Prevention may be an overlooked aspect of the effort to stem the nation’s opioid epidemic, and much can be done to both reduce the risk of opioid naive patients from becoming persistent users and reduce the number of excess pills in a community.
That was the message of University of Michigan Associate Professor Chad Brummett, MD, during a recent webinar sponsored by the AMA Organized Medical Staff Section.
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Dr. Brummett, who directs pain research and clinical anesthesia research efforts for the Department of Anesthesiology, presented evidence demonstrating that patients’ post-operative pain can be managed with fewer pills prescribed. And he also shared findings that doing so does not lead to patient discomfort or decreased satisfaction.
These included an April 2017 report by Dartmouth researchers published in Annals of Surgery. They studied patients undergoing five common outpatient procedures and found that opioid prescriptions for post-operative pain varied widely and 70 percent of prescribed pills were never used.
Physicians “want to make sure that the pain patients experience from surgery is minimized, so they prescribe enough to satisfy the patient who requires the most opioids,” the Dartmouth researchers wrote.
Dr. Brummett cited a June 2017 Annals of Surgery study by University of Michigan researchers that found the refill rate was not associated with size or strength of the original prescription.
In fact, post-operative opioid prescribing also did not have a correlation with scoring on a Hospital Consumer Assessment of Healthcare Providers and Systems pain measures, according to a May 2017 JAMA research letter written by Dr. Brummett and his colleagues.
They developed new prescribing guidelines for post-operative laparoscopic gall bladder removal that lowered the median total oral morphine milligram equivalent (MME) of prescriptions by 63 percent, from 250 MME to 75 MME. In a March 2018 JAMA Surgery research letter, Dr. Brummett and colleagues wrote that patients reported using fewer opioids and that refill reductions dropped from 4.1 percent to 2.5 percent.
“If we give them less, they will take less,” Dr. Brummett said. He compared it to people eating more if given a bigger plate with more food on it.
By prescribing 35 fewer pills for 370 patients, 13,000 pills were kept out of the community. The University of Michigan also takes part in the Opioid Prescribing Engagement Network, which sponsored an event last September where residents in eight Michigan communities could drop off their unused prescription medicines. In all, 766 people dropped off 900 pounds of prescription drugs, including 17,500 opioid pills. The number of drop-off points was tripled for an April 28 event and more than 54,000 opioid pills were collected.
Dr. Brummett described these excess pills as “loaded weapons” in people’s medicine cabinets. Most people 12 and older who misuse opioids obtain them from a friend or family member and only 4.4 percent buy them from a drug dealer or stranger, according to data from the Centers for Disease Control and Prevention.
Preventing persistence pays off
Another focus area for Dr. Brummett and his colleagues has been the risk of patients becoming new persistent users of opioids after receiving a post-operative prescription.
He and his colleagues measured prescription refills 90 and 180 days after a procedure as a measure of persistent use, as they reported in a June 2017 JAMA Surgery study. Following more than 29,000 patients who had minor surgery and more than 7,100 who had major surgery, they found that 5.9 percent of the first group and 6.5 percent of the second group became persistent users.
The statistically insignificant difference suggested that prolonged opioid use was not entirely due to surgical pain. Other factors associated with prolonged use included tobacco use, alcohol and substance-use disorders, anxiety, mood disorders, pre-operative back and neck pain, and arthritis.
The AMA Opioid Task Force recently released its 2018 progress report, which notes that:
- Opioid prescribing has fallen for the fifth year in a row.
- Prescription drug-monitoring program registration and use continues to rise.
- Physicians are enhancing their education on pain management, substance-use disorders and related areas.
- Access to naloxone is rising.
- Treatment capacity is increasing.
“While this progress report shows physician leadership and action to help reverse the epidemic, such progress is tempered by the fact that every day, more than 115 people in the United States die from an opioid-related overdose,” said Patrice A. Harris, MD, chair of the task force. “What is needed now is a concerted effort to greatly expand access to high quality care for pain and for substance use disorders. Unless and until we do that, this epidemic will not end.”
The AMA offers CME, such as “A Primer on the Opioid Morbidity and Mortality Crisis: What Every Prescriber Should Know,” on this and many other important topics.