A study of health insurance claims showed that patients undergoing 11 of the most common types of surgery were at an increased risk of becoming chronic users of opioid painkillers, according to researchers at the Stanford University School of Medicine.

But the slight overall increase in risk of 0.5 percent in no way suggests that patients should skip surgery over concern of becoming addicted to opioids, the study said. Instead, it’s a reminder that surgeons and physicians should closely monitor patients’ use of opioids after surgery — even patients with no history of using the pain-relieving drugs — and use alternate methods of pain control whenever possible.

The study was published July 11 in JAMA Internal Medicine.

“For a lot of surgeries there is a higher chance of getting hooked on painkillers,” said the study’s lead author, Eric Sun, MD, PhD, a Stanford Health Policy researcher and instructor in anesthesiology at Stanford. Sean Mackey, MD/PhD, professor of anesthesiology, is the senior author of the study and SHP's Laurence Baker was another co-author of the study.

Patients who had knee surgery had the largest risk, as they were roughly five times more likely than a control group of nonsurgical patients to end up using opioids chronically, followed by those undergoing gall bladder surgery, whose risk was three-and-a-half times greater than those in the control group.

“We also found an increased risk among women following cesarean section, which was somewhat concerning since it is a very common procedure,” adding that the risk was 28 percent higher than among the control group, Sun said.

Other factors that contributed to an increased risk for chronic opioid use included being male, elderly, taking antidepressants or abusing drugs.

The opioid abuse epidemic

Since prescription painkillers became cheap and plentiful in the mid-1990s, drug overdose death rates in the United States have more than tripled, according to the Centers for Disease Control and Prevention. Seventy-eight Americans die every day from an opioid overdose, it reported.

Previous studies have shown increased risks of chronic opioid use post-surgery, but unlike past studies, Sun and colleagues set out to examine patients who hadn’t received prescriptions for opioids for at least one year prior to surgery. Among the opioid prescription drugs examined in the study were hydrocodone, oxycodone and fentanyl — the drug responsible for the recent accidental overdose death of legendary musician Prince.

The researchers examined health claims from 641,941 privately insured patients between the ages of 18 and 64 who had not filled an opioid prescription in the year prior to surgery, then compared them with about 18 million nonsurgical patients, who also hadn’t received opioid prescriptions for at least a year. The claims were filed between 2001 and 2013 and provided by Marketscan, a database of 35 million beneficiaries.

Except for the minor procedures known to be somewhat pain-free, such as a cataract surgery and laparoscopic appendectomy, all 11 types of surgery were associated with an increased risk of chronic opioid use, the study said.

Other pain-control measures

“The message isn’t that you shouldn’t have surgery,” Sun said. “Rather, there are things that anesthesiologists can do to reduce the risk by finding other ways of controlling the pain and using replacements for opioids when possible.”

Sun said he and his colleagues in surgery and anesthesia at Stanford try to use regional anesthetics when possible to reduce the need for opioids post-surgery. He added that patients should also be encouraged to use pain-management alternatives such as Tylenol following surgery.

Sun is featured in this CBS news story:

 

“Even when taken exactly as prescribed, opioids carry significant risks and side effects,” said study co-author Beth Darnall, PhD, clinical associate professor of anesthesiology and author of the book Less Pain, Fewer Pills: Avoid the Dangers of Prescription Opioids and Gain Control over Chronic Pain. “Ideally, opioids are avoided in treating chronic pain, and pain treatment should emphasize comprehensive care, including physical therapy, pain psychology and self-management strategies.”

As a pain psychologist and clinician-scientist, Darnall emphasizes alternate methods of pain management based on evidence-based techniques that can help calm the nervous system such as diaphragmatic breathing, progressive muscle relaxation and mindful meditation.

She is studying the use of a pain psychology class at Stanford for women undergoing surgery for breast cancer called “My Surgical Success” designed to help patients develop a personalized pain-management plan to control the anxiety associated with anticipating surgical pain.

“It turns out that a lot of chronic pain develops from surgery, and pre-surgical pain ‘catastrophizing’ is a major risk factor for having a lot of pain,” Darnall said. “We hope that by optimizing patients’ psychology — and giving them skills to calm their own nervous system — they will have less pain after surgery, need fewer opioids and recover quicker.”

The research was funded by a grant from the Foundation for Anesthesia Education and Research and the Anesthesia Quality Institute.

Stanford’s Department of Anesthesiology also supported the work.

 

Tracie White is a science writer for the medical school’s Office of Communication & Public Affairs. Email her at tracie.white@stanford.edu.

The Asia Health Policy Program at Stanford’s Shorenstein Asia-Pacific Research Center, in collaboration with scholars from Stanford Health Policy's Center on Demography and Economics of Health and Aging, the Stanford Institute for Economic Policy Research, and the Next World Program, is soliciting papers for the third annual workshop on the economics of ageing titled Financing Longevity: The Economics of Pensions, Health Insurance, Long-term Care and Disability Insurance held at Stanford from April 24-25, 2017, and for a related special issue of the Journal of the Economics of Ageing.

The triumph of longevity can pose a challenge to the fiscal integrity of public and private pension systems and other social support programs disproportionately used by older adults. High-income countries offer lessons – frequently cautionary tales – for low- and middle-income countries about how to design social protection programs to be sustainable in the face of population ageing. Technological change and income inequality interact with population ageing to threaten the sustainability and perceived fairness of conventional financing for many social programs. Promoting longer working lives and savings for retirement are obvious policy priorities; but in many cases the fiscal challenges are even more acute for other social programs, such as insurance systems for medical care, long-term care, and disability. Reform of entitlement programs is also often politically difficult, further highlighting how important it is for developing countries putting in place comprehensive social security systems to take account of the macroeconomic implications of population ageing.

The objective of the workshop is to explore the economics of ageing from the perspective of sustainable financing for longer lives. The workshop will bring together researchers to present recent empirical and theoretical research on the economics of ageing with special (yet not exclusive) foci on the following topics:

• Public and private roles in savings and retirement security
• Living and working in an Age of Longevity: Lessons for Finance
• Defined benefit, defined contribution, and innovations in design of pension programs
• Intergenerational and equity implications of different financing mechanisms for pensions and social insurance
• The impact of population aging on health insurance financing
• Economic incentives of long-term care insurance and disability insurance systems
• Precautionary savings and social protection system generosity
• Elderly cognitive function and financial planning
• Evaluation of policies aimed at increasing health and productivity of older adults
• Population ageing and financing economic growth
• Tax policies’ implications for capital deepening and investment in human capital
• The relationship between population age structure and capital market returns
• Evidence on policies designed to address disparities – gender, ethnic/racial, inter-regional, urban/rural – in old-age support
• The political economy of reforming pension systems as well as health, long-term care and disability insurance programs

Submission for the workshop

Interested authors are invited to submit a 1-page abstract by Sept. 30, 2016, to Karen Eggleston at karene@stanford.edu. The authors of accepted abstracts will be notified by Oct. 15, 2016, and completed draft papers will be expected by April 1, 2017.

Economy-class travel and accommodation costs for one author of each accepted paper will be covered by the organizers.

Invited authors are expected to submit their paper to the Journal of the Economics of Ageing. A selection of these papers will (assuming successful completion of the review process) be published in a special issue.

Submission to the special issue

Authors (also those interested who are not attending the workshop) are invited to submit papers for the special issue in the Journal of the Economics of Ageing by Aug. 1, 2017. Submissions should be made online. Please select article type “SI Financing Longevity.”

About the Next World Program

The Next World Program is a joint initiative of Harvard University’s Program on the Global Demography of Aging, the WDA Forum, Stanford’s Asia Health Policy Program, and Fudan University’s Working Group on Comparative Ageing Societies. These institutions organize an annual workshop and a special issue in the Journal of the Economics of Ageing on an important economic theme related to ageing societies.

More information can be found in the PDF below.

Studying the microorganisms that live in our gut is a relatively new field, one that has only really taken off in the last decade. In fact, it is estimated that half of the microbes that live in and around our GI track have yet to be discovered.

“This means there is a huge amount of this dark matter within us,” said Ami S. Bhatt, an assistant professor of medicine and genetics who runs the Bhatt Lab at the Stanford School of Medicine. The lab is devoted to exploiting disease vulnerabilities by cataloguing the human microbiome, the trillions of microbes living in and on our bodies.

“I think if we fast-forward to the impact of some these findings in 10 years, we’re going to learn that modifying the microbiota is a potent way to modulate health,” Bhatt said. “Humans are not only made up of human cells, but are a complex mixture of human cells and the microbes that live within us and among us — and these microorganisms are as critical to our well-being as we are to theirs.”

Bhatt, along with key collaborators at the University of Witwatersrand in Johannesburg, and the INDEPTH research consortium, now intends to take this research to Africa.

She is this year’s winner of the of the Rosenkranz Prize for Health Care Research in Developing Countries, awarded by Stanford Health Policy to promising young Stanford researchers who are investigating ways to improve health care in developing countries.

The $100,000 prize is targeted at Stanford’s emerging researchers who are dedicated to improving health care in poorer parts of the world, but may lack the financial resources.

Bhatt, MD, PhD, intends to take the prize money to execute the first multi-country microbiome research project focused on non-communicable disease risk in Africa. The project intends to explore the relationship between the gut microbiome composition and body mass index (BMI) in patients who are either severely malnourished or obese.

“As a rapidly developing continent with extremes of resource access, Africa is simultaneously faced with challenges relating to the extremes of metabolic status,” Bhatt wrote in her Rosenkranz project proposal. The Bay Area native, who is also the director of global oncology at Stanford, came to the School of Medicine in 2014 to focus on how changes in the microbiome are associated with cancer.

In this new project, Bhatt and members of her lab will team up with colleagues in Africa, first in South Africa, and then in Ghana, Burkina Faso, and Kenya. They will leverage the infrastructure already in place at the INDEPTH Network of researchers, using an existing cohort of 12,000 patients at within those four countries. The patients have already consented to be involved in DNA testing and have given blood and urine specimens.

Identifying alterations of the microbiome that are associated with severe malnutrition or obesity could pave the way for interventions that may mitigate the severity or prevalence of these disorders, Bhatt said.

“These organisms are critical to our health in that they are in a delicate balance with one another and their human hosts,” she said. “Alterations in the microbiome are associated with various diseases — but have mostly been studied in Western populations. Unfortunately, little is known about the generalizability of these findings to low- and middle-income countries – where most of the world’s population lives.”

Bhatt said that as Africa rapidly continues to develop, the continent is simultaneous faced with challenges relating to extreme weight gain and loss. While the wealthy are facing obesity and its associated disease such as stroke, heart failure and diabetes, many people are still faced with issues related to food insecurity, hunger and malnutrition.

The research, she hopes, could lead to aggressive behavioral, dietary and lifestyle modifications targeted at maintaining healthy BMI in at-risk individuals.

Video by Ankur Bhatt

Grant Miller, an associate professor of medicine and core faculty member at Stanford Health Policy who chaired the Rosenkranz Prize committee this year, believes Bhatt’s research could eventually break new ground.

“The entire Rosenkranz Prize selection committee was highly impressed with Ami and the innovation of her project,” Miller said. “Ami’s work on the human microbiome in the extremes of nutritional status in developing countries — including its potential link to obesity, an emerging challenge in low income countries — is potentially path-breaking.”

The award’s namesake, George Rosenkranz, first synthesized cortisone in 1951, and later progestin, the active ingredient in oral birth control pills. He went on to establish the Mexican National Institute for Genomic Medicine, and his family created the Rosenkranz Prize in 2009.

The award embodies Dr. Rosenkranz’s belief that young scientists hold the curiosity and drive necessary to find alternative solutions to longstanding health-care dilemmas.

When the Soviet Union collapsed in 1991, the worry in the West was what would happen to that country’s thousands of nuclear weapons. Would “loose” nukes fall into the hands of terrorists, rogue states, criminals – and plunge the world into a nuclear nightmare?

Fortunately, scientists and technical experts in both the U.S. and the former Soviet Union rolled up their sleeves to manage and contain the nuclear problem in the dissolving Communist country.

One of the leaders in this relationship was Stanford engineering professor Siegfried Hecker, who served as a director of the Los Alamos National Laboratory before coming to Stanford as a senior fellow at the Center for International Security and Cooperation. He is a world-renowned expert in plutonium science, global threat reduction and nuclear security.

Hecker cited one 1992 meeting with Russian scientists in Moscow who were clearly concerned about the risks. In his new book, Doomed to Cooperate: How American and Russian scientists joined forces to avert some of the greatest post-Cold War nuclear dangers, Hecker quoted one Russian expert as saying, “We now need to be concerned about terrorism.”

Earning both scientific and political trust was a key, said Hecker, also a senior fellow at Stanford’s Freeman Spogli Institute for International Studies. The Russians were proud of their scientific accomplishments and highly competent in the nuclear business – and they sought to show this to the Americans scientists, who became very confident in their Russian counterparts’ technical capabilities as they learned more about their nuclear complex and toured the labs.

Economic collapse, political turmoil

But the nuclear experts faced an immense problem. The Soviets had about 39,000 nuclear weapons in their country and in Eastern Europe and about 1.5 million kilograms of plutonium and highly enriched uranium (the fuel for nuclear bombs), Hecker said. Consider that the bomb that the U.S. dropped on the Japanese city of Nagasaki in 1945 was only six kilograms of plutonium, he added. Meanwhile, the U.S. had about 25,000 nuclear weapons in the early 1990s.

Hecker and the rest of the Americans were deeply concerned about the one million-plus Russians who worked in nuclear facilities. Many faced severe financial pressure in an imploding society and thus constituted a huge potential security risk.

“The challenge that Russia faced with its economy collapsing was enormous,” he said in an interview.

The Russian scientists, Hecker said, were motivated to act responsibly because they realized the awful destruction that a single nuclear bomb could wreak. Hecker noted that one Russian scientist told him, “We arrived in the nuclear century all in one boat, and a movement by anyone will affect everyone.” Hecker noted, “Therefore, you know, we were doomed to work together to cooperate.”

All of this depended on the two governments involved easing nuclear tensions while allowing the scientists to collaborate. In short order, the scientists developed mutual respect and trust to address the loose nukes scenario.

The George H.W. Bush administration launched nuclear initiatives to put the Russian government at ease. For example, it took the nuclear weapons off U.S. Navy surface ships and some of its nuclear weapons off alert to allow the Russians to do the same. The U.S. Congress passed the Nunn-Lugar Cooperative Threat Reduction legislation, which helped fund some of the loose nuke containment efforts.

While those were positive measures, Hecker said, it was ultimately the cooperation among scientists, what they called lab-to-lab-cooperation, that allowed the two former superpower enemies to “get past the sensitivity barriers” and make “the world a safer place.”

Since the end of the Cold War, no significant nuclear event has occurred as a result of the dissolution of the Soviet Union and its nuclear complex, Hecker noted.

Lesson: cooperation counts

One lesson from it all, Hecker said, is that government policymakers need to understand that scientists and engineers can work together and make progress toward solving difficult, dangerous problems.

“We don’t want to lose the next generation from understanding what can actually be done by working together,” he said.  “So, we want to demonstrate to them, Look, this is what was done when the scientists were interested and enthusiastic and when the government gave us enough room to be able to do that.”

Hecker said this scientific cooperation extended to several thousand scientists and engineers at the Russian sites and at U.S. nuclear labs – primarily the three defense labs: Lawrence Livermore, Los Alamos, and Sandia national laboratories. Many technical exchanges and visits between scientists in Russia and the United States took place.

He recalled visiting some of the nuclear sites in Russian cities shrouded by mystery. “These cities were so secret, they didn’t even appear on Soviet maps.”

Change of threat

When the Soviet Union collapsed, the nature of the nuclear threat changed, Hecker said. The threat before was one of mutual annihilation, but now the threat changed to what would happen if nuclear assets were lost, stolen or somehow evaded the control of the government.

“From an American perspective we referred to these as the ‘four loose nuclear dangers,'” he said.

This included securing the loose nukes in the Soviet Union and Eastern Europe; preventing nuclear materials or bomb fuel from getting into the wrong hands; the human element involving the people who worked in the Soviet nuclear complex; and finally, the “loose exports” problem of someone trying to sell nuclear materials or technical components to overseas groups like terrorists or rogue nations.

For Hecker, this is not just an American story. It is about a selfless reconciliation with a longtime enemy for the greater global good, a relationship not corrupted by ideological or nationalistic differences, but one reflective of mutual interests of the highest order.

“The primary reason,” he said, “why we didn’t have a nuclear catastrophe was the Russian nuclear workers and the Russian nuclear officials. Their dedication, their professionalism, their patriotism for their country was so strong that it carried them through these times in the 1990s when they often didn’t get paid for six months at a time … The nuclear complex did its job through the most trying times. And it was a time when the U.S. government took crucial conciliatory measures with the new Russian Federation and gave us scientists the support to help make the world a safer place.”

FSI SENIOR FELLOWS FRANCIS FUKUYAMA & LARRY DIAMOND DISCUSS DEMOCRACY IN THE JULY/AUGUST ISSUE OF FOREIGN AFFAIRS

Larry Diamond and Francis Fukuyama, senior fellows at the Freeman Spogli Institute, have both written essays in the July/August 2016 issue of Foreign Affairs. Follow the links below to read the full articles without a subscription block:

Diamond, who is also the former director of the Center for Democracy, Development and the Rule of Law (CDDRL), takes stock of the global democratic recession and urges the next president to make democracy promotion a pillar of his or her foreign policy agenda in his article "Democracy in Decline."

In "American Political Decay or Renewal?" Fukuyama, the Olivier Nomellini Senior Fellow at FSI and the Mosbacher Director of CDDRL, analyzes the rising tide of populism as represented by the current candidates for the US Presidential elections.

In the July/August edition of Foreign Affairs, Larry Diamond takes stock of the global democratic recession, and urges the next president to make democracy promotion a pillar of his or her foreign policy agenda. 

Click here to read the full article.