Opioid Medication Disposal Programs: Reviewing Their Effectiveness
Three recent reports examined the issue of leftover prescription opioids and the effectiveness of community drug disposal programs. The first report showed that opioid prescriptions returned for disposal had greater than 60% of the dispensed amount remaining unused. The second and third reports showed that current practices related to sharing, storing, and disposal of opioid medications are suboptimal and that controlled substances returned at take-back events and permanent drug donation boxes constituted a miniscule proportion of the number dispensed.
Report #1: Quantifying Opioids Returned for Disposal
This first study was conducted at the University of Wisconsin - Madison, School of Pharmacy. Find the report at: Welham GC, Mount JK, Gilson AM. “Type and frequency of opioid pain medications returned for disposal.” Drugs — Real World Outcomes 2015; 2:129-135.
Community “take-back” programs are one mechanism for legally collecting unwanted and expired opioid prescription medications from households for disposal. The goals of the study by Welham, et al, were to quantify the prescription opioids returned for disposal to a local take-back program and to examine selected drug characteristics to predict the quantity of unused opioids.
The authors used data collected during a four-hour medication take-back event in a county in Wisconsin. This event consisted of a drive-through service, wherein volunteers collected unwanted medications for disposal. Data were recorded by trained pharmacy students, and the study focused only on the opioid medications returned for disposal.
The study examined 605 returned prescriptions for opioid pain medications, which included 11 different opioids. These were:
- Fentanyl transdermal patch
- Morphine SR
- Oxycodone ER
These accounted for 38% of all returned prescriptions and 48% of all returned dosage units.
Among the opioid prescriptions:
- The three combination products containing hydrocodone, oxycodone, and codeine accounted for 82.4% of the prescriptions and 73.5% of the dosage units returned for disposal.
- The hydrocodone/acetaminophen returns accounted for 45% of total opioid prescriptions, oxycodone/acetaminophen for 20%, and codeine/acetaminophen for 17%.
- The percentages of units remaining for the various drugs were 64.9% for hydrocodone/ acetaminophen, 57.6 % for oxycodone/ acetaminophen, and 67.8 % for codeine/ acetaminophen.
- Short-acting medications were dispensed and returned for disposal in smaller amounts than long-acting/extended release products (i.e., morphine SR, oxycodone ER).
- Medications prescribed to be taken “as needed” (PRN) were dispensed and returned with a smaller number of dosage units and days’ supply than those returned medications that were prescribed to be taken on schedule.
- The statistical models constructed by the authors indicated that days’ supply of medication dispensed was a strong predictor of days’ supply remaining. For example, an increase of one-day supply dispensed resulted in an additional quarter to half-day supply returned for disposal.
Opioid prescriptions returned for disposal had greater than 60% of the amount dispensed remaining unused. Also, short-acting and combination opioids accounted for greater than 80% of the prescriptions returned for disposal. Finally, days’ supply dispensed was the strongest predictor of days’ supply remaining.
The study showed that inclusion of data collection as a component of disposal programs offers a unique perspective on unused prescription medication. Since the days’ supply of medication dispensed was the strong predictor of the days’ supply of drug remaining for disposal, prescribers should consider this while writing prescriptions for opioids of any kind (long-acting, short-acting, single entity, or combination products).
Report #2: Examining Opioid Users’ Practices
This study was conducted at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland. It can be accessed at: Kennedy-Hendricks A, et al. “Medication sharing, storage and disposal practices for opioid medications among US adults.” JAMA Intern Med 2016; 176:1027-29.
This national survey of U.S. adults who had recently used opioid medication examined the pervasiveness of sharing opioid medications, as well as medication storage and disposal practices. The survey identified 1,055 eligible individuals based on their past year’s use of opioid medications; 1,032 of them completed the survey. Respondents answered questions about their practices and beliefs related to sharing, storing, and disposal of opioid medications.
- At the time of the survey, 440 respondents (46.7%) were still using opioid medications.
- 57.2% of respondents had, or expected to have, leftover opioid medication.
- Among those with leftover medication, 61.3% reported keeping them for future use.
- 21% of respondents reported having shared opioid medications with another person, in most cases to help the other person to manage pain.
- Some respondents reported storing their opioid medication in a locked (8.6%) or latched (20.9%) location.
- Nearly half of the adults with recent opioid medication use did not recall receiving information on safe storage (48.7%) or proper disposal (45.3%). Among those who received information on proper disposal, sources included the pharmacist (34.7%), print or television news (31.3%), and medication packaging (29.6%).
The breakdown of opioid medication disposal practices according to respondents having leftover medications is as follows:
- Keep for future use: 48.8%
- Flush down toilet: 13.8%
- Throw out in trash: 7.1%
- Throw out in trash after mixing: 6.4%
- Turn in to take-back program or pharmacist: 12.1%
- Sell: 1.0%
- Do not remember: 10.8%
The findings suggest that the current practices related to sharing, storing, and disposal of opioid medications are suboptimal. Altering prescribing practices to reduce the quantity of opioid medications that patients receive may limit the opportunities for the nonmedical use of the drugs. The authors state that more research is needed to identify effective strategies to advance safer practices related to opioid medication sharing, storage, and disposal. The dissemination of clear recommendations on the safe storage and disposal of opioids medications widely to the public and prescribers may reduce risks of opioid misuse and abuse.
Report #3: The Effectiveness of Take-back Programs
This study was conducted at Wake Forest School of Medicine in North Carolina. It can be accessed at: Egan KL, et al. “From dispensed to disposed: evaluating the effectiveness of disposal programs through a comparison with prescription drug monitoring program data.” Am J Drug Alcohol Abuse 2016; Oct 31:1-9.
Take-back programs and permanent drug donation boxes are strategies for disposal of controlled medications, such as opioid drugs. Little is known as to whether this strategy actually reduces the overall availability of these medications for the purposes of diversion or misuse. This study was conducted to compare the number and types of controlled medications that were disposed of through organized efforts to the number of drugs dispensed in local communities.
The study measured quantity and type of controlled, dangerous medication collected from three take-back events and permanent drug donation boxes over four-week-long periods in five counties in south central Kentucky. Those results were compared to the number of controlled medications dispensed, as reported by Kentucky All Schedule Prescription Electronic Reporting system.
Annually, controlled dangerous medications disposed through the take-back programs in this study were estimated to account for 0.3% of those dispensed.
There were 21,121,658 controlled medication units dispensed in 2013. They break down as follows:
- Opioids: 46.9%
- Tranquilizers: 13.1%
- Other (unidentified): 37.3%
Of that total, 21,503 controlled medication units were collected in 2013. They break down as follows:
- Opioids: 39.9%
- Tranquilizers: 2.7%
- Other (unidentified): 57.4%
The authors concluded that controlled medications collected by take-back events and permanent drug donation boxes constituted a miniscule proportion of the number dispensed. The findings suggested that organized drug disposal efforts may have a minimal impact on reducing the availability of unused controlled medications at a community.
Richard L. Wynn, BS Pharm, PhD, is professor of pharmacology at the Baltimore College of Dental Surgery, Dental School, University of Maryland Baltimore.
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