Episode 2: The Surgeon’s Role in Preventing Opioid Abuse

HOSTS: Henry Pitt, MD; Michael Englesbe, MD

This episode is hosted by Dr. Henry Pitt from Rutgers Cancer Institute of New Jersey and the Robert Wood Johnson University Hospital where he serves as the Chief of Oncologic Quality. Dr. Pitt trained in surgery and began his career as a hepato-pancreato-biliary surgeon. Today he will be interviewing Dr. Michael Englesbe from University of Michigan on the topic of opioid use in surgery. Dr. Englesbe is Professor of Surgery at the University of Michigan in the Section of Transplantation Surgery and does kidney and liver transplantation in adults and children.


Transcript

This transcript has been edited for readability.

Dr. Henry Pitt:

Mike thank you so much for being with us today, we really appreciate your expertise. Before we really get started on the topic, the Michigan Surgical Collaborative has been a unique program that’s been put together and obviously the OPEN program on top of it to help with opioids work has been great. Obviously, you’ve become very engaged with the opioid epidemic and trying to improve the outcomes after surgery. Tell us what personally got you involved in this work.

Dr. Michael Englesbe:

Henry, thanks for asking. I always tell students and residents: try to fix problems that make you angry. My angry event was probably about two years before the opioid epidemic was known about where it was definitely already happening, at least in Michigan. I’m a transplant surgeon, so I had a day where I did three donors in a row across the Michigan or Eastern Ohio / Michigan / Indiana region. And all three donors had an  overdose. And, it was like the same human being. So sad. I’ve been a surgeon a long time and things don’t usually get under the Teflon. You do your job: serve the patient. But this definitely affected me.

I can remember these donors. They’d be in the operating room, and, as the surgeon, I was going to take out their livers. And, I was talking to my partner—coordinating  all the timing—and they would read these little statements from the family about the Gift and the Donor. And, I had been through this experience before, but seeing this beautiful 19 year old woman on the OR table, prepped and draped, and we’re about to take out her heart and lungs and her liver and her kidneys and all that… Hearing the story of her journey towards opioid overdose. It was obviously a strong moment.

And, it just got repeated. Literally, same weekend, two other times. A 19 year old: sports injury in high school, exposed to opioids, became addicted, heroin, overdose. And the second one was a wisdom tooth extraction. Young person, even, I think, that person was like 17, overdosed on pills. Third one was an undergraduate student who experimented with opioids that they got at a college party and alcohol for the first time and overdosed at the party. All young women, all in this peri-18-year age. I think that was the first time I guess for me that I was like, this isn’t just three anecdotes; is there something here.

I think fortuitously, some leading researchers in pain started talking about oxycontin and how that was a bad actor for patients and a lot of chronic opioid use… so we just built growing interest and became aware of it as a big public health problem in our state. And that’s how we got our “go”.

Dr. Henry Pitt:

You’ve alluded to that probably the athlete was seeing her orthopedic surgeon and the other young lady saw her dentist. There are obviously lots of surgical specialties and there’s been an awful lot of work done over the last 6/7 years. Talk a little bit about which specialties have done the most work, where do we still have gaps, and certain specialties where we still have work to do.

Dr. Michael Englesbe:

            Yeah, good question. I think most specialties have done a lot of great work. This became such a hot topic. I think dental care is probably the least well-coordinated care across the country. Um, there’s a lot of individual practitioners; they’re not quite as hooked-in to candidly best evidence and national guidelines and stuff. So… you know, you can’t work at a big organization and not follow the evidence-based guidelines get integrated into the processes of care but when you’re an individual practitioner, then it can be harder.

I think our first take on this was laparoscopic cholecystectomy. You don’t think about it as a problem. It really was our very first intervention, 5 or 6 years ago. And then it built across the portfolio. We started with the easy stuff first, and then worked our way towards diseases or surgical indications that have a lot of pain involved with them. So, total hip, total knee, spine surgery, some of the other procedures, like hand surgery, that are done frequently for chronic pain problems because those are more complicated but they’ve also made a lot of progress.

I think the biggest gap in care, personally, is the use of opioids in young people for wisdom tooth extraction in the United States. There’s no evidence that it should really be done, and it’s still commonly done. And I think that is particularly important to be thoughtful about exposure of opioids to people age 25 and younger. So, I think that’s where the biggest current gap is.

Dr. Henry Pitt:

So we’ve talked a little bit about the providers, and you’ve given some examples of young women… is this more an issue of the young versus the old, is it more of an issue of women vs men, uh, are there certain subgroups of our population where this is a bigger problem than others? Talk a little bit more about the patients

Dr. Michael Englesbe:

It’s across all shapes and sizes of patients. The fundamental problem is being opioid-naïve; having something happen to you and having the doctors prescribe you opioids and then you really being unable to stop those opioids. And, I think anyone is at risk. Patients who are particularly at risk are patients who have anxiety, depression. People in underserved, particularly rural parts of the United States.

Anyone’s at risk, more prevalent in people with anxiety and depression when they come into major health events. And more prevalent, at least in Michigan, about two-fold more prevalent in the white community. Not exactly sure why.

Dr. Henry Pitt:

You’ve alluded a little bit to urban versus rural. How about suburban? There are examples of Philadelphia where people have gone from the suburbs into the inner city to get the opioids…

Dr. Michael Englesbe:

The data on chronic opioid use – and it’s changed a lot in the last two or three years in a good way – but, generally rural areas are about two-fold more likely to be affected compared to urban areas. And then suburban areas are right in the middle. So, about 1½-fold more likely. Which is unusual—a lot of the foundational health problems are worse in cities, but not in the case of the rural community, and there’s a lot of speculation as to why that is.

But you can look across – we know the data in Michigan the best – and the really rural places are two- or three-fold more likely that there is opioid use disorder in those communities. And if you look at towns that have a lot of challenges around poverty and access to care and black patients and their ability to get equitable care—Flint, Detroit—it was less of a problem. And not exactly sure why. Interesting though.

Dr. Henry Pitt:

We’ve been doing a little bit of work in Southeast Pennsylvania with the Pennsylvania NSQIP Consortium and have built some variables around opioid use into our NSQIP platform and one of the  things in the early analysis that we did around ventral hernia was that people who were on benzodiazepines had worse outcomes just like people who were on opioids, and it was more likely for women to be on benzos than men. Have you seen similar things in MI or are you aware of more literature around the effect that benzodiazepines may be having in this whole epidemic?

Dr. Michael Englesbe:

Yeah, we’ve seen the same thing. And it’s hard to tease out causality, of course. So… Anxiety, depression are treated with benzos frequently and patients with anxiety/depression are more likely to go from opioid-naïve to chronic opioid use. And patients particularly around surgery who have really severe sentinel events, like apnea, and just really major complications with opioid use tend to also be on benzodiazepines.

So, your risk of a major perioperative pain-related complication is nine-fold higher if you’re co-prescribed benzodiazepines and opioids. And that’s not frequently done outside of some of the orthopedic procedures and spine procedures, but I will say a lot of the orthopedic and spine physicians are very thoughtful and they understand chronic pain better than you and I would because we just don’t deal with it all the time. So, they’ve taken a pretty proactive approach to how to best manage this.

I think if someone’s having non-orthopedic surgery and they’re on benzodiazepines, when you as a physician or you as a patient are having that care, you need to have a candid conversation with each other regarding safe opioid prescribing and being very careful about very parsimonious prescribing because they’re more than at-risk, they’re exponentially at risk to be a surgical event.

Dr. Henry Pitt:

You mentioned depression once or twice. I mean, we have more depression and manic depression in the United States than in most other parts of the world and we don’t really have time to go into why that is, but it is a fact. What kind of data are there, if any, from Michigan or elsewhere with respect to patients who are on antidepressants and their outcomes and addictions?

Dr. Michael Englesbe:

I don’t know, to be honest. Most anxiety and depression in the United States is probably undertreated. Particularly, I think, in the last two years there’s become more and more of a gap in public health for many of our patients. And, people who are on treatment, it’s hard to know… maybe they’re getting holistically overall better care. But, I don’t have any specific data, or, if we’ve done that analysis, I don’t remember any obvious conclusions related to co-prescribing for pain and depression.

Dr. Henry Pitt:

We’re in the process of adding an antidepressant variable to our platform, and hopefully a couple years from now we’ll have some good data there. A lot of work has been done among the surgeons and anesthesiologists with respect to opioid avoidance, medications, blocks… Do you feel like we’ve really made some progress there in getting our providers to manage the patients differently perioperatively?

Dr. Michael Englesbe:

Yeah, I do. I think the anesthesia community has kind of led the way. The lingo is “multi-modal pain care”. So, you hit pain from three or four different angles, whether it be local anesthetics, other regional anesthetics, other centrally acting medications, non-opioid medications, and opioid medications. And the best pain care generally is a combination of all of the above. So, I think multi-modal pain care for the peri-operative and post-operative period is now standard of care and I think most good hospitals provide that to the majority of their patients.

In Michigan, it’s one of our core quality measures for all of our surgical collaborative – that there’s a multi-modal pain pathway and that patients get multi-modal care. And the definition of that is at least two different types of pain medications. Just opioids alone is really not best care anymore.

Dr. Henry Pitt:

When this all began, we realized that we were prescribing way too may opioids at the time of discharge. A lot of work has been done by your group and other groups to talk about how to reduce the number of pills patients are given and ways to build into the electronic health record nudges so that it’s harder to prescribe too many pills. Talk a little bit more about where we are now with discharge opioid pills versus where we were four or five years ago.

Dr. Michael Englesbe:

I think the average prescription size in Michigan five years ago was about 38 pills, which now sounds a lot, but I can remember when I was writing for twice that many. It’s now about 6 pills. And, you know, with good data – meaning following patients, making sure to have patient-reported outcomes – around pain, quality of life, and all that haven’t budged. I think that Michigan is ahead of the curve for the data, but most states have made significant progress around how many pills that we’re prescribing.

Now, I think standard of care for many patients having routine surgery is going to be around the clock Tylenol/Ibuprofen, and then opioids if needed for breakthrough pain—and, a small opioid prescription. That’s what we do for most folks. Now, concerns around Tylenol and ibuprofen… many physicians have those, but we’ve done a lot of work around what that means to be safe. And in our experience the vast majority of patients neither need nor take opioids after surgery.

Dr. Henry Pitt:

I think one of the worries when we started creating these guidelines with very small numbers of pills was that everybody would be calling for refills day 3, 4, 5, 6. Has that really come to fruition, or is it not a problem?

Dr. Michael Englesbe:

The challenge, of course, is expectation-setting with patient: this is how many pills the average patient takes; we care about you. Having everyone carry the same kind of pathway… nurses, anesthesia, surgeons, family – around ‘surgery hurts and pain free is not the expectation’ and what’s an acceptable amount of pain. And with that we have not seen more calls. In fact, our more recent data shows that we have fewer calls than ever.

It’s definitely a good question. And, you know, you don’t just stop writing for opioids; it’s a whole stem-to-stern kind of thinking about how to best do pain care after surgery, it involves everyone.

Dr. Henry Pitt:

I think we learned a few years back that even for minor elective procedures, 4-6% of patients wind up becoming addicted to opioids, and we’ve been working to try to reduce that percentage. Do we have any evidence yet to say that we’re down to 2-3% or is it still too early to tell?

Dr. Michael Englesbe:

I don’t have clear evidence in Michigan, where we’ve been spending a lot of time resourcing this, that there are significantly fewer overdoses. Now, anecdotally, maybe, I see that as a transplant surgeon, but that’s not data. And then, the pandemic certainly put a kink in most things, and certainly we saw more alcohol use and substance use during the pandemic. But, that having been said, our most recent assessment in Michigan, that number is between 2 and 3% now. We haven’t published that number yet. In no way would I attribute causality between the work that we did and that number, because it’s 10 million people and there are so many amazing forces that have come together. But it does seem like it is less prevalent at least in our state, particularly in our most vulnerable populations, our younger people, our at-risk populations. So, that’s good news.

You fix one problem we probably found two other ones. The new ones we found are: we have this huge gap in mental health care – it’s a crisis. And then, two: people with substance abuse when they have care we don’t have any easy way without a lot of resources to give them best pain care.

Dr. Henry Pitt:

When I was practicing pancreatic surgery, one of my subgroups that I took care of were patients that had chronic pancreatitis and obviously the opioid addiction is a real issue there and for right or for wrong, I used to take that responsibility myself, I figured if I had done a big pancreas operation, it was my job to get them off of their opioids. Frequently it would take 6 months or a year, but once you make that personal commitment to the patient and vice-versa, it’s very important.

And one of the things I learned from a psychologist actually back in the medical college of Wisconsin a number of years ago was that it was important to have a contract with the patient. And the contract would be very simple, I mean, it was something you could write out by hand, and you’d get them to sign this contract that they were going into this operation with the goal to get off of opioids. What do you think about that sort of surgeon taking on that role and doing a contract with the patient?

Dr. Michael Englesbe:

I guess my initial flippant response is: you’re a better doctor than I am. You’re well known to be that kind of surgeon. I don’t think many of us are, meaning having that longitudinal commitment to follow up. I think it does take a really strong commitment between not only the patient but a really committed physician.

The challenge with that is, from a system perspective or policy perspective it is not scalable. You can’t necessarily create that. If a patient’s lucky enough to get a physician who practices at that level, then good.

I think people who do really complicated things, like taking care of people with chronic pancreatitis, doing re-do spine surgery, take your pick of the really really challenging problems, I think that many of them are that level of physician and it can work out OK. But, for the vast majority of patients coming in, I think it is a challenge if they’re on chronic pain medications to have an exit strategy that keeps them opioid-free after surgery.

Dr. Henry Pitt:

With respect to the chronic pancreatitics, again, they were dually or triply addicted, it wasn’t just opioids, but it usually started with alcohol and there was smoking. We always had rules about getting people off of alcohol but figured that the smoking was the least of the three evils. Certainly, in ventral hernia repair and vascular surgery and a number of the areas that we work in as surgeons, the smoking addiction is real and affects outcomes as well. You alluded to the fact that during the pandemic we had more people on alcohol now than we did before. Talk a little bit about how complex these issues are, how interrelated they are.

Dr. Michael Englesbe:

Between substance use disorder, alcohol use, opioids, other inadequately treated mental health challenges and just such an anxious time in our society, let alone smoking… it can be insurmountable.

I’m a huge fan of the small habit approach to behavioral change, and we actually intentionally build strategy around this for every perioperative event. You can’t essentially get rid of all your bad habits. Now, surgery is a uniquely powerful opportunity to get rid of one of them. So, we do use it as a launching board to try to work on from a patient’s perspective, whether it be alcohol, opioid use, or smoking, which one they think they would have the most success with.

And candidly, I think from a health perspective, smoking is probably the most impactful. If someone was to quit smoking you add like five to seven years to their life. Not that the others aren’t bad for you. So anyway, we do try to use any interaction with the healthcare system to do some of that work. Now, the challenge there is no one wants to do that work. So, you have to build incentive models or payment models to support that. And that is really hard, but making some significant progress.

If you come in for surgery and you come in with the major risk factors to shorten your life in our society—which essentially inactivity, smoking, anxiety, depression… the things that make people instead of live 85 years live 65 years—we can’t just take out your gall bladder and send you on your way. We need to make some progress. That’s the next level of high quality peri-operative care. And I got really excited about that model based on our work around opioids where I saw that for some people it really can be a new lease on life. They come in on opioids and they can actually use surgery to get off them, as you just described – your pancreatectomy patients for chronic pancreatitis – it can change their life forever.

It does take a long-term commitment. It takes policy and payment models to support that amount of work for the perioperative services. Everything, as you know, is about efficiency these days. And it’s not very efficient to invest that much in your patients.

Dr. Henry Pitt:

Mike, you’ve alluded to the fact that you have a unique situation in Michigan where you have a payor who’s willing to give surgeons certain incentives. Would you talk a little more about some of that work and how we could influence payors in other states to be like Michigan.

Dr. Michael Englesbe:

It’s just a broader business case for quality that isn’t unique to Michigan because most states have a dominant private payor. It’s just a matter of bringing the physician community together with the payors. I don’t really blame the payors here; I really blame the physician community. Blame is a hard word, but payors and hospitals need to listen to the physicians. And, physicians need to own this and lead this movement, because hospitals can’t really make doctors do all that much. They try, but it’s really hard. And, payors can’t really engage physicians either.

It needs to start with the physician communities. That’s where professional societies can have a big impact here or local or regional groups of physicians—like, Henry, what you’re trying to do in southeastern Pennsylvania. I think physicians can really get the ball rolling. And in our experience, it’s been going on for 25 years in Michigan, the payors fall all over themselves to pay for high-value, impactful care. Like, smoking cessation across the state of Michigan; that’s not super-sexy. Opioid prescribing… that was a hot topic, but they really want to invest their precious resources in high-value care that really affects the population and improves patients’ lives. They’re just looking for those opportunities. We as nurses and doctors know those better than anyone.

Dr. Henry Pitt:

How about your final thoughts about existing gaps, and what are the two/three things that we should be really focusing on in the next year or two or three?

Dr. Michael Englesbe:

Yeah, I guess three. One is, if you’re a patient or a parent and you’re not on opioids and surgery is happening, ask to be considered for an opioid-free care pathway. Have that conversation with your provider for the sake of your family, particularly older patients or younger patients; it’s really, I think, important. That’s talking point one.

Two is: I think the physician community has been responsive and come a long way, and I think most physicians know a lot more about pain than they did a couple years ago, which is a good process. I think now the next big challenge is going to be people who have substance use disorder… meaning, they not only have chronic pain, but they have addiction, whether it is alcohol or opioids or whatever the case may be. And specifically, if you have those patients in your practice or if you are one of those patients, I think you really need subspecialty care. You need to seek expert advice on any care that you get, so that it can be coordinated and tight.

And three is access to substance use disorder treatment, which has gotten a lot better. A lot of the national resources have a suboxone access and things like that, and that needs to continue to expand. So that if you come into an emergency room and you have an overdose, that someone actually links you to treatment and doesn’t just send you away, so that you may overdose in two or three days. So that there’s a hand off to community-based resources.

I think those are the three big take-homes.

Dr. Henry Pitt:

Mike, thank you so much for your time today and for all of your great efforts around the opioid epidemic not only in your state but providing information to all of us around the country, that have helped us in our efforts, so thank you

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