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On today’s The Fundamentals is Dr. Brummett, Professor at the University of Michigan where he serves as the Senior Associate Chair for Research in the Department of Anesthesiology. He has more than 280 publications, including articles in top journals such as JAMA, JAMA Surgery, Anesthesiology, and Annals of Surgery. He is the Co-Director of the Opioid Prescribing Engagement Network or OPEN at the University of Michigan, which aims to apply a preventative approach to the opioid epidemic in the US through appropriate prescribing after surgery, dentistry and emergency medicine. Moreover, he is the Co-Director of the cross-campus Opioid Research Institute, which was launched in the spring of 2023. He leads multiple NIH grants studying these concepts and receives funding from the Michigan Department of Health and Human Services, SAMHSA, CDC, and multiple foundations.

Learn more about Dr. Brummett, and follow Dr. Brummett @drchadb and you can follow the department of anesthesiology @UMichAnesthesia on X.

Resources

• Find out more about the research stories mentioned at the top of the show at the links below:
  • The feeling of hunger itself may slow aging in flies
    Research examines changes in the brain that prompt the drive to seek food
  • Different pain types in multiple sclerosis can cause difficulty staying active
    Chronic pain can present in multiple forms for multiple sclerosis patients. Some forms make it harder to stay active than others.
• You can learn more about The Fundamentals on our website.
• Learn more about other exciting research happening at the University of Michigan, by checking out Health Lab, Michigan Medicine's daily online publication featuring news and stories about the future of healthcare.

Transcript

Kelly Malcom:

Welcome to The Fundamentals, a podcast focused on the incredible research at the University of Michigan Medical School. I'm your host Kelly Malcom.

Jordan Goebig:

And I'm Jordan Goebig. And this episode's guest is an accomplished researcher and anesthesiologist. I enjoyed learning about how his collaborators and the students at Michigan Medicine have inspired him. And spoiler alert, thought it was pretty cool that his research group has a musical. But before I give too much away, let's share a few research articles that might be of interest to our listeners. I recently read an article published in the Michigan Medicine Health Lab blog about how different pain types in multiple sclerosis or MS can cause difficulty staying active. The article highlights the importance of understanding what types of pain people with MS are experiencing to create physical therapy plans.

Kelly Malcom:

And this next Health Lab article is unrelated to pain but all about hunger pangs. This is a study in fruit flies that found that the hunger drive itself may underlie the life extending effects of diet restriction.

Jordan Goebig:

We'll provide links to the full articles and info about our featured guest in the show notes. Now let's get on to the guest.

Kelly Malcom:

In the studio with us today is Dr. Chad Brummett. Dr. Brummett is a Professor at the University of Michigan where he serves as the Senior Associate Chair for Research in the Department of Anesthesiology. He has more than 280 publications, including articles in top journals such as JAMA, JAMA Surgery, Anesthesiology, and Annals of Surgery. He is the Co-Director of the Opioid Prescribing Engagement Network or OPEN at the University of Michigan, which aims to apply a preventative approach to the opioid epidemic in the US through appropriate prescribing after surgery, dentistry and emergency medicine. Moreover, he is the Co-Director of the cross-campus Opioid Research Institute, which was launched in the spring of 2023. He leads multiple NIH grants studying these concepts and receives funding from the Michigan Department of Health and Human Services, SAMHSA, CDC, and multiple foundations. Welcome.

Dr. Chad Brummett:

Thanks. It's a pleasure to be here.

Jordan Goebig:

Welcome. It's so great to have you here today. So usually we kick things off with hopefully a simple question, which is just telling us about your journey to the University of Michigan.

Dr. Chad Brummett:

Sure. So I did my medical training in Indiana and ended up here for anesthesiology residency. I took a brief stint out to Johns Hopkins for my pain fellowship, not really expecting to come back, but just really appreciating all that the University of Michigan has to give both in terms of excellent clinical care, but also just a collaborative vibrant research environment. And that really made it easy to come home to Michigan.

Jordan Goebig:

Wonderful. And as a trained anesthesiologist, what led to your interest in opioids as a research focus?

Dr. Chad Brummett:

So I was always interested in pain medicine in medical school. I don't really remember exactly how I came across it, but I came into anesthesiology training, interested in pain. I had done some work in the emergency department and really saw anesthesia and chronic pain medicine as a long-term career goal and opportunity. And so I am a little different than a lot of our anesthesia residents in that I came in expecting to do a chronic pain fellowship. And so following my residency, that's when I went out to Johns Hopkins for that pain fellowship.

Jordan Goebig:

Oh, very interesting.

Kelly Malcom:

So you've done a lot of work illuminating opioid prescribing practices. What sticks out to you as maybe the most problematic practice or a research finding that you found surprising?

Dr. Chad Brummett:

There have been so many interesting and surprising findings along the way. I mean, I think I want to start by acknowledging that I think opioids have a role, a really important role. Every time I'm in the pain clinic, I prescribe opioids. When I was doing operating room anesthesia and rounding in our inpatient service taking care of patients after surgery, we used opioids. I think they're a critical tool, and yet I also believe that we got a little beyond where we should have been with respect to prescribing. And that's probably an understatement. And I think that as we've moved along, I've been surprised how much we've reduced prescribing, but in a positive way where we're not seeing... And this is from tens of thousands of patients, these are data from tens of thousands of patients across 70 hospitals in the state of Michigan showing that we've really reduced prescribing by about 75% in the state of Michigan without changing patient's report of pain or their satisfaction with their care or the likelihood that they need to refill.

And these things all vary. People do have pain after surgery and that was true when we were prescribing a lot of opioids, but we're not seeing more now with the less opioids and people do refill and opioid refills are important, but it's interesting that you can prescribe a lot less and not have those things happen. But I think the area where we've really been most interested, at least within the OPEN group, is thinking about this concept of becoming a new chronic user or a new persistent user as we've termed it, that a sizable percentage of patients, maybe one of the most common complications after surgery is coming in, not using opioids and then continuing to take them long after what would be a normal recovery from surgery.

And that has its own complications associated. We've seen that for that population they go on, there's an increased risk of developing a more bona fide addiction, death, overdose, hospital readmissions, and just increased cost of care. And so this has been a really important point for our group in trying to think about how we still care for people's pain after surgery, help them through a quality recovery without leaving them on opioids in a long-term manner, so as to think about their positive long-term future.

Kelly Malcom:

So you've definitely seen some positive impact from these studies looking at prescribing practices. Have you gotten any other feedback from practitioners about maybe they've come across having some difficulty in helping their patients or maybe they want to prescribe opioids and feel like they can't? What's sort of been the feedback that you've gotten from your colleagues?

Dr. Chad Brummett:

From the colleagues, the feedback's been largely positive. I think that most of our surgeons show up wanting to do the right thing. But it was kind of amazing when we released our prescribing guidelines in 2017, those were the first evidence-based prescribing guidelines ever written. Really largely we gave opioids based on how much your senior resident told you to prescribe when you were the intern, that there was sort of a path in which the decision to prescribe was based not on evidence or based on guidelines, but just based on people's opinions. And I think that most of our surgeons have really embraced guidelines and been pleased to have some guidance. And no doubt we see some people probably taking it too far. And this is going to happen with anything. We are, as I said, we believe that opioids are a tool and they're an important tool and that many people needs opioids after surgery, but within that avoidance of overprescribing it is an important practice.

Kelly Malcom:

It's kind of crazy that there were no evidence.

Jordan Goebig:

I know.

Kelly Malcom:

There's no evidence behind...

Jordan Goebig:

Yeah. When you were talking, you read what I was wondering, what was the history of this? What was going on beforehand?

Dr. Chad Brummett:

Well, it's interesting because it's not only in the US that this is the truth. As I've traveled around the world, there's a lot of surgeons who... Actually surgeons all over the world prescribe, send the patient out, and they're worried about other things appropriately. How well are you recovering from your surgery? If I took out your cancer, did your cancer recur? There are bigger things that sometimes surgeons are thinking about, and this was not a lack of interest, but pain was just a symptom, if you will. This is a symptom, this is a part of the surgery, but not necessarily something that we were thinking about in terms of is our pain treatment potentially leading to its own problems? And there is this cliché sort of discussion of pendulums and people are now concerned that our pendulum is swinging too far the other way. And I think it's something we have to talk about and think about.

We as a group talk about how we make sure our prescribing recommendations make clear that prescribing is still important and is still appropriate, but we were largely flying blind. And so examples would be after a knee or hip replacement, you might go home with 100 pills, where after a knee we would say you need probably between 40 and 50, and after hip probably 20 to 30. And about 20% of people weren't using any pills when they went home. So it was like there was really nothing out there to guide this. And then even more extreme cases where cardiac surgery, I mean it's a big surgery. People have their chests cut open, they have their heart surgery, but they stay in the hospital a long time and a lot of them leave the hospital really not using any opioids, but we were still giving them 70, 80, 90 opioid pills. And these sit in medicine cabinets for decades and they become a source for people to, in particular vulnerable people, teens, adolescents, to misuse and abuse these medications.

And so it's a complex layered narrative and there's no way in a short podcast to talk all the complexity and I could go too deep, but I'll just say that if I look back on it, I guess I was probably surprised that there's no evidence-based guidelines. But then as you think about it more and think about the perspective of a surgeon, it makes sense.

Jordan Goebig:

So something that Kelly mentioned in your bio and then you also mentioned again was OPEN and I'd love to hear more about your involvement in that. And then kind of a twofold is you're also involved with the UM Opioid Research Institute, so your involvement with that as well.

Dr. Chad Brummett:

Yeah. So the great part about Michigan as I mentioned before, is sort of the culture of broad collaboration and the want for people to work together. And I do think that's a unique sort of go blue Michigan thing. And I've felt this as I've traveled around the country. Our faculty and staff want to collaborate. And so OPEN happened organically. For most of my career, I studied chronic post-surgical pain trying to understand who develops pain after surgery is a huge issue and one for which we're still doing a lot of work. And my colleague Mike Englesbe, a transplant surgeon, he's the Chief of Transplant here, came in and just sort of said, I want to do some work in opioids. And I said, well, what work? And it just sort of happened. And then we brought in Jennifer Waljee, a plastic surgeon, hand surgeon, probably the University of Michigan's most effective person.

And we said, gosh, what can we do here? And we really thought about this. We originally were thinking, how do we take care of a patient who's using opioids chronically before surgery as a starting point? And while that seems like a natural place to start, we realized that the majority of patients, about 80 to 90% of people are not using opioids before surgery or giving them an opioid routinely. And we didn't really have a path or a thought for that. And so that's how we started. And through the statewide collaboratives that are funded by Blue Cross Blue Shield of Michigan, which is just bringing surgeons across the state together, we were able to actually get state representative data. Data from real patients that represent all kinds of care across the state of Michigan to tell us how they did after surgery, which is unique, that's a unique platform.

And from that also disseminate faster than any place in the country. And that's where we went to our Medicaid office here in the state of Michigan and said, this is what we want to do. And we think that Michigan uniquely as a state, uniquely suited to do this. Now, as OPEN has evolved, we are much more than just prescribing. We're now thinking about how to manage more challenging populations, those using opioids before surgery because they need special care, can't treat them just the same. And then people with opioid use disorder, we are seeing, which is the diagnostic term for addiction. People are living long and healthy lives after developing [inaudible 00:13:49] but is a lifelong disease and not a moral failing. And we need to give these people good effective care after surgery, but they need special care.

And that's where our colleagues, Mark Bicket, who joined us from Johns Hopkins a few years ago, he's an anesthesiologist, pain physician, is really driving that work. And then Amy Bohnert, another of my colleagues, is doing work across the space, really thinking about how we get more people into long-term recovery, which is such important work. So our pathway now, I would say we do a little bit of everything within OPEN as it relates to opioids, and it's sort of organically then led into the Opioid Research Institute. And that is now in collaboration with my colleague Amy Bohnert, who is an epidemiologist and just a world-class researcher. She and I are leading this new initiative, just started this year, early in the spring 2023. And our goals are really to be a small but mighty force that brings the individual pockets of research excellence in opioids across the campus together to think about how each of these groups can bring something unique to the table to be greater than the sum of its parts.

And this will also include more direct connection with our state and our communities so as to ensure that our communities can heal and that we can be a healthier, safer state. And that we have a lot of opioid settlement money coming through, and I worry that it not... That it be used well.

Kelly Malcom:

I know that overall the opioid epidemic has sort of raised the profile of our alternatives for pain relief like cannabis to be specific. Are you studying the effectiveness of cannabis for some of the procedures or conditions where opioids may have been prescribed? And what do you think about this line of research?

Dr. Chad Brummett:

The opioid narrative is broad and complex, and one of the challenges we see right now, and I'm very empathetic to is that there are people who use opioids for chronic pain. And through all of the positive work that we're doing to try to make our state and nation and world healthier, I can see that some of this is leading to concerns about stigma for opioids and their appropriateness. And it's hard to find balance in our work and in our messaging. In a world of Twitter or X where everything is effectively a punchline and the nuance is gone, I think sometimes we miss where we can leave people feeling that opioids are never correct. I still, as I said in my clinic, I still treat people with opioids chronically. Some I've treated for my whole career. I don't know, all 16, 17 years of my career, I've had patients that I've been managing on opioids for that time.

We still recommend opioids for many pain conditions. There are concerns out there that our recommendations suggest zero pills, and what we recommend is a range of zero to a number, but that range is because some people don't need any, not because we're encouraging surgeons to try to drive to zero. And I think that that's a place where that messaging has been lost and we're actively talking about how to address that. But it is a challenging time. I would say that it's interesting because for a long time, substance use disorders of which opioids are a substance use disorder have been stigmatized. Now I can see that the chronic pain community and those using opioids feel that stigma, and I think it's something we have to continue to address.

Yeah, I think studying cannabinoids is really important and needed. I unfortunately believe that our irrational scheduling and making cannabis schedule one, which is making it equivalent to heroin, has been just wrong. And we are seeing now increased societal acceptance of cannabis both for medical and recreational use. And I think what unfortunately the scheduling and the regulations have led to the data not being great in either direction. And so our group more broadly in the Chronic Pain and Fatigue Research Center, Dan Clauw, Kevin Boehnke, are doing a lot of really great work trying to understand mechanisms and profiles of different cannabinoids, both CBD and THC, the two components of cannabis.

And more recently, we were just launching a new grant where we're going to be studying CBD oil, which is not scheduled, not regulated, but is used right now only for refractory seizures in kids, but actually about 18% of adults without FDA approval use CBD oil for pain and inflammation and sleep and all these other things, but we actually don't know if it works. And so we're doing a multi-site study together with Henry Ford Hospital in Detroit to try to study this both before and after knee replacement, a really painful surgery, not in lieu of opioids, but in addition to opioids to try to see whether it can reduce opioid use post surgically. They'll still have the same number available, but will they reduce their use? Will they improve pain, sleep, inflammation? And trying to get some additional mechanistic data. But I think we're not the only group out there doing work in this space, but I think it's needed and I think physicians want to know how to counsel patients about the use of cannabis for pain and other conditions.

Jordan Goebig:

I'm curious, so my next question is kind of describing a project that you've worked on with a clinical team, and not everybody that we have in here, that sits in here has that MD background, but also that research background, although many people do because it's Michigan and Michigan's awesome. But I would like to... This is something that's a little new to me. I've only been on campus for a year, didn't come from a place like Michigan beforehand. And so I would love if you could describe what having clinical teams to work with is like at Michigan and what the process is when you're working on a project and you can use a specific project to walk through the example.

Dr. Chad Brummett:

Well, I think the specific example would be how OPEN sort of started. We had a person at the time who was a fourth year student, Ryan Howard, who's now a senior surgery resident here at Michigan who sort of came in young, bright, energetic and was asking this question, why do we prescribe so much after gallbladder removal? Common surgery. We were generally giving 40, 50 pills. But when he called patients afterwards, they were taking on average about six pills. And he thought, well, this is an opportunity. And we looked and we said, well, the 75th percentile, trying to think about attending to the majority of people was 15 pills, still much more than six, but let's try... 15 is a lot less than 40.
Ryan reached out to the Chair of Surgery at the time, Michael Holland, who said, all of our residents need to see this. And so Ryan did a presentation for the residents, and it was amazing. Soon after 15 pills became the norm, and I've joked that the editors of the journal, JAMA Surgery that published it, sort of accused us of fabricating our data because there was no variance. 15 pills just was the norm, and it became this established pathway all through a presentation with it included a story, some data and a clear plan, and it was just a really fun way for us to launch OPEN.

Jordan Goebig:

Yeah, I mean that's really neat and a fast way to make it, not fast, it took time to do this, but making a big difference, which is really cool. I don't know if this will be on the record, but I'm curious because you said you call folks after their surgery. How long do you end up following up with people?

Dr. Chad Brummett:

Yeah, it depends on the study, but our studies, when we talk about those statewide Blue Cross collaboratives, not all, but some have effectively like a 30 day follow-up because I think as surgeons, they tend to think about that care management depending on the type of surgery. As a more minor surgery where recovery is expected, 30 days for some, like a knee replacement, three months. And so that's that time period where they sort of say, I'm responsible for the care of this patient. And so that window varies, but that would be an example of a 30 day window. Some of our prospective studies, and I'm part of the NIH Acute to Chronic Pain Signatures program or A2CPS. This is the biggest investment the NIH has ever made in studying who develops pain after surgery. And we are recruiting from six hospitals in the state of Michigan, thoracic patients.

Those patients get followed out for a year, but with their primary outcomes being six months later and it's really granular data, we're collecting an app, we're getting brain imaging, omics, blood samples for omics. They get pain testing at their surgical site. And so this will be one of the most rigorous studies, chronic post-surgical pain, looking at both thoracic surgery, so chest wall surgery and total knee replacement. And that's an exciting national effort that includes folks in Chicago at Rush, at University of Chicago, and then other centers, Hopkins, Texas, UCSD, there's groups all over the country, University of Iowa.

Jordan Goebig:

Wow, that's really neat. That's everywhere.

Dr. Chad Brummett:

It has a... When we look at the map, we do feel nationally represented, but most of the data collections happening, actually all of the data collection in terms of the patients are being recruited from the state of Michigan and the city of Chicago. And so I think we can feel proud that we're really directly contributing to a very important study like that.

Jordan Goebig:

Again, I don't know if this will be in, but now I'm spiral thinking with all of these. When you collect this data, do you segment? Are you looking at how men versus women are recovering and things like that?

Dr. Chad Brummett:

So whenever we study pain, and I think this is just expected, you have to analyze men and women separately or at least look. Sometimes we'll just adjust for sexes when we're doing our analyses, but we certainly see meaningful differences in the way that men and women experience pain. And generally most chronic pain conditions are more common in women. But interestingly, when you talk about something like how much opioid a person will use in their first 30 days, men use more. And so there is variance and it's really important, but it goes beyond men and women. We really want to account for race and ethnicity and think about those different factors, whether it be something like how they experience pain or when you think about something like opioid use disorder or addiction treatment, we see meaningful discrepancies in how black and brown patients are getting care.

There's less patients in recovery, and despite the fact that black and brown patients and white patients abuse drugs in the similar way or have similar rates of opioid use disorder or addiction, but why patients are more likely to get long-term care? And so these are important factors that... I'm not leading these studies, but others in our group have been looking in those spaces and really trying to break down individual patient differences because ultimately I believe that we need this next phase of our work is to understand the individual patient variance that allows us to better tailor care to people.

Jordan Goebig:

Yeah, that makes a lot of sense. We hear that in a lot of different areas when we've had people here talking about that need for more individualized treatment plan for folks.

Kelly Malcom:

Yeah, precision medicine.

Dr. Chad Brummett:

Precision medicine.

Kelly Malcom:

And that's sort of what I was going to ask you next was hopefully we'll sort of get over this hump around the opioid epidemic and address this immediate issue, but what are the next issues or next challenges for folks who are coming into the field?

Dr. Chad Brummett:

There are no shortage of opportunities. We can reduce prescribing I believe, and we've shown this, I don't believe this... We've seen it. You can reduce prescribing after surgery without increasing pain, reducing satisfaction or increasing refill requests, but that by itself won't address unmet needs within pain, so that we still have people who have severe acute pain. We still have people who develop chronic post-surgical pain. So understanding who those people are and thinking about how we treat their pain better, but hopefully preventing chronic post-surgical pain or treating it when it develops. Prevention would be a heck of a lot better. But then there's also opportunities to think about, as I said, this next phase will be harder and stickier and more challenging, but how do we better screen patients coming in for surgery, for opioid use disorder and other substance use disorders? We're seeing more alcohol use in the community since COVID, a lot more people drinking more.

We're seeing increases in stimulants, methamphetamines, and so how do we detect... Because I think for a long time, substance use disorders were stigmatized and many have said, and I think appropriately so, when young white kids started dying, everybody cared about opioids. And I think that's true, but it'd be a shame if we didn't take advantage of it, if we didn't say, okay, this is an opportunity for us to reframe the whole conversation for all people about substance use disorders, making it normal to be asked about whether or not you have a substance use disorder and not have it be a way that people are holding things over you or withholding care, but instead embracing you and getting you into long-term care and recovery. And that's a place where we're moving. And then also acknowledging that between... Depending on the numbers, you look at 2 and 10 million people with an opioid use disorder in the US and the average American having nine surgeries in their lifetime. How do we make sure that we have care patterns and care pathways for those people that recognize that they deserve a safe and effective surgical [inaudible 00:29:16]?

Jordan Goebig:

Are there any other projects that you wanted to make sure that you mentioned? Anything upcoming that you wanted to talk about?

Dr. Chad Brummett:

I think I've hit a lot of our big projects. We're a big group, and I will just again say we have an incredible team and none of it happens without the team, and I'm very fortunate to have the best collaborators.

Jordan Goebig:

I think this has been super interesting. I feel like I was a little foggy at the beginning and you woke me up, so I appreciate you for doing that. Yes.

Kelly Malcom:

Yeah, thank you Dr. Brummett. You and the team are doing really important, great work, and I'm proud to be associated with Michigan and all of the opioid research that's going on here. So thank you and thanks for joining us.

Dr. Chad Brummett:

Thanks for having me. Go blue.

Kelly Malcom:

The Fundamentals is produced by the Michigan Medicine Department of Communication in partnership with the University of Michigan Medical School. Find us and subscribe wherever you listen to podcasts.