Opioid Oversupply After Joint and Spine Surgery

A Prospective Cohort Study

Mark C. Bicket, MD; Elizabeth White, RN; Peter J. Pronovost, MD, PhD; Christopher L. Wu, MD; Myron Yaster, MD; G. Caleb Alexander, MD, MS

Disclosures

Anesth Analg. 2019;128(2):358-364. 

In This Article

Abstract and Introduction

Abstract

Background: Many patients receive prescription opioids at hospital discharge after surgery, yet little is known regarding how often these opioids go unused. We estimated the prevalence of unused opioids, use of nonopioid analgesics, and storage and disposal practices after same-day and inpatient surgery.

Methods: In this prospective cohort study at a large, inner-city tertiary care hospital, we recruited individuals ≥18 years of age undergoing elective same-day or inpatient joint and spine surgery from August to November 2016. Using patient surveys via telephone calls, we assessed patient-reported outcomes at 2-day, 2-week, 1-month, and 6-month intervals, including: (1) stopping opioid treatment and in possession of unused opioid pills (primary outcome), (2) number of unused opioid tablets reported after stopping opioids, (3) use of nonopioid pain treatments, and (4) knowledge and practice regarding safe opioid storage and disposal.

Results: Of 141 eligible patients, 140 (99%) consented (35% taking preoperative opioids; mean age 56 years [standard deviation 16 years]; 47% women). One- and 6-month follow-up was achieved for 115 (82%) and 110 patients (80%), respectively. Among patients who stopped opioid therapy, possession of unused opioids was reported by 73% (95% confidence intervals, 62%–82%) at 1-month follow-up and 34% (confidence interval, 24%–45%) at 6-month follow-up. At 1 month, 46% had ≥20 unused pills, 37% had ≥200 morphine milligram equivalents, and only 6% reported using multiple nonopioid adjuncts. Many patients reported unsafe storage and failure to dispose of opioids at both 1-month (91% and 96%, respectively) and 6-month (92% and 47%, respectively) follow-up.

Conclusions: After joint and spine surgery, many patients reported unused opioids, infrequent use of analgesic alternatives, and lack of knowledge regarding safe opioid storage and disposal. Interventions are needed to better tailor postoperative analgesia and improve the safe storage and disposal of prescription opioids.

Introduction

Rates of injuries and deaths from prescription and nonprescription opioids continue to increase in the United States, with the number of deaths reaching an all-time high in 2016.[1] One cause of these injuries and deaths stems from taking unused opioids that were prescribed to another person. While considerable focus has been placed on opioids prescribed for the management of chronic noncancer pain,[2] opioids are also used commonly in other settings, including for treatment of moderate to severe acute postsurgical pain,[3] especially among patients undergoing orthopedic and other invasive surgeries.[4,5] The prescribing of postoperative opioids to surgical patients contributes to the opioid epidemic, with 3%–8% of opioid-naive patients continuing to take opioids at 1 year after surgery.[6,7]

We previously conducted a systematic review to examine how commonly postsurgical prescription opioids remain unused among adult surgical patients, given that unused opioids may lead to misuse or diversion.[8] In the published studies included in the review, most patients reported unused opioid pills in the weeks after various surgeries, and rates of safe storage and proper disposal were low. Despite insights from this review, most of the eligible studies focused on outpatient rather than inpatient surgeries, and none examined invasive surgeries such as knee or hip replacements or spine surgery. In addition, while some studies reported unused pill counts, none provided precise estimates of opioid volume, such as morphine milligram equivalents, that remained after surgery.

To fill this gap in knowledge, we conducted a prospective cohort study to estimate the prevalence of unused opioids after joint and spine surgery. We also explored patients' use of nonopioid analgesics, as well as their knowledge and practices of safe storage and disposal. We hypothesized that ≥50% of patients undergoing invasive joint and spine surgery would report possessing unused opioids after stopping their postoperative therapy.

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