Nancy A. Melville

May 22, 2017

PITTSBURGH, Pennsylvania — Patients are commonly prescribed more opioids to treat postoperative pain than they wind up using, and few store or dispose of the drugs appropriately, posing the risk for misuse and overdose through diversion, according to new research.

"We found that one in four patients had at least 200 unused morphine equivalents leftover at 1 month (postsurgery)," first author, Mark E. Bicket, MD, an assistant professor at Johns Hopkins University School of Medicine, in Baltimore, Maryland, told Medscape Medical News.

"These leftover opioids represent an important reservoir of pills that can contribute to opioid injuries and deaths."

With the high rate of drug diversion well known as a key contributor to the nation's opioid addiction epidemic, the need to avoid prescribing anything more than needed is a pressing public health interest.

In exploring the patterns of postsurgical opioid use and disposal, Dr Bicket and his colleagues evaluated a prospective cohort of 101 adult patients who underwent same-day (40%) or inpatient (60%) orthopedic surgery between July and October 2016.

The study was presented here at the American Pain Society (APS) 2017 Annual Scientific Meeting.

The patients' prescriptions were verified and patients were interviewed by telephone at 2 days, 2 weeks, and 4 weeks after discharge to determine whether the prescriptions were filled, the duration of use, the number of unused pills at the completion of therapy, how pills were stored or disposed of, and patient satisfaction with the amount of medication prescribed.

Of 93 (92%) patients who completed the surveys until therapy completion or the 4-week time-point, 96% filled at least one opioid prescription, with 85% of the prescriptions containing immediate-release oxycodone.

Patients were prescribed an average of 80 pills, and the mean number of days opioids were taken was 7. At the 1-month follow-up, 59% of patients were no longer taking opioids.

Of patients who reported completing their opioid therapy, as many as 85% said they had unused pills remaining, with an average of 30 remaining pills.

Among all patients in the study, 28% reported having 20 or more unused pills at the end of treatment, and 24% had 200 or more unused morphine equivalents.

In terms of storage and disposal, only 16% reported knowing how to properly store their medications, 11% stored the drugs securely, only 22% knew how to dispose of the drugs, and only 4% disposed of the drugs.

"Some of these patients had conversations with hospital staff or pharmacists about opioids, though ultimately our system of care did not successfully convey the message about where to keep the pills and what to do with them when done," Dr Bicket said.

Patients were generally satisfied with their pain treatment, with 39% rating the treatment as excellent, 34% giving good ratings, 14% rating the treatment fair, and 4% describing it as poor; 9% had no response.

The authors reported on the findings from orthopedic surgery for the initial study because the subspecialty is the leading prescriber of opioids and because patients could include a mix of inpatients and same-day surgery patients.

A larger analysis of other surgical specialties show similar figures, however, with more than 80% of patients reporting leftover opioids in thoracic, dermatologic, dental, cesarean, and general surgeries.

Of the various likely reasons for the oversupply of opioids, one that stands out is a lack of agreement on the appropriate prescribing levels, Dr Bicket noted.

"Right now, there is not a consensus about the optimal volume of opioids for a patient after surgery," he said.

Complicating matters is the complexity of pain, which is unique to each individual and can be influenced by a wide array of factors, Dr Bicket explained.

"Psychological and sociocultural factors play a role, [and] pain also varies by procedure, adding another variable to what's already a complex system."

Yet another factor is the clinical challenge that is central to opioid prescribing in a time of such widespread misuse — the need to adequately treat pain without contributing to the problem.

"Any change to how we prescribe opioids must strike a balance between our desire to minimize the abuse of prescription opioids with the need to ensure legitimate access to patients in pain," Dr Bicket said.

"This principle of balance guides us as we work to improve pain control and the use of opioids for pain, especially after surgery."

Key Finding

The finding that upwards of 80% of patients have leftover opioids after treatment is troubling, commented David J. Tauben, MD, clinical professor and chief of the University of Washington Division of Pain Medicine in Seattle.

"This is a key finding: the overprescribing of opioids, both dose and here very well demonstrated as total numbers of pills, has filled this enormous reservoir of excess that contributes importantly to the flooding of opioids into our communities," he told Medscape Medical News.

He agreed that the findings underscore the challenges in management of postoperative pain, for the prescriber as well as the patient.

"Every patient is different, and so surgeries will inevitably vary in both approach and 'who' that patient is, such as preoperative opioid use, co-occurring biomedical conditions, home care support, and very importantly, patient expectations."

Various strategies can help tackle the problem, he noted, including open discussion with the patient. "Sharing goals and managing reasonable expectations for dose and duration of opioids for postop pain control can be challenging but need be done."

The limitation of the discharge prescription supply of opioids could not only leave patients with an undersupply but result in time and resources spent in a return visit for a refill, he noted.

Dr Tauben meanwhile underscored the importance of better educating patients on the storage and disposal of opioids.

"Patient and family education is crucial regarding careful storage far from the reach of children and pets, and out of site from teenagers and any others that may casually visit the patient at home," he said. 

"Increased knowledge about and improved numbers and availability of take-back options is critical too, and encouraging hospital facilities and pharmacies to provide disposal sites would certainly limit the excess reservoir of opioids in household medicine cabinets."

The study received funding from the National Institutes of Health's (NIH) National Institute of General Medical Sciences and from Johns Hopkins University's Blaustein Pain Research Fund and Stimulating and Advancing ACCM Research.

American Pain Society (APS) 2017 Annual Scientific Meeting. Abstract 232. Presented May 20, 2017.

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