“Three to Take or Throw”, “Four to Fill or Flush” – how and why we wean off acute opioid prescribing. Unlike other drug crises, 80% of opioid addiction starts with a pill prescribed by a physician or dentist. 76 Billion pills, it seems, prescribed in the 6 years that led to 100,000 deaths. The late 1990’s ushered in a perfect storm for prescribing: humanitarian good will, the desire to correct pain treatment inequities (that persist), the rise of the HMO and “patient as customer”, and a giant push from pharma accompanied by overt and covert teaching that “opioids aren’t addictive if you’re really in pain.” We know more now. We know 10-15% of people are susceptible to addictive highs beyond pain relief due to genetic speed of metabolism. We know 5.8% of young adults who got opioids for wisdom tooth removal are addicted within a year, compared to 0.4% who did not. Most importantly, we know that for most outpatient injuries and surgeries, OPIOIDS ARE INFERIOR TO OVER THE COUNTER CARE. It is time to wean ourselves off of writing for opioids. Considering risk, efficacy, and why we prescribe, we can change our habits of writing opioids for acute