OK We Know There is an Opioid Crisis But What Can We Do About It?
Rita Agarwal MD
Yes, I know we have written about the opioid crisis many times before, but ever since Drs. Connie Monitto, Myron Yaster and their colleagues at Johns Hopkins first recognized the massive over prescription of opioids for children after surgery,(1-3) the question has always been “well what can I do about it?” After all, other than those of us in pain management, few pediatric anesthesiologists actually write these prescriptions, plus isn’t illicit fentanyl the main issue now? While illicit fentanyl is the current major contributor to opioid related overdose deaths,(4-6) many children and adolescents are first introduced to opioids from their own or others’ prescription medications.(6) So other than getting, carrying or keeping naloxone available, what else can anesthesiologists do? Well, anesthesiologists are in the ideal position to promote opioid stewardship in their institutions. Several anesthesiology departments among them Texas Children’s, Johns Hopkins, University of North Carolina, and the University of Michigan have undertaken various means to decrease unnecessary opioid prescriptions, increase disposal and/or increase return of unused opioids.(7) So other than making sure you get and keep naloxone handy, you can read today’s article and perhaps get inspired to get involved with opioid stewardship at your institution.
Original article
Adler AC, Bryant BE, Baszynski D, Lee A, Medellin E, McCarthy J, White A, Nathanson BH, Chandrakantan A. The impact of planned parental follow-up on compliance with opioids disposal following pediatric surgery. Paediatr Anaesth. 2022 Aug;32(8):970-972. doi: 10.1111/pan.14467. PMID: 35445783
Adam Adler, Arvind Chandrakantan and their team at Texas Children’s Hospital(8) have been investigating ways to improve opioid disposal in an attempt to decrease the amount of unused opioids (the “reservoir”) in the community. Their efforts have included the creation and dissemination of educational pamphlets and a USPS/DEA approved, preaddressed prepaid disposal bag. In previous studies the same authors have demonstrated the feasibility of this technique,(9) however they only had a 19.3% return of opioids. In this study all patients received the mail back envelope, written information and counseling from an anesthesiologist or pharmacists, and an email reminder 2 weeks after the surgery. At 4 weeks after the surgery willing patients/parents/caregivers received a phone call from a research assistant in either English or Spanish depending on their preference. In line with theirs and other studies opioid return or disposal rates in the group not receiving a phone call was approximately 16 %. However, the addition of the phone call increased the opioid disposal or return rate to approximately 40%. Similar studies by Terri Voepel Lewis and her colleagues at the University of Michigan have shown the scenario tailored educational vignettes focusing on risk of left over opioids in the home, decreased leftover opioid retention by 50%.(10,11)
Obviously, there is still a lot more work to do to decrease left over opioids at home and in the community. Decreasing prescriptions to better match the need for opioids post-operatively is probably ideal, but given interpatient variability, this is difficult. Continuing to work on methods to improve appropriate disposal of any left-over opioids is critical. We know this is important, we know that lives depend on continuing to decrease the availability of prescription opioids in communities. According to Monitoring the Future
https://monitoringthefuture.org/
while the use of prescriptions opioids started decreasing in high school aged children in 2009 until 2020, in 2022 there was a significant increase in the use of prescription opioids in 12 graders in the previous 12 months.
PS From Myron: How to safely dispose of opioids is not so clear. Many of the commercial products that say they are FDA approved for this purpose are in fact not FDA approved AND many use activated charcoal to simply absorb the opioid. Unfortunately, when these products are put into landfills the drug will leach out into the water supply making it not much better tan simply flushing them into the toilet. A simple solution suggested by Dr. Nancy Glass at a SPA meeting several years ago was to encourage parents to mix their left over meds with dish detergent.
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References
1. Monitto CL, Hsu A, Gao S, Vozzo PT, Park PS, Roter D, Yenokyan G, White ED, Kattail D, Edgeworth AE, Vasquenza KJ, Atwater SE, Shay JE, George JA, Vickers BA, Kost-Byerly S, Lee BH, Yaster M. Opioid Prescribing for the Treatment of Acute Pain in Children on Hospital Discharge. Anesth Analg 2017;125:2113-22.
2. Hunsberger JB, Monitto CL, Hsu A, Yenokyan G, Jelin E. Pediatric surgeon opioid prescribing behavior: A survey of the American Pediatric Surgery Association membership. J Pediatr Surg 2021;56:875-82.
3. Yaster M, Park PS, Hsu A, Roter D, George JA, Shay JE, Monitto CL, Lee BH. Physicians Dispense More Opiod than Needed to Treat Pediatric Pain: A Prospective Cohort Study. Anesthesiology 2015;A1056.
4. Kelly E, Sutcliffe K, Cavallo D, Ramos-Gonzalez N, Alhosan N, Henderson G. The anomalous pharmacology of fentanyl. Br J Pharmacol 2023;180:797-812.
5. Kharasch ED, Clark JD, Adams JM. Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management. Anesthesiology 2022;136:10-30.
6. Kuehn BM. Fentanyl Drives Startling Increases in Adolescent Overdose Deaths. JAMA 2023;329:280-1.
7. Garren BR, Lawrence MB, McNaull PP, Sutherland R, Bukowski TP, Nielsen ME, Woody N, Clark McCall MHA, Ricketts K, Chidgey BA, Ross SS. Opioid-prescribing patterns, storage, handling, and disposal in postoperative pediatric urology patients. J Pediatr Urol 2019;15:260.e1-.e7.
8. Adler AC, Bryant BE, Baszynski D, Lee A, Medellin E, McCarthy J, White A, Nathanson BH, Chandrakantan A. The impact of planned parental follow-up on compliance with opioids disposal following pediatric surgery. Paediatr Anaesth 2022;32:970-2.
9. Adler AC, Yamani AN, Sutton CD, Guffey DM, Chandrakantan A. Mail-Back Envelopes for Retrieval of Opioids After Pediatric Surgery. Pediatrics 2020;145.
10. Voepel-Lewis T, Boyd CJ, Tait AR, McCabe SE, Zikmund-Fisher BJ. A Risk Education Program Decreases Leftover Prescription Opioid Retention: An RCT. Am J Prev Med 2022;63:564-73.
11. Voepel-Lewis T, Farley FA, Grant J, Tait AR, Boyd CJ, McCabe SE, Weber M, Harbagh CM, Zikmund-Fisher BJ. Behavioral Intervention and Disposal of Leftover Opioids: A Randomized Trial. Pediatrics 2020;145.