Funding and Disclosures
• Funding
• NIAMS/NIH: R01 AR060392; P50 AR070600
• NIDA/NIH: R01 DA038261; R01 DA042859
• Michigan Department of Health and Human Services
• SAMHSA
• CDC
• Precision Health 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 8410140
• Consultant- Heron Therapeutics
die every day from
an opioid overdose
(that includes prescription
opioids and heroin).
130
AMERICANS
SOURCE: AP & IQVIA’s Institute for Human Data Science
SOURCE: CDC
Prescribing and Overdose Timeline
Acute care prescribing 2010-2016
- 8.2%
+ 17.6%
+ 2.4%
+ 68%
OMEs in Rx
2010-2016
240 ïƒ 403
201 ïƒ 283
128 ïƒ 226
143 ïƒ 154
Larach et al. Annals of Surgery 2018
Change in % of new
opioid Rx 2010-2016
OMEs in Rx
2014-2016
396 ïƒ 403
380 ïƒ 283
197 ïƒ 226
153 ïƒ 154
Why do surgeons prescribe too much?
#
=
The amount of opioid prescribed after surgery was not
associated with patient satisfaction or refill rate
Lee JS, et al. JAMA 2017; Sekhri S, et al. Ann Surg 2017
New Persistent Opioid Use
8%
Goesling J et al. Pain. 2016;157(6).
13%
Johnson SP et al. JHS. 2016;41(10).
5%
Harbaugh CM et al. Pediatrics. 2017. Epub.
10%
Lee JS et al. JCO. 2017. Epub
19%
Marcusa D et al.
PRS. 2017;140(6).
6%
Brummett CM et al. JAMA Surg. 2017; 152(6).
13%
Deyo RA et al. Pain. 2018. Epub.
Who is at Risk for New Chronic Opioid Use?
Chronic pain conditions
Anxiety
Substance use disorder
Tobacco use
Mood Disorders
Sleeping Problems
Remote Opioid Use
Postoperative Prescribing Practices Influence Outcomes
High prescribing
Preoperative opioid use
Increased amount of
opioid prescribed
Increased opioid
consumption
Increased risk of new
chronic use
Increased risk of refill and
new chronic use
Bicket MC, et al. Am J Surg 2019; Brummett CM, et al. JAMA Surg 2017; Gil JA, et al. Am J Sports Med 2019; Larach DB, et al. Annals Surg 2019
Can we improve prescribing?
Yes
Howard, R, Waljee JF, Lee JS, Brummett CM, Englesbe MJ. Reduction in Opioid Prescribing
Through Implementation of Evidence-Based Prescribing Guidelines. JAMA Surgery 2018, 153(3)
Average Prescribed
Average Consumed
Guidelines
50 pills ïƒ 15 pills
No change in calls
for refills (3-4%)
No change in patient-
reported pain scores
Patients consumed
fewer pills
Howard et al, JAMA Surgery 153(3)
Average Prescribed
Average Consumed
Guidelines
50 pills ïƒ 15 pills
No change in calls
for refills (3-4%)
No change in patient-
reported pain scores
Patients consumed
fewer pills
Howard et al, JAMA Surgery 153(3)
Supersize it!
David Marchiori, Esther K. Papies, Olivier Klein, The portion size effect on food intake. An anchoring and adjustment process?, Appetite (2014),
doi: 10.1016/j.appet.2014.06.018
370
Patients
↓35 pills
per patient
x
= 13,000 pills kept
out of the community
Michigan Surgical Quality Collaborative (MSQC)
participating sites
New prescribing
recommendations
based on patient
consumption
Reductions in
opioid prescribing
Reductions in
patient opioid
consumption
Monitor
Satisfaction,
PROs
Prescribing Recommendations
UPDATED 2019
Procedure
Thyroidectomy
Laparoscopic Anti-reflux (Nissen)
Appendectomy – Lap or Open
Laparoscopic Donor Nephrectomy
Hernia Repair – Major or Minor
Sleeve Gastrectomy
Laparoscopic Cholecystectomy
Open Cholecystectomy
Colectomy – Lap or Open
Open Small Bowel Resection or Enterolysis
Dental Extraction
0
0 - 5
0 - 10
0 - 10
0 - 10
0 - 10
0 - 10
0 - 10
0 - 15
0 - 15
Oxycodone*
5mg tablets
0 - 20
Ileostomy/Colostomy Creation, Re-siting, or Closure 0 - 15
Prostatectomy 0 - 10
Procedure
Carotid Endarterectomy
Cardiac Surgery via Median Sternotomy
Cesarean Section
Hysterectomy – Vaginal, Lap/Robotic, or Abdominal
Lumpectomy + Sentinel Lymph Node Biopsy
Sentinel Lymph Node Biopsy Only
Wide Local Excision ± Sentinel Lymph Node Biopsy
Simple Mastectomy ± Sentinel Lymph Node Biopsy
Total Hip Arthroplasty
Total Knee Arthroplasty
0 - 10
0 - 15
0 - 15
0 - 15
0 - 5
0 - 5
0 - 5
0 - 20
0 - 20
0 - 30
0 - 50
Oxycodone*
5mg tablets
Breast Biopsy or Lumpectomy
Modified Radical Mastectomy or Axillary Lymph Node Dissection
0 - 30
*If prescribing hydrocodone 5mg, the number of tablets remains the same as listed above.
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0
10
20
30
40
0
2
4
6
8
10
# P
ills of 5 m
g oxycodone
slope: -0.5 pills/month
slope: -1.3 pills/month*
Prescribing Guideline Release
S
a
t
i
s
f
a
c
t
i
o
n
S
c
o
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e
(
0
-
1
0
)
/
P
a
i
n
S
c
o
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e
(
1
-
4
)
Pain Score (N=7610)
Satisfaction Score (N=7670)
1. HCUP Fast Stats. Healthcare Cost and Utilization Project (HCUP). March 2017. Agency for Healthcare Research and
Quality, Rockville, MD.
2. HCUP Central Distributor SASD File Composition. Healthcare Cost and Utilization Project (HCUP). March 2017.
Agency for Healthcare Research and Quality, Rockville, MD.
33 extra pills per prescription
X
1,881,481 operations / year
1,2
62 million
unused pills/year
55.0%
17.3%
11.4%
7.1%
4.8%
4.4%
Obtained for free from friend or relative
Taken from friend or relative without
permission
Purchased from friend or relative
Purchased from drug dealer or stranger
Prescribed by clinician
Other
Source: CDC 2011/Drugfree.org
Sources of Prescription Opioid Abuse
Fall 2017
Spring 2018
Fall 2018
Spring 2019
7
counties
8 sites
17
counties
27 sites
33
counties
62 sites
34
counties
54 sites
Take Back Events
9,600 lbs
Unused Medications
172,700
Opioid Pills
How to Store and Dispose?
Storage
Disposal
Store opioids out of sight and reach
of children, teen, and pets
Store opioids in private areas and lock up
your pills if possible. Do not store in
common rooms (ex: bathrooms) or purses
Keep a count of how many
pills you have left
Use a permanent medication drop box
Drop off at a community Medication Take
Back Event
Use household trash as last resort
**DO NOT flush opioids down the toilet
Mix with unappealing substances (ex: coffee
grounds) and throw away
Scratch out personal information and dispose
original container
 Michigan-OPEN.org/takebackmap
0
20
40
60
80
100
Usual care Information Sheet Deterra Drug Deactivation System
Activated Charcoal Bag for In-Home Disposal
Increased Self-Reported Opioid Disposal after Surgery
Brummett CM et al, JAMA Surgery 2019
School of Music,
Theatre, & Dance
Vincent Cardinal
Arthur and Martha Hearron
endowed Professor
Chair of Musical Theatre and
Professor of Music
Jacob Ryan Smith
Noah Keiserman
Peter Scattini
www.opioidprescribing.info
Educate
patients and set
expectations
Encourage
Acetaminophen, NSAIDs, local
anesthetics, and other non-
opioid treatments
Avoid co-prescribing
benzodiazepines and sedatives
Check a PDMP
before prescribing opioids
Practical
Guidelines for
Postop
Prescribing
MiCarePath
A better way to prepare for surgery.
Afton Hassett, PsyD
Associate Research Scientist
Clinical Psychologist
Anesthesiology
Jennifer Waljee, MD, MPH, MS
Associate Professor of Surgery
Co-Director, Michigan OPEN
MiCarePath Breathe
Diaphragmatic Paced Breathing
Participants are taught the basics about diaphragmatic and
paced breathing. Clicking on this module will take patients to
a screen with a breathing pacer stimulus and an audio file
that will talk patients through the breathing exercise.
Opioid Prescribing for Opioid Naïve Patients
Prescribe only 1 short-acting opioid
No long-acting opioids
Avoid pre-op opioid prescription
Prescribe naloxone in high-risk patients
How do we stop this from happening?
GET DATA
GUIDE/REWARD CHANGE
COLLABORATE
How do we stop this from happening?
Michigan OPEN Co-Directors
Jennifer Waljee, MD, MPH, MS
Plastic and Hand Surgery
Michael Englesbe, MD
Transplant Surgery
Chad Brummett, MD
Pain Medicine/Anesthesiology
The Team, The Team, The Team.
