On Saturday, April 27, Michigan residents in 34 counties brought opioids and other unused and expired prescription medications out to this spring’s Medication Take Back Event. The 54 simultaneous statewide events helped hundreds of families to properly dispose of a total of 3000 pounds of medication, including approximately 46,200 opioids. The event raises needed awareness in the community about safe medication disposal. The collective effort is made possible by local partnerships with the Michigan Opioid Prescribing Engagement Network (Michigan OPEN) and healthcare organizations, law enforcement, and community organizations.
“Our events are community-based, providing a safe and convenient way to dispose of unused medications thereby removing the risks associated with opioids from our communities.”Dr. Chad Brummett, co-director of Michigan OPEN.
Michigan Medicine has added a medication disposal box at Taubman Health Center to provide an option to safely get rid of any unused or expired medications. Located on the second floor of the Taubman Health Center, in the Neurosurgery and Preoperative Clinic (Reception G) Room 2360. The disposal box is accessible during clinic hours, Monday-Friday from 7:30am-5:00pm.
The best practices for medication disposal are to use a permanent disposal box or visit a Medication Take Back Event. Click below to find disposal box locations throughout Michigan, the date of the next Medication Take Back Event, and how to bring a take back event to your community.
Michigan OPEN’s Opioid Prescribing Recommendations for 2019 are now available. Visit our Prescribing Recommendations page to download as a PDF.
What’s new for 2019?
- Recommendations for ten additional procedures, totaling 25 procedures overall
- Updated numbers for several previous recommendations
Important to note are the revisions to previous recommendations. Michigan OPEN constantly aims to improve upon these recommendations and will continue to make changes as needed.
Want to be notified by email when the recommendations are updated? Go to our Prescribing Recommendations page to complete the request form and be added to our subscriber list.
Michigan OPEN was among the 2018 honorees at the Greater Detroit Area Health Council’s annual Salute to Healthcare on November 8. The ceremony recognizes individuals and organizations who are working to improve the health and well-being of the southeast Michigan community.
The Michigan OPEN team was awarded the 2018 Eagle Award for Visionary Leadership. The Eagle Award was created in 2004 to recognize organizations in southeast Michigan that have made advances in improving healthcare quality, access, or cost. Michigan OPEN Co-Director, Dr. Michael Englesbe, was present at the ceremony to accept the award.
Also honored at the event were Paul Bridgewater, Former President and CEO of the Detroit Area Agency on Aging; Betty Priskorn, Vice President of Community Health & Outreach, Beaumont; and Hassan Abdallah, Co-Founder & Executive Director, SAFE Substance Abuse Coalition.
Thank you, to the Greater Detroit Area Health Council, for this honor, and congratulations to all of the honorees!
Many surgeons write prescriptions for opioid pain medications four times larger than what their patients will actually use after common operations, a new study shows.
And the size of that prescription may be the most important factor in how many opioid pills the patient will take – outweighing their pain scores, the intensity of their operation and personal factors, the research suggests.
The study, published in JAMA Surgery by a team from the University of Michigan that has studied many aspects of surgical opioids, highlights the importance of using real-world information about surgical patient opioid use to guide prescribing. It also points to a need to provide options for surgical patients to dispose of unused opioids safely, so that the pills aren’t misused or lead to a poisoning or overdose.
The study used in-depth data from 2,392 patients who had one of 12 different common operations at 33 Michigan hospitals. On average, patients took only 27 percent of all opioids prescribed to them. But for every 10 additional pills prescribed, patients took five of them.
“It’s striking to see the major discrepancy between prescribed amount and the amount patients actually take,” says Joceline Vu, M.D., surgical resident at Michigan Medicine and Michigan OPEN research fellow.
“This is not a phenomenon of a few outlier surgeons – it was seen across the state, and across many operations.”
Ryan Howard, M.D., surgical resident, adds, “In what we tell patients about what kind of pain to expect after surgery, and how many pills we give, we set their expectations — and what the patient expects plays a huge role in their post-operative pain experience. So if they get 60 pain pills, they think they have to take many of them.”
Vu and Howard note that psychology research has dubbed this the anchoring and adjustment heuristic, where the baseline data someone receives – the size of a plate of food, for instance – makes a difference in how much they consume.
The median number of pills patients received was 30 – but the median number used was nine. The number of pills a patient received was the strongest predictive factor of the number they used. The next strongest was the patient’s self-reported memory of whether they had no pain, or moderate or severe pain in their first week after surgery: those who said they had severe pain took 16 more opioid pills than those with no pain.
Howard says, “We hope that by shining a spotlight on the difference between prescription size and actual use, we can empower surgeons to change their prescribing habits, and be a better steward to both their patient and the broader community.”
On Saturday, October 27, Michigan residents in 32 counties had a chance to get opioids and other unused and expired prescription medicines out of their medicine cabinets through 60 simultaneous events held around the state. The collective effort resulted in hundreds of families safely removing over 3,000 pounds of medication, including approximately 40,000 opioids, from their homes while also increasing awareness in the community about safe medication disposal.
The statewide effort is made possible by local partnerships with the University of Michigan’s Michigan Opioid Prescribing Engagement Network (Michigan OPEN) and healthcare organizations, law enforcement and community organizations. The Fall 2018 event doubled the amount of Take Back locations from the Spring 2018 event.
Michigan OPEN works with partners to hold community opioid and medication take back events twice a year. Consistent with findings from the Spring Event, when participants were asked how they disposed of medications prior to coming to the Take Back Event, more than 50% answered, “did not dispose,” highlighting the continuing need for these community events.
Interested in bringing a take back event to your community in spring 2019?
A new study recently published in JAMA by Michigan OPEN researchers finds a link between filling an opioid prescription after wisdom tooth extraction and long-term opioid use
Young people ages 13 to 30 who filled an opioid prescription immediately before or after they had their wisdom teeth out were nearly three times as likely as their peers to still be filling opioid prescriptions weeks or months later.
Those in their late teens and twenties had the highest odds of persistent opioid use, compared with those of middle school and high school age
Led by Calista Harbaugh, M.D., a Michigan OPEN research fellow and University of Michigan surgical resident, the researchers used insurance data to focus on young people who were ‘opioid naïve’ — who hadn’t had an opioid prescription in the six months before their wisdom teeth came out, and who didn’t have any other procedures requiring anesthesia in the following year.
“Wisdom tooth extraction is performed 3.5 million times a year in the United States, and many dentists routinely prescribe opioids in case patients need it for post-procedure pain. Until now, we haven’t had data on the long-term risks of opioid use after wisdom tooth extraction. We now see that a sizable number go on to fill opioid prescriptions long after we would expect they would need for recovery, and the main predictor of persistent use is whether or not they fill that initial prescription.”Dr. Harbaugh
Other factors also predicted risk of long-term opioid use. Teens and young adults who had a history of mental health issues such as depression and anxiety, or chronic pain conditions, were more likely than others to go on to persistent use after filling their initial wisdom tooth-related prescription.
More about the study
In all, 1.3 percent of 56,686 wisdom tooth patients who filled their opioid prescription between 2009 and 2015 went on to persistent opioid use, defined as two or more prescriptions filled in the next year written by any provider for any reason. That’s compared with 0.5 percent of the 14,256 wisdom tooth patients who didn’t fill a prescription.
Though those numbers may seem small, the high number of wisdom teeth procedures every year mean a large number of young people are at risk, notes Harbaugh.
The team used data from employer-based insurance plans, available through the Truven MarketScan database. Chad Brummett, MD, co-director of Michigan OPEN and is senior author of the new research. The team also includes U-M School of Dentistry professor Romesh Nalliah, DDS, MHCM.
The data show opioid prescriptions filled, but not actual use of opioid pills by patients. Leftover opioids pose a risk of their own, because they can be misused by the individual who received the prescription, or by a member of their household or a visitor. The researchers also couldn’t tell the reason for the later opioid prescription fills by those who went on to persistent use.
Importance for providers
The authors suggest that dentists and oral surgeons should consider prescribing non-opioid painkillers before opioids to their wisdom tooth patients. If pain is acute, they should prescribe less than the seven-day opioid supply recently recommended by the American Dental Association for any acute dental pain.
“There are no prescribing recommendations specifically for wisdom tooth extraction,” says Harbaugh. “With evidence that nonsteroidal anti-inflammatories may be just as, if not more, effective, a seven-day opioid recommendation may still be too much.”
Brummett adds, “These are some of the first data to the show long-term ill effects of routine opioid prescribing after tooth extractions. When taken together with the previous studies showing that opioids are not helpful in these cases, dentists and oral surgeons should stop routinely prescribing opioids for wisdom tooth extractions and likely other common dental procedures.”
Nalliah, the dentist on the Michigan OPEN research team, agrees. “I believe that opioid prescribing for dental procedures can be cut to a fraction of what it is today,” he says. “Through wisdom tooth extraction, the dental profession has an enormous opportunity to fight the opioid crisis by preventing early introduction of opioids to America’s young people. We hope that our study will make my fellow dentists think twice about removing wisdom teeth, and to more strongly consider non-opioid solutions.”
Michigan OPEN has created patient educational materials for dentists and oral surgeons to use, free of charge, within their practice. Information within these brochures include facts about opioids, questions for the patient to ask the doctor, and information about safe opioid medication storage and disposal. Michigan OPEN will co-brand these brochures with the dentist’s logo, free of charge, should they request it.
Importance for patients and parents
Getting a prescription for an opioid painkiller around the time of a wisdom tooth procedure comes with many decision points, Harbaugh says.
“Patients must decide whether to fill the prescription and take the medication, and where to store and dispose of the unused pills. All of these decision points need to be discussed with patients,” she says. “Patients should talk to their dentists about how to control pain without opioids first. If needed, opioids should only be used for breakthrough pain, as backup if the pain’s not controlled with other medications.”
The Michigan-OPEN team is currently studying the wisdom tooth extraction population further, by speaking with patients and parents about their experience and how many opioid pills they actually took. This will allow them to create evidence-based prescribing guidelines just like the ones they’ve developed for other operations.
The research was funded by the federal Substance Abuse and Mental Health Services Administration, the Michigan Department of Health and Human Services, and University of Michigan Precision Health.
Did you know that millions of adults in the United States live with daily pain? Injuries, surgeries, and procedures are common among older adults, and can result in acute and chronic pain. In March 2018, Michigan OPEN teamed up with the University of Michigan National Poll on Healthy Aging to ask a national sample of adults age 50–80 about their use of opioids for pain management, the education they received about the opioid medications, how they disposed of unused medications, and perceptions of current and proposed policies related to opioid disposal and prescribing. Michigan OPEN Co-Director Jennifer Waljee, MD, presents the findings from the poll in the video below:
Nearly a third of older adults have received a prescription for an opioid pain medicine in the past two years, but many of them didn’t get enough counseling about the risks that come with the potent painkillers, how to reduce their use, when to switch to a non-opioid option, or what to do with leftover pills, a new poll finds.
But the poll also finds that nearly three-quarters of older adults would support limits on how many opioid pills a doctor could prescribe at once. Even more supported other efforts to limit exposure to these medications, and potentially combat the national epidemic of opioid misuse due to medication diversion.
The new findings, from the National Poll on Healthy Aging, suggest a major opportunity for providers and community organizations to focus on safe opioid use and safe disposal among older Americans. These findings also could help state and federal policymakers understand the views of a key demographic group at a critical time.
The poll of 2,013 adults between the ages of 50 and 80 was conducted by Michigan OPEN, the University of Michigan Institute for Healthcare Policy and Innovation, and sponsored by AARP and Michigan Medicine, U-M’s academic medical center.
“We know that unused opioid medications that linger in homes are one of the primary pathways to diversion, misuse, abuse, and dependence. As prescribers, we must find opportunities to discuss safe opioid use, storage, and disposal with our patients…
says Jennifer Waljee, M.D., M.P.H., M.S., the co-director of the Michigan Opioid Prescribing Engagement Network (Michigan OPEN) and an associate professor of surgery at Michigan Medicine.
…It is critically important to provide a detailed plan for patients who get opioids for pain management and resources for disposal.”
Waljee worked with NPHA director and U-M professor Preeti Malani, M.D., and IHPI National Clinician Scholar and Michigan OPEN Research Fellow Calista Harbaugh, M.D., to design the poll.
They focused not only on older adults’ own opioid use but also their storage and disposal habits, as well as their perceptions of recent policy measures around opioid prescribing.
Common prescribing, inadequate counseling
Most of the 589 older adults who said they’d received an opioid prescription in the previous two years said it related to arthritis pain, back pain, surgery and/or an injury. While the majority remembered their doctor, pharmacist or other health care provider talking with them about how often to take the medication, the percentage who said they’d talked with any provider about other opioid issues was much lower.
For instance, less than half said their doctor or other provider had counseled them about the risk of addiction or overdose. Just over a quarter said their pharmacist had provided counseling. Slightly more individuals reported that doctors and pharmacists discussed options to reduce the amount of opioids they were taking.
Only 37 percent said their doctor had talked with them about what to do with leftover opioid pills, while 25 percent said their pharmacist had done so. Half of those who had been prescribed an opioid said they had had pills left over, and 86 percent said they kept them for later potential use.
“The fact that so many older adults report having leftover opioid pills is a big problem, given the risk of abuse and addiction with these medications,”
says Alison Bryant, Ph.D., senior vice president of research for AARP.
“Having unused opioids in the house, often stored in unlocked medicine cabinets, is a big risk to other family members as well. These findings highlight the importance of improving older adults’ awareness and access to services that will help them safely dispose of unused opioid medications.”
Disposal vs. keeping unused pills
The poll also asked those who didn’t have leftover medication, and those who had not been prescribed an opioid in the past two years, what they would have done with leftover pain pills. Two-thirds said they would save them for future use, 27 percent said they would dispose of them at home, and 36 percent said they would take them to an approved disposal facility.
Disposing of leftover medications may require travel to a facility such as a police station, authorized pharmacy, or community “takeback” event that can sometimes be logistically difficult for patients.
The poll asked all respondents to think about what they would do if there were a safe-disposal product that they could pick up along with their prescription. Such products are already on the market and include powders that can be poured into the bottle with extra pills, mixed with water, and safely disposed of in the trash. In all, 39 percent said they would definitely use it, but the majority of the rest said they’d save the medication for future use. And if the safe-disposal product cost $5 or $10, only 9 percent said they would be very likely to buy it.
Opioid policy opinions
The researchers suspect that older adults may fear that they will not be able to obtain pain medications when needed as new state opioid-related policies and laws target reduced prescribing.
Current and proposed laws in some states require providers to look at patients’ prescription records before prescribing opioids, and some require patients to tell their provider if they have been taking pain medications. Other states have proposed special provider education, prescribing restrictions, and required return of unused medications.
The poll shows that nearly all older adults support policies such as required review of prescription records and disclosure of prior opioid medication use, despite concerns that these policies may be perceived as invading patients’ privacy. A slightly lower percentage supported requiring providers to get special training before they can prescribe opioids. But the poll team was surprised to find that 74 percent supported restrictions on the number of opioid pills, or the number of days’ supply, for which prescribers could write a single prescription. On the other hand, just under half of older adults said they’d support required return of unused medications.
Taken together, Malani says, the poll results suggest that healthcare providers who prescribe or dispense opioids should do more to help patients understand how to safely use and dispose of them, in language that patients understand. This should include a disposal plan that helps patients understand why they should dispose of extra medications, and how best to do so.
“When a patient is prescribed an opioid, there are often many other aspects of care at the forefront of patient’s minds, such as their diagnosis, social stressors, work-related concerns, and caring for loved ones, and it can result in education fatigue,” says Waljee. “But we spend a lot of time educating our patients on when they can drive, return to work, and take care of their painful condition or surgical incision sites. Similarly, we need to educate our patients on what to expect following pain, the role and risks of opioids, and important alternatives such as over-thecounter analgesics, breathing, exercise, and sleep.”
The poll results are based on answers from a nationally representative sample of 2,013 people ages 50 to 80. The poll respondents answered a wide range of questions online. Questions were written, and data interpreted and compiled, by the IHPI team. Laptops and Internet access were provided to poll respondents who did not already have it.
Dr. Michael Englesbe, co-director of Michigan OPEN and a transplant surgeon at the University of Michigan, has recently taken major strides in curbing the negative outcomes of the opioid epidemic. Describing the role of physicians in mitigating these consequences, he stated that,
“Every surgeon, no matter what specialty or procedure they do, dentists included, needs to be thoughtful about how they prescribe opioids and be realistic that overprescribing can really have some devastating complications.”
It was with this mindset that Dr. Englesbe and his research team set out to create opioid prescribing recommendations for a common elective surgery, laparoscopic cholecystectomy (minimally invasive gallbladder removal).
Predicting that his recommendations would reduce prescribing for this operation, the surgeon discovered a spillover effect that led to approximately 10,000 fewer opioid pills being prescribed for four additional operations. Upon reflection, Dr. Englesbe reported that, “the [gallbladder removal guidelines] had a significant impact on how we prescribe for other procedures.” In striving to create safe and effective prescribing practices, Dr. Englesbe and his team generated findings that are relevant to surgeons in every specialty across the nation.
“We believe patient-reported outcomes are a better way to guide than expert consensus”-Michigan OPEN Co-Director Chad Brummett, MD.
In the midst of the Opioid Epidemic, much fueled by the over prescribing of painkillers after surgery, surgeons and researchers are searching for evidence-based guidelines regarding optimal prescription sizes after surgery.
Michigan OPEN, with collaborators MSQC released guidelines for opioid prescribing for various procedures back in Fall of 2017, which were again updated to include more procedures in March of 2018. These guidelines are updated quarterly to add more procedures and better refine guidelines for its current procedures as we gather more data.
Many others have adapted this approach within their state as well, including Marty Makary, a surgeon, researcher and professor of surgery at Johns Hopkins School of Medicine in Baltimore.
On Saturday, April 28, Michigan residents in 17 counties had a chance to get opioids and other unused and expired prescription medicines out of their medicine cabinets through 27 simultaneous events held around the state. The collective effort resulted in hundreds of families safely removing a total of 2000+ pounds of medication, including approximately 54,000 opioids from their homes while also increasing awareness in the community about safe medication disposal.
The statewide effort is made possible by local partnerships with Michigan OPEN and healthcare organizations, law enforcement and community organizations. The Spring 2018 event tripled the amount of Take Back locations from the Fall 2017 event and tripled the amount of opioids removed from Michigan communities.
Michigan-OPEN works with partners to hold community opioid and medication take-back events twice a year. These events provide a safe process for disposing of unused medications in order to protect communities, children and the environment. When Take Back Event participants were asked how they disposed of medications prior to coming to the Event, more than 50% answered, “did not dispose,” highlighting the need for these community events.