This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

From 2000 to 2018, Michigan opioid overdose deaths grew tenfold. In 2019, 2,354 Michiganders died from opioid overdose. In 2020, that number grew to 2,738. And as COVID-19 undermined mental health, opioid overdose killed 956 Michiganders between January and April 2021 alone. If the trend continues once 2021 data are fully reported, the state will reach a new record number of annual opioid overdose deaths.

In light of these sobering statistics, a new collaborative called the Michigan Opioid Prescribing Engagement Network (Michigan OPEN) is taking a preventive approach to the opioid epidemic. Michigan OPEN launched in 2016 with support from the Michigan Department of Health and Human Services, Blue Cross Blue Shield of Michigan Value Partnerships, and the Institute for Healthcare Policy and Innovation at the University of Michigan. Michigan OPEN's approach focuses on setting prescribing recommendations for providers; educating patients about safe use of opioids; distributing Naloxone, a drug that reverses overdose, at hospital emergency departments; and reducing surplus opioids within Michigan's communities to prevent misuse and addiction.

"What we're seeing in Michigan is, unfortunately, what we're seeing nationally in the era of COVID: an increase in overdose deaths," says Dr. Chad Brummett, co-director of Michigan OPEN. "It's caused by loneliness, challenges with access to health care, financial stress, anxiety. It's been a hard time for everyone. And it's been particularly hard for those with substance use disorders."
Dr. Chad Brummett.
A class of highly addictive drugs derived from the opium poppy, opioids relieve pain. Doctors and dentists legally prescribe opioids like oxycodone (Percocet or OxyContin), hydrocodone (Vicodin or Norco), morphine (Kadian), and codeine (Tylenol No. 3 or No. 4) after surgery. Prolonged opioid use leads to higher tolerance and physical dependence. Prescribed opioids can lead to addiction and fuel addictions already in place.

"In recent years, [Michigan OPEN has] done a lot of work in dentistry to demonstrate that there's a lot of opportunity to improve prescribing," Brummett says. "Randomized control trials show that acetaminophen and ibuprofen are better than an opioid for treating pain after dental extraction. And yet, about 11 or 12 million opioid prescriptions written last year were written by dentists for dental extraction."

Michigan OPEN guidelines used across Michigan and U.S.

Michigan OPEN Prescribing Recommendations give providers evidence-based guidelines for various surgical and dental procedures in an easy-to-access online format. In addition, a series of brochures educates patients about the proper use of opioids as relates to their condition.  

"The analysis that we do — and the way the work that we put out informs providers — actually ends up saving people's lives," says Vidhya Gunasaleen, Michigan OPEN clinical information analyst. "The entire analytical team at Michigan OPEN realizes that these are not just numbers. These are people."
Vidhya Gunasaleen, Michigan OPEN clinical information analyst.
Michigan OPEN compiles data from Medicaid, Medicare, private insurance claims, electronic health records, the Michigan Genomics Initiative, the State of Michigan Automated Prescribing System, and patient surveys to inform its prescribing guidelines.

"The information that we put out is all strongly grounded in data and a lot of clinical knowledge," Gunasaleen says. 

Michigan OPEN's methodology has gained statewide and national recognition. For example, a panelist at the 2021 virtual American College of Surgeons Clinical Congress advised surgeons prescribing opioids to use recommendations established by Michigan OPEN.

Michigan OPEN's work has driven quality improvement projects within various Michigan hospitals that want to improve prescribing. It has reduced postoperative opioid use and unintended distribution of opioids into communities.

"No one data set can answer all the questions that we may have or that can provide evidence for the different kinds of things that we do. There are different databases and data sources that we use for different purposes," Gunasaleen says. "Surveys that go out to specific patients ask questions about their usage of opioids after surgery, how their pain has been since surgery, and what has been their satisfaction with daily life."

Through partnerships with law enforcement and community health organizations, Michigan OPEN hosts biannual opioid take-back events in the spring and fall. Its online map of opioid disposal sites lets Michiganders know where they can get rid of unused opioids the rest of the year. According to Michigan OPEN, three in five teens say prescription pain medication is easy to get from their parents' medicine cabinet.

"How do we dispose of those medications that go unused, because probably billions of unused opioids are in medicine cabinets in our communities?" Brummett says. "We need to find more ways to help people dispose of those in an environmentally friendly way."

"Carry Naloxone. It saves lives." 

By viewing patients' surgeries, emergency room visits, and care transitions as touchpoints to detect substance use disorder (SUD), providers can prescribe more carefully so as not to feed existing addictions or create new dependence. When providers suspect SUD, they can also send patients home with Naloxone.

"Our initial work was really focused on how we keep healthy people healthy, considering how we first prescribed to patients," Brummett says. "Now our work has moved into screening for substance use disorders." 

Michigan OPEN currently provides 23 Michigan hospital emergency departments with Naloxone kits. In the span of two years, these emergency departments have distributed 2,448 kits to patients deemed at risk for opioid overdose.

Michigan OPEN partnering provider Dr. Chin Hwa (Gina) Dahlem practices at Packard Health clinics located at the Shelter Association of Washtenaw County and Avalon Housing in Ann Arbor. She has been involved in harm reduction, Naloxone education, and overdose prevention since 2013, when she would often see shelter clients overdosing in bathrooms.

"We knew what drug to give but we didn't have it at the clinic," Dahlem says. "Emergency departments reach a lot of clients who not only have overdose, but who are at higher risk for an overdose. So they have a larger pool of active patient engagement."

While Naloxone traditionally has been given to individuals living with opioid addiction, Dahlem is excited to see that its distribution at emergency departments can include the patient's family and friends.
Dr. Chin Hwa (Gina) Dahlem.
"A person who uses drugs may not be able to self-administer Naloxone. It's all the more important to train family and friends and other lay people how to reverse overdoses," Dahlem says. "That's why this project through Michigan OPEN is so exciting. We're reaching a greater audience and providing greater accessibility to Naloxone."

Dahlem sees Michigan OPEN's Naloxone initiative as a starting point for making other harm reduction tactics more widely and uniformly available across the state. She would also like to see more syringe service programs, which help prevent HIV/AIDS and hepatitis until individuals are ready to seek SUD treatment. And she would like to see municipalities change drug paraphernalia and good Samaritan laws so fewer people are criminalized because of SUD.

"I always say, 'Carry Naloxone. It saves lives,'" Dahlem says. "We need people alive in order for them to get into recovery. We need to be normalizing that conversation about addiction and about people who use drugs — and thinking about addiction as a chronic disease."

More careful prescription of opioids is essential to a healthier Michigan. Simply being on opioids can cause nausea, vomiting, constipation, suppressed immune function and impaired sexual health. While opioids can be effective for managing short-term acute pain, longer-term use for chronic conditions leads to dependence — and, in too many cases, addiction.

"For a lot of people, chronic opioids are not effective," Brummett says. "Yet they're really hard to stop once you've been taking them for a long period of time."

Brummett relates that after a long period of using opioids, people are likely to experience anxiety, restlessness, nausea, sweating, and a racing heartbeat when they stop taking them.

"Probably the most common complication after elective surgery is becoming newly dependent on opioids," Brummett says. "And those with opioid use disorder needing care  — they need surgery. They need dental procedures. How do we help move them through those care episodes in a way that attends to their pain, leaves them satisfied with their care, but doesn't leave them worse off?"

A freelance writer and editor, Estelle Slootmaker is happiest writing about social justice, wellness, and the arts. She is development news editor for Rapid Growth Media and chairs The Tree Amigos, City of Wyoming Tree Commission. Her finest accomplishment is her five amazing adult children. You can contact Estelle at Estelle.Slootmaker@gmail.com or www.constellations.biz.

All photos by Doug Coombe.