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Study finds prescription opioids often go unused after surgery, low rates of safe pill storage
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Investigators found most patients who underwent surgery had prescription opioids that were unused, undisposed and unsafely stored, which could lead to opioid-linked injuries and death.
“In this investigation, we found that unused opioids were reported by more than two out of every three patients after a diverse range of surgical procedures,” Mark C. Bicket, MD, told Healio.com/Orthopedics. “Opioid pills were often stored unsafely and remained undisposed months after surgery.”
Bicket and colleagues performed a systematic review and searched Medline, Embase and the Cochrane Center Register of Controlled Trials to identify studies that detailed opioid oversupply for adults following surgery. Specific search terms focused on adult populations, opioids, surgery or procedure, medication use and prescription.
Investigators identified six studies that reported a total of 810 patients who underwent seven different types of surgery. Overall, 67% to 92% of patients reported having unused opioids. Surgical patients did not use 42% to 71% of the opioid tablets they obtained.
According to researchers, most patients either stopped or did not use opioids due to adequate pain control; while 16% to 29% of patients reported that they had developed opioid-induced adverse effects.
Two studies on opioid storage safety showed 73% to 77% of patients did not store their prescription opioids in locked containers. Low rates of anticipated disposal or actual disposal were reported in all studies; however, none of the studies reported more than 9% of patients who used FDA-recommended methods for opioid disposal. – by Monica Jaramillo
Disclosures: Bicket reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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Brent Morris, MD
The authors of this study performed a systematic review to determine opioid oversupply after surgery. Opioid oversupply was determined by the percentage of filled, but unused, opioids or unfilled prescriptions. Six eligible studies were identified in this review with various surgical procedures including outpatient upper extremity surgery, cesarean delivery, thoracic surgery, urologic surgery, dermatologic surgery, general surgery and dental surgery. The included studies were cross-sectional (four), a prospective cohort and a randomized clinical trial.
The authors concluded that between 67% and 92% of patients reported at least some unused opioids after surgery. A large percentage of unused opioid tablets were reported with up to 71% of opioid tablets going unused in one study. Furthermore, only up to 9% of patients disposed of opioids in accordance with US FDA-recommended disposal methods.
This study highlights the delicate balancing act between postoperative pain control with prescription opioids and a potential oversupply of opioids that could potentially be diverted for non-medical use. Non-medical opioid use contributes to many unintended consequences for patients, families and society with opioid-related morbidity and mortality.
There are several limitations that the authors acknowledged and other limitations that need to be discussed. The study included a heterogenous patient population with a small number of included studies (six) and patients (810) relative to the scope of the problem. The patient population included inpatient and outpatient surgeries; highly variable surgical procedures; and a mix of preoperative opioid users and opioid naïve patients. Actual morphine equivalent dosage or the type of opioid medication was not provided. Finally, patient questionnaires or phone surveys were used in the studies rather than pharmacy records or actual pill counts in the office, which may introduce recall bias.
The study included 250 patients following elective outpatient upper extremity surgery and 77% of these patients reported unused opioids following surgery. It is not possible to translate postoperative pain protocols from elective outpatient upper extremity surgery to other orthopedic procedures, such as total joint arthroplasty, trauma or spine procedures. However, a new approach to postoperative pain control should be considered. It is time to reconsider the type and quantity of postoperative opioids that are provided. Patient-specific and procedure-specific opioid prescription and opioid taper protocols are needed. Opioids in the postoperative period should be limited when possible.
It is difficult to balance the burden on patients struggling with postoperative pain and running out of postoperative pain medications vs. an oversupply to patients that may experience less postoperative pain. It is currently challenging to predict which patients will have difficulties with postoperative pain. Perhaps preoperative screening tools (pain catastrophizing scale, opioid risk tool, among others) will help us to better stratify patients and counsel preoperatively and postoperatively regarding pain control techniques. Patients screened and anticipated to have high postoperative pain demands may benefit from a multimodal and multi-system approach including preoperative pain management consultation, while lower opioid doses and lower supplies should be considered when possible.
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