Myron Yaster, MD
Following on the heels of a 2015 inpatient study, researchers at the Johns Hopkins University School of Medicine have found that health care providers dispense far more medicine than is necessary to treat pain after pediatric outpatient surgery. They hypothesized that the tremendous amount of unused medications may be contributing to the national epidemic of nonmedical use of prescription opioids.
With the national prioritization of treating pain, both the number of written opioid prescriptions and the amount of drug dispensed have grown substantially. While this is ultimately a laudable goal, noted Myron Yaster, MD, unused opioids are often diverted and abused, only adding to the growing burden of nonmedical use of prescription opioids. In the end, the question of opioid prescribing becomes: When does too much of a good thing become a bad thing?
“The good news is we know that opioids work,” said Dr. Yaster, the Richard J. Traystman Distinguished Professor at the Johns Hopkins University School of Medicine, in Baltimore. “We can’t lose sight of the fact that patients go home in pain after surgery and the opioids work.”
Pediatric Same-Day Surgery Patients
To help gain perspective on how much opioids are left unused at the end of treatment, Dr. Yaster and his colleagues enrolled 152 English-speaking outpatients, all of whom were given opioid prescriptions on discharge from a pediatric same-day surgical suite. Prescriptions were generated by the hospital’s computerized narcotic prescription writer and subsequently analyzed by the investigators for drug, formulation and quantity dispensed.
The investigators interviewed parents by phone within two days of discharge and again 10 to 14 days after discharge to determine:
- whether prescriptions were filled;
- whether pain was controlled (using a 4-point Likert scale);
- how long opioids were used;
- the amount of medication left at the end of therapy;
- whether patients were given instructions regarding the disposal of leftover drugs; and
- whether remaining drugs were actually discarded.
The number and ages of all people residing in the patient’s household also were collected.
It was found that parents of 118 patients completed the two-day and/or 10- to 14-day interviews. Oxycodone was prescribed to 85% of patients; the remaining 15% received hydrocodone and acetaminophen. Most patients (88%) received the drugs in a liquid formulation, while 12% received tablets. Patients took opioids for 4±3 days (range, 0-11 days). Pain control was rated as excellent (51%), good (31%), fair (7%) and poor (1%); 10% did not respond.
Good News: Everybody Liked the Medicine
“Nobody thought they got too little medicine,” Dr. Yaster reported at the 2016 annual meeting of the International Anesthesia Research Society (abstract S-244). “Everybody thought they either got just right or too much. And parents are really satisfied that the drugs work.”
Yet as the investigators learned, the amount of drug remaining after treatment was startling (Figure 1). Indeed, at 14 days, 12±9 tablets (range, three to 25 tablets), 86±118 mL (range, 0-505 mL) and 22±14 doses (range, zero to 60) of medication were unused. Put another way, patients only used an average of 34% of their dispensed drug. Most parents (63%) were not told what to do with the leftover medication.
Figure 1. Morphine milligram equivalents: dispensed and remaining.
“And no matter what they were told, almost nobody [only 7% of parents in the study] actually disposed of their medicine,” Dr. Yaster revealed (Figure 2).
Figure 2. Disposition of remaining opioids.
“This is exactly what we saw with the other study with inpatients. I would suspect that if any of us go home and open up the medicine cabinet, we’ll find medications from five or six years ago. And if you’ve ever had surgery or needed an opioid yourself, I’ll bet there is a container in your medicine cabinet that’s labeled as an opioid.”
Yet for Dr. Yaster, the study’s most troubling finding was yet to come. The survey revealed that patients averaged 1±1 siblings (range, zero to six) living in the same household. Twenty-six percent had a sibling 12 years of age or older living with them. This, he said, is a recipe for potential disaster.
Bad News: Leftover Opioids Are Gateway Drugs
“The important point here is that leftover opioid is the gateway drug for opioid addiction in the U.S.,” he declared. “It’s not heroin; the gateway medicine is prescription opioids. And then they switch to heroin because it’s cheaper.
“We have to remember that the teenage brain is not the same as the adult brain,” he continued. “Heroin is a terrible thing to teenagers. But in their mind, oxycodone—because it’s prescribed by a physician and dispensed by a pharmacist—is safe. So that’s why it becomes the introductory drug.”
The answer to this problem can take several different forms, whether it be proper disposal routes, specific dosing requirements or a self-degrading drug that loses potency over time. “We’ve been working very hard on this problem at our school of bioengineering, and we may have a solution,” he said.
For Peter J. Davis, MD, professor and chief of pediatric anesthesiology at the University of Pittsburgh Medical Center, a more immediate solution involves specifically tailoring the prescription to the patient in question.
“You have all these same-day surgery patients undergoing different procedures, but everybody writes the prescription the same way: 10-day supply, no matter what it is,” he said.
“The real issue is that different operations warrant different drug interventions. If you look at tonsillectomy/adenoidectomy, you might need three days of treatment. That’s a whole lot different than a patient who just had a total knee arthroplasty.”
“The bottom line is that we need a better system of figuring out why we dispense so much,” Dr. Yaster concluded. “There are no data to give anybody any idea how much to dispense to our patients.”