Investigators are studying the problems of surgery centers and physicians prescribing opioid medication with too little information about patients’ history with opioids and without adequate patient education on using and disposing of leftover drugs.

When two out of five opioid overdose deaths can be traced to a prescription opioid addiction, healthcare researchers are taking note. (More statistics on this subject from the CDC are available at: http://bit.ly/2N8TJ2k.) The epidemic of opioid overdoses now exceeds AIDS deaths during the peak years in the mid-1990s. The 64,070 opioid overdose deaths in the United States in 2016 is higher than the total number of American combat deaths sustained during the entirety of the Vietnam War. (The full 2017 report from the Police Executive Research Forum is available at: https://bit.ly/2y6XNfI.)

A national poll of Americans 50-80 years of age found that 29% said they had filled a prescription for opioid pain medication in the past two years, says Preeti N. Malani, MD, professor of internal medicine at the University of Michigan Medical School and chief health officer at the university’s office of the president. “The main reasons for the prescriptions were arthritis-related pain, back pain, surgery, and injury,” Malani explains.

Researchers have highlighted opioid problems among preoperative and postsurgery patients. It is an issue that surgeons and ambulatory surgery center (ASC) staff must address with policies and procedures that reduce the risk of opioid misuse and harm. Some research even shows how presurgery opioid use can increase adverse outcomes post-surgery. For example, the authors of one recent study found that prolonged, preoperative opioid use was associated with worse outcomes after joint replacement surgery, including hospital readmissions and revision surgery.1

“We looked at a large national, health market database, looking at all patients with knee replacement, over 300,000 patients,” says Hue H. Luu, MD, associate professor, department of orthopaedic surgery and rehabilitation medicine, University of Chicago Medicine & Biological Sciences. “We looked at readmission rates and revision surgery for these patients, either hip or knee. We looked at how many were taking opioids. Essentially, we found that patients who had been taking opioids before surgery, especially if they were taking it for more than 60 days, had a much higher rate of readmission to the hospital and, also, the likelihood of having additional revision surgery.”

The study authors concluded that preoperative opioid use was a significant risk factor for surgical complications in total knee arthroplasty and total hip arthroplasty.1 Preoperative opioid use is common, with more than one in four patients presenting for surgery reporting opioid use.2

“It’s important we have our patients minimize narcotic use prior to surgeries, especially if they’ve been using opioids for more than 60 days,” Luu offers. “Cutting down on narcotics will make their recovery much better and improve our ability to manage their pain much better after surgery.”

Opioid medication diversion is another common problem. Opioids prescribed by physicians to treat postsurgery pain in older adults often are excessive and can end up in the hands of people who do not need the medication, according to the July/August 2018 National Poll on Healthy Aging, conducted by the University of Michigan. (Read much more about the poll online at: https://bit.ly/2BYZZbJ.) The authors of a new study found that surgical patients often are prescribed too many opioid pills and receive too little education about how to safely dispose of leftovers. Implementing evidence-based opioid prescribing recommendations could reverse this trend.3

“Our findings highlight the prevalence of opioid medications that individuals have in their home,” says Jennifer F. Waljee, MD, MPH, MS, associate professor of surgery at the University of Michigan Medical School.

While respondents to the National Poll on Healthy Aging said they were educated about how to take an opioid, when to wean off the medication, and which other medications were safe to use with opioids, there was less education around safe disposal of leftover opioid drugs, Waljee explains. Additionally, the survey revealed that nearly half of people who filled an opioid prescription within the past two years had leftover medication, Malani says.

“We also asked, ‘If you did have leftovers, what would you do?’” Malani notes. Some said they would dispose of it at home. Others said they would take the leftover opioids to an approved disposal facility. However, most said they would keep the leftovers, Malani adds.

“It is concerning to see the number of individuals who are not inclined to dispose of opioids after being done with them,” Waljee laments. “Overall, we encourage people to dispose of these medications whenever [finished] using them because we know misdirected medication is a gateway to misuse.”

As more attention is given to opioid use and prescribing practices, things will change for the better, Malani predicts.

“I’m really hopeful because I do feel that physicians, surgeons, and other health providers will respond to the data pretty well,” she says. “It’s one of these issues where a generation ago, people talked about pain being the fifth vital sign and how we need to treat pain [aggressively]. Now, there’s more thought that people don’t need as many opioid pills as we give them.”

Adding to the arsenal of recent studies concerning opioid use among surgical patients, the authors of another new investigation concluded that 40% of chronic, pre-operative opioid users still fill opioid prescriptions 12 months after major orthopedic surgery.4

“It was surprising to us how distinct it was. If you were a chronic opioid user presurgery, the surgery did not seem to correct the need for these medications,” says Andrew J. Pugely, MD, assistant professor in orthopedic surgery, division of spine surgery, at the University of Iowa Hospitals & Clinics.

Opioid medication is important for managing pain, especially for surgical care. “For procedural care, making sure patients have safe, comfortable recovery is critical to helping them return to their activities of daily living, families, and work,” Waljee says. “Opioids play an important role after surgery, but we need to make sure we’re prescribing according to what patients need.”

Once opioid medication is no longer needed, patients should dispose of it properly, Waljee advises. “We strongly encourage people to dispose of them in an FDA-approved manner.”

Overprescribing occurs because there are too few guidelines on how to prescribe opioids after surgery. “For years, we have prescribed without evidence-based guidelines around that. It’s also coupled with the fact that these medications were thought to not be addictive, if given in the context of acute pain,” Waljee explains. “We now know that’s different. There still is a lot of information and evidence to be learned about why physicians tended to overprescribe.”

A recent analysis revealed that prescribing limits are effective in reducing opioid misuse and that opioid-naïve patients might need far fewer pills than doctors typically prescribe, Waljee says. For instance, future investigations could help identify patients who go from using opioids for acute pain to persistent use and how to find pathways to deal with those patients, she adds.

“With better research, we’ll better tailor our prescribing to patients’ needs based on risk factors, and we’ll have less excess of opioid pills after surgery,” Waljee says. “It will make a dent in the opioid epidemic by preventing those pills from going on to unintended use by getting them out of communities.”

REFERENCES

  1. Weick J, Bawa H, Dirschl DR, Luu HH. Preoperative opioid use is associated with higher readmission and revision rates in total knee and total hip arthroplasty. J Bone Joint Surg Am 2018;100:1171-1176.
  2. Hilliard PE, Waljee J, Moser S, et al. Prevalence of preoperative opioid use and characteristics associated with opioid use among patients presenting for surgery. JAMA Surg 2018 Jul 11. doi: 10.1001/jamasurg.2018.2102. [Epub ahead of print].
  3. Howard R, Alameddine M, Klueh M, et al. Spillover effect of evidence-based opioid prescribing after surgery. J Am Coll Surg 2018 Jul 2. pii: S1072-7515(18)30436-8. doi: 10.1016/j.jamcollsurg.2018.06.007. [Epub ahead of print].
  4. Pugely AJ, Bedard NA, Kalakoti P, et al. Opioid use following cervical spine surgery: Trends and factors associated with long-term use. Spine J 2018 Apr 10. pii: S1529-9430(18)30129-3. doi: 10.1016/j.spinee.2018.03.018. [Epub ahead of print].

Disposing of Opioids Safely

Research shows that patients often hoard unused opioid medications, unwilling or uneducated about how to dispose of them. Jennifer F. Waljee, MD, MPH, MS, offers some helpful advice.

  • Make proper disposal convenient. Patients need a convenient access to opioid disposal, Waljee offers. “We’ve seen pharmacies create methods for disposing of medications, whether it’s creating charcoal bags for putting medications in for disposal or creating take-back sites within hospitals and clinics.” Additionally, post-op patients can return for a visit, bringing unused pills with them.
  • Improve education. ASC staff should educate both clinicians and patients about why it is important to dispose of opioids properly. They also should emphasize the risks of keeping leftover opioid pills in the home, Waljee says.
  • Reassure patients. “It’s important for us to reassure patients that we’ll manage their pain when needed,” Waljee says. “Sometimes, patients are concerned about prescribing limits and that people won’t get medications when they need them. We want to reassure patients we’ll make certain their pain is well managed and that it’s a paramount concern for us.”