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As a medical student who has just started participating in clinical medicine, the current opioid epidemic has seemed overwhelming. Over the past few months many changes regarding the prescribing of opioids have been made across the country, including in Michigan. Many clinicians with whom I have worked with offer differing views on the epidemic, as well as the way it can best be addressed. It is difficult as medical students to form our own opinions on these issues when we know comparatively so little. However, the changes being implemented to address the current opioid epidemic represent the first in a long series of dramatic changes to health care that will occur during our careers. Given the staggering numbers of people being affected by opioid use and abuse, we have a responsibility as the future physicians of this country to understand the problem, where changes can be made, and how those changes can be implemented.
Luckily, here in Michigan, a lot of this work has already begun. The Opioid Prescribing Engagement Network (OPEN, www.michigan‐OPEN.org ) is a unique organization working to address this problem across by addressing opioid prescribing after acute care (surgery, dentistry/oral surgery, emergency medicine, and trauma). They have identified the perioperative period as a key time when many opioid‐naïve patients are first introduced to opioids. Between 2010–16, opioid prescribing by primary care physicians decreased, and thus, there has been a relative increase of new opioid prescriptions by surgeons and dentists by 17 percent and 68 percent, respectively.1 Moreover, they have shown that 6–10 percent of opioid‐naïve patients continue to fill opioid prescriptions 3 months following their procedure, which can be considered new persistent use.2,3,4 If you consider how many people undergo procedures in the United States annually, this could mean millions of new chronic users of opioids each year after surgery.
Furthermore, about 70 percent of the opioids prescribed for surgery go unused and become a source for diversion and abuse.5 Lastly, studies have found that there is no association between the number of pills prescribed to those patients not using opioids before surgery and the likelihood of refill or satisfaction with their care.6,7,8 For these reasons, OPEN is aiming to reduce the opioids prescribed for acute care by more than 50 percent. Whereas opioids have a role for acute use after painful surgery, prescribing more opioids than patients need or are using poses a great deal of potential harm. It may send the message to patients that they need additional doses, prompting them to use more and consequently increase their own likelihood of dependence. Furthermore, unused pills are difficult to dispose of safely, and can lead to greater misuse in the community when left in medicine cabinets. Using data from the Blue Cross Blue Shield of Michigan‐funded surgical collaboratives from the 73 major hospitals in the state, OPEN is working to fill the gaps in knowledge about the amount of opioids most patients required after a given procedure by crafting guidelines for initial post‐op prescriptions following different surgical procedures—currently recommendations can be found for 18 common surgeries with many new recs coming soon (www.opioidprescribing.info). This will help to guide physicians in prescribing a reasonable amount of opioids, while reducing the risk of patients developing new dependence, as well as distribution of unused opioids in the community.
Additionally, because we know that a considerable portion of opioids prescriptions go unused and become a potential source for misuse and abuse, OPEN is working to improving disposal practices of unused opioids in our communities by holding medication take‐back days across the state. These events provide a way for patients to dispose of any unused medications safely. In their last opioid drive in 2017, they organized 27 cities for a single event and collected more than 2,300 pounds of pills, which brings their total collected to more than 3,500 pounds. The website has a toolkit for hosting your own opioid drive, and their team will help guide and support your group, even if you are outside of Michigan.
These are just some of the things being done in one state to address a large and complex problem. First and foremost, we need to start involving ourselves in the often‐difficult conversations with patients about opioid use, as well as learning about ways that prescribing is changing to help us be more equipped physicians in the future. Additionally, more large‐scale work, like the work being done by OPEN, offers a unique opportunity for us, as students, to get involved in shaping the future of medicine. And if nothing else, the changes being implemented provide one model of how we can work to address future large‐scale changes to the practice of medicine as they inevitably arise.
References
1. Larach DB, Waljee JF, Hu HM, et al. Patterns of initial opioid prescribing to opioid‐naïve patients [published online July 24, 2018]. Ann Surg. doi:10.1097/SLA.0000000000002969
2. Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgery in US adults. JAMA Surg.
4. Harbaugh CM, Lee JS, Hu Hm, et al. Persistent opioid use among pediatric patients after surgery [published online December 4, 2017]. Pediatrics. 2018;141(1):e20172439.
6. Lee JS, Hu HM, Brummett CM, et al. Postoperative opioid prescribing and the pain scores on hospital consumer assessment of healthcare providers and systems survey. JAMA. 2017;317(19):2013‐2015.
7. Sekhri S, Arora N, Cottrell H, et al. Probability of opioid prescription refilling after surgery: does initial prescription dose matter? Ann Surg. 2018;268(2):271‐276.
8. Bateman BT, Cole NM, Maeda A, et al. Patterns of opioid prescription and use after cesarean delivery. Obstet Gynecol. 2017;130(1):29‐35.
