DAVID LEVIN: You’re listening to Harvard Chan, This Week in Health. I’m David Levin. Today, we’re talking about how opioid painkillers are being overprescribed and what some health care providers are doing to fix that.
CHAD BRUMMETT: As a pain physician, I do prescribe some of my patients opioids as part of their chronic pain care, and yet I don’t believe that the vast use of opioids in the U.S. has positively addressed pain.
DAVID LEVIN: That’s Dr. Chad Brummett from the University of Michigan. He specializes in pain management. He’s working on new ways to reduce the amount of opioids prescribed to patients. He says that’s still a major cause of the opioid crisis that’s spreading throughout the country.
Dr. Brummett covered that and more during a recent conference at Harvard called “Stigma and Access to Treatment.” It was the second of two conferences on the topic. The first one was in Michigan last May. In this episode, he talks about his approach with Mary Bassett, director of Harvard Chan’s FXB Center for Health and Human Rights.
MARY BASSETT: So you’re trained as an anesthesiologist. You’re a clinician. You’re a researcher. And now, you’ve also become, really, a public person, not just in Michigan, but nationally on crafting and response to the overdose crisis that we’ve seen that began with the profligate prescribing of painkillers.
People often say this is no longer a prescription opioid crisis. It’s a problem of heroin. It’s a problem of fentanyl. But of course, it was overprescribing of prescription opioids that sort of opened the door to the current escalation that we saw. Could you just reflect a little bit on where prescription opioids fit in the whole picture of the overdose epidemic?
CHAD BRUMMETT: Yeah, I think you’re right that as we look year over year and try and think about solutions to what is the biggest public health problem facing the country right now, there is no single answer. And so I do believe heroin and fentanyl are driving mortality today. I think that’s pretty obvious. That’s a data-driven statement.
And that there are other solutions that will effectively change mortality today, such as better access to addiction treatment, decreased stigma, the things that we’re really planning to focus on at the Harvard Michigan summit in October. I think that that’s really where the focus should be today– better distribution and access to naloxone– this life-saving antidote that just shouldn’t be questionable. I mean, really, we need to put it out there more.
But I come back though and say at its core, at its root, this is an iatrogenic problem. You know, physicians and providers, advanced practice practitioners, we had to write these prescriptions.
So whenever I give a lecture to a group of physicians, I’m always very clear, I’m part of the opioid epidemic. I helped create the opioid epidemic. I didn’t mean to. It wasn’t my intent. I meant to provide great care, but I prescribed too much. I was overprescribing, not understanding the ill effect of what I was doing. And I think that most physicians– all physicians– and all APPs really want to take that level of ownership because I think only through that level of ownership will we see change.
Now, I’d also like to believe I’m here for change. I’m here for positive. I’m here to make a difference today. And I think we really need to be very, very careful about this counternarrative of how this is no longer a prescribing epidemic. I do believe at its core, and even today, prescriptions are still in part fueling the epidemic because many of the patients who move down the path of heroin and fentanyl begin with a prescription.
Rather than only studying those folks using opioids, we really saw an opportunity for a preventative narrative thinking about how to shepherd people through the path of acute care– so surgery, dentistry, emergency medicine trauma– where most people coming in for those care episodes are not using opioids, and yet the exposure is predictable. You can go down to our pre-op right now, and I could walk through pre-op and without really knowing much about the patient other than what surgery they’re having, I can tell you who’s going to get an opioid and how much they’re going to get.
And so this really became an opportunity to think about shepherding people through that path to not only ensure that they were healthy at the end of it, but also thinking about their community and their friends and family and what can happen if you sort of are spilling excess pills in the community, which can certainly lead to diversion and misuse.
And we have a really unique platform in our state to ensure that we weren’t only doing this at the level of a major academic medical center, but really thinking about what this looked like in big communities, small communities, rural settings, urban settings.
MARY BASSETT: And are you talking about Michigan OPEN–
CHAD BRUMMETT: I am.
MARY BASSETT: –when you talk about the wider platform? I know that it stands for Michigan Open Prescribing Engagement Network and that’s the acronym OPEN, but can you just say a little bit more about what it is, what you do because it is a public-facing network, not just aimed at academics?
CHAD BRUMMETT: That’s correct. Yeah, I think that that’s a distinguishing factor that while Michigan OPEN does a lot of research, we’re really interested in serving the community. So Michigan OPEN really came together to sort of initially think about surgery and how to do better management of pain, while really reducing the overprescribing of opioids after surgery. And then that has now spilled into dentistry.
And we’re now working with emergency medicine, thinking not only about how to better manage pain in emergency medicine, but even thinking about naloxone distribution and even MAT induction in the ERs, and then trauma, and so really thinking about acute care episodes.
The other unique factor of Michigan OPEN is we are a collaboration. We are partially funded by Michigan Department of Health and Human Services, so Medicaid, but also leveraging funding from Cross Blue Shield of Michigan, which is our dominant private payer in our state. And we’ve really been able to tap into these networks where you have 72 hospitals with a physician, a nurse, and Blue Cross all physically coming together three times a year to talk about quality.
And we were able to sort of superimpose an opioid narrative on top of that collaborative to get real-world prescribing data, real-world consumption data through their existing patient-reported outcome platforms. And we’ve been I think even more successful than we anticipated in the first three years. And now, we’re starting to move into these more challenging kind of messy areas.
MARY BASSETT: So this is really a public-private partnership that you’ve achieved in Michigan.
CHAD BRUMMETT: It is.
MARY BASSETT: That’s great. It’s rare to see both a public payer and a private payer collaborate to ensure better quality health care and more patient safety. I remember at the Michigan meeting there was a conversation and presentation of data showing that patient satisfaction with their management around a surgical event wasn’t affected by offering lower doses and shorter course of pain medication. That people often didn’t take all of the pills that were prescribed to them, something that everybody’s familiar with who’s ever been given an opioid prescription.
And also that people were not complaining when the judicious prescribing practices led to lower doses and shorter courses. Have I remembered that correctly?
CHAD BRUMMETT: Perfectly. We’ve now published a few studies in that space. But we started out at a local level just saying, could we change one surgical condition, and what would be the outcomes. And as you said, we drastically reduced prescribing after laparoscopic gallbladder removal. This was led by one of our former medical students, Ryan Howard, who’s now one of our surgery residents, who reduced prescribing.
And we saw no changes in refill requests, pain complaints. But what happened, is when we gave people less pills, they actually took less pills. This concept of, in the social psychology literature, of called anchoring and adjustment. So it’s just like with your plate of food, if I put more food on your plate, you’ll eat more. But not necessarily because you wanted to eat more or you needed more.
And so I think the same things spill over to opioid prescribing. But our most robust data to date in this space just came out in the New England Journal led by one of our other really terrific mentees, Jocelyn Voo, where we disseminated our prescribing recommendations. And what we showed is that we reduced prescribing across the state by about 40% across 35 hospitals with no change in satisfaction or pain. That we really made incredible changes.
And we’ve reduced prescribing even further at a state level because we continue to see that as we give people less, they’re taking less, their pain’s well managed, their satisfactions high. And as we give them less they still have excess pills. So we’re not in every case looking to go to 0 or saying opioids should never be used. But what we’re seeing, consistent with what I think you see now in other countries like Sweden or other places in Europe where the health care system is just different. There are probably a lot of surgical conditions where we routinely prescribe opioids, but for which opioids are probably not warranted in most cases.
MARY BASSETT: Not indicated. Right. Something that did come up in Michigan that I have to say that I thought I hadn’t thought enough about, is the whole problem of demonizing opioid painkillers. And for example, the health commissioner for the state of Massachusetts pointed out to me that some pharmacies have signs up saying that they’re not filling prescriptions. And you know, of course there have been too many opioids prescribed. But these remain a useful part, and appropriate medication for patients.
And some patients are now on them because they were prescribed them. And they can’t simply be told, actually time’s up for you. More needs to be done for them, because they would be harmed by abrupt tapering. So that’s the flip side of the overprescribing. That there are people who are getting these drugs who were prescribed them and now need help because they’re dependent on them. And there also are people who should be getting them because it is the best management.
CHAD BRUMMETT: Yeah. I think you’re spot on there, Mary. And the truth is, even when you find a person who you don’t believe is benefiting from the opioids, acute withdrawal is not an appropriate management plan. And tapering and how long to taper, how quickly to taper, and at what point you should see benefit from a taper, is still something where the science has lagged. And these are complicated studies to do. We’re seeing more data come out.
But I would say that there is a big portion of the chronic opioid using population that would probably benefit from weaning down or even off. And yet there are some patients that show benefit. And by benefit, I mean pain relief, ability to function, do activities, daily living without dose escalation or any behaviors that start to suggest opioid use disorder.
And there is a population like that. And, as I said, as a pain physician, I do manage some of my patients with pain. I still struggle a bit, because the evidence for the efficacy of opioids chronically is pretty poor, poor to none. And so I think where it becomes complicated is the people for whom I should start an opioid. But I think again, if we go back to all the benefits of the CDC guidelines, the CDC guidelines really just laid out a roadmap to say, if you’re going to start an opioid, start low, go slowly. And as you’re going along, reassess the patient.
And I think that this seems very obvious, and yet was not how we were managing patients for decades. We would give people a prescription, and we would refill month over month. And just because of the way we manage patients’ clinical care and the challenges of continuing to– when I think about primary care physicians and the pressures to see patients day over day, lots and lots of patients, it’s much faster to just refill the prescription than to really go into understanding the efficacy and any potential concerns.
And so I think there are some patients that benefit. There are some patients certainly that should be maintained. And even in the case where you feel like somebody needs to be weaned off, that’s a structured process and you really should never pull the rug.
MARY BASSETT: That’s a really important thing to point out to people who may be listening to this podcast. Thanks again, Chad. I’ll see you soon. The weather’s great in Boston so I think you won’t be disappointed.
CHAD BRUMMETT: Fantastic.
MARY BASSETT: Take care.
CHAD BRUMMETT: Thanks Mary.
MARY BASSETT: Bye, bye. Thank you.
DAVID LEVIN: Special thanks to Drs. Chad Brummett and Mary Bassett for sitting down to this interview. To hear more conversations with public health experts, and learn about new solutions to the opioid epidemic, visit us online. That’s hsph.harvard.edu.
Physicians’ over-prescription of opioid painkillers opened the door to the current opioid crisis. What can health care providers do to fix it?
Chad Brummett, a pain management specialist from the University of Michigan, shares a new approach to combat Michigan’s opioid crisis that could be a model for the rest of the nation. Brummett sat down with Mary Bassett, director of Harvard’s FXB Center for Health and Human Rights.
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