Primary prevention of prescription opioid diversion: a systematic review of medication disposal interventions

Efficacy of high-voltage, long-duration pulsed radiofrequency for the treatment of acute herpes zoster-related trigeminal neuralgia in a patient with permanent pacemaker

Background

Recognizing the seriousness of the misuse and abuse of medical narcotics, the South Korean government introduced the world's first narcotic management system, the Narcotics Information Management System (NIMS). This study aimed to explore the recent one-year opioid prescribing patterns in South Korea using the NIMS database.

Methods

This study analyzed opioid prescription records in South Korea for the year 2022, utilizing the dispensing/administration dataset provided by NIMS. Public data from the Korean Statistical Information Service were also utilized to explore prescription trends over the past four years. The examination covered 16 different opioid analgesics, assessed by the total number of units prescribed based on routes of administration, type of institutions, and patients’ sex and age group. Additionally, the disposal rate for each ingredient was computed.

Results

In total, 206,941 records of 87,792,968 opioid analgesic units were analyzed. Recently, the overall quantity of prescribed opioid analgesic units has remained relatively stable. The most prescribed ingredient was oral oxycodone, followed by tapentadol and sublingual fentanyl. Tertiary hospitals had the highest number of dispensed units (49.4%), followed by community pharmacies (40.2%). The highest number of prescribed units was attributed to male patients in their 60s. The disposal rates of the oral and transdermal formulations were less than 0.1%.

Conclusions

Opioid prescription in South Korea features a high proportion of oral formulations, tertiary hospital administration, pharmacy dispensing, and elderly patients. Sustained education and surveillance of patients and healthcare providers is required.

Self-Reported Prescription Opioid Use Among Participants with Chronic Spinal Cord Injury

Background

Individuals with spinal cord injuries (SCI) experience high rates of prescription opioid use, yet there is limited data on frequency of opioid use and specific medications being taken.

Objectives

To examine the frequency of self-reported prescription opioid use among participants with SCI and the relationship with demographic, injury, and socioeconomic characteristics.

Methods

A cohort study of 918 adults with SCI of at least 1-year duration completed a self-report assessment (SRA) that indicated frequency of specific prescription opioid use based on the National Survey on Drug Use and Health (NSDUH).

Results

Forty-seven percent of the participants used at least one prescription opioid over the last year; the most frequently used was hydrocodone (22.1%). Nearly 30% used a minimum of one opioid at least weekly. Lower odds of use of at least one opioid over the past year was observed for Veterans (odds ratio [OR] = 0.60, 95% CI = 0.38, 0.96) and those with a bachelor's degree or higher (OR = 0.63, 95% CI = 0.44, 0.91). When restricting the analysis to use of at least one substance daily or weekly, lower odds of use was observed for those with a bachelor's degree or higher and those with income ranging from $25,000 to $75,000+. None of the demographic or SCI variables were significantly related to prescription opioid use.

Conclusion

Despite the widely established risks, prescription opioids were used daily or weekly by more than 28% of the participants. Usage was only related to Veteran status and socioeconomic status indicators, which were protective of use. Alternative treatments are needed for those with the heaviest, most regular usage.

Assessing the Impact of a Serious Game (MedSMARxT: Adventures in PharmaCity) in Improving Opioid Safety Awareness Among Adolescents and Parents: Quantitative Study

BACKGROUND

The opioid crisis continues to worsen across the United States, affecting people of all demographics. Few evidence-based interventions exist for educating families, particularly those with adolescents, about opioid prescription safety. Serious games have demonstrated impacts in improving medication-related outcomes for various health conditions. The characterizing goal of this serious game is to improve opioid safety knowledge and awareness among adolescents and their families.

OBJECTIVE

This study evaluated the impact of a serious game, MedSMARxT: Adventures in PharmaCity, designed to foster opioid safety awareness among adolescents and their parents.

METHODS

A national sample of parents and their adolescent children was recruited through Qualtrics research panels, social media, listservs, and snowball sampling. Eligible participants were adolescents aged between 12 and 18 years and their parents. Study participants were required to reside in the United States; speak, read, and understand English; and have access to a computer with a webcam. Parent-child dyads completed pregame and postgame surveys and participated in gameplay for up to 30 minutes. Primary outcome scales have been previously evaluated by the study team.

RESULTS

A total of 60 adolescent participants and 68 parent participants met full attention criteria for inclusion in this study. Statistical analysis confirmed that both adolescents' and parents' concept scores improved from baseline regarding opioid safety self-efficacy (adolescent: mean 0.35, SD 0.60; P<.001; parent: mean 0.28, SD 0.42; P<.001), perceived knowledge (adolescent: mean 1.08, SD 1.04; P<.001; parent: mean 0.56, SD 0.55; P<.001), behavioral intent (adolescent: mean 0.26, SD 0.39; P<.001; parent: mean 0.25, SD 0.32; P<.001), safe storage (adolescent: mean 0.12, SD 0.27; P<.001; parent: mean 0.03, SD 0.11; P=.03), disposal knowledge (adolescent: mean 0.10, SD 0.27; P=.006; parent: mean 0.07, SD 0.16; P<.001), and knowledge about misuse behavior (adolescent: mean 0.05, SD 0.14; P=.002; parent: mean 0.04, SD 0.10; P<.001). Participant groups, stratified by who completed and who did not complete gameplay, improved their knowledge and awareness, with no significant differences between subgroups.

CONCLUSIONS

The use of this serious game to improve opioid prescription safety practices among parents and adolescents was supported by the study findings. MedSMARxT: Adventures in PharmaCity is an intervention with the capability of teaching parents and adolescents about safe opioid prescription practices. Further studies and game refinement are needed to demonstrate the effectiveness of a game-based intervention in clinical settings and community pharmacies.

Opioid Risk Mitigation Practices of Interprofessional Oncology Personnel: Results From a Cross-Sectional Survey

BACKGROUND

This study explored the risk mitigation practices of multidisciplinary oncology health-care personnel for the nonmedical use of opioids in people with cancer.

METHODS

An anonymous, cross-sectional descriptive survey was administered via email to eligible providers over 4 weeks at The Ohio State University's Arthur G. James Cancer Hospital. The survey asked about experiences and knowledge related to opioid use disorders.

RESULTS

The final sample of 773 participants included 42 physicians, 213 advanced practice providers (APPs consisted of advanced practice nurses, physician assistants, and pharmacists), and 518 registered nurses. Approximately 40% of participants responded feeling "not confident" in addressing medication diversion. The most frequent risk reduction measure was "Checking the prescription drug monitoring program" when prescribing controlled medications, reported by physicians (n = 29, 78.4%) and APPs (n = 164, 88.6%).

CONCLUSION

People with cancer are not exempt from the opioid epidemic and may be at risk for nonmedical opioid use (NMOU) and substance use disorders. Implementing risk reduction strategies with every patient, with a harm reduction versus abstinence focus, minimizes harmful consequences and improves. This study highlights risk mitigation approaches for NMOU, representing an opportunity to improve awareness among oncology health-care providers. Multidisciplinary oncology teams are ideally positioned to navigate patients through complex oncology and health-care journeys.

Parents' Perceptions of a Serious Game for Educating Families on Prescription Opioid Safety: Qualitative Pilot Study of MedSMARxT: Adventures in PharmaCity

BACKGROUND

Opioid misuse is a pervasive, worsening problem that affects the health of people throughout the United States, including adolescents. There are few adolescent-focused interventions designed to educate them about opioid medication safety. The MedSMARxT: Adventures in PharmaCity, is a serious educational video game that teaches parents and their youths about safe opioid practices.

OBJECTIVE

This study aimed to elucidate parent's perceptions of MedSMARxT: Adventures in PharmaCity and its potential use by parents and their adolescents.

METHODS

Parents of adolescents aged 12 to 18 years who live in the United States were recruited from April to October 2021 via Qualtrics research panels, social media, email listserves, and snowball sampling. The study participants played MedSMARxT: Adventures in PharmaCity for 30 minutes and then participated in a 30-minute postgame interview via WebEx (Cisco). Questions were developed and piloted to examine adults' perceptions of the game. Participants were asked three sets of open-ended questions: (1) questions about the game and elements of the game, (2) what they learned from the game, and (3) questions about their experience with games. Audio recordings were transcribed verbatim. Interview transcripts were coded using content and thematic analysis by study team members to identify major themes and subthemes from the data.

RESULTS

Parent participants (N=67) played MedSMARxT: Adventures in PharmaCity and completed a postgame interview. Analysis extrapolated four primary themes from the data: (1) participant gaming experience, (2) perception of game features, (3) educational purpose of the game, and (4) future use of the game. Most participants (n=56, 84%), had at least some experience with video games. More than half of the participants (n=35, 52%) participants, had positive reactions to the game characters and scenes depicted in MedSMARxT: Adventures in PharmaCity and stated they were realistic for adolescents. Most participants (n=39, 58%), would recommend the game to others. Significant difficulties with gameplay navigation were reported by 38 (57%) participants, as well as a slow game pace. All participants were able to accurately identify the overarching goal of the game: opioid or medication safety. The game reinforced existing knowledge for participants, though many (n=15, 22%), reported a new awareness of the need to store opioid medications in a locked area and the availability of medication disposal drop boxes at pharmacies. Participants stated that they would recommend the game for future use by families and youths in various health care and non-health care settings.

CONCLUSIONS

The use of a tailored serious game is a novel, engaging tool to educate adolescents on opioid safety. MedSMARxT: Adventures in PharmaCity can be used as a tool for parents and adolescents to facilitate meaningful dialogue about safe and appropriate opioid use.

MedSMA℞T Adventures in PharmaCity Game: Youth Experiences and Recommendation for Use in Opioid Safety Education

Adolescents are often excluded from the creation of opioid safety interventions; therefore, it is crucial to design evidence-based interventions tailored for and with youth. Video games are ubiquitous and approachable to adolescents making them an accessible educational modality. MedSMA℞T: Adventures in PharmaCity is a serious game that educates adolescents and their families on the safe, appropriate, and responsible use of opioid prescriptions. The first objective of the study was to elucidate adolescents' experiences and perceptions of the game. The second objective was to elicit their recommendations for use and suggestions for improvement. Adolescents were recruited through Qualtrics research panels, social media, listservs, and snowball sampling. Recruitment occurred between April 2021 and October 2021. Eligible adolescents played the game and completed a follow-up virtual semi-structured interview with a study team member. Interviews were transcribed verbatim and uploaded to NVivo for data analysis. A thematic content analysis was performed. A total of seventy-two adolescents participated. Analysis yielded four themes: prior gaming experience, educational salience, game design impressions, and recommendations for improvement. Most adolescents approached MedSMA℞T with prior gaming experience. The youth correctly identified the game's intended objective: the promotion of opioid medication safety. Adolescents had overarchingly positive impressions of the game's levels, characters, and graphics. Study participants suggested expanded game levels, improved controls, and more instructions for gameplay. In summary, adolescents had favorable experiences using the MedSMA℞T game which allude to the wide-spread acceptability of this intervention among young people.

Evaluation of medication disposal behaviors after counseling by a community pharmacist and provision of a home medication disposal kit

OBJECTIVES

To evaluate providing an at-home medication disposal kit on opioid disposal behaviors. Self-report of prior disposal behaviors also was assessed to describe the sample.

DESIGN

Pilot study with randomization. Surgery outpatients were counseled on medication disposal by a pharmacist from the outpatient community pharmacy at the bedside and given an informational pamphlet detailing recommended disposal methods. Patients on even-numbered dates also received an at-home medication disposal system, creating a quasi-randomized assignment.

SETTING

Hospital outpatient surgery center.

PARTICIPANTS

Ambulatory surgery outpatients filling an opioid prescription.

OUTCOME MEASURES

Patients were called one month after discharge to answer a structured interview about their disposal behaviors. Responses were recorded. Descriptive statistics were calculated to describe disposal behaviors, and chi-squared and t-tests were used to assess group differences.

RESULTS

A total of 45 patients participated, with 24 receiving a disposal packet. Of the 23 patients that had left-over tablets, 8 patients disposed of them. Seven (30.4%) of patients with leftovers disposed of their medication safely as recommended by the pharmacist during counseling. Rates of appropriate disposal were statistically similar. Of the 14 patients who had left-over opioids and received a disposal packet, 5 (35.7%) patients used the provided packet. Of the 9 patients with left-over opioids who did not receive the disposal packet, 2 (22.2%) patients disposed of their left-over opioids appropriately.

CONCLUSION

This pilot provides insight into the implementation of medication disposal services in the ambulatory surgery setting and the potential impact that a community pharmacist can have in promoting safe medication disposal. While the study demonstrated similar rates of disposal, those with the disposal packet exclusively reported using the packet as their method of disposal, suggesting having the packet on-hand simplified decision-making.

Pharmacists' perspectives on MedSMA℞T: A serious game to educate youth about opioid safety

BACKGROUND

Adolescent opioid misuse has been recognized as a dire public health issue. Despite efforts to address the opioid epidemic in the United States, opioid-related morbidity and mortality have continued to rise. Few interventions have been tailored to prevent adolescent opioid misuse. MedSMA℞T: Adventures in PharmaCity (MedSMA℞T), is a serious game that educates the end-user by challenging them to make applicable decisions in a low-stakes environment.

OBJECTIVE

The study aimed to characterize pharmacists' perspectives on using MedSMA℞T to educate adolescents and families about opioid medication safety.

METHODS

Pharmacists were recruited from the Pharmacy Practice Enhancement and Action Research Link (PearlRx) and the Pharmacy Society of Wisconsin. Consented pharmacists played the MedSMA℞T game for 30 minutes while a research team member observed via Zoom. Virtual semi-structured interviews (45 minutes) were recorded and transcribed verbatim. Two members of the research team independently coded each transcript using NVivo software to conduct inductive thematic analyses. Bi-weekly meetings were held to discuss and refine codes as well as the master codebook, and identify prevalent themes (intercoder reliability, kappa = 0.91).

RESULTS

Twenty-two pharmacists were interviewed between August and November 2021. Four themes were identified: game content and design, patient education, implementation barriers, and implementation facilitators. Most pharmacists perceived MedSMA℞T to be an effective resource for opioid safety education. Pharmacists reported that age-appropriate language was used in combination with realistic scenarios and relatable characters. Pharmacists also highlighted the value of interactive gameplay to engage the player to actively learn and recall educational content.

CONCLUSIONS

Pharmacists play an integral role as medication experts and contributed valuable insights into using and incorporating the MedSMA℞T game into various pharmacy practice settings. Future work is necessary to understand parents' and adolescents' perceptions of using MedSMA℞T as an opioid safety education tool in pharmacies.

Implementation of an opioid reduction toolkit in pancreatectomy patients significantly increases patient awareness of safe practice and decreases amount prescribed and consumed

BACKGROUND

Postoperative opioid abuse following surgery is a major concern. This study sought to create an opioid reduction toolkit to reduce the number of narcotics prescribed and consumed while increasing awareness of safe disposal in pancreatectomy patients.

METHODS

Prescription, consumption, and refill request data for postoperative opioids were collected from patients receiving an open pancreatectomy before and after the implementation of an opioid reduction toolkit. Outcomes included safe disposal practice awareness for unused medication.

RESULTS

159 patients were included in the study: 24 in the pre-intervention and 135 in the post-intervention group. No significant demographic or clinical differences existed between groups. Median morphine milliequivalents (MMEs) prescribed were significantly reduced from 225 (225-310) to 75 (75-113) in the post-intervention group (p < 0.0001). Median MMEs consumed were significantly reduced from 109 (111-207) to 15 (0-75), p < 0.0001), as well. Refill request rates remained equivalent during the study (Pre: 17% v Post: 13%, p = 0.9) while patient awareness of safe disposal increased (Pre: 25% v Post: 62%, p < 0.0001).

DISCUSSION

An opioid reduction toolkit significantly reduced the number of postoperative opioids prescribed and consumed after open pancreatectomy, while refill request rates remained the same and patients' awareness of safe disposal increased.

Patient Willingness to Dispose of Leftover Opioids After Surgery: A Mixed Methods Study

We examined how convenience and financial incentives influence patient willingness to dispose of leftover prescription opioids after surgery. We also identified additional barriers and facilitators to disposal.

Background

In the United States, up to 70% of surgical patients are prescribed opioids and up to 92% will have leftover tablets. Most do not dispose of leftover opioids, increasing the risk for opioid-related harm. Current interventions promoting opioid disposal have shown mixed success.

Methods

We conducted a mixed methods study using a standard gamble survey and semi-structured interviews. Participants estimated willingness to dispose in 16 scenarios with varying convenience (time requirements of <5, 15, 30, and 60 minutes) and financial incentives ($0, $5, $25, $50). We estimated the likelihood of disposal using a multivariable mixed effects modified Poisson regression model. Semi-structured interviews explored how convenience, financial incentives, and other barriers and facilitators influenced decisions to dispose.

Results

Fifty-five participants were surveyed and 42 were interviewed. Most were willing to dispose when the time required was <15 minutes. Few were willing to dispose if the process required 60 minutes, although a $50 financial incentive increased rates from 9% to 36%. Anxiety about future pain, opioid scarcity, recreational use, family safety, moral beliefs, addiction, theft, and environmental harm also influenced decision-making.

Conclusions

Interventions promoting opioid disposal should focus on convenience, but the selective use of financial incentives can be effective. Tailoring interventions to individual barriers and facilitators could also increase disposal rates.

Factors Associated With Safe Prescription Opioid Disposal After Surgery in Adolescents

INTRODUCTION

Unused prescription opioids contribute to diversion, unintended exposure, and poisonings in adolescents. Factors associated with safe prescription opioid disposal for adolescents undergoing surgery are unknown.

METHODS

Parents of adolescents (13-20 y) undergoing surgery associated with an opioid prescription were enrolled preoperatively. Parents completed a baseline survey measuring sociodemographics and family history of substance abuse and two postoperative surveys capturing opioid use and disposal at 30 and 90 d. Safe disposal was defined as returning opioids to a healthcare facility, pharmacy, take-back event, or a police station. Factors associated with safe opioid disposal were assessed using bivariate analysis.

RESULTS

Of 119 parent-adolescent dyads, 90 (76%) reported unused opioids after surgery. The majority of parents reporting unused opioids completed the surveys in English (80%), although many (44%) spoke another language at home. Most reported income levels <$60,000 (54%), did not attend college (69%), and had adequate health literacy (66%). Most parents (78%) did not report safe opioid disposal. Safe opioid disposal was associated with younger patient age, (median 14 y, IQR 13-16.5 versus median 15.5 y, IQR 14-17, P = 0.031), fewer days taking opioids (median 5, IQR 2-6 versus median 7, IQR 4-14, P = 0.048), and more leftover pills (median 20, IQR 10-35 versus median 10, IQR 5-22, P = 0.008).

CONCLUSIONS

Most parents fail to safely dispose of unused opioids after their adolescent's surgery. Younger patient age, shorter duration of opioid use, and higher number of unused pills were associated with safe disposal. Interventions to optimize prescribing and educate parents about safe opioid disposal are warranted.

Efficacy of a password-protected, pill-dispensing device with mail return capacity to enhance disposal of unused opioids after cancer surgery

BACKGROUND

Opioid misuse is a public health crisis, and unused postoperative opioids are an important source. Although 70% of pills prescribed go unused, only 9% are discarded. This study evaluated whether an inexpensive pill-dispensing device with mail return capacity could enhance disposal of unused opioids after cancer surgery.

METHODS

A prospective pilot study was conducted among adult patients who underwent major cancer-related surgery. Patients received opioid prescriptions in a mechanical device (Addinex) linked to a smartphone application (app). The app provided passwords on a prescriber-defined schedule. Patients could enter a password into the device and receive a pill if the prescribed time had elapsed. Patients were instructed to return the device and any unused pills in a disposal mailer. The primary end point was feasibility of device return, defined as ≥50% of patients returning the device within 6 weeks of surgery. Also explored was total pill use and return as well as patient satisfaction.

RESULTS

Among 30 patients enrolled, the majority (n = 24, 80%) returned the device, and 17 (57%) returned it within 6 weeks of surgery. In total, 567 opioid pills were prescribed and 170 (30%) were used. Of 397 excess pills, 332 (84% of unused pills, 59% of all pills prescribed) were disposed of by mail. Among 19 patients who obtained opioids from the device, most (n = 14, 74%) felt the benefits of the device justified the added steps involved.

CONCLUSIONS

Use of an inexpensive pill-dispensing device with mail return capacity is a feasible strategy to enhance disposal of unused postoperative opioids.

A safe in-home disposal system with every opioid prescription? Food and Drug Administration is considering a potential new Risk Evaluation and Mitigation Strategy that could impact pharmacists

Misuse of prescription opioids contributes to the ongoing crisis of opioid-related overdose and deaths in the United States. The failure of patients and caregivers to safely dispose of unused opioids contributes to the problems. In 2018, Public Law 115-271 provided the U.S. Food and Drug Administration (FDA) authority to mandate a Risk Evaluation and Mitigation Strategy (REMS) for safe disposal packaging or safe disposal solutions for opioid analgesic medications. The FDA has been collaborating with stakeholders to determine whether a new REMS is needed. A new or revised opioid REMS could substantially affect opioid packaging, pharmacist roles and services, and dispensing activities such as education, counseling, and product distribution. The pharmacy profession has provided limited input to FDA regarding a potential new or revised opioid REMS. In this commentary, we aim to (1) provide awareness and raise questions on pertinent issues regarding opioid use and safe home disposal, (2) offer considerations for regulators on needed research in the development and assessment of a new REMS, and (3) highlight actions for pharmacist engagement in patient care services to promote safe use and safe home disposal of opioids. Consideration of a potential mandate regarding enhanced safety packaging or safe disposal solutions for opioids presents opportunities to revisit professional roles and engage proactively with the FDA and other stakeholders. We hope this commentary stimulates timely feedback by pharmacy leaders, researchers, and practitioners on whether and how options for safe home disposal of opioids should be included in a REMS in contemplation of potential benefits, unintended consequences, expanded professional roles, timeline, assessment of program effectiveness, and adequate compensation. We support a shared opioid REMS that funds the counseling of patients and caregivers on safe opioid use and safe home opioid disposal options and provides appropriate education and products to facilitate that disposal.