Opioids & surgery: IHPI's entry in STAT Madness

March Madness isn't just for basketball anymore.

A team from IHPI has made the cut for another tournament - a tournament of science. Called STAT Madness, and run by the STAT medical news service owned by the Boston Globe, it's a fun competition aimed at raising awareness of the role of universities in biomedical and health research of all kinds. 

IHPI's contender is a team of surgeons, anesthesiologists, statisticians, dentists, public health professionals and others who have worked for several years to understand the prescribing of opioid painkillers to surgery patients, and develop ways to prevent unintended consequences from them. This IHPI Brief summarizes their work.

See how the IHPI team fared in the tournament here

STAT Madness pits teams against one another based on the strength of a single research paper published in the previous year. Through a free online voting process, half of the teams are eliminated each week until a final round just before the basketball March Madness concludes. 

In the IHPI team's case, that paper came out in November, 2018 in JAMA Surgery. It summarized the findings of a team led by Department of Surgery residents Ryan Howard, M.D., and Joceline Vu, M.D., and including IHPI members Michael Englesbe, M.D., Chad Brummett, M.D., Jennifer Waljee, M.D., MPH, M.S., and Darrell "Skip" Campbell, M.D. 

The team discovered that surgical patients were only taking about a quarter of the opioids they had been prescribed, and that the larger their initial prescription size, the more opioids they took. Even before the paper came out, the team used the data to create the first-ever opioid prescribing guide for surgical teams. The study relied heavily on data from the Michigan Surgical Quality Collaborative (MSQC), a statewide effort funded by Blue Cross Blue Shield of Michigan.

Howard reflects on the impact of the work, and next steps the team is already working on:

Your paper came out in November. What has the response from the surgical community been?

Overall we’ve had a very positive response from the surgical community. I think surgeons were anecdotally starting to see that opioids were a big problem after surgery.

What we hoped to accomplish with our study was to establish some population-level data to show that yes, opioids are over-prescribed after all kinds of surgical procedures. We also wanted to empower surgeons to take ownership of their prescribing habits by demonstrating the link that the more we prescribe, the more patients use.
     
Even before the paper was published, you had started rolling out new prescribing guidelines to MSQC hospitals and online. How is that effort going? 

We’re really blown away by all the progress that’s been made with the prescribing guidelines! What started as a small pilot project after a single surgery at a single hospital is now a set of robust guidelines for 25 different surgical procedures.

We get feedback from all over the state that surgeons are using them, and we even hear from some out-of-staters that they use www.opioidprescribing.info to decide how much to prescribe. We’re excited to see if our prescribing guidelines are going to have a measurable impact beyond just our own health system.

What's the main aim of the overall research effort? 

One thing we always try to highlight is that by reducing opioid prescribing, we’re not just out to bash opioids altogether – we’re really just trying to find the “right amount” for each surgery.

We think that’s a pretty good first step in combating the opioid epidemic. A crucial next step is going to be finding the right amount for each patient by adjusting our prescribing based on pain conditions or other health conditions that may play a role in an individual patient’s pain experience.

What are the next steps for dissemination/implementation of the prescribing guidelines, and for further research by your team?

One of the next steps we’ve been excited about is using preoperative counseling with patients to sometimes avoid opioids altogether after surgery. We’re starting to discover that there are certain patients and certain procedures that really don’t require any opioids – and incredibly, pain control is just as good.

So considering that up to 10 percent of patients can develop chronic opioid use after just a single surgery, we think that helping patients achieve great pain control without exposing them to that risk would be something well worth pursuing.