Money and pain first fed Michigan’s opioid crisis, but the state’s largest insurer hopes money might starve it, too.

Blue Cross Blue Shield of Michigan is offering a 35 percent boost in insurance reimbursement — hundreds of dollars per procedure — to doctors who follow tight, new prescribing guidelines that reduce the number of pills sent home with patients after surgery.

Instead of pills, doctors spend time explaining to patients the addictive nature of these drugs, the pain that can be expected after surgery and safer, alternative ways to manage it — by switching between ibuprofen and acetaminophen, for example.

Surgeons don’t want to “leave patients in pain,” said David Bye, Blue Cross’ health care manager of value partnerships programs.

But overprescribing increases a patient's chance for addiction and risks allowing pills to fall into the wrong hands. “We’re trying to rightsize that,” he said, “to reduce the gap between what’s prescribed and what’s consumed.”

Recent research has spotlighted a lack of consensus on how often doctors should prescribe opioids and in what quantities. In a 2017 study published in Annals of Surgery, 642 patients who underwent five common surgeries — gallbladder removal or hernia repair, for example — reported using just 28 percent of the pills they were prescribed after surgery.

And while the average number of pills prescribed was 20 or 30, depending on the surgery, some doctors prescribed 100 or more pills, depending on the procedure.

Other research suggests the United States is an outlier in its reliance on opioids compared to many countries.

In September, research from the University of Pennsylvania’s Perelman School of Medicine found that U.S. patients were seven times more likely to likely to fill prescriptions for pain than patients in Sweden. According to the same study, published in the Journal of the American Medical Association (JAMA), U.S. doctors prescribed an average of 33 pills, while Swedes received an average of 26 pills, and Canadians 22 pills.

About 6 percent of U.S. surgery patients become chronic opioid users, according to a 2017 study by University of Michigan researchers, also published in JAMA. Surgery patients who have been smokers or diagnosed with alcohol or drug addictions, depression, anxiety or chronic pain conditions are particularly susceptible.

Indeed, misuse of opioids is now the top complicating factor in surgery in Michigan — more so than infection, blood clots, strokes or heart attacks, said Michael Englesbe, a University of Michigan transplant surgeon.

Many doctors are reluctant to change their prescription routines, a process that Englesbe and others say is made more difficult by inflexible medical record software, complex billing codes, and the daily pressures of seeing one patient after another.