The U.S. is in the midst of an unprecedented opioid crisis. In 2016, 11.5 million Americans reported nonmedical use of prescription opioids and 2.1 million Americans had a diagnosis of an Opioid Use Disorder (OUD), usually initiated with exposure to prescription opioids. Between 2010 and 2015, the rate of drug overdose deaths in the US increased in 30 states, and 63% of those deaths involved an opioid. Opioid fatality and non-fatality costs are roughly $504 billion annually.
Most patients who develop OUD or die from opioid overdose begin opioid use with prescribed opioids. Opioid pain relievers are essential for treatment of pain after trauma, with over half of hospitalized trauma patients experiencing moderate to severe pain, and pain prevalence at hospital discharge as high as 97%. Persistent pain after trauma is common and associated with poor quality of life, psychological distress, reduced return to work, and the development of chronic pain. Most trauma patients are discharged on opioids. Patients discharged after major trauma are at high risk for opioid misuse and OUD, with 68% having at least one risk factor for unintentional opioid overdose and almost half showing signs of misuse. Post-injury prescribing often extends beyond the hospital, where it affects the risk of development of OUD.
Few opioid tapering guidelines exist for patients discharged after injury. Opioid tapering requires collaboration among the trauma center, the patient, and the primary care provider (PCP). This collaboration is especially difficult for patients living in rural areas remote from the trauma center, resulting in inequities in risks for OUD and opioid overdose. Harborview Medical Center is the only Level 1 trauma center in the 5-state Northwest region of the US, covering 25% of the land mass of the US. The affiliated Harborview Injury Prevention and Research Center (HIPRC), founded in 1985, is a worldwide leader in injury etiology and prevention research.
We propose to address the CDC priority concerning the adoption, implementation, and impact of clinical practice guidelines, clinical decision supports, and coordinated care plans within primary care practices in health systems. We will investigate the implementation of an individualized collaborative pain care and opioid taper program for patients discharged from Level 1 inpatient trauma care and at high risk for opioid dependence because of the severity of their injury, their acute care exposure to opioids, and their discharge while still on opioids to rural areas in Washington State known to have high opioid mortality rates. Our research team has unique combined expertise in advanced trauma care, pain management, and engaging remote primary care practitioners in relevant clinical research.14–16 We have proven expertise in disseminating information and in supporting systemic practice changes in remote PCP settings through direct collegial interventions and in using advanced tele-medicine capabilities. Our collaborative care model has potential for national dissemination through the CDC Injury Prevention Research Centers Network to trauma programs serving rural populations, thereby addressing an important entry point for opioid misuse.
COTAT was awarded funding by the Centers for Disease Control and Prevention.
My clinical service and research focuses on the interaction of mental and physical illness, especially in patients with chronic pain. Much of my research in recent decades has focused on the risks of treating chronic pain with opioids. I have developed educational programs and outcome tracking tools to assist with opioid treatment of chronic pain. I have published a book about patient empowerment in chronic disease care, The Patient as Agent of Health and Health Care (Oxford, 2017). I have another book written with Jane Ballantyne forthcoming, The Right to Pain Relief and other deep roots of the opioid epidemic (Oxford, 2022).
Laura-Mae Baldwin, MD, MPH, is Director of Research and a Professor at the UW Department of Family Medicine, an investigator at the WWAMI Rural Health Research Center and the UW Center for Health Workforce Studies, and a practicing family physician. Most recently, Dr. Baldwin became the director of Outreach at the Harborview Injury Prevention & Research Center. For over a decade, Dr. Baldwin’s research has largely been focused on racial/ethnic and rural-urban health disparities, cancer prevention and treatment, and perinatal health, all with an eye towards ensuring equitable access to high quality health services across U.S. She brings particular expertise in the use of large secondary databases to examine the quality and outcomes of clinical care. As co-director of the Community Outreach and Research Translation core for the UW Institute of Translational Health Sciences, Dr. Baldwin is leading the development of a primary care practice-based research network that links the electronic health records of geographically dispersed clinical practices in the WWAMI region. This has led Dr. Baldwin to a new research focus on disseminating effective health interventions into primary care practice. She has been a Principal Investigator or Co-I on grants funded by the National Cancer Institute, the Centers for Disease Control and Prevention, the American Cancer Society, and the Health Resources and Services Administration. Dr. Baldwin received her MD at the University of Southern California and her MPH at the University of Washington School of Medicine.
Saman Arbabi, MD, MPH, FACS, is a UW professor of Surgery in the division of Trauma, Burns and Critical Care at Harborview Medical Center.Dr. Arbabi believes in patient autonomy. He will explain the treatment options, then choose the best option for the patient together. Dr. Arbabi earned his medical degree from UC Davis. Currently, he is a National Institutes of Health-funded investigator and is active in lab and clinical research at Harborview. In addition, he is the Acute Care section head at the Harborview Injury Prevention and Research Center. His research interests include inflammatory cell signaling in burn injury, wound healing, surgical infections, critical care medicine, injury prevention and surgical outcomes studies. Dr. Arbabi has mentored several surgical resident and clinical scientists in the art and science of medicine.