Shriners Children’s Anesthesiologist Sundeep Tumber Conducts Groundbreaking Opioid Research

This article is part of an ongoing series spotlighting the innovative research of providers throughout the Shriners Children's system. Read another.

The first thing Sundeep “Sunny” Tumber, D.O., tells me when we get on a call to discuss his system-wide study of opioid use in patients at Shriners Children’s is that he has two teen daughters.

“It’s very scary raising children in today’s world,” said the chair of the department of anesthesiology at Shriners Children’s Northern California in Sacramento. “You know that it doesn’t matter from what socioeconomic background they come from – they could easily get access to some sort of tablet from a friend, and then they could die.”

As a doctor who prescribes such painkillers to teens every day after sports injury surgeries, the probability of opioid abuse is top-of-mind for Dr. Tumber. So, for an upcoming QI (quality improvement) project, he and a team of colleagues are tackling the problem head-on.

The system-wide research project, which focuses on at-risk patients in pediatric sports medicine, is three-pronged. First, he and his team are analyzing practices at 10 Shriners locations nationwide to conduct a retrospective review of opioids prescribed for some of the most common sports procedures.

Next, they’re working to create standardized prescription care sets for specific procedures as well as improved patient education to emphasize the importance of balanced pain control through both opioid and non-opioid means.

Finally, through a mobile software program called RXCheckIn, the study will contact patients regularly to collect data on opioid use and pain levels. Dr. Tumber hopes to collect about three years’ worth of data this way.

Vulnerable Population

But why are young athletes so likely to abuse opioids? “Those adolescents are our highest-risk patients,” said Dr. Tumber. He explained that, when a sudden injury gets in the way of practicing sports, a passion for many youths, they become depressed, and they’re suddenly introduced to a new medicine that makes them feel good.

“The data actually shows that 80% of children’s usual first exposure to any sort of opioid is after surgery,” he said. “So now we have two things there: adolescents with not fully developed brains.” He explains that the prefrontal cortex does not develop fully until about age 25 or 26, making patients who come in for sports surgeries, especially substantial ones like ACLs or shoulders, at very high risk of developing an opioid use disorder. “[They] should have been very productive members of our society, and now it’s almost like a lifetime sentence – not only for that patient but for the family as well,” Dr. Tumber said.

And it’s not just the patients themselves who may abuse the opioids. He explains that most use about one-third of their prescription, and the rest often winds up in a medicine cabinet. “So, I call those leftover opioids a ticking time bomb,” Dr. Tumber said. A sibling in the house could start abusing those meds, or the original patient could come back to them after recovering from the surgery and begin using them recreationally when feeling low. “I thought that this would be a really good project,” Dr. Tumber said, “with a very high-risk group, to see: What are we doing across the system?”

Retrospective Analysis

Traditionally, opiates are over-prescribed for these types of patients, Dr. Tumber said, because surgeons simply don’t want patients to be in pain, and refilling prescriptions for controlled substances can often be a hassle for the patient because they must be filled in person. “We don’t want to under-prescribe, but we also don’t want to over-prescribe these opioids.”

Working with the Shriners Children’s system for this type of project is a huge advantage because the country has so few large networks of hospitals on the same EMR (electronic medical records) system that are completing so many of the same surgeries to contribute data, Dr. Tumber said. “I think it’s very similar to comparing us to the [Veterans Health Administrations] system here in the U.S., where everything is protocolized or should be protocolized and everybody’s on the same EMR and they’re all part of a larger system.”

For the retrospective analysis, the team focused on one of the most common procedures in sports medicine: ACL surgery. Between January 2021 and December 2024, the 10 Shriners Children’s locations completed 545 ACL surgeries, and Shriners Children’s Northern California did 152 alone.

It was found that an average of 15 doses of opioids, typically oxycodone, were prescribed for these procedures, and most patients seemed satisfied in terms of their pain control after surgery. However, Dr. Tumber noted that, once patients went home, there was no way to track how much they were taking and if they were also taking non-opioid medicines, like acetaminophen and ibuprofen, which are routinely recommended to be paired with opioids. Patients may not have been prescribed non-opioid medications in the first place (that’s not reflected in the records being evaluated for the retrospective analysis) or may simply have decided not to take them, doubting their efficacy.

“What’s interesting is that those two medications can significantly reduce opioid consumption by around 30%,” Dr. Tumber said. “Or, when you combine ibuprofen with acetaminophen and you schedule it, some patients don’t need any opioids.”

Even though a baseline of 15 doses was established, having so many providers, including anesthesiologists, surgeons, nurse practitioners, physician assistants, etc., writing prescriptions for patients can often lead to deviations from that number.

Care Sets

The team decided that standardized care sets, which give providers explicit prescribing and discharge instructions depending on each procedure in question, are part of the solution to ensure consistent care across the board. With this approach, every patient who has undergone an ACL surgery will be prescribed the same amount of opioids and non-opioids, with limited allowance for modification depending on the severity of the surgery or the history of the patient (e.g., substance abuse).

“If you build that as part of a care set, that prescription for Motrin and Tylenol will get filled by the pharmacy, along with the oxycodone, and it will have all the discharge instructions,” Dr. Tumber said. “And then you can start beginning to standardize medications.”

By having the non-opioid medication built into a prescription, patients are much more likely to take it, he said. Their research has also found that, when a care set is in place, the number of opioids prescribed “just naturally went down,” he said.

They’re also working to create discharge brochures that focus explicitly on medication education, including dosage, frequency, and concurrent use of non-opioids, because this information can often get lost among pages of lengthy discharge papers. Using simple language and colorful graphics and tables may help patients better understand their medication plan and, hopefully, better follow it.

Patient App

However, doctors rarely know how patients fare with their prescriptions once they leave the hospital or clinic, and that’s where the third part of the study comes in, which Dr. Tumber called “probably the most exciting.”

Using a doctor-designed third-party mobile app, RXCheckIn, which Dr. Tumber described as a “really slick software program,” providers can track patients’ medication use, pain levels and more on a regular basis. Patients begin using the app even before surgery starts: They can watch educational videos about opioid use, how to dispose of unused medications and how important it is to use non-opioid medications.

This companion app is especially crucial for patients who come in for same-day surgery – which are about half the cases in the U.S., Dr. Tumber said – and aren’t being monitored in person as they recover and undergo pain management.

“Nobody tracks these patients when they go home, so that’s the biggest problem,” he said. “Nobody knows what happens to these patients. We give them the prescription, and they go home.” Even though the doctor may see the patient a month later for a checkup, “we don’t know what’s happening on a day-to-day basis with these patients.”

The research team hopes RXCheckIn will shed some light on that and provide potential solutions.

The Time Is Now

Dr. Tumber and his team aim to conduct the study over the course of three years, recruiting somewhere around 1,000 patients to participate. “We’re going to start collecting the data, and, at the end of three years, let’s say, just hypothetically speaking, we get 1,000 ACLs as a system, and everyone’s doing the same thing in regards to prescribing non-opioids and patient education,” he said. If so, no existing research can compare in terms of scope and metrics, Dr. Tumber said, and time is of the essence.

“The data doesn’t exist, and, if you wait for the data to get published somewhere, that’s potentially thousands of kids that could be exposed to too many opioids,” he said. “There’s a certain percent of those, unfortunately, that will end up developing an opioid use disorder. So we wanted to do something a lot more.”

Luckily, Dr. Tumber, who has been with Shriners Children’s for 19 years, feels the full support of the organization behind him in conducting this important research. “It really is a unique place in that we’re able just take care all comers,” he said. “The Shrine has this wonderful mission and has been nothing but supportive.”