Tailoring Opioid Prescribing after Major Trauma

The overarching purpose of this study is to generate robust pilot data toward a future R01-level proposal that will implement a multifaceted intervention to reduce excess prescription opioids in the community.  In the state of Michigan, mortality related to prescription opioids is accelerating even more rapidly than the national average, and was 20% higher than the national average in recent years.11 At the University of Michigan, the Acute Care Surgery services cares for over 1,300 (1,100 trauma, 200 burn) patients each year who suffer major trauma, burn injuries, or require emergent procedures for non-elective surgical conditions (e.g., necrotizing fasciitis, intestinal perforation). In this mixed-methods study, we will examine the match between opioid prescribing and consumption after discharge, conduct a needs-assessment among providers caring for patients with major injury, and develop an intervention targeted to providers designed to align reach opioid prescribing and consumption.

Aim 1. Assess opioid prescribing and consumption following hospital discharge following major trauma, burn injury, or emergent surgical procedure. Over a 12-month period, we will recruit adult patients discharged from the University of Michigan Acute Care Surgery (ACS) service and collect daily assessments using interactive voice response technology (IVR) and text-messaging. We will prospectively collect patient-reported pain and opioid consumption among individuals discharged from the hospital following traumatic injury over a 2-week period. Participants who stop taking opioids will be given a brief message about safe disposal. From this, we will obtain normative data regarding patient-reported pain and opioid requirements, which will be measured against medications prescribed at discharged.

Aim 2: Qualitatively examine provider preferences regarding postoperative opioid prescribing. We will conduct semi-structured interviews of ACS providers (resident physicians, physician assistants, nurse practitioners, fellows, attending surgeons) to describe attitudes, knowledge, and prescribing patterns with respect to outpatient pain management and prescription opioid prescribing. Interviews will begin with open-ended questions regarding pain management, with follow-up questions regarding the factors that influence decision-making regarding choice of opioid, dose, duration and number of pills prescribed, knowledge of opioid disposal, as well as alternative opioid analgesics.

Aim 3: Develop and pilot a provider-based feedback intervention regarding opioid prescribing and consumption. We will constructive a normative feedback intervention (i.e. dashboard) that integrates opioid prescribing (gathered from the medical record) with opioid consumption, pain, and opioid disposal (gathered from patient surveys), and constructed at monthly intervals. Information will be displayed in aggregate across all providers on the ACS service, and circulated at monthly quality control conference meetings. We will examine the change over time in overall prescribing, opioid consumption, and patient-reported pain. We hypothesize that provider feedback will result in a reduction in overall opioid prescriptions dispensed, a closer match between opioid prescribing and consumption, without an increase in patient-reported pain.   These de-identified aggregate dashboards will be circulated in order to highlight awareness of opioid prescribing practices and highlight opportunities for opioid alternatives.

Principal Investigator: 
Jennifer Waljee
Assistant Professor
Plastic Surgery
2016 - 2017
Abstract Text: 
Aim 1 Results: The patient portion of the pilot completed subject recruitment with 94 consented study participants. After subject withdrawals, we have data from 90 day of discharge surveys. We have data from 71 two-week follow up surveys, a 79% response rate. Of the remaining, 47% were lost to follow up and the remaining 53% were readmitted to a medical facility and had their participation terminated. Additionally, we have data from 68 one-month follow up surveys, a 76% response rate. Of the remaining, 38% were lost to follow up and the remaining 62% were readmitted to a medical facility and had their participation terminated. A total of 24 subjects were enrolled in the interactive voice response and texting system. Six subjects completed the 14 day period with 0 responses and all other subjects ranged between 1 and 14 total responses. One subject completed the 14-day period with 100% response rate and three subjects completed with 93% response rate. We plan to use standard univariate statistics and regression analysis to understand the patient-level predictors of pain and opioid consumption following discharge for acute surgical conditions. 45 participants responded to the one month survey and the primary variable of interest. Of these, 5 participants continued to take opioids 1 month after discharge. Additionally, 22.5% of the 40 participants required a refill of opioid pain medication. Aim 2 Results: This portion of the study is ongoing. A total of 13 completed semi-structured interviews with mid-level ACS providers (physician assistants and nurse practitioners) have been completed as well as 5 interviews with resident physicians. Four emerging themes from the semi-structured interviews with mid-level providers have been identified: 1. Support and resources needed to manage complex patients, 2. Desire to minimize risks associated with opioids, 3. Desire to obtain and implement evidence-based guidelines into practice, and 4. Patient-centered approach to prescribing. Aim 3 Results: This portion of the study is still underway as we are still constructing opioid trajectories from recently discharged patients (from Aim 1). The dashboard templates have been built surgical procedures, and can be applied to this population in next phases of the study. The anticipated implications of our findings for practice include improving effective pain management and minimizing inappropriate opioid prescribing by creating functional guidelines to direct pain management following major trauma or surgery, as well as establishing the effectiveness of a pain medication disposal information intervention in practice.
PI Title: 
Assistant Professor