Opioid Solutions

By Alex Piazza
apiazza@umich.edu

It was around 4 a.m. when Linda Davis awoke to the sound of her teenage daughter crying in a nearby bedroom.

Davis rushed out of bed to check on her daughter, a straight-A student who traveled the country as a competitive cheerleader.

Over the next hour, Davis learned her 17-year-old was addicted to heroin, an opioid drug made from morphine. She described the next few months as “horrendous.”

“Once it took hold of her, everything went downhill really fast,” said Davis, a district court judge in southeast Michigan. “She was 86 pounds soaking wet and I literally was watching her die on a daily basis.”

This scenario has played out in homes across the United States. About 115 Americans die each day from an opioid overdose—almost five every hour—and the numbers are increasing, according to the Centers for Disease Control and Prevention.

“The opioid epidemic in our communities does not discriminate by race or socioeconomic status,” said Rebecca Cunningham, associate vice president for research at the University of Michigan who studies opioid overuse and overdose from both the clinical and policy perspective. “I have seen firsthand that this medical illness affects everyone—rich, poor, rural, urban, educated and uneducated, young adolescents and elderly adults.”

A wide range of U-M researchers are working to tackle the root causes of, and potential solutions for, this national crisis. A campus-wide network encourages and coordinates their efforts to find solutions to what the federal government has declared a public health emergency.

Opioid Solutions, a resource developed by the U-M Office of Research, the Injury Prevention Center and the Institute for Healthcare Policy and Innovation, serves as a central hub for U-M research, educational activities and community outreach related to opioids. The network draws on nearly 100 U-M faculty—in fields ranging from psychiatry, pharmacy and public policy to basic science and law—whose research explores opioid misuse and overdose.

“We need to realize that not one entity is going to solve this problem,” said Davis, whose daughter has been clean for 11 years. “We need to think outside the box, expand our thoughts, expand our vision and be open to new ideas. We need to work as a community if we’re ever going to change this.”

The Epidemic

In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to new formulations of pain medication.

That led health care providers to prescribe opioids at greater rates, according to the U.S. Department of Health and Human Services, which then sparked widespread misuse and diversion of these medications.

Sales of prescription opioids in the U.S. nearly quadrupled from 1999 to 2014, CDC data shows. During that same stretch, the number of opioid overdose deaths more than quadrupled.

“The fact that the public makes assumptions about the epidemic contributes to the ongoing problem,” said Carol Boyd, Deborah J. Oakley Collegiate Professor of Nursing and director of the interdisciplinary Center for the Study of Drugs, Alcohol, Smoking and Health (DASH Center), housed in the U-M School of Nursing.

Boyd has more than 40 years of experience in the substance use field, and her research often follows drug epidemics, ranging from crack cocaine in the 1980s to the current opioid crisis. As co-directors of the DASH Center, Boyd and Sean Esteban McCabe explore why certain populations, such as youth, emerging adults and sexual minorities, are at greater risk for substance use disorders—with a strong emphasis on opioids.

“As a result of several factors, the U.S. consumes the majority of the world’s prescription opioid supply,” said McCabe, research professor at both the Institute for Research on Women and Gender and the School of Nursing.

Most research focuses on opioid use among adults, but Boyd and McCabe partnered with U-M colleagues Brady West, Phil Veliz, Sarah Stoddard and Vita McCabe to examine opioid misuse among high-school seniors over the past four decades.

Their research, based on long-term trends, indicates about 20 percent of high-school seniors self-reported medical or nonmedical use of prescription opioids. Another consistent finding is that the majority of nonmedical users of prescription opioids have a prior history of medical use.

This finding should concern health professionals who prescribe opioid medications to adolescents, Boyd said, given the serious health consequences associated with nonmedical use of painkillers.

“Every drug comes with a risk, but what sets pills apart is their availability,” she said. “People often perceive controlled medications as completely safe, a belief that may stem from the way in which pharmaceutical companies advertise these products to consumers.”

Boyd and McCabe share a sense of cautious optimism, when after a decade-long increase, their research cites national declines in medical and nonmedical use of opioid medication.

“The hope is that these declines are due to more careful prescribing practices and enhanced monitoring of prescription opioids among adolescents,” said McCabe, who notes the importance of sustaining these declines.

A Guide to Prescribe

How many prescription pain pills should a patient receive after surgery?

The answer should be simple, but surgical teams did not have an evidence-based guide to help them prescribe powerful opioid pain medications wisely.

Now they do. A tool developed at U-M looks at 16 common operations, ranging from breast cancer surgery to hernia repair, and then offers a recommended number of prescription pain pills to prescribe to patients who undergo those procedures.

The tool, developed by members of the Michigan Opioid Prescribing and Engagement Network that got its start at IHPI, is just one of the clinical efforts that has tremendous potential to drive continued improvement in prescription practices nationwide.

“It’s embarrassing to admit this, but we’ve never had any evidence to inform how much opioid we prescribe to surgical patients,” said Jay Lee, a general surgery resident at U-M who helped create Opioid Prescribing Recommendations for Surgery. “These recommendations provide a crucial first step for improving the safety of opioid prescribing.”

The amounts are not arbitrary. They represent the actual maximum opioid use reported by 75 percent of actual surgery patients. Most patients actually took far less, from 0 to 5 pills, even when they were prescribed more by their surgeon or other provider.

The tool has tremendous potential to drive continued improvement in prescription practices nationwide.

“Surgical teams are all very much aware of the crisis caused by overprescribing opioids, and have embraced these recommendations as an effective tool to begin addressing this problem,” Lee said. “As counseling and pain management strategies improve, patients will use less opioid medication.”

A cohort of bioscience researchers at the university’s Edward F. Domino Research Center, housed in the U-M Department of Pharmacology, also is exploring opioid addiction at the molecular and cellular levels. The center, led by pharmacology Professor John Traynor, aims to understand the addiction process at a neuroscience and animal behavioral level, to identify medications to treat opioid abuse and overdose, and design non-addictive pain medication.

“A basic science approach is critical when addressing a crisis as serious as opioids because it provides us all with a better understanding of how to manage pain effectively and safely,” said Traynor, Edward F. Domino Research Professor of Pharmacology.