The Role of Acute Care Prescribing in the Opioid Epidemic

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1 The Role of Acute Care Prescribing in the Opioid Epidemic Chad M. Brummett, M.D. Associate Professor Department of Anesthesiology Division of Pain Medicine University of Michigan Medical School

2 Funding and Disclosures Funding NIAMS/NIH: R01 AR060392; P50 AR NIDA/NIH: R01 DA038261; R01 DA Michigan Department of Health and Human Services SAMHSA CDC Michigan Genomics Initiative Department of Anesthesiology Neuros Medical, Inc Disclosures Patent for the use of peripheral perineural dexmedetomidine alone and in combination with local anesthetics. Application number 12/791,506; Issue Date 4/2/13; Patent Number Consultant- Recro Pharma, Heron Therapeutics

3 115 AMERICANS die every day from an opioid overdose (that includes prescription opioids and heroin).

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5 Prescription Opioids In America 2012: 259 million opioid prescriptions :

6 More Drug Overdose Deaths Now Involve Heroin than Prescription Painkillers

7 Faces of the opioid epidemic

8 How did we get here?

9 Porter J, New Engl J Med 1980; 302 (2)

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11 NEJM letter regarding opioid addiction misrepresented and heavily cited Leung A, et al. (N Engl J Med 376;22)

12 For Whom Do We Prescribe?

13 Opioid naive Chronic 8% Intermittent 30%

14 Pre-Operative Opioid Use and Associated Outcomes after Major Abdominal Surgery Cron DC, Englesbe MJ, Bolton CJ, Joseph MT, Carrier KL, Moser SE, Waljee JF, Hilliard PE, Kheterpal S, Brummett CM. Annals of Surgery 2016.

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16 Our Role

17 Why do surgeons prescribe too much?

18 HCAHPS Prescribing HCAHPS Pain Control Score < >570 Hospital Quintiles of Postoperative Opioid Prescribing (OMEs) Lee JS, Hu HM, Brummett CM, Syrjamaki JD, Dupree JM, Englesbe MJ, Waljee JF. JAMA May 16, 2017

19 Refills?

20 Quantity Does Not Predict Refill 14% N = 26,250 Probability of Refill 12% 10% 8% 6% 4% 2% 0% >60 # of pills (hydrocodone 5mg) Sekhri S, Arora NS, Cottrell H, Baerg T, Duncan A, Hu HM, Englesbe MJ, Brummett C, Waljee JF, Ann Surg 2017

21 Opioid naive Chronic 8% Intermittent 30% New Persistent Use

22 New Persistent Opioid Use 6% Brummett CM et al. JAMA Surg. 2017; 152(6). 8% Goesling J et al. Pain. 2016;157(6). 13% Johnson SP et al. JHS. 2016;41(10). 5% Harbaugh CM et al. Pediatrics Epub. 10% Lee JS et al. JCO Epub 19% Marcusa D et al. PRS. 2017;140(6).

23 Opioid prescription fill after extraction of wisdom teeth is independently associated with new chronic opioid use Harbaugh C et al, unpublished data

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25 6 tabs/day of Norco 5/325

26 6 tabs/day of Norco 5/325

27 Who Prescribes for New Persistent Users?

28 Can we improve prescribing? Yes

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30 77% of prescriptions Howard, R, Waljee JF, Lee JS, Brummett CM, Englesbe MJ Reduction in Opioid Prescribing Through Implementation of Evidence-Based Prescribing Guidelines. JAMA Surgery, In Press.

31 77% of prescriptions Howard, R, Waljee JF, Lee JS, Brummett CM, Englesbe MJ Reduction in Opioid Prescribing Through Implementation of Evidence-Based Prescribing Guidelines. JAMA Surgery 2017

32 Guidelines 15 Oxycodone 5 mg 1q4-6 PRN 15 Norco 5/325 mg 1q4-6 PRN + Tylenol AND Motrin + Patient Education

33 Howard et al, JAMA Surg 2017, In press Howard, R, Waljee JF, Lee JS, Brummett CM, Englesbe MJ JAMA Surgery 2017

34 370 Patients x 35 pills per patient = 13,000 pills kept out of the community

35 No change in calls for refills (3-4%) Patients consumed fewer pills No change in patientreported pain scores

36 Supersize it! David Marchiori, Esther K. Papies, Olivier Klein, The portion size effect on food intake. An anchoring and adjustment process?, Appetite (2014), doi: /j.appet

37 Michigan Surgical Quality Collaborative (MSQC) participating sites

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39 33 extra pills per prescription 62 million X unused pills/year 1,881,481 operations / year 1,2 1. HCUP Fast Stats. Healthcare Cost and Utilization Project (HCUP). March Agency for Healthcare Research and Quality, Rockville, MD. 2. HCUP Central Distributor SASD File Composition. Healthcare Cost and Utilization Project (HCUP). March Agency for Healthcare Research and Quality, Rockville, MD.

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43 Vision for the Future

44 Vision for the Future

45 Source of Abused Prescription Painkillers 4.8% 7.1% 4.4% Source: CDC 2011/Drugfree.org 11.4% 55.0% 17.3% Obtained free from friend or relative Bought from friend or relative Took from friend or relative without asking Prescribed a MD Other Got from drug dealer or stranger

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47 Michigan OPEN Sept 2017 Medication Take-Back Event 900 lbs of pills 17,500 opioid pills colle 1976 oldest opioid coll Surgery most common reason

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55 Opioid Use Before Surgery: 34,186 participants from a single tertiary care center Preoperative opioid use common Likelihood higher for some surgeries Opioid users report different characteristics Upper extremity aor = 3.07 Spine/spinal cord aor = 2.68 Pelvic (non-hip) aor = % Lower extremity aor = 3.61 Higher rates of substance use, comorbidities, sleep apnea, psychological distress, widespread body pain Hilliard PE, et al. Under review

56 Opioid Use Before Surgery: 34,186 participants from a single tertiary care center Preoperative opioid use common Prevalence higher for some surgeries Opioid users report different characteristics 23% Orthopedic Surgery (65%) Neurosurgery Spine (55%) Higher rates of substance use, comorbidities, sleep apnea, psychological distress, widespread body pain Hilliard PE, et al. Under review

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60 Reductions in patient opioid consumption Monitor Satisfaction, PROs New prescribing recommendations based on patient consumption Reductions in opioid prescribing

61 Michigan OPEN Co-Directors Jennifer Waljee, MD, MPH, MS Plastic and Hand Surgery Michael Englesbe, MD Transplant Surgery Chad Brummett, MD Pain Medicine/Anesthesiology

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64 Learn more about our work and support our efforts