Study adds to evidence that most prescribed opioid pills go unused

August 2, 2017
Credit: CC0 Public Domain

In a review of half a dozen published studies in which patients self-reported use of opioids prescribed to them after surgery, researchers at Johns Hopkins report that a substantial majority of patients used only some or none of the pills, and more than 90 percent failed to dispose of the leftovers in recommended ways.

A summary of the review, published August 2 in JAMA Surgery, highlights the need for more personalized management to avoid overprescribing opioids and reduce risks linked to improperly stored opioids in the home.

"Physicians write a lot of prescriptions for to fill for home use after they have inpatient or outpatient , 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, M.D., an assistant professor of anesthesiology and critical care at the Johns Hopkins University School of Medicine and the paper's first author.

The review he and his team published found that 67 to 92 percent of a total of 810 patients in the six studies did not use their entire prescription, yet still held onto them, increasing the risk of misuse, says Bicket. Opioid abuse and misuse rates have been rising in the U.S., adding to what public health officials are calling an epidemic of opioid deaths and overdoses.

Commonly, Bicket notes, prescriptions for opioid pills permit patient discretion for dosing, such as taking one pill every four hours "as needed" for pain. Instead of a one-size-fits-all approach, Bicket says, clinicians need to do a better job of personalizing and dosing for each patient.

Some studies suggest that nonopioid drugs such as acetaminophen and naproxen can often suffice for moderate postoperative pain, says Bicket, who also recommends that prescribers spend more time assessing postoperative pain and prescribe smaller amounts of opioids or alternatives as appropriate.

"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."

To examine the potential prevalence of unused prescription opioids following surgery, the research team searched three published research paper databases from their inception dates through October 18, 2016, collecting data from all studies describing opioid oversupply. The studies eligible for inclusion in their first round of analysis could be in any language, could involve any type of surgery on adult patients, could include both inpatient and outpatient populations, and had to contain some level of reporting about unused pills.

Of the 2,419 studies screened, the research team identified six that met all eligibility criteria, with a combined total enrollment of 810 patients. In all, the patients underwent seven types of surgeries, including orthopedic surgery, urologic surgery, dermatologic surgery, thoracic surgery, Cesarean section, dental surgery and general surgery. Among these procedures, thirty patients were women who had had Cesarean section, and some 65 percent (523/810) of the patients had outpatient surgery.

To calculate the average number of patients who had an oversupply of a prescription opioid, the research team added the number of patients who didn't fill their opioid prescription to those who filled their prescription but reported unused opioids. This sum was then divided by the total number of patients who received an opioid prescription.

The researchers found that between 67 and 92 percent of patients reported unused opioids. A small number of patients either did not fill their opioid prescription (range of 0 to 21 percent) or filled the prescription but did not take any opioids (range of 7 to 14 percent).

Overall, Bicket reports, anywhere from 42 to 71 percent of prescribed pills dispensed went unused among the 810 patients. A majority of patients reported they stopped or used no opioids due to adequate pain control, while 16 to 29 percent of patients reported they stopped because of opioid-induced side effects, such as nausea, vomiting or constipation.

In two of the studies that looked at storage safety, the Johns Hopkins analysis showed that 73 to 77 percent of patients reported that their prescription opioids were not stored in locked containers. Five studies that examined patients' opioid disposal practices showed that only 4 to 30 percent of patients reported that they disposed of their unused opioids or said they planned to.

A smaller proportion of patients (4 to 9 percent) said they considered using or had used a disposal method recommended by the Food and Drug Administration, such as returning unused medications to a pharmacy or flushing them down a toilet.

Bicket notes the study's limitations included variability in the quality of the studies reviewed and differences in the questionnaires used to ask patients about how much opioid medication they used. Data on usage and disposal were also based on the self-report of patients, and the studies did not use pill counts to independently verify unused tablets.

"We need to do more research into why some people need more medication than others. Perhaps there are some characteristics in a patient, such as whether he/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," says Bicket. For now, he says, there are no proven ways to absolutely verify pain levels or predict them, but the high rate of unused opioids found in their review suggests that doctors can often prescribe less, because patients often need less.

Bicket cautions that his research is not intended to encourage withholding opioids from people in pain, and says he and his team are conducting research to better understand patients' pain experiences in a bid to someday identify better ways to optimize the way in which opioid are prescribed after surgery.

At the end of the day, though, Bicket says that "we need better data and tools to ensure patients have access to adequate pain relief after surgery while reducing the risks of opioid overprescribing."

Explore further: Patients taking opioids prior to ACL surgery more likely to be on pain medications longer

More information: JAMA Surgery (2017). DOI: 10.1001/jamasurg.2017.0831

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15 comments

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dirk_bruere
5 / 5 (2) Aug 02, 2017
Only an idiot throws away powerful opiods. When you are in sever pain, you do not want to make an appointment with a doctor for a new prescription.
Eikka
3 / 5 (4) Aug 02, 2017
Why opioids in the first place?

Most pain can be managed with non-opioid painkillers. I've personally never taken anything stronger than paracetamol after surgery, and even then just baby doses to take the edge off. A slight hot throbbing in a wound doesn't bother me at all - it's not what I call "pain".

It's not necessary to remove all sensation of the injury, because then I'm worried I may ignore signals that I'm injuring myself more, and for as long as I'm using the painkiller I can't feel if I'm getting better.
dirk_bruere
4 / 5 (4) Aug 02, 2017
@Eikka Try a paracetamol for a kidney stone, and report back
TheGhostofOtto1923
2.6 / 5 (5) Aug 02, 2017
Most pain can be managed with non-opioid painkillers. I've personally never taken anything stronger than paracetamol after surgery
-and so what makes you think you are entitled to an opinion on how others choose to deal with their pain?
I'm worried I may ignore signals that I'm injuring myself more
-and what makes you think opioids work this way? Opioids not only reduce pain, they change your attitude toward it. And this can be very important for persistent, nagging, maddening pain. Opioids restore a quality of life for sufferers unlike any other drug or combination of drugs.

Opioids are indeed addictive but at the same time they are easy to control because quantities in addictive amounts cause impaired motor skills, perceptual changes, sleepiness, and hallucinations.
TheGhostofOtto1923
1 / 5 (4) Aug 02, 2017
Drug companies lost a lot of business 20-30 years ago as patents were expiring and new drugs were not being created. So in order to keep them from failing they were allowed to produce heroin and morphine in pill form. As a result, millions have taken them without serious problems for decades.

This perhaps unexpected result tells us more about the fiction that heroin and opium are evil drugs of moral decay than about the greed of the great pharmaceutical corporations.

But it does tell us a lot about how these corporations, along with the tobacco and alcohol companies, are willing to vilify any competition to their products, and how unscrupulous politicians and lawyers and judges are are willing to support them in this endeavor.
TheGhostofOtto1923
1 / 5 (4) Aug 02, 2017
The story above nullifies gov. Christie's claim that we are taking enough opioids to medicate the entire US population for a year. He knows that pfizer, astrazenica, Novo Nordisk, merck, and the dozens of other major and minor concerns in his state need to begin moving new product. So they have to get people to stop using the old, one way or another.
TheGhostofOtto1923
1 / 5 (4) Aug 02, 2017
So now we have hysterical screams about a national crisis rivaling 9/11 and the 1918 flu pandemic. This is not so surprising as we are being inundated with lies at unprecedented scales about just about everything, and people have little choice but to believe at least some of it.

Whats curious is that the bulk of problems is from the recent flood of fentanyl on the black market. Cops are getting ODs just from touching it. Kids are somehow getting dosed while walking home from school.

So whos producing it? Where is it coming from? And why is it showing up just when the drug companies need to begin moving all their brand new alternatives like Lyrica with a $150 copay?
Eikka
3.7 / 5 (3) Aug 02, 2017
Try a paracetamol for a kidney stone, and report back


How about you try not being stupid, and report back.

-and so what makes you think you are entitled to an opinion on how others choose to deal with their pain?


I don't. I was merely giving a personal anecdote in support of the article which itself points out that:

A majority of patients reported they stopped or used no opioids due to adequate pain control


Most people just don't need the opioids they're being prescribed.

So in order to keep them from failing they were allowed to produce heroin and morphine in pill form. As a result, millions have taken them without serious problems for decades.


Opioid addiction and abuse is at an all-time high, and overdose deaths have quadrupled since 2000.
TheGhostofOtto1923
1 / 5 (3) Aug 02, 2017
Most people just don't need the opioids they're being prescribed.
But this is not a personal anecdote in support of the article, is it?
Opioid addiction and abuse is at an all-time high, and overdose deaths have quadrupled since 2000
Addiction is hard to judge. If it is based on pills prescribed then the article disproves it.

If you look at these graphs
https://www.cdc.g...sis.html

-you see that the spike in overdoses is due to fentanyl and heroin. But the press wants us to believe that prescription drugs are the problem which isnt true.
TheGhostofOtto1923
1 / 5 (3) Aug 02, 2017
"Mexico is the source of much of the illicit fentanyl for sale in the U.S. However, in April 2006, there was one domestic fentanyl lab discovered by law enforcement in Azusa, California. The lab was a source of counterfeit 80 mg OxyContin tablets containing fentanyl instead of oxycodone, as well as bulk fentanyl and other drugs.[85][86] In November 2016, the DEA uncovered an operation making counterfeit oxycodone and Xanax from a home in Cottonwood Heights, Utah. They found about 70,000 pills in the appearance of oxycodone and more than 25,000 in the appearance of Xanax. The DEA reported that millions of pills could have been distributed from this location over the course of time. The accused owned a pill press and ordered fentanyl in powder form from China."

-Counterfeit fentanyl and heroin account for the bulk of overdoses. Without them the increase in ODs mirror the increase in prescriptions. Ie there is no epidemic of legal opioid abuse, despite what you hear and read.
TheGhostofOtto1923
1 / 5 (3) Aug 02, 2017
And in fact this is exactly what the CDC is telling us.

"Sales of prescription opioids in the U.S. nearly quadrupled from 1999 to 2014,1 but there has not been an overall change in the amount of pain Americans report.2,3 During this time period, prescription opioid overdose deaths increased similarly."
Bart_A
not rated yet Aug 03, 2017
I received opiods once during an extreme medical emergency. About 5 years ago. Used only 1/3 of them. Still have the rest for the future "just in case". Why throw them away?

TheGhostofOtto1923
1 / 5 (2) Aug 03, 2017
So waaaaalt and Bart what are your objections to what I posted? Care to discuss it?

Like I say, there is no prescription opioid epidemic. Here is one of the reasons the industry and politicians want you to believe there is:

"The U.S. Food and Drug Administration today issued a draft guidance intended to support industry in their development of generic versions of approved opioids with abuse-deterrent formulations (ADF) while ensuring that generic ADF opioids are no less abuse-deterrent than the brand-name drug."

Here's another:

"The National League of Cities (NLC) and the National Association of Counties (NACo) have launched a joint task force to address our nation's opioid and heroin abuse crisis... comprised of city and county leaders..."

-'Task forces' at city, state, and federal levels popping up all over the country while new drugs being developed, all being paid for with your tax dollars and patients pocket money.

It's a huge scam and you're paying for it.
barakn
not rated yet Aug 04, 2017
Having lost several family members to prescription opioids, Ghost, I can assure you your head is firmly planted up your rectum. Part of the issue with the statistics you are relying on for your misguided opinion is that a death of an individual found with a needle stuck in their arm is almost always going to be blamed on the illicit drug in the needle, but when someone dies due to a prescription opioid the death is often attributed to natural causes or whatever underlying disease caused the pain that made the individual seek the pain meds in the first place.
TheGhostofOtto1923
1 / 5 (1) Aug 04, 2017
Having lost several family members to prescription opioids, Ghost
Heresay. But let me ask - were they prescribed these drugs or did they get them illegally?

The statistics I posted show that the percentage of ODs from prescribed drugs increased at the same rate as the overall number of prescriptions. And according to the article most of these drugs arent even being consumed. The increase of ODs per capita is due to illegal fentanyl and heroin which have only recently flooded the market, and that is the truth.
when someone dies due to a prescription opioid the death is often attributed to natural causes or whatever underlying disease caused the pain that made the individual seek the pain meds in the first place
I dont understand - are you saying that coroners cant tell the difference between OD fatalities and natural causes? You have statistics on this phenomenon?

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