Study: Most Prescribed Opioid Pills Go Unused and Not Disposed Of In Recommended Ways
By Chanapa Tantibanchachai
Image of Hydrocodone tablets from Wikimedia Commons
A substantial majority of patients prescribed opioids after surgery fail to use their entire prescription, and more than 90 percent of them fail to dispose of leftover pills in the recommended ways, a team of researchers from Johns Hopkins University found in a recent review of half a dozen published studies.*
Opioid abuse has been rising in the US, with some public health officials referring to the rate of opioid overdoses and deaths as an epidemic. The review highlights the need for personalizing pain management after surgeries so that physicians can avoid overprescribing opioids and patients can avoid the risks of improperly storing opioid medications in the home.
Results were published online in the journal JAMA Surgery.
"Physicians write a lot of prescriptions for patients to fill for home use after they have inpatient or outpatient surgery, but our review suggests that there's a lot we don't know about how much pain medication people really need or use after common operations," says Mark Bicket, an assistant professor of anesthesiology and critical care at the Johns Hopkins University School of Medicine and the paper's first author.
"If we can better tailor the amount of opioids prescribed to the needs of patients, we can ensure patients receive appropriate pain control after surgery yet reduce the number of extra oxycodone and other opioid tablets in many homes that are just waiting to be lost, sold, taken by error, or accidentally discovered by a child."
The Hopkins researchers found that between 67 and 92 percent of a total of 810 patients self-reported that they had unused opioids after a surgery. A small number either did not fill their opioid prescription (up to 21 percent) or filled the prescription but did not take any of the pills (between 7 and 14 percent). Overall, Bicket says, anywhere from 42 to 71 percent of prescribed pills dispensed went unused among the patients, but a pill count was not used to independently verify the number of unused tablets.
A majority of patients reported that they stopped taking pills or didn't take any pills in the first place because they could adequately control their pain. Between 16 and 29 percent of patients reported that they ended their opioid use because of the medication's side effects, such as nausea, vomiting, or constipation.
Analysis of two studies — which focused on opioid storage and safety — shows that up to 77 percent of patients reported that their opioids were not stored in locked containers. Five studies looking at opioid disposal practices revealed that less than a third of patients reported that they had disposed of their unused pills or that they planned to, and a smaller portion of patients—less than 10 percent—said they had considered using or had used a disposal method recommended by the Food and Drug Administration.
Bicket notes that the review's limitations include the number of studies reviewed and differences in the questionnaires used in each, as well as limitations related to the reliability of self-reported data and unconfirmed pill counts.
To cut down on instances of unused opioids, Bicket says doctors and clinicians should personalize prescriptions and dosing instructions for patients instead of using a one-size-fits-all approach. He cautions that the research is not meant to encourage doctors to withhold opioid prescriptions from people who are in pain.
"We need to do more research into why some people need more medication than others," he says. "Perhaps there are some characteristics in a patient, such as whether he or she is on opioids before the surgery or has certain genetic markers, that can let me determine that one needs more pain medication than another. ... We need better data and tools to ensure patients have access to adequate pain relief after surgery while reducing the risks of opioid overprescribing."
*A New study, published online in the journal Pharmacoepidemiology and Drug Safety, draws from survey data gathered by the National Health and Nutritional Examination Survey, conducted every two years since 1999-2000. Prescription opioid use, the paper found, rose from 4.1 percent of U.S. adults in 1999-2000 to 6.8 percent in 2013-2014, an increase of 60 percent. Long-term prescription opioid use, defined as 90 days or more, increased from 1.8 percent in 1999-2000 to 5.4 percent in 2013-2014.
"What's especially concerning is the jump in long-term prescription opioid use, since it's linked to increased risks for all sorts of problems, including addiction and overdoses," says study author Ramin Mojtabai, a professor in the Department of Mental Health at the Bloomberg School. "The study also found that long-term use was associated with heroin use as well as the concurrent use of benzodiazepines, a class of widely prescribed drugs that affect the central nervous system."
This is one of the paper's more worrisome findings, Mojtabai notes, since combining opioids and benzodiazepines significantly increases the risk of overdose, even if the patient is taking a moderate dosage of opioid medication. Combining these drugs can also cause respiratory suppression, he says.
For the paper, Mojtabai examined eight consecutive biannual surveys, each of which included more than 5,000 adults living throughout the United States. A total of 47,356 adults participated in the eight surveys, and the response rate ranged from 71 percent to 84 percent.
Despite the upward trend, there is scant evidence supporting benefits of longer-term prescription opioid use, Mojtabai says, with no randomized clinical trials that support their extended use, given the risks.
Prescription opioids were originally designed for shorter-term use, which involves fewer patient risks. Many patients who take opioid medication for weeks or months develop a tolerance that over time requires higher dosages for the medication to relieve pain. As a result, patients will take more medication to reduce their pain, setting them on the path to possible addiction. While there is no clear delineation as to when addiction kicks in, longer-term use is thought to be a risk factor.
The Centers for Disease Control and Prevention issued new guidelines last year, recommending that physicians prescribe opioids for chronic pain only after other options have been proven ineffective. The guidelines also recommend short-term use (three days instead of seven) and lower dosages. The impact of these new guidelines is not yet known, Mojtabai says.
"Given the urgency, it's critical that we continue to try and understand what benefits, if any, exist for prescribing opioids for both short- but especially for longer-term consumption," says Mojtabai. "There may be alternative treatments. We also need to understand what other factors contribute to the considerable risks of prescription opioid medication among different groups, especially those with other drug or alcohol use in their profiles."
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