Revisiting U-M work from 2017 that is helping clinicians manage — or limit — opioid prescriptions so patients can avoid misuse and addiction.
The pain that follows many operations, and torments patients with other medical conditions, often requires strong medication.
But prescribing opioid painkillers when they’re not needed, or in excess amounts, has helped create the crisis of addiction and overdose affecting the United States.
Because of how opioid molecules act on the brain, patients can become dependent on the medicine intended to help them. Meanwhile, any leftover pills could get into the hands of others seeking a high.
The issue has fueled a wide range of research at the University of Michigan. Across various schools and departments, researchers seek to learn more about how opioid prescribing can be improved, which patient populations need better monitoring and tailored care — and how those who become addicted can get effective help.
Here’s what U-M experts, many of them members of IHPI, found in work published this year:
Some factors make surgical patients more likely to abuse drugs.
Six percent of people who have never taken a pain medication before (a group known as “opioid-naive”) are at greater risk for abusing the medication after surgery.
Several pre-existing factors fuel that scenario: whether a patient has been a smoker — or diagnosed with alcohol, drug, depression, anxiety or chronic pain conditions before surgery, according to a study from U-M’s Institute for Healthcare Policy and Innovation.
Knowing those details can help doctors better manage opioid refills. “This is not about the surgery itself but about the individual who is having the surgery and the predisposition they might have,” says Chad Brummett, M.D., the study’s lead author and director of the pain research division at U-M’s medical school.
1 in 20 young adults uses opioids for too long after common surgeries.
Adults aren’t the only patients at risk for post-surgical opioid dependence. Research from University of Michigan C.S. Mott Children’s Hospital finds that nearly 5 percent of young adults continue to receive opioid refills long after surgery.
Although researchers looked at opioid prescriptions, not actual use, the fact that teens were getting refills three to six months after a surgery reveals a dangerous precedent.
“Whether they are using the opioids themselves or giving them away to peers, this presents a great health risk for both patients and the community,” says Calista Harbaugh, M.D., a resident at U-M’s medical school and a Mott pediatric researcher.
When prescribing opioids, a patient’s voice can be a guide.
For surgeons, opioid prescribing seems like a double-edged sword: Prescribe too much and your patient may be at risk, but prescribe too little and patients might suffer, and your staff could get inundated with calls for refills.
A U-M team listened to patients and created an opioid prescribing guide based on their responses, proving that a middle ground may exist. The team, led by Ryan Howard, M.D., and Michael Englesbe, M.D., analyzed data and interviews from hundreds of gallbladder surgery patients, and used that information to advise surgical teams on how much to prescribe to future patients.
The result: fewer unnecessary opioids entering patients’ homes, and no change in pain scores or refill requests.
Research-based guidelines can help surgical teams prescribe accurately.
How many pain pills should a patient get after appendectomy? How about someone recovering from hernia repair? The number has long been murky.
“It’s embarrassing to admit this, but we’ve never had any evidence to inform how much opioid we prescribe to surgical patients,” says Jay Lee, M.D., a Michigan Medicine general surgery resident who, working with the Michigan Opioid Prescribing Engagement Network and the Michigan Surgical Quality Collaborative, crafted a set of guidelines to help.
Opioid Prescribing Recommendations for Surgery lists 11 common operations — and, for each one, prescription amounts based on pain control and surgical quality research plus data and patient surveys from hospitals across Michigan.
Past opioid use strains patients and hospital systems.
Operating on people who took prescription opioid painkillers before having elective surgery comes at a cost.
These patients, a U-M Institute for Healthcare Policy and Innovation study found, have longer hospital stays. They’re also more likely to require follow-up care via a hospital or rehab center than counterparts who didn’t use opioids prior to the same surgeries.
Doctors already view smoking, anticoagulant use and other health conditions as factors to delay a patient’s surgery. “These findings suggest that preoperative opioid use warrants the same awareness,” says Jennifer Waljee, M.D., a Michigan Medicine plastic surgeon and the study’s lead author.
Hysterectomy recipients get twice as many opioids as necessary.
Some hysterectomy patients don’t need opioids after surgery. Many others receive far more drugs than necessary.
Women are commonly prescribed about 40 hydrocodone pills after the procedure, a U-M study of 100 hysterectomy patients found. But they only use about 18 — heightening the risk that leftover medication could be stolen or misused.
Given that 600,000 hysterectomies are performed annually in the United States, “we hope to identify specific patient factors that may be associated with how much pain medication should be prescribed,” says study lead author and Michigan Medicine gynecological surgeon Sawsan As-Sanie, M.D., MPH.
Improper migraine treatment is a widespread problem.
Migraines are more frequent and severe in black patients. But a U-M study intended to examine wider racial disparities in migraine care found a common thread among all recipients of all ethnicities.
“(All) people were getting prescribed opioids as much as they were getting prescribed medications that are much better for migraines,” says Larry Charleston IV, M.D., M.Sc., a U-M assistant professor of neurology and the study’s first author.
Other options, he and co-authors note, are safer and more effective. Those include level A abortives (such as a triptan or dihydroergotamine) and preventive medications known as prophylactic treatment.
Cancer patients are more likely to overuse opioids.
About 6 percent of people who had never used opioids prior to surgery take them for longer than necessary. But those who receive curative-intent cancer surgery are almost twice as likely to do so: More than 10 percent use opioids for three to six months, according to a U-M study.
Emotional trauma of a cancer diagnosis, pain from invasive surgery and miscommunication among a large care team all contribute. “That’s a tremendous burden to leave with cancer survivors,” says Jay Lee, M.D., the study’s lead author.
It’s why doctors need more education about cancer and opioids (post-surgical chemotherapy is tied to higher persistent opioid use, the study found). Physicians, Lee says, should first advise Tylenol or Motrin, suggesting opioids — ideally at a lower dose — only as a last resort.
Electronic tracking helps curb “doctor shopping” for drugs.
There’s power in prescription drug monitoring programs. Also known as PDMPs, the secure digital record systems track prescription and dispensing data to detect “doctor shopping” — when patients use multiple sources at once to obtain excess opioids for themselves or to sell.
Several U-M studies have examined the practice. One, a joint effort with Cornell University, found that states with stronger PDMP laws target problematic prescription patterns more effectively. Another examining private insurance data from Kentucky and Tennessee drew similar conclusions.
A third paper cites the potential of PDMPs to curb misuse — but only if doctors take the tools seriously. Clinicians “can no longer be bystanders” to the epidemic, write U-M opioid researchers Amy Bohnert, Ph.D., and Pooja Lagisetty, M.D., M.Sc.
Primary care doctors play a role in ending the crisis.
Some familiar faces could be key allies in helping the 2 million Americans facing opioid addiction break the habit: a patient’s primary care team.
A combination approach known as medication-assisted treatment, or MAT, has mainly been delivered in addiction-care settings. But evidence is growing that primary care teams can successfully facilitate the needed check-ins as well as the start and maintenance of the anti-addiction medicine buprenorphine.
The work requires eight hours of training and time from a physician’s schedule, acknowledges Pooja Lagisetty, M.D., M.Sc., a U-M and VA primary care doctor who provides MAT and co-authored a review of the treatment. Still, she notes, the extra effort can be lifesaving.