Page 14 - Volume 69 Number 1
P. 14

Acting Locally to Reduce
Excessive Opioid Prescribing
with the Michigan Opioid Prescribing
and Engagement Network (M-OPEN)
By Ryan Howard, M-4, University of Michigan Medical School
Ibegan to learn about the opioid epidemic in the United States at the start of my fourth year at University of Michigan Medical School. I had heard about it on the news, and I vaguely recalled Governor Snyder creating a commission to address the issue in Michigan, but my knowledge was not very deep. It was then that one of my mentors, Dr. Michael Englesbe, approached me with a proposition I couldn’t refuse: Pick a problem in healthcare and find a way to actually fix it.
This opportunity arose as part of changes in our curriculum aimed at getting students out of the artificial world of the classroom and into the real world, thinking about how to make needed change. With this opportu- nity, I would have time and support to work on it, but the goal couldn’t simply be getting a paper published. I had to do something that would actually make an impact. Thus I decided to work with Dr. Englesbe and the newly established Michigan Opioid Prescribing and Engage- ment Network (M-OPEN) on addressing opioids in the world of surgery.
At the outset, I did what any dutiful medical student would do: I dove straight into the literature. I came across oft-quoted statistics about quadrupling opioid sales occurring simultaneously with a quadrupling of opioid overdose deaths. Of the many issues that underlay this trend, that one that jumped out to me as something to focus on was the problem of diversion of leftover medica- tion. Of the estimated 4.7 million Americans using pre- scription painkillers non-medically, 56% obtained the medication from a friend or relative for free. This number jumps to 70% when taking into account individuals who stole or bought the medication from these acquaintances.
In my own community, I also discovered that having leftover opioid medication was virtually a universal experience among post-operative patients. Everyone I know could relate a story about how they or a friend of theirs came home after a surgical procedure with a bottle full of opioids and then only needing or taking a few, leaving many left over. When I looked in my own medicine cabinet I discovered a bottle of Norco 5/325 from some distant dentist office visit. The prescription had been for 50 tablets; I counted 48 remaining. (I challenge readers to take good look into their own medicine cabinets.)
To address this problem in a local, manageable way, we picked a common surgical procedure – laparoscopic cholecystectomy – and asked: what prescriptions do we usually give these patients for post-operative pain, and what do the patients actually use? This is a simple question that is rarely asked, but would seem to be highly pertinent.
Data obtained from the electronic medical records showed immediately that prescribing practices were tremendously variable. Some patients went home with as few as 12 tablets of Norco 5/325, and some with as many as 100. When it came to actual usage, half of the patients used five pills or less.
Given these data, we developed prescribing guide- lines that would be more consistent with actual patient use. If we could get surgeons to follow these guidelines, and patients to accept the result, it would reduce the incredible excess of opioids entering the community while still providing satisfactory management for post-operative pain. It was the process of implementing these guidelines that truly got me out of the classroom and into the real world.
Writing a guideline is one thing; building consensus among providers and getting them to accept and follow it is another. We set up a series of meetings and presenta- tions with staff at all levels at the ambulatory surgery center where laparoscopic cholecystectomies are done. The presentations I found myself giving hardly resem- bled what I had always thought of as traditional medical education. I found myself learning what it actually takes to bring about change in clinical care. We had to change the whole system, and educate all the people in the system. The doctor writing the prescription is only one small part of the issue. Telling the doctor to write fewer opioid prescriptions wouldn’t change anything. We found that the system, starting with the patient’s first encounters prior to surgery, had created misleading expectations regarding pain management. Everyone involved in the patient’s care, at all levels, as well as the patient, had to accept the new guideline and know the new expectations.
We started by observing and talking to patients and caregivers in the pre-operative clinic, where patients are given pre-op counseling. We observed the questions
14 Washtenaw County Medical Society BULLETIN JANUARY / FEBRUARY / MARCH 2017

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