Opioid Disposal Research Articles

Opioid Disposal in Patients Undergoing Total Joint Replacement Utilizing a Carbon-Based Home Medication Disposal Pouch

AimsThe purpose of the pilot study was to determine if an educational program on opioid safety and disposal during a preoperative joint replacement class would increase the frequency of disposal of unused opioids with a disposal pouch at the end of the episode of care in patients undergoing joint replacement. A secondary aim was to quantify the milligrams of morphine equivalents prescribed, used, disposed, and remaining in joint replacement patients. DesignThe study design is quasi-experimental. MethodsA medication disposal pouch was provided to all study subjects preoperatively. A 2-minute opioid safety and disposal instruction and demonstration of the use of the disposal pouch was performed at a weekly preoperative joint replacement class which was optional for subjects to attend. A nine-question phone survey was then administered to subjects postoperatively. ResultsOne hundred and four patients completed the study survey. Of the subjects who attended the class and had opioids remaining, 74% disposed of their opioids compared with 36% that did not attend the class (p = .005). ConclusionsProvision of a disposal pouch in combination with a live educational program on opioid safety and disposal increased the rate of disposal of unused opioids in a postoperative population.

Effect of Drug Disposal Kits and Fact Sheets on Elimination of Leftover Prescription Opioids: The DISPOSE Multi-Arm Randomized Controlled Trial.

To determine how passively providing informational handouts and/or drug disposal kits affects rates of leftover prescription opioid disposal. A multi-arm parallel-group randomized controlled trial with masked outcome assessment and computer-guided randomization. Johns Hopkins Health System outpatient pharmacies. Individuals who filled ≥1 short-term prescription for an immediate-release opioid for themselves or a family member. In June 2019, 499 individuals were randomized to receive an informational handout detailing U.S. Food and Drug Administration-recommended ways to properly dispose of leftover opioids (n = 188), the informational handout and a drug disposal kit with instructions on its use (n = 170), or no intervention (n = 141) at prescription pickup. Subjects were subsequently contacted by telephone, and outcomes were assessed by a standardized survey. The primary outcome was the use of a safe opioid disposal method. By 6 weeks after prescription pickup, 227 eligible individuals reported they had stopped taking prescription opioids to treat pain and had leftover medication. No difference in safe disposal was observed between the non-intervention group (10% [6/63]) and the group that received disposal kits (14% [10/73]) (risk ratio = 1.44; 95% confidence interval: 0.55 to 3.74) or the group that received a fact sheet (11% [10/91]) (risk ratio = 1.15; 95% confidence interval: 0.44 to 3.01). These findings suggest that passive provision of a drug disposal kit at prescription pickup did not increase rates of leftover opioid disposal when compared with provision of a fact sheet alone or no intervention. Active interventions may deserve further investigation.

A Clinical Trial of a Video Intervention Targeting Opioid Disposal After General Surgery: A Feasibility Study

BackgroundThe opioid epidemic continues and although some initiatives have shown promise in reducing the number of opiates prescribed, few studies have focused on education of general surgery patients about home storage and safe disposal. The purpose of this feasibility study was to explore the use of an online video intervention to prepare surgical patients to properly dispose of unused opioids. MethodsEligible patients undergoing elective general surgery between August and October 2019 were enrolled into this prospective randomized controlled feasibility study. Patients with reported opioid use preoperatively were excluded from the study. The control group followed usual care, and the intervention group received usual care plus a brief educational video guided by the theory of reasoned action describing safe storage and disposal practices of unused opioid pills. Measures were collected at baseline and 2 wk postoperatively. ResultsA total of 40 participants were enrolled in the study; average age was 44.7 (range 21-75 y); most were Caucasian, educated, and employed. Recruitment took 11 wk, and the retention rate was excellent at 85%. Differences in opioid disposal were not significantly different by age, sex, education, or type of surgery. The video intervention was positively received, but the majority (80%) still stored their pills unsecured. ConclusionsResults demonstrate that a video intervention addressing safe storage and disposal practices of unused opioids is feasible, and more research is needed to determine efficacy in increasing rates of secure storage and disposal of unused opioid pills.

Resident Opioid Prescribing Habits Do Not Reflect Best Practices in Post-Operative Pain Management: An Assessment of the Knowledge and Education Gap

To evaluate deficiencies in knowledge and education in opioid prescribing and to compare surgical resident opioid-prescribing practices to Opioid Prescribing Engagement Network (OPEN) procedure-specific guidelines. Anonymous web-based survey distributed to all general surgery residents to evaluate prior education received and confidence in knowledge in opioid prescribing. The number of 5 milligram oxycodone tablets prescribed for common procedures was assessed and compared with OPEN for significance using Wilcoxon signed rank tests. General surgery residency program within large university-based tertiary medical center. Categorical general surgery residents of all postgraduate years. Fifty-six of 72 (78%) categorical residents completed the survey. Few reported receiving formal education in opioid prescribing in medical school (32%) or residency (16%). While 82% of residents felt confident in opioid side effects, fewer felt the same with regards to opioid pharmacokinetics (36%) or proper opioid disposal (29%). Opioids prescribed varied widely with residents prescribing significantly more than recommended by OPEN in 9 of 14 procedures. Tackling the evolving opioid epidemic requires a multidisciplinary approach that addresses prescribing at all steps of the process, starting with trainee education.

Perianesthesia Patient Education for the Promotion of Opioid Stewardship

Opioid overdose deaths and opioid use disorders are a crisis in the United States and other western countries around the globe. Opioid prescriptions more than doubled after the turn of the century, particularly for postoperative patients. Unfortunately, many who have abused opioids were able to obtain those opioids from friends or family who had held on to prescribed, but unused opioids. One method to manage and decrease the opportunity for unused opioids to become black-market opioids is to educate patients and families regarding the safe use, safe storage, and proper disposal of unused prescription opioids. Perianesthesia nurses, particularly those who educate patients before and after surgery, have an excellent opportunity to educate patients and families who are discharged to home after surgery.

Enhanced discharge counseling to reduce outpatient opioid use after cesarean delivery: a randomized clinical trial

Strategies to curb overprescribing have focused primarily on the prescriber as the point of intervention. Less is known about how to empower patients to use fewer opioids and decrease the quantity of leftover opioids. Previous studies in nonobstetrical populations suggest that patient counseling about appropriate opioid use improves disposal of unused opioids and overall knowledge about opioid use. Less is known about whether counseling reduces opioid use after hospital discharge. This study examines whether enhanced discharge counseling on optimal analgesic use after cesarean delivery reduces opioid use and improves proper disposal of unused opioids and opioid use knowledge after hospital discharge. Women who underwent an uncomplicated cesarean delivery were randomized to enhanced counseling on optimal analgesic use or usual care. Enhanced counseling addressed the following 4 points: (1) pain is normal after cesarean delivery; (2) scheduled ibuprofen should be taken to maintain baseline pain control; (3) opioids should be used sparingly and should be tapered over several days; and (4) all unused opioids should be returned to pharmacy or flushed in a toilet. All participants received 30 tablets of 5 mg hydrocodone-acetaminophen and 30 tablets of 600 mg ibuprofen at discharge. They were contacted 14 days later to determine opioid use and location of leftover opioids and to complete a 10-question analgesic strategies quiz with a score of 1 to 10. We estimated that outcome data on 172 women total would provide an 80% power to detect a 30% reduction in postdischarge opioid use with enhanced counseling. Notably, 79% of eligible women consented to the study and 175 of 196 participants (84 enhanced counseling, 91 usual care) completed the follow-up. Compared with usual care, the enhanced counseling group was more likely to follow recommendations for proper opioid disposal (risk ratio, 2.3; 95% confidence interval, 1.3-3.9). They also scored significantly higher on the analgesic strategies quiz (10 points [interquartile range, 9-10] vs 8 points [interquartile range, 7-9]; P<.001) than the usual care group. Although the enhanced counseling group used less opioids (7.5 tablets [interquartile range, 2-15] vs 10.0 tablets [interquartile range, 2-16]; P=.55) and a smaller proportion of prescribed opioids (25.0% [6.7-50.0] vs 33.3% [6.7-53.3], P=.55) than the usual care group, differences were not statistically significant. There was no statistically significant evidence of interaction between participant education level and any of the study outcomes. Enhanced discharge opioid counseling doubled the frequency of participants reporting proper opioid disposal and improved overall knowledge about the risks associated with opioids. This intervention did not decrease opioid use in a population of women with low overall opioid use. These findings highlight possible methods to intervene on the short-term (misuse and diversion) and long-term (persistent opioid use) consequences of overprescribing.

Prescribing Opioids: Universal Education on Opioid Use, Storage, and Disposal

This article highlights the challenges in opioid prescribing and provides guidance on patient education for opioid safety, storage, and disposal as well as recommendations for cautious prescribing for a patient with cancer. Amid the opioid crises, multiple groups have reported that there is a gap in knowledge among patients and prescriber on proper opioid use, storage, and disposal that contributes to unsafe opioid practices. Opioids are important in the treatment of pain in majority of patients with advanced cancer. Clinicians managing cancer-related pain have faced significant challenges in safely prescribing opioids in the time of an opioid epidemic and mounting evidence of non-medical opioid use in this patient population.

Self-reported disposal of leftover opioids among US adults 50–80

ObjectiveTo test the association between self-reported opioid disposal education and self-reported disposal of leftover opioids among older adults.DesignWeb-based survey from the National Poll on Healthy Aging (March 2018) using population-based...

Postoperative Opioid Prescribing and Consumption after Hysterectomy: A Prospective Cohort Study

To examine opioid prescribing and consumption patterns after hysterectomy and identify factors associated with postoperative opioid consumption. Prospective cohort study. Single university medical center. Women undergoing hysterectomy for benign, nonobstetric indications. Participant preoperative and surgical characteristics were obtained through chart review and patient report of baseline pain score. During the third postoperative week, participants completed a telephone interview, including a direct count of remaining opioid pills and assessment of satisfaction with pain management. We assessed factors associated with opioid consumption in oral morphine equivalents (OME) using a linear regression model. Of the 129 participants, 113 (88%) completed the postoperative survey after hysterectomy: 16 vaginal, 43 robotic-assisted, 42 conventional laparoscopic, and 12 abdominal hysterectomies. The median amount of opioid prescribed was 150 OME (interquartile range [IQR] 113-200), while the median amount consumed was 75 (IQR 10-135), reflecting an average consumption of about 50% of the prescription. Opioid prescription size was associated with consumption; for every additional oral morphine equivalent prescribed, on average, an additional 0.5 was consumed (p <.001). If the indication for hysterectomy was related to pain, participants consumed 25.3 additional OME (p = .04). The amount of opioid prescribed was inversely correlated with pain management satisfaction; every additional point on a 1 through 5 Likert scale of increasing satisfaction was associated with 44 fewer OME prescribed (standard error 9 OME, p <.001). For the 1464 total unused pills among the 104 participants with leftover opioids, only 20% reported an Food and Drug Administration -compliant opioid disposal plan. Gynecologic surgeons can respond to the opioid epidemic by reducing excess opioid pills after hysterectomy by providing both the smallest effective prescription size and concrete resources for safe opioid disposal. These actions may contribute to a reduction in opioid use disorder cases or overdose deaths.

Effect of drug disposal bag provision on families’ disposal of children’s unused opioids

ObjectiveOne strategy to combat opioid misuse is to remove excess opioids from circulation by providing patients with drug disposal products that enable the safe disposal of opioids. We aimed to evaluate opioid use and disposal of unused opioids among children and young adults before and after pharmacy staff at our institution began to provide patients and families filling opioid prescriptions with a drug disposal bag. MethodsWe performed a prospective pre-post cohort study of patients who filled an opioid prescription in May-August 2019 at the outpatient pharmacies of a large tertiary children’s hospital. Patients and caregivers were enrolled at the time the opioids were dispensed. During the first half of the study period, standard opioid-related education was offered by pharmacy staff. During the second half of the study period, standard education was offered, and a drug disposal bag and instructions on its use were provided when the opioids were dispensed. A follow-up survey to assess opioid use and disposal was completed online or by telephone 4-7 weeks after the opioids were dispensed. ResultsA total of 215 participants were enrolled; 117 received a drug disposal bag and 98 did not. Of those, 68% of the participants completed a follow-up survey. In both groups, the median patient age was 11 years, and most patients had been prescribed opioids after a procedure. More than 70% had opioids leftover after they had stopped taking them, and this did not vary by group. However, among families with leftover opioids, the receipt of a drug disposal bag was associated with a higher likelihood of disposal of the unused opioids (71.7% vs. 52.1%, P = 0.04). ConclusionProviding a drug disposal bag to families of children receiving opioids increases the likelihood of excess opioid disposal. Greater availability of drug disposal products can complement prescribing reduction efforts aimed at decreasing prescription opioid misuse.

Engaging the Opioid Epidemic Head on: Improving Proper Disposal of Unused Opioid Medications after Surgery

Study Objective To improve proper opioid disposal rates after surgery by providing educational materials along with a disposal bag Design Prospective Cohort Setting Academic Patients or Participants Surgical Interventions A prospective cohort study first evaluating a baseline understanding of medication disposal using a questionnaire was given. Subsequently, patients were provided written information on proper disposal and medication disposal bag. Study patients were then asked to complete a survey about how they disposed of their unused opioids at their last visit. The success of education and proper disposal of opioid medications were evaluated. Measurements and Main Results Thirty-one patients successfully completed both surveys. The surgeries performed included a variety of gynecologic procedures. Prior to education, 52%(n=16) of patients did not dispose of their narcotics. Furthermore, 71%(n=22) of patients state they had never been educated by a medical provider regarding appropriate disposal. 19%(n=6) confirmed they have used a narcotic medication prescribed to someone else. After intervention, 93.5%(n=29) of patients properly disposed of their narcotics which identifies a 45% increase in proper disposal(p= Conclusion This study clearly shows that patient education, coupled with a reliable option for opioid disposal, is effective. We encourage other institutions to implement similar practices not only for our surgical patient's safety but also the estimated 42,000 patients who died of opioid abuse in the last year.

“Addressing the Opioid Epidemic at the Front Lines”: Surveying Opioid Prescribing Practices of Obgyn Residents across Canada

Study Objective Opioid over-prescription in surgical patients has been described as a leading contributor to the opioid epidemic. At academic centres, the discharge prescription is often written by the resident. The objective of this study is to identify the prescribing practices of gynecology residents to manage post operative pain. Design This is a cross-sectional survey to elicit gynecology residents’ opioid prescribing habits. The anonymous study was disseminated to residents via email. Setting N/A. Patients or Participants The inclusion criteria was any resident enrolled in postgraduate years (PGY) 1 to 5 at a Canadian OBGYN residency. Staff OBGYNs, fellows, and cross specialty trainees were excluded. 486 residents were emailed the survey with 102 responses. Interventions N/A. Measurements and Main Results Respondents encompassed all five years with the majority of respondents as PGY-4 (28). Up to 67% of trainees reported having formal training on pain management including 100% of PGY-1s and 53% of PGY-5s. The average MME (Morphine Milligram Equivalents) prescribed for total laparoscopic hysterectomy (TLH) was 37.5 (standard deviation [SD]=64) compared to 68.5 (SD=39.3) for total abdominal hysterectomy (TAH). For TLH, PGY-1s prescribed an average of 18 whereas PGY-5s prescribed the highest (43, p=0.078). Regional differences in prescribing demonstrated the highest average MME in Western provinces (70.8) compared to the lowest in Eastern provinces (11.9, p=0.072). Procedure type was listed as the most influential factor by 65%, with patient factors (35%) and staff preference (33%) being the next most influential. Only 25% of respondents felt comfortable prescribing non-opioid alternative therapies. The majority of respondents (46%) report rarely or never counselling patients on safe opioid disposal. Conclusion Senior residents appear to prescribe higher MME and have lower rates of pain management education. Targeted resident education and interventions focussed on shared decision making between patients and providers could reduce MME prescriptions. Trainees would benefit from education on non opioid alternative therapies and safe opioid disposal.

A Simple Brochure Improves Disposal of Unused Opioids: An Observational Cross-Sectional Study.

We evaluated the effectiveness of a simple, low-cost educational brochure in improving disposal rates of unused opioids after outpatient upper extremity surgery. This cross-sectional study enrolled eligible adult patients from a peripheral nerve clinic between November 2017 and September 2018. Patients either received or did not receive the educational brochure, which outlined a simple method to dispose of unused opioids and completed a survey at 2 weeks after surgery. We compared the proportion of patients who disposed of unused opioids after surgery between the group that had received the brochure and the group that had not. Categorical data were analyzed with χ2 test, proportions data with binomial tests, and numerical data with Mann-Whitney U test, all with a significance level of P < .05. There were 339 survey respondents. Nineteen patients who did not meet inclusion criteria were excluded. Of the 320 remaining patients, 139 received the brochure and 181 did not. An additional 55 patients were excluded due to preoperative opioid use. Overall, 35.3% of recipients and 38.3% of those who did not receive the brochure used all of their prescribed opioid medication (P = .625; confidence interval = -14.6%-8.8%). Among patients with unused opioid medication, a significantly higher proportion of brochure recipients disposed of the medicine compared with those who did not receive the brochure (46.7% vs 19.6%, P < .001). Distribution of an educational brochure significantly improved disposal of unused opioids after surgery. This easily implemented intervention can improve disposal of unused opioids and ultimately decrease excess opioids available for diverted use in the community.

Decreasing opioid use in postoperative gynecologic oncology patients through a restrictive opioid prescribing algorithm

ObjectiveThe objective of this study was to evaluate the impact of a post-surgical restrictive opioid prescribing algorithm (ROPA) in gynecologic oncology patients. MethodsThis cohort study included gynecologic oncology patients undergoing any surgical procedure from 08/2018–7/2019 after implementation of a ROPA. Patients were compared to historical controls managed without a ROPA from 10/2016–9/2017. Patients were educated preoperatively about pain management goals, the ROPA, and opioid disposal. A 4-tiered system was developed to standardize prescriptions at discharge based on surgical complexity and inpatient opioid requirements. Patients were surveyed at their postoperative visit to assess home opioid use and satisfaction. Statistical analysis was performed using SPSS Statistics v.24. Results2549 patients met inclusion criteria; 1321 in the historical control group and 1228 in the ROPA group. Demographics, including age, BMI, and performance status were similar. Compared with the control group, the average number of opioid pills prescribed was significantly lower in the ROPA group (30.5 vs 11.3; p < 0.001) along with the morphine milligram equivalents (MME) (152.5 MME vs. 83.3 MME; p < 0.001). The percentage of patients requiring opioid refill within 30 days was similar (13.0% vs. 12.6%; p = 0.71). 95.7% of patients surveyed were satisfied with their pain regimen. The total number of pills prescribed annually decreased from 34,130 in the control group to 13,888 in the ROPA group. ConclusionsA restrictive prescribing practice allows for a significantly lower number of opioids to be prescribed to postoperative patients while maintaining patient satisfaction. There was no increase in opioid refill requests using a ROPA in patients undergoing surgery.

Pediatric surgeon opioid prescribing behavior: A survey of the American Pediatric Surgery Association membership

BackgroundThe opioid crisis has led to increasing numbers of overdose fatalities in teens and young adults. Surgery, as a common cause of acute pain in children, drives much of the opioid prescribing in pediatrics. Therefore, we sought to characterize opioid prescribing practices of pediatric surgeons by surveying members of the American Pediatric Surgery Association (APSA). Study designAfter receiving approval from our institutional review board, we sent an online survey to the entire APSA membership. The survey included four vignettes of common pediatric surgical procedures with questions regarding analgesic prescribing practices, the rationale for these practices, and knowledge about opioid risk mitigation. ResultsOf 1127 APSA members contacted, 327 (29%) provided survey responses. For all vignettes, opioid prescribing was within standard ranges for 83% of respondents. Eighty-eight percent of respondents prescribed nonopioid pain medicine. Additionally, 25% reported routinely utilizing a prescription drug monitoring program, 64% did not tell patients how to dispose of opioids, and 37% did not know themselves how to dispose of leftover opioids. ConclusionsPrescribing by APSA surgeons is largely within standard ranges, but improvement is needed, particularly regarding opioid disposal. Procedure-specific consensus guidelines for opioid prescribing and opioid risk mitigation strategies are warranted. Level of evidenceObservational study, level III.

Patterns of Storage, Use, and Disposal of Prescription Opioids by Young Adults with Cancer

Studies have demonstrated that adults with cancer and parents of children with cancer do not use and store prescription opioids safely. Most YAs (135/146, 92%) unsafely stored opioids. Fifty-two of 146 patients (36%) unsafely used, and 16 of 146 patients (11%) unsafely disposed of opioids. YAs with hematologic malignancies (p < 0.05) were more likely to use opioids safely compared with YAs with other types of malignancies. More research is necessary to understand the scope of this issue. Our data suggest that universal educational interventions regarding the safe storage, use, and disposal of opioids are justified for YAs.

Provision of a Drug Deactivation System for Unused Opioid Disposal at Surgical Dismissal: Opportunity to Reduce Community Opioid Supply.

ObjectiveTo determine the impact of a drug deactivation system to post-surgical patients on the rate of opioid prescription disposal.Patients and MethodsTwo hundred post-operative patients discharged after inpatient surgery at a large academic medical center. This study was conducted August 20, 2018, through November 30, 2018. Patients were provided with a drug deactivation system (DDS) and instruction sheet along with their opioid prescription. Three to 4 weeks after dismissal, patients were surveyed about quantity of opioids remaining, use of DDS or other disposal methods, and satisfaction with DDS if used.ResultsOne hundred forty-nine of 200 (74.5%) patients were surveyed. One hundred six reported leftover opioids and 29 (27.3%) had disposed of these medications. By the time of survey, 23 (21.2%) participants with leftover opioids had used the DDS to destroy their remaining supply and an additional 33 (31.1%) participants reported plans to use the disposal bag on a future date. Of the 23 participants who used the DDS, 22 (96.0%) reported that they were very satisfied with the disposal process.ConclusionParticipants are willing to use a DDS and are satisfied with the process; however, additional education is needed to ensure timely disposal.

Stakeholder Perspective on Opioid Stewardship After Prostatectomy: Evaluating Barriers and Facilitators From the Pennsylvania Urology Regional Collaborative

OBJECTIVETo evaluate existing practice patterns and potential barriers to implementing opioid stewardship protocols after robot-assisted prostatectomies among providers in the Pennsylvania Urology Regional Collaborative. METHODSThe Pennsylvania Urology Regional Collaborative (PURC) is a voluntary quality improvement initiative of 11 academic and community urology practices in Pennsylvania and New Jersey representing 97 urologists. PURC distributed a web-based survey of 24 questions, with 74 respondents, including 56 attendings, 11 residents, and 7 advanced practice providers. RESULTSMore pills were prescribed if there was a default number of pills from the electronic health record (median 30) then if the number of pills was manually placed (P = .01). Only 8% discussed how to dispose of opioids with their patients, and less than a third of respondents discussed postoperative pain expectations or risks of opioid use. Patient level risk factors were often not reviewed, as 42% did not ask about previous opioid exposure. CONCLUSIONThis study revealed extensive knowledge disparities among providers about opioid stewardship and significant gaps in the evidence-to-practice continuum of care. In the next year, PURC will be implementing targeted interventions to augment provider education, establish clear pathways for opioid disposal, improve utilization of known resources and implement opioid reduction protocols in all participating sites.

Buyback Program of Unused Prescription Opioids in US Rural Communities, 2017-2018.

Objective. To implement an opioid buyback program after ambulatory surgery.Methods. We performed a prospective cohort study of 578 opioid-naïve patients prescribed opioids after ambulatory surgery at a rural US Veterans Affairs (VA) hospital from 2017 to 2018. We reimbursed $5 per unused opioid pill ($50 limit) returned to our VA for proper disposal. We tracked the number of participants, number of unused opioid pills returned, surgeon prescribing, and refill requests.Results. Out of 578 eligible patients, 171 (29.6%) returned 2136.5 unused opioid pills. Information shared with surgeons after 6 months led to a 27% decrease in opioid prescribing without an increase in refills.Conclusions. With this opioid buyback program, rural patients had a safe and convenient place to dispose of unused opioids. Surgeons used information about returns to adjust opioid prescribing after common ambulatory surgeries without an increase in refill requests.Public Health Implications. Although providers prescribe within state opioid guidelines, there will be variations in patient use after ambulatory surgery. An opioid buyback program helped our patients and surgeons decrease unused prescription opioids available for diversion in our rural communities.

Patient and Family Knowledge of Proper Opioid Disposal Following Surgery

Patient and Family Knowledge of Proper Opioid Disposal Following Surgery