job will be to bring the bariatric unit's success to the rest of Roper's facilities.

Reach Mary Katherine Wildeman at 843-937-5594. Follow her on Twitter @mkwildeman.