Unused Opioid Pills Research Articles

Nationwide, County-Level Analysis of the Patterns, Trends, and System-Level Predictors of Opioid Prescribing in Surgery in the US: Social Determinants and Access to Mental Health Services Matter.

The diversion of unused opioid prescription pills to the community at large contributes to the opioid epidemic in the US. In this county-level population-based study, we aimed to examine the US surgeons' opioid prescription patterns, trends, and system-level predictors in the peak years of the opioid epidemic. Using the Medicare Part D database (2013 to 2017), the mean number of opioid prescriptions per beneficiary (OPBs) was determined for each US county. Opioid-prescribing patterns were compared across counties. Multivariable linear regression was performed to determine relationships between county-level social determinants of health (demographic, eg median age and education level; socioeconomic, eg median income; population health status, eg percentage of current smokers; healthcare quality, eg rate of preventable hospital stays; and healthcare access, eg healthcare costs) and OPBs. Opioid prescription data were available for 1,969 of 3,006 (65.5%) US counties, and opioid-related deaths were recorded in 1,384 of 3,006 counties (46%). Nationwide, the mean OPBs decreased from 1.08 ± 0.61 in 2013 to 0.87 ± 0.55 in 2017; 81.6% of the counties showed the decreasing trend. County-level multivariable analyses showed that lower median population age, higher percentages of bachelor's degree holders, higher percentages of adults reporting insufficient sleep, higher healthcare costs, fewer mental health providers, and higher percentages of uninsured adults are associated with higher OPBs. Opioid prescribing by surgeons decreased between 2013 and 2017. A county's suboptimal access to healthcare in general and mental health services in specific may be associated with more opioid prescribing after surgery.

Prescription Opioid Use for Adolescents With Neurocognitive Disability Undergoing Surgery: A Pilot Study

IntroductionParents frequently report retaining unused opioid pills following their child's surgery due to fear of untreated postoperative pain. Assessment of pain in adolescents with neurocognitive disability is challenging. We hypothesized that parents of adolescents with neurocognitive disability may report less opioid use and higher opioid pill retention. MethodsAdolescents (13-20 y) undergoing elective surgery (posterior spinal fusion, hip reconstruction, arthroscopy, tonsillectomy) were prospectively enrolled from a tertiary children's hospital from 2019 to 2020. Only adolescents prescribed opioids at discharge were included. Parents completed a preoperative survey collecting sociodemographic characteristics and two postoperative surveys at 30- and 90-d. Neurocognitive disability was determined at time of enrollment by caregiver report, and included adolescents with cerebral palsy, severe autism spectrum disorder, and discrete syndromes with severe neurocognitive disability. ResultsOf 125 parent-adolescent dyads enrolled, 14 had neurocognitive disability. The median number of opioid pills prescribed at discharge did not differ by neurocognitive disability (29, interquartile range {IQR}: 20.0-33.3 versus 30, IQR: 25.0-40.0, P = 0.180). Parents of both groups reported similar cumulative days of opioid use (7.0, IQR: 3.0-21.0 versus 6.0, IQR:3.0-10.0, P = 0.515) and similar number of opioid pills used (4, IQR: 2.0-4.5 versus 12, IQR: 3.5-22.5, P = 0.083). Parents of both groups reported similar numbers of unused opioid pills (17, IQR: 12.5-22.5 versus 19, IQR: 8.0-29.0, P = 0.905) and rates of retention of unused opioids (15.4% versus 23.8%, P = 0.730). ConclusionsThe number of opioid pills prescribed did not differ by neurocognitive disability and parents reported similar opioid use and retention of unused opioid pills. Larger studies are needed to identify opportunities to improve postoperative pain control for children with neurocognitive disability.

Paper 07: Postoperative Opioid Usage and Disposal Strategies Following Outpatient Arthroscopic Sports Medicine Procedures: A Prospective Observational Study

Objectives: While several studies have noted that patients are routinely over-prescribed opioids, few have reported usage following arthroscopic surgery. Nearly 2 million arthroscopic procedures are performed annually, and one study estimates that opioids are prescribed in excess in 88% of patients recovering from arthroscopic knee surgery. Such surplus of postoperative opioid prescription creates a conundrum, as many patients do not appropriately dispose of unused opioid pills, and the majority of recreational opioid users obtain these medications from friends or family. The objectives of this study were to determine opioid consumption, utilization of total prescription, and allocation for unused opioids following five common arthroscopic surgeries. Methods: This study is a prospective trial enrolling patients between the ages of 15-40 who were scheduled to undergo elective anterior cruciate ligament (ACL) reconstruction, labral repair of the hip or shoulder, meniscectomy, or meniscal repair. Patients were prescribed either 5-325 hydrocodone-acetaminophen or 5-325 oxycodone-acetaminophen based on surgeon preference. Patients completed a daily opioid usage survey during the 2-week postoperative period. In addition, patients completed a survey on postoperative day 21 inquiring about continued opioid use and medication disposal, if applicable. Opioid medication consumption was converted to morphine milliequivalents (MME) where one 5 mg oxycodone pill is equivalent to 7.5 MME and one 5 mg hydrocodone pill is equivalent to 5.0 MME. T-tests or Mann-Whitney U tests were used to calculate differences between continuous data. Chi-Square or Fisher’s Exact were used for categorical data. Results: Of the 200 patients enrolled in the study, 100 (50%) underwent ACL reconstruction, 26 (13%) underwent arthroscopic hip labral repair, 37 (19%) underwent arthroscopic shoulder labral repair, 23 (12%) underwent meniscectomy, and 14 (7%) underwent meniscal repair. The mean MME consumption in the 14 days following each procedure was calculated: ACL reconstruction (88.9), hip arthroscopy (84.8), shoulder arthroscopy (55.5), meniscectomy (24.3), and meniscal repair (31.2). This corresponded to a utilization rate of 40.4%, 36.5%, 40.7%, 37.4%, and 34.6% respectively (Table 1). Mean MME consumption was greatest on postoperative day 1 in all procedures, and only 6.6% of patients reported continued opioid use in the third postoperative week. Of the 141 patients available for follow up at 3 weeks, 113 reported having opioid medication remaining. Of the patients with remaining medication, 25.6% intended to keep their medication for future use (Figure 2). Conclusions: The results of our study indicate that patients who undergo the aforementioned arthroscopic procedures consume a mean of 70 MME in the 2-week postoperative period, translating into an average of 9-14 pills consumed, depending on medication prescribed. Few patients reported requiring opioid medication after 2 weeks postoperatively. Patients undergoing ACL reconstruction and hip labral repairs consumed the highest MME, followed by shoulder labral repair patients who consumed approximately 3 times more opioids than primary meniscal procedures. Approximately 65% of total opioids prescribed went unused, and over one fourth of patients intended to keep their remaining medication for future usage. [Table: see text]

Nudging patients and surgeons to change ambulatory surgery pain management: Results from an opioid buyback program

BackgroundOptimal postoperative opioid stewardship combines adequate pain medication to control expected discomfort while avoiding abuse and community diversion of unused prescribed opioids. We hypothesized that an opioid buyback program would motivate patients to return unused opioids, and surgeons will use that data to calibrate prescribing. MethodsProspective cohort study of postambulatory surgery pain management at a level II Veterans Affairs rural hospital (2017–2019). Eligible patients were offered $5/unused opioid pill ($50 limit) returned to our Veterans Affairs hospital for proper disposal. After 6 months, buyback data was shared with each surgical specialty. ResultsOverall, 934 of 1,880 (49.7%) eligible ambulatory surgery patients were prescribed opioids and invited to participate in the opioid buyback. We had 281 patients (30%) return 3,165 unused opioid pills; this return rate remained constant over the study period. In 2017, 62.4% of patients were prescribed an opioid; after data was shared with providers, prescriptions for opioids were reduced to 50.7% and 38.3% of eligible patients in 2018 and 2019, respectively (P < .0001). The median morphine milligram equivalents prescribed also decreased from 108.8 morphine milligram equivalents in 2017 to 75.0 morphine milligram equivalents in 2018 and sustained at 75.0 morphine milligram equivalents in 2019 (P < .001). Surgical providers, surgeries performed, patient characteristics, and 30-day refill rates were similar throughout the study period. ConclusionA small financial incentive resulted in patients returning unused opioids after ambulatory surgery. Feedback to surgeons regarding opioids returned reduced the proportion of patients prescribed an opioid and the amount of opioid after ambulatory surgery without an increase in refills.

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.

Opioid Use in the Postpartum Period: Are We Prescribing Too Much?

The first exposure to opioids for many women of reproductive age follows childbirth. Current data show a significant correlation between the number of days supplied and continued use/abuse of opioids. The number of women with opioid dependency in pregnancy is steadily increasing, and opioid use is directly linked to an increase in maternal and neonatal morbidity and mortality. However, there are no clear opioid-prescribing guidelines for the postpartum period. To compare the number of opioid pills prescribed with the number used by patients in the postpartum period. Patients were recruited to this pilot study at the time of admission to the labor and delivery unit at a community hospital in Oklahoma City, Oklahoma; 84 patients gave informed consent to participate. Medical records were reviewed to determine the number of opioids prescribed. Phone surveys were conducted 4 to 6 weeks after discharge to identify the number of opioids used during the postpartum period. Welch t test was used to determine P values. After exclusion criteria were applied, records of 23 patients with vaginal deliveries and 14 patients with cesarean sections were included in the study. Patients who were prescribed opioids after a vaginal delivery were prescribed significantly more pills than were used (P<.001); a mean of 10 opioid pills per patient remained unused. Patients prescribed opioids after cesarean section were also often prescribed more opioid pills than used (P<.05); an average of 7.5 opioid pills per patient remained unused. Of 37 patients, only 2 disposed of unused opioid pills. The data in this study show a clear example of overprescibing opioids after vaginal and cesarean deliveries leading to increased opioid pill availability within the community.

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.

Education Increases Disposal of Unused Opioids After Total Joint Arthroplasty: A Cluster-Randomized Controlled Trial.

Unused opioid pills are a danger to patients and their loved ones as they may be diverted for abuse or misuse. The purpose of this study was to determine the baseline rate of proper disposal of unused opioids among patients undergoing total joint arthroplasty and to determine how education impacts disposal rates. In this study, 563 patients undergoing primary total joint arthroplasty (183 patients undergoing total hip arthroplasty, 293 patients undergoing total knee arthroplasty, and 87 patients undergoing unicompartmental knee arthroplasty) were cluster-randomized to groups that received no education, educational pamphlets, or educational pamphlets plus text messages. Patients were randomized by education class and were blinded to participation to avoid behavioral modifications. Patients were surveyed at 6 weeks postoperatively to determine if they disposed of their unused opioid pills using a U.S. Food and Drug Administration-recommended method, which was the primary outcome. Assuming a 15% difference in opioid disposal rates as clinically relevant, power analysis determined that 76 patients with unused opioids were required per group (228 total). An as-treated analysis was conducted with the Fisher exact text and analysis of variance with alpha = 0.05. A total of 539 patients (95.7%) completed the survey, and 342 patients (63.5%) had unused opioid pills at 6 weeks postoperatively: 89 patients in the no education group, 128 patients in the pamphlet group, and 125 patients in the pamphlet and text message group. Of these 342 patients, 9.0% of patients in the no education group, 32.8% of patients in the pamphlet group, and 38.4% of patients in the pamphlet and text message group properly disposed of their unused opioids (p = 0.001 for each educational intervention compared with no education). Unused opioid pills were kept by 82.0% of patients in the no education group, 64.1% of patients in the pamphlet group, and 54.4% of patients in the pamphlet and text message group (p < 0.001 for the no education group compared with either educational strategy group). Patients who underwent total hip arthroplasty were more likely to properly dispose of their unused opioids compared with those who underwent total knee arthroplasty (odds ratio, 2.1; p = 0.005). There were no demographic differences between groups, including inpatient opioid use, refills, and preoperative opioid use, other than sex (41.5% male patients in the no education group, 55.0% male patients in the pamphlet group, and 37.4% male patients in the pamphlet and text message group; p = 0.001), suggesting appropriate randomization. The rate of opioid disposal is very low after total joint arthroplasty. Education on opioid disposal more than triples opioid disposal rates compared with no education. To help to prevent diversion of unused opioid pills, all patients who undergo total joint arthroplasty should be educated on the proper disposal of unused opioids.

Opioid prescriptions for acute pain after outpatient surgery at a large public university-affiliated hospital: Impact of state legislation in Florida

BackgroundIn response to the growing opioid crisis, Florida recently implemented a law restricting the duration of opioid prescriptions for acute pain. Little is known about the impact of such legislation on opioid prescription practices at the time of discharge after surgery. The objective of this study was to determine whether Florida’s new legislation changed opioid prescription practices for analgesia after surgery. MethodsAdults 18 years of age and older undergoing cholecystectomy, appendectomy, hernia repair, hysterectomy, mastectomy, or lymph node dissection were included in this retrospective cohort study at a large public university–affiliated hospital. We analyzed opioid prescriptions on discharge after these common outpatient surgical procedures between June 1, 2017, and December 31, 2018. Florida House Bill 21 was passed on March 2, 2018, and subsequent implementation of this law took place on July 1, 2018. The law restricts the duration of opioid prescriptions for acute pain to 3 days, which can be extended up to a maximum of 7 days with additional documentation. The outcomes studied included the following: the proportion of patients receiving opioid prescriptions on discharge, total opioid dose prescribed, daily opioid dose prescribed, and the proportion of patients receiving more than a 3-day supply of opioids. We colledted data on emergency department cumulative visits within 7 and 30 days after discharge. Drug doses were converted to morphine milligram equivalents and calculated for each selected procedure. ResultsA total of 1,467 surgical encounters were included. The cohort was predominantly female (963 [65.6%]) with a mean (SD) age of 49.6 (14.4) years. At 6 months after implementation of HB 21, the proportion of patients receiving opioid prescriptions decreased by 21% (95% CI 16.8% to 25.3%, P < .001), mean total opioid dose prescribed decreased by 64.2 morphine milligram equivalents (95% CI 54.7 to 73.7, P < .001) from a baseline mean (SD) of 172.5 (78.9) morphine milligram equivalents. The mean daily opioid dose prescribed increased by 3.5 morphine milligram equivalents (95% CI 1.8 to 5.1, P < .001) from a baseline mean (SD) of 30.5 (9.4) morphine milligram equivalents. The proportion of patients receiving opioid prescriptions for longer than a 3-day supply decreased by 68% (95% CI 63.4% to 72.7%, P < .001). We observed no change in the number of postoperative emergency department visits before and after implementation of the law. ConclusionOpioid prescriptions for patients undergoing common outpatient surgical procedures at a large public university–affiliated hospital in Florida were substantially reduced within 6 months after implementation of state legislation limiting the duration of opioid prescriptions. This reduction was not associated with an increase in the number of postoperative emergency department visits. The legislation should significantly decrease the amount of unused opioid pills potentially available for diversion and abuse. Secondary effects from the enactment of this law remain to be evaluated.

Who Is Keeping Their Unused Opioids and Why?

To better understand patients' reasoning for keeping unused opioid pills. As part of a larger study, patients were asked their plans for their unused opioids. Responses were categorized as "dispose," "keep," and "don't know." Baseline characteristics were compared between the "keep" and "dispose" groups. Verbatim responses categorized as "keep" were analyzed qualitatively using a team-based inductive approach with constant comparison across cases. One hundred patients planned to dispose of their pills; 117 planned to keep them. There were no differences in demographics between the groups. Among patients who planned to keep their pills, the mean age was 43 years and 47% were male. Analysis revealed four categories of patient responses: 1) plans to keep their pills "just in case," with reference to a medical condition (e.g., kidney stone); 2) plans to keep pills "just in case" without reference to any medical condition; 3) plans to dispose in delayed fashion (e.g., after pill expiration) or unsure of how to dispose; and 4) no identified plans, yet intended to keep pills. In this sample, there were no differences in characteristics of those reporting planning to keep vs dispose of pills; however, there were diverse reasons for keeping opioids. This manuscript describes a sample of patients who kept their unused opioids and presents qualitative data detailing their personal reasoning for keeping the unused pills. Awareness of the range of motivations underpinning this behavior may inform the development of tailored education and risk communication messages to improve opioid disposal.

The James A. Rand Young Investigator's Award: Large Opioid Prescriptions Are Unnecessary After Total Joint Arthroplasty: A Randomized Controlled Trial

BackgroundThe purpose of this randomized controlled trial is to determine whether the quantity of opioid pills prescribed at discharge is associated with the number of opioid pills consumed or unused by patients after primary hip and knee arthroplasty within 30 days after discharge. MethodsA total of 304 opioid-naïve patients were randomized to receive either 30 or 90 5-mg oxycodone immediate-release (OxyIR) pills at discharge. Daily opioid consumption, number of unused pills, and pain scores were calculated for 30 days with a patient-completed medication diary. Statistical analysis involved t-test, rank-sum, chi-squared tests, and multiple linear regression with alpha = 0.05. ResultsOf the 304 patients randomized, 161 patients were randomized to receive 30 pills and 143 to receive 90. In the first 30 days after discharge, the median number of unused pills was 15 in the 30 group vs 73 in the 90 group (P < .001). Within 90 days of discharge, 26.7% of the 30 group and 10.5% of the 90 group requested a refill (P < .001), leading to a mean of 777.1 ± 414.2 morphine equivalents vs 1089.7 ± 536.4 prescribed (P < .0001). There was no difference between groups in mean morphine equivalents consumed. Regression analysis demonstrated that being prescribed 90 OxyIR pills was independently associated with taking more OxyIR pills (P = .028). There was no difference in pain scores within the first 30 days and in patient-reported outcome scores at 6 weeks postoperatively. ConclusionPrescribing fewer OxyIR pills is associated with a significant reduction in unused opioid pills and decreased opioid consumption with no increase in pain scores and no difference in patient-reported outcomes. Level of EvidenceLevel I. Randomized controlled trial.

Opioid Oversupply After Joint and Spine Surgery: A Prospective Cohort Study.

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. 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. 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. 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.

Prescribed to Death: Memorial Strives to Put a Face on Opioid Overdose Statistics

Back to table of contents Previous article Next article CommunityFull AccessPrescribed to Death: Memorial Strives to Put a Face on Opioid Overdose StatisticsLinda M. RichmondLinda M. RichmondSearch for more papers by this authorPublished Online:20 Dec 2018https://doi.org/10.1176/appi.pn.2018.12a2AbstractA traveling memorial seeks to honor victims of prescription opioid overdose and motivate visitors to action to stop the worst drug crisis in American history.As the nation grapples with the worst drug crisis in United States history, the National Safety Council (NSC) wants to put a face on the toll it has taken. NSC’s exhibit “Prescribed to Death: A Memorial to the Victims of Opioid Crisis” is traveling around the country and may be coming to a city near you. It seeks to personalize the data points and drive its visitors to action.At the National Safety Council’s opioid memorial exhibit, a computer-driven engraving machine continuously carves a face onto a little white pill every few minutes to signify another life lost to the opioid epidemic. The CDC reported there were nearly 49,000 opioid overdose deaths in 2017.National Safety CouncilOne in four Americans has been directly impacted by the opioid crisis, yet NSC poll data show that 40 percent still do not consider it to be a threat to their own family. “The most important thing about this crisis is not the statistics, but the faces,” explained NSC President and CEO Deborah A.P. Hersman. NSC is a nonprofit that works to eliminate preventable deaths. “The Prescribed to Death memorial not only brings visitors face to face with this everyday killer, but also encourages actions that will help us eliminate these preventable deaths.”The centerpiece of the exhibit is a black wall of pills, row after row, with each pill intended to represent one of the 22,000 individuals lost to prescription opioid overdose in 2015—the year the memorial was conceptualized. Onto each pill has been carved the face of an individual who lost his or her life to the opioid epidemic.Infinity mirrors affixed to both ends of the wall make it appear to go on forever, reminding visitors that the opioid crisis, too, will continue “unless we do something about it,” said Maureen Vogel, an NSC spokesperson.Messaging added onto the sides of the wall explains to visitors that the opioid overdose death toll has tragically continued since the memorial’s inception: of the 42,000 individuals who died from opioid overdoses in 2016, about 40 percent (17,000) involved prescription opioid analgesics.When NSC unveiled the memorial at its Chicago headquarters in 2017, a computer-driven engraving machine worked nearby, continuously carving a new face onto a pill every few minutes and dropping it onto a table to signify another life lost. “Now, it’s every 12 minutes that someone is overdosing on opioids in our country,” Vogel said.A woman gazes at the centerpiece of the National Safety Council’s opioid memorial exhibit, a massive wall of perfectly spaced white pills. Onto each pill has been carved the face of an individual who lost his or her life to the opioid epidemic.National Safety CouncilA separate installation adjacent to the memorial wall invites visitors to enter the recreated personal space of one individual lost to opioid overdose or one who battled opioid use disorder. Each installation contains personal artifacts: handwritten journal entries; a specially knitted blanket; a card a son had left his mother just prior to his overdose, telling her how much he loved her.“We want to make sure people understand the opioid crisis is human. It’s not just data points,” Vogel said. “These are real people, just like you and me. They had real relationships … and they’re not here anymore because of something we know how to stop.”Visitors to the memorial receive a special envelope to allow for safe disposal of unused opioid pills in their homes and an “Opioids: Warn Me” label to affix to their insurance cards, empowering them to discuss with prescribers the risks of taking opioids—and explore whether other pain relief options are available.The exhibit traveled to six additional cities throughout the country in 2018: Fayetteville, Ark.; Pittsburgh; Atlanta; Buffalo, N.Y.; Houston; and Washington, D.C., where it was displayed in a tent on the Ellipse in President’s Park at the White House. NSC spent more than $1 million to create the exhibit and is seeking sponsors to help bring it to other locations and events in 2019. ■View the “Prescribed to Death” memorial online here. ISSUES NewArchived

Excess Opioid Medication and Variation in Prescribing Patterns Following Common Orthopaedic Procedures.

Postoperative pain management in orthopaedic surgery accounts for a substantial portion of opioid medications prescribed in the United States. Understanding prescribing habits and patient utilization of these medications following a surgical procedure is critical to establishing appropriate prescribing protocols that effectively control pain while minimizing unused opioid distribution. We evaluated prescribing habits and patient utilization following elective orthopaedic surgical procedures to identify ways of improving postoperative opioid-prescribing practices. We performed a review of prescribing data of 1,199 procedures and gathered telephone survey results from 557 patients to determine the number of opioid pills prescribed postoperatively and the number of unused pills. The data were collected from adult patients who underwent 1 of the 5 most common elective orthopaedic procedures at our institution in fiscal year 2015: total hip arthroplasty, total knee arthroplasty, endoscopic carpal tunnel release, arthroscopic rotator cuff repair, or lumbar decompression. We converted all dosages to opioid equivalents of oxycodone 5 mg and performed analyses of prescribing patterns, patient utilization, and patient disposal of unused opioids. Prescribing patterns following the 5 orthopaedic procedures showed wide variation. The median numbers of oxycodone 5-mg equivalent opioid pills prescribed upon discharge were 90 pills (range, 20 to 330 pills) for total hip arthroplasty, 90 pills (range, 10 to 200 pills) for total knee arthroplasty, 20 pills (range, 0 to 168 pills) for endoscopic carpal tunnel release, 80 pills (range, 18 to 100 pills) for arthroscopic rotator cuff repair, and 80 pills (range, 10 to 270 pills) for lumbar decompression. Thirty-seven percent of patients overall requested and received at least 1 refill. The mean number of total pills prescribed (and standard deviation) including refills was 113.6 ± 75.7 for total hip arthroplasty, 176.4 ± 108.0 for total knee arthroplasty, 24.3 ± 29.0 for carpal tunnel release, 98.2 ± 59.6 for rotator cuff repair, and 107.4 ± 64.4 for lumbar decompression. Participants reported unused opioid medication in 61% of cases. During the study year, >43,000 unused opioid pills were prescribed. Forty-one percent of patients reported appropriate disposal of unused opioid pills. Prescribing patterns vary widely, and a large amount of opioid medications remains unused following elective orthopaedic surgical procedures. Effective prescribing protocols are needed to limit this source of potential abuse and opioid diversion within the community.

204 “I’m Keeping Them Just in Case”: Patients Rationale for Retaining Unused Opioid Pills

A significant proportion of misused opioids are diverted from unused prescriptions. Lack of risk communication on proper opioid disposal is one contributing factor to patients’ retaining unused opioids, which may lead to later misuse. Little is known regarding patients’ rationale for retaining their opioids after completing treatment. The objective of this study was to characterize patients’ reasons for keeping their leftover opioids. This is a qualitative study utilizing patient interview data obtained as part of a larger intervention trial promoting safe opioid use. Consecutively discharged patients at an urban academic ED (annual volume >88,000 visits) with a new opioid prescription were enrolled. Participants were eligible if they were age 18+, English-speaking and not chronic opioid users. Follow-up interviews were conducted 1-2 weeks and 1 month after ED discharge. Patients who had unused pills at the time of these interviews were asked “What do you plan to do with the leftover pills when you are finished taking them?” Participants who indicated a current intention to keep the pills were asked to elaborate on their reasons why. This study used content and constant comparative analysis to explore verbatim responses to this question. Responses were analyzed for a total of 144 participants; mean age was 45, and 45% were male. Analyses revealed six predominant themes. One emergent theme reflected patients’ decision to keep their pills “just in case,” in the context of a specific medical condition (“In case I ever get kidney stones again”). Additionally, some participants similarly described their intention to keep pills “just in case,” without mentioning any specific condition (“Just in case, you never know. There’s other symptoms for Norco too, so you never know what could come up with me personally”). Plans for disposal of the opioid at some time in the future formed another theme. These participants voiced their intention to dispose of the medication, but often after a certain time had elapsed (“Hold onto them until they expire⋯”). Also under this theme, patients voiced uncertainty regarding methods of medication disposal (“I don't know, what should I do? I know I'm not supposed to flush them down the toilet.”). Additional, but less frequently expressed themes included: lack of anticipation of having unused pills (“I probably won’t have any left at this rate.”); no identified plans, yet intention to keep pills nonetheless, sometimes citing habit or financial rationale (“They usually just sit there”; “waste not want not”); and plans to keep pills specifically for “emergencies” or to avoid seeking emergent care (“Save them for emergencies, I’m accident prone”). Patients note diverse reasons for keeping their unused opioid pills. Awareness of the range of intentions underlying patient motivations provides critical information for future development of tailored risk communication messages to improve opioid disposal.

LO10: Quantity of opioid to prescribe for acute pain to limit misuse after emergency department discharge

Introduction: A 2008 survey found that 1.9% of the entire US population was using prescription pain medication non-medically and that 56% obtained them from a friend or relatives. Diversion of pain medication may occur when a portion of the prescription is unused for pain relief after an ED visit. We hypothesized that at least 10 pills (~40%) of an opioid prescription 2 weeks after an ED visit, will not be consumed and become available for potential misuse. Objective: Determine the quantity of unused opioids pills for common acute pain diagnoses, 2 weeks after an ED visit for acute pain. Methods: Prospective observational cohort study of consecutive ED patients from a tertiary academic urban hospital with 60,000 ED visits annually. Inclusion criteria: aged ≥18 years, acute pain conditions present ≤2 weeks, pain intensity at triage of ≥4 (on a 0-10 numeric rating scale; NRS), and discharged with a new opioid prescription. ED physicians identified (24/7) eligible patients. They recorded the pain complaint/location, the final diagnosis, the quantity and type of prescribed pain medication. Discharged patients completed paper or electronic 14-day diary (REDCap database) to document their pain medication consumption. As a mitigation strategy, they were also contacted by phone at 2 weeks for the same information. A paired t-test was used to test the difference between the amounts of opioids prescribed and consumed. Results: 350 patients were recruited. Mean age 50 (SD ±16) and 54.2% were men. Painful diagnosis: fracture (18.2%), acute back pain (15.3%), renal colic (15.3%), Sprain (excluding back/neck pain) (6.9%), Contusion (6.4%), acute neck pain (5.8%), abdominal pain (4.9%), and other (27.2%). Opioids prescribed: oxycodone (47%), morphine (37%) and hydromorphone (16%). Means quantity of opioid pills prescribed: 24 (IC95%: 23-26). Filled opioid prescription: 92%. Means quantity of opioid pills consumed: 8 (IC95%: 7-9). Means quantity of unused opioids pills: 16. Opioid pills available for misuse in our cohort: 5,600 pills. Conclusion: After an ED visit for acute pain a significant portion of opioids prescribed is unused and available for misuse. A large pragmatic study should be done to confirm that an opioid prescription strategy based on our results will limit unused opioid pills while maintaining pain relief.

Unused Opioid Pills After Outpatient Shoulder Surgeries Given Current Perioperative Prescribing Habits

Background: In the past 16 years, the number of prescription opioids sold in the United States, as well as deaths from prescription opioids, has nearly quadrupled. However, the overall amount of pain reported by patients has not changed significantly. Specific information about opioid prescriptions in the perioperative period is lacking. Of the studies that have been published, investigators have shown that the majority of patients have unused postoperative opioid pills. Moreover, patients appear to lack information about disposal of unused opioid pills. Purpose: To compare the number of pills prescribed versus the numbers left unused after outpatient shoulder surgeries at an orthopaedic surgery institution. Study Design: Case series; Level of evidence, 4. Methods: In this prospective, observational study, 100 patients (age >18 years) undergoing outpatient shoulder surgery (rotator cuff repair, labral repair, stabilization/Bankart repair, debridement) were enrolled. Follow-ups were conducted via surveys on postoperative days (PODs) 7, 14, 28, and 90. The primary outcome was the number of unused pills from the originally prescribed medication. Results: For all procedure types, the median (Q1, Q3) number of prescribed pills was 60 (40, 80). On POD 90, patients reported a median (Q1, Q3) of 13 (0, 32) unused pills; patients who underwent rotator cuff repairs had the lowest number of pills remaining (median [Q1, Q3], 0 [0, 16]), whereas patients who had stabilization/Bankart repairs had the highest number of unused pills (median [Q1, Q3], 37 [29, 50]). Patient satisfaction with pain management ranged from an average of 70% to 90%. Only 25 patients received instructions or education about opioid disposal. Conclusion: Most outpatient shoulder surgery patients who underwent certain operations were prescribed more opioid analgesics than they consumed. Patient education regarding the disposal of opioids was lacking.

Unused opioid analgesics and drug disposal following outpatient dental surgery: A randomized controlled trial

BackgroundIndividuals who abuse prescription opioids often use leftover pills that were prescribed for friends or family members. Dental surgery has been identified as a common source of opioid prescriptions. We measured rates of used and unused opioids after dental surgery for a pilot program to promote safe drug disposal. Methods: We conducted a randomized controlled trial of opioid use patterns among patients undergoing surgical tooth extraction at a university-affiliated oral surgery practice. The primary objective was to describe opioid prescribing and consumption patterns, with the number of unused opioid pills remaining on postoperative day 21 serving as the primary outcome. The secondary aim was to measure the effect of a behavioral intervention (informing patients of a pharmacy-based opioid disposal program) on the proportion of patients who disposed or reported intent to dispose of unused opioids. (NCT02814305) Results: We enrolled 79 patients, of whom 72 filled opioid prescriptions. On average, patients received 28 opioid pills and had 15 pills (54%) left over, for a total of 1010 unused pills among the cohort. The behavioral intervention was associated with a 22% absolute increase in the proportion of patients who disposed or reported intent to dispose of unused opioids (Fisher’s exact p=0.11). Conclusion: Fifty-four percent of opioids prescribed in this pilot study were not used. The pharmacy-based drug disposal intervention showed a robust effect size but did not achieve statistical significance. Dentists and oral surgeons could potentially reduce opioid diversion by moderately reducing the quantity of opioid analgesics prescribed after surgery.