I’ve been involved in the problem of left over, unconsumed opioids for almost a decade. The data is overwhelming: a significant amount of prescribed opioids are unused, left unsecured in the home, and are not destroyed or returned to a reclamation site for destruction. These left over opioids represent a pool available for potential diversion, misuse, addiction, and accidental overdose. So, controlling the amount of left over opioids should have an effect in reducing opioid overdose deaths. Right? As we saw in last week’s PAAD, like many good intentions this hasn’t happened. Indeed, the majority of opioid overdose deaths are now really linked to illicit fentanyl and limiting the pool of pharmaceutical opioids may have had the unintended consequence of driving opioid abusers to the illicit opioid market. First heroin and now fentanyl. The ecosystem of supply, demand, left over opioids and methods of opioid destruction were discussed last week in the PAAD. In essence, the current approaches to reduce the number of the prescription opioid pool has simply not worked at preventing opioid overdose deaths, or in the words of Albert Einstein: “Insanity is doing the same thing over and over and expecting different results.” Myron Yaster MD
Original article
Amanda L Stone, Dima Qu'd, Twila Luckett, Scott D Nelson , Erin E Quinn, Amy L Potts, Stephen W Patrick, Stephen Bruehl, Andrew D Franklin. Leftover Opioid Analgesics and Disposal Following Ambulatory Pediatric Surgeries in the Context of a Restrictive Opioid-Prescribing Policy. Anesth Analg. 2022 Jan 1;134(1):133-140. PMID 33788776
Another in a series of articles by Stone et al from Vanderbilt University demonstrated that a specific state’s (Tennessee) policy aimed at reducing leftover opioids, did not really work very well. Indeed, a significant proportion of prescribed opioids were left over following pediatric ambulatory surgeries despite limiting the amount of opioid dispensed to a 3 day supply (12 doses). Again, like virtually all other studies, the investigators found that a majority of parents did not engage in safe opioid disposal or storage practices. Why? most patients and parents keep their unused opioids deliberately for many reasons, like potential future need. The authors conclude: “Given the safety risks related to leftover opioids in the home, further interventions to improve disposal rates and tailor opioid prescribing are warranted after pediatric surgery”. Really?
As Elliot Krane and I discussed in last week’s PAAD (prescription opioid ecosystem) is their conclusion warranted? In last week’s PAAD the conclusion we came to: it is abundantly clear that current approaches to the opioid crisis are not succeeding.
The study “did not assess parent or patient satisfaction with postoperative pain management or other metrics such as emergency department visits for pain that could indicate the child’s pain was managed inadequately at home. Given concerns that children’s pain is often undermanaged, future studies should evaluate the extent to which parents underutilize opioid analgesics in the context of severe postoperative pain due to fear or lack of knowledge regarding appropriate use”. Like the original CDC guidelines, states and governmental agencies mandating policy restrictions on how much opioid can be dispensed do not measure, nor are they accountable for, patient outcomes.
I think there will always be left over, unconsumed opioids. If there aren’t, this would suggest that pain has been inadequately treated or that a one size fits all policy will work. How much pain people experience and their need for analgesics is very variable. Thus, how to manage the left over pool is a key in the opioid ecosystem. One new idea raised by the Kharasch et al., discussed in last week’s PAAD, and recently enacted into law, is for partial filling of opioid prescriptions. Currently, if a prescriber orders 30 tablets of a drug, the pharmacist must dispense all 30. What if they could dispense only some of the drug AND if the patient needed more they could get it at the pharmacy without a new prescription and without another co-pay?
Are any of you taking advantage of this new prescribing policy? Let us know and I’ll publish in reader responses next week.
Myron Yaster MD