In a review of half a dozen published studies in which patients self-reported use of opioids prescribed to them after dental and other surgeries, researchers at Johns Hopkins report that a substantial majority of patients used only some or none of the pills and that more than 90% failed to dispose of the leftovers in recommended ways. The researchers say the review highlights the need for more personalized pain management to prevent overprescribing opioids and to reduce the risks linked to improperly stored opioids in the home.
“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,” said Mark Bicket, MD, an assistant professor of anesthesiology and critical care at the Johns Hopkins University School of Medicine and the study’s first author.
According to the review, 67% to 92% of a total of 810 patients in the six studies examined did not use their entire opioid prescription yet still held on to them, increasing the risk of misuse. Opioid abuse and misuse rates have been rising in the United States, adding to what public health officials are calling an epidemic of opioid deaths and overdoses. Prescriptions often permit patient discretion for dosing, and instead, Bicket said, clinicians need to do a better job of personalizing prescriptions and dosing for each patient.
Some studies have suggested that non-opioid drugs such as acetaminophen and naproxen can suffice for moderate postoperative pain, Bicket added. He 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,” Bicket said.
The researchers searched 3 published paper databases from their inception dates through October 18, 2016, collecting data from all studies describing opioid oversupply. The studies eligible for inclusion in the first round of analysis could have been in any language, could have involved any type of surgery on adult patients, could have included both inpatient and outpatient populations, and had to include some level of reporting about unused pills.
Of the 2,419 studies screened, 6 met all eligibility criteria, with a combined total enrollment of 810 patients. The patients underwent 7 types of surgeries, including orthopedic surgery, urologic surgery, dermatologic surgery, thoracic surgery, Cesarean section, dental surgery, and general surgery. Among these procedures, 30 were women who had Cesarean sections, and 65% (523 of 810) had outpatient surgery.
To calculate the average number of patients who had an oversupply of a prescription opioid, the researchers added the number of patients who didn’t fill their opioid prescription to those who filled their prescription but reported unused opioids. This sum then was divided by the total number of patients who received an opioid prescription.
Between 67% and 92% of patients reported unused opioids. A small number either did not fill the prescription (0% to 21%) or filled the prescription but did not take any opioids (7% to 14%). Overall, anywhere from 42% to 71% of prescribed pills went unused among the 810 patients. Most patients reported that they stopped or used no opioids due to adequate pain control, while 16% to 29% reported they stopped because of opioid-induced side-effects such as nausea, vomiting, or constipation.
In a pair of studies that looked at storage safety, 73% to 77% of patients reported that their prescription opioids were not stored in locked containers, and 5 studies that examined disposal practices showed that only 4% to 30% of patients disposed on their unused opioids or said they planned to. A smaller proportion, 4% to 9%, 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 noted that 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-reporting 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,” Bicket said. “Perhaps there are some characteristics in a patient, such as whether he or she is on opioids before the surgery or has certain genetic markets, that can let me determine that one needs more pain medication than another.”
For now, Bicket said, there are no proven ways to absolutely verify pain levels or predict them, but the high rate of unused opioids suggests that doctors often can prescribe less because patients often need less. Still, Bicket cautions that the research should not discourage prescriptions for people in pain, as he and his team investigate ways to better understand pain experiences and identify better ways to optimize how opioids are prescribed after surgery.
“We need better data and tools to ensure patients have access to adequate pain relief after surgery while reducing the risks of opioid overprescribing,” said Bicket.
The study was published in JAMA Surgery.