Postoperative Prescription Opioids Often Go Unused, Unlocked, and Undisposed
More than two-thirds of patients reported unused prescription opioids following surgery, investigators from Johns Hopkins Medical Institutions found as part of a recent study.
In order to assess numbers of leftover opioid pills from prescriptions for pain relievers, and to assess storage and disposal practices, the investigators used a total of six published studies that reported on a total of 810 patients who underwent seven different types of surgical procedures. Five of those studies examined storage and disposal practice and found that three out of every four patients reported failing to store opioids in a locked location and that safe disposal of opioids rarely occurred.
The review study was conducted at the Johns Hopkins School of Medicine and Johns Hopkins Bloomberg School of Public Health and can be accessed at Bicket MC, et al. “Prescription opioid analgesics commonly unused after surgery. A systematic review.” JAMA Surg.doi:10.1001/jamasurg.2017.831. Published online August 2, 2017.
The authors searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from database inception to July 20, 2016, with an updated search on October 18, 2016.
The primary outcome was to determine opioid oversupply defined as the number of patients who either elected to not fill an opioid prescription or filled the opioid prescription but did not use the medication following surgery. Also, the study examined the volume of unused opioids, reasons for not taking the medication, and storage and disposal practices.
The authors’ concern was that patients may fill the prescription, but not use all the medication, leading to a reservoir of pills that can potentially contribute to the nonmedical use of opioids.
The authors included clinical trials of adult surgical patients who were prescribed an oral opioid medication at the time of discharge. They included both inpatient and outpatient procedures and did not apply any restrictions regarding surgery type. They required studies to report on unused opioid medication, defined as unfilled prescriptions or unused tablets.
To be considered, relevant studies needed to feature both opioid storage and disposal methods. Storage included the location and recommended use of a lock to secure opioids, according to the guidelines of the U.S. Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC). For disposal, the FDA recommended methods which included returning the medication to the pharmacy or a drug take-back program.
Six studies were eligible for inclusion and prospectively evaluated the oversupply of opioids after various types of surgery, including obstetric, thoracic, orthopedic, and urologic. In all, 810 patients received at least one opioid prescription after surgery. Patient samples ranged in size from 30 for cesarean delivery to 250 for orthopedic surgery.
- For all types of surgeries examined, 67% to 92% of patients reported unused opioids.
- Patients reported large amounts of unused opioids following both outpatient surgery (77% to 90%) and inpatient surgery (67% to 90%).
- In 5 of the 7 surgical settings examined, more than 80% of patients reported unused opioids.
- Data from 3 of the studies found 0% to 21% of patients did not fill their opioid prescriptions and 7% to 14% filled the scripts but did not use them.
- A significant number of opioid tablets went unused, ranging from 42% to 71% of pills dispensed.
Reasons for not consuming the medications:
- Most patients (71% to 83%) described not taking opioids because of adequate pain control.
- Some (16% to 29%) reported concerns for adverse effects induced by opioids.
- One study reported that 8% of patients didn’t take opioids because of concerns about addiction.
Storage and disposal:
- In those studies that obtained data on storage, most patients (54% to 70%) reported storing opioids in a medicine cabinet or another box
- 21% to 26% of patients used a cupboard or wardrobe
- 73% to 77% of patients reported storing opioids in unlocked locations
- In those studies that examined disposal practices, few patients (4% to 30%) planned to dispose of their unused prescription opioids
- Even fewer patients (4% to 9%) considered or used a disposal method recommended by the FDA
Discussion and Authors’ Conclusions
More than two-thirds of patients reported unused prescription opioids following surgery. These findings were observed across several studies of general, orthopedic, thoracic, and obstetric surgeries. For disposal practices, 3 of 4 patients reported failing to store opioids in locked location, and planned or actual safe disposal of opioids rarely occurred. Opioids were seldom stored and disposed of correctly. This can result in the stockpiling of opiate pain medications. Nonetheless, it is common, given the time and trouble it takes to properly dispose of these medications. Patients may also perceive a future use for opioids and keep the “extras” on hand in case acute pain should return.
According to the authors, Drug Enforcement Agency-sanctioned take-back days and community-based collection events secure only a small fraction of opioids available for misuse and abuse. They cite a 2015 National Survey on Drug Use and Health, which estimated that 3.8 million Americans engage in the nonmedical use of opioids every month. More than half of people (54%) who misused an opioid medication in 2014 obtained them from a friend or relative. Most of the pills were either given for free, bought, or taken without asking.
“Increased efforts are needed to develop and disseminate best practices to reduce the oversupply of opioids after surgery,” the authors said, “especially given how commonly opioid analgesics prescribed by physicians are diverted for nonmedical use and may contribute to opioids-associated injuries and death.”
Where and How to Dispose of Unused Medications
The FDA offers medication disposal guidelines, which include the following tips:
Drug take-back programs
- Follow any specific disposal instructions on the prescription drug labeling or patient information that accompanies the medicine. Do not flush medicines down the sink or toilet unless this information specifically instructs you to do so.
- Take advantage of programs that allow the public to take unused drugs to a central location for proper disposal. Call your local law enforcement agencies to see if they sponsor medicine take-back programs in your community.
- Transfer unused medicines to collectors registered with the DEA. Authorized sites may be retail, hospital, or clinical pharmacies and law enforcement locations. Some offer mail-back programs or collection receptacles (“drop boxes”).
Disposing medicines in household trash
Almost all medicines can be thrown into your household trash. These include prescription and OTC drugs.
Follow these steps:
- Remove the drugs from their original containers and mix them with something undesirable such as used coffee grounds, dirt, or cat litter. This makes the medicine less appealing to children and pets and unrecognizable to someone who might go through trash looking for drugs.
- Place the mixture in something you can close to prevent the drug from leaking or spilling out. This can be a re-sealable zipper storage bag, empty can, or other container.
- Throw the container in the garbage.
- Scratch out all personal information on the empty medicine packaging to protect identity and privacy. Throw the packaging away.
Flushing drugs and the water supply
Some people wonder if it’s okay to flush certain medicines. There are concerns about small levels of drug that may be found in surface water such as rivers and lakes. The FDA and EPA take the concerns of flushing certain medicines in the environment seriously.
Some prescription drugs such as powerful pain medicines and other controlled substances have instructions for flushing to reduce the danger of overdose from unintentional or illegal use.
One example is the fentanyl patch. This adhesive patch delivers a strong pain medicine through the skin. Even after a patch is used, a lot of the medicine remains. That’s why the drug comes with instructions to flush used or leftover patches.
Richard L. Wynn, BS Pharm, PhD, is professor of pharmacology at the Baltimore College of Dental Surgery, Dental School, University of M
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