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Bottle Size Matters: Surgical Care and Opioids (08:50)

One day about 3 years ago, Michael Englesbe, a kidney and liver transplant surgeon, was sent on three procurements in a row across the state of Michigan.

The first donor had overdosed on opioids: she’d been hooked on them ever since she’d had a sports injury. The second donor had the same story, but for a wisdom tooth extraction. The third donor was a young girl who’d experimented with opioids at a high school graduation party and overdosed.

“Organ donation is a remarkable gift,” says Englesbe. In appreciation for this, his organ procurement organization started a new policy: a 20-second prayer, song, or reading about the donor’s story before every operation, followed by an additional 20 seconds of absolute silence.

“Any surgeon or anesthesiologist will tell you that silence in an operating room, if you ever experience it you’ll never forget it. Total silence. You’re standing there scrubbed in, listening to the story, staring at this donor,” says Englesbe.

Greatly affected by this, Englesbe asked two of friends, Chad Brummett, a pain doctor and scientist, and Jennifer Waljee, a plastic surgeon and health services researcher, if he could partner with them on battling the opioid epidemic.

About 3 years ago, they started work on the overwhelming problem of chronic opioid users coming in for surgical care. “These people are humbling, and they’re very hard to care for,” admits Englesbe. “Opioid use, misuse, addiction, pain — they’re complex problems, and I immediately failed and I immediately became humbled by just an appreciation of the remarkable, almost mythical grip that opioids can have on people.”

Realizing the problem was too complex for them as surgeons, Brummett suggested that they pivot. “We need to focus on keeping healthy people healthy,” Englesbe recalls Brummett saying. “We need to prevent new persistent chronic opioid use.”

“We learned that most heroin users, most people who overdose, get their introduction from opioids from someone like me, or a dentist after a wisdom tooth extraction or an orthopedic surgeon after a sports injury,” says Englesbe. “So we dug in.”

Englesbe, Brummett, and Waljee introduced their research to the broader team at the University of Michigan’s Institute for Healthcare Policy and Innovation (IHPI), along with research collaborators, experts in the field, and policymakers. They partnered with Blue Cross & Blue Shield of Michigan, the Michigan Department of Health and Human Services, and Michigan Medicaid. This collaboration across groups became the Opioid Prescribing Engagement Network (Michigan-OPEN), and helped Englesbe’s team better understand the problem — and what to do about it.

“Becoming a new opioid user is probably the most common surgical complication in the United States,” says Englesbe. Six percent of surgical patients who are opioid naïve become new chronic opioid users. The number is even higher for certain at-risk patients: for example, 1 in 5, or 20%, of women with breast cancer who receive systemic therapy, radiation, mastectomy, and reconstruction. “The most devastating number that we found: 5% of adolescents who have surgical care leave the surgical event as chronic opioid users.”

“Needing opioids every day can happen to any of us,” Englesbe says. The usual story is: “I had my wisdom teeth removed or I had surgery on my knee. I took the opioids for a couple days, then I stopped. Then I felt really bad, so I took some more — and that continued.” Americans have an average of 9 surgical procedures over the course of their lives, making us all at risk for this life-changing complication.

“We believe that [surgical care] is the root cause of the opioid epidemic. Certainly, it’s important,” he says. But describing this problem in academic papers is not enough — we need to fix it. That’s where partnerships such as Michigan-OPEN are key.

Michigan-OPEN was partly inspired by a study at Michigan Medicine that asked patients who’d had gallbladder surgery, a minor operation, how many pills they were given: about 45. How many pills did patients actually take? Six. The researchers made a 5-minute video for all Michigan Medicine surgeons and surgical house officers suggesting that if gallbladder patients are given 45 pills but generally only take 6, then they should reduce the number of pills provided to 15.

Since that time, every lap chole patient at Michigan Medicine has received 15 pills or fewer, and “something interesting happened,” says Englesbe. “Patients are now only taking about two pills, and patients report their pain care as good, if not even better.” Learning from these findings, they developed new pill protocols. Many patients even recover from procedures without needing opioids at all.

“This little experiment became the basis of our strategy to try to transform opioid prescribing in our state, and hopefully the United States, after surgical care and dental care,” says Englesbe.

Through the Michigan-OPEN collaborative, Michigan Medicine can now ask patients how many pills they receive across Michigan versus how many they take, along with such questions as, “How was your care? Did you get adequate pain care?”

“Turns out, if you get a huge bottle of pills, you take a lot of pills. If you get a few, you just take a few. Your pain care is the same,” says Englesbe.

Englesbe’s team has since created an expanding list of procedures describing how many pills patients should receive. Within the first 6 months after implementing recommendations for 15 procedures in October 2017, opioid prescribing after surgical care across Michigan’s state health system decreased by 20%.

“We think this is a remarkable accomplishment. Obviously, much more needs to be done, but it’s only available because of the unique public / private partnerships that we have in our state,” says Englesbe. Right-sizing opioid prescribing is relatively low-hanging fruit, he notes, as is educating caregivers and patients about the risks of opioids. “But the story is not so simple as just write for fewer opioids.”

“Many patients have been harmed, but many patients still need excellent pain care and need opioids. But we can do better,” says Englesbe. Over the next 5 years, Michigan-OPEN’s goal is to have 50% of Michigan’s outpatient procedures like hernias and gallbladders done without prescribing opioids after, while at the same time improving pain care for every patient. “That will reduce that 6% number and help us tackle potentially the root cause of this devastating epidemic.”

“I hope I never [again] have to do three donor operations in a row in the same day,” Englesbe says, “but if I do I am confident that in Michigan it will never be three beautiful young people who overdosed on opioids.”

From the NEJM Catalyst event Essentials of High-Performing Organizations, held at the University of Michigan’s Institute for Healthcare Policy and Innovation, July 25, 2018.

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