Using an Environmentally Friendly Disposal Bag to Discard Leftover Opioids After Gynecologic Surgery

A Double-Blinded Randomized Controlled Trial Assessing the Efficacy of Opioid Disposal Instructions with Parental Education on Proper Opioid Disposal Rates Following Ambulatory Pediatric Urologic Surgery

OBJECTIVES

To determine if the administration of standardized opioid disposal instructions with focused parental education improves proper disposal of leftover opioid medication among families of children undergoing ambulatory urologic surgery compared to routine postoperative instructions.

METHODS

A prospective, double-blinded, single-center randomized controlled trial was conducted in children 6-18y undergoing ambulatory urology procedures between October 2021-April 2023. Patients were randomized (1:1) to receive either the Food and Drug Administration (FDA) opioid disposal best practices worksheet plus nursing parental education or routine postoperative instructions alone. All patients were prescribed acetaminophen and ibuprofen and a per-protocol rescue opioid prescription. The primary outcome was rate of proper opioid disposal at 10-14d post-procedure. Secondary outcomes included parents postoperative pain measure (PPPM) scores, numerical pain scale (NPS) scores, and weight-based opioid utilization at 48h and 10-14d.

RESULTS

We randomized 104 participants (53 intervention, 51 control) with 97% (101/104) complete follow-up data at 10-14d. Patient demographics, procedural characteristics, and analgesia use were similar between groups. We observed no significant difference in proper opioid disposal rates between arms (31% intervention vs. 18% control; estimated difference in proportion 13% [95% CI, -4-29%]; p=0.1). There was no increased odds of proper disposal of leftover opioid medication at 10-14d with the intervention compared to the control (OR 2.0 [95% CI 0.8-5.1]; p=0.1). We observed no differences in PPPM scores, NPS scores, or opioid utilization at 48h or 10-14d.

CONCLUSIONS

Providing formal opioid disposal instructions with parental education did not improve proper disposal of leftover opioid medication nor did it alter post-discharge opioid utilization after pediatric urologic surgery.

Evaluation of a tiered opioid prescription algorithm in an ERAS pathway: exploring opportunities for further refinement

BACKGROUND

Opioid over-prescription is wasteful and contributes to the opioid crisis. We implemented a personalized tiered discharge opioid protocol and education on opioid disposal to minimize over-prescription.

OBJECTIVE

To evaluate the intervention by investigating opioid use post-discharge for women undergoing abdomino-pelvic surgery, and patient adherence to opioid disposal education.

METHODS

We analyzed post-discharge opioid consumption among 558 patients. Eligible patients included those who underwent elective gynecologic surgery, were not taking scheduled opioids pre-operatively, and received discharge opioids according to a tiered prescribing algorithm. A survey assessing discharge opioid consumption and disposal safety knowledge was distributed on post-discharge day 21. Over-prescription was defined as >20% of the original prescription left over. Descriptive statistics were used for analysis.

RESULTS

The survey response rate was 61% and 59% in the minimally invasive surgery and open surgery cohorts, respectively. Overall, 42.8% of patients reported using no opioids after hospital discharge, 45.2% in the minimally invasive surgery and 38.6% in the open surgery cohort. Furthermore, 74.9% of respondents were over-prescribed, with median age being statistically significant for this group (p=0.004). Finally, 46.4% of respondents expressed no knowledge regarding safe disposal practices, with no statistically significant difference between groups (p>0.99).

CONCLUSION

Despite implementation of the tiered discharge opioid algorithm aimed to personalize opioid prescriptions to estimated need, we still over-prescribed opioids. Additionally, despite targeted education, nearly half of all patients who completed the survey did not know how to dispose of their opioid tablets. Additional efforts are needed to further refine the algorithm to reduce over-prescription of opioids and improve disposal education.

Effect of a Medication Disposal Pouch versus Usual Care on Post Discharge Disposal of Unused Opioids: A Randomized Controlled Trial

PURPOSE

To determine frequency of disposal of unused opioids after surgical procedures based on medication disposal pouch use or usual care, and patient factors associated with disposal.

DESIGN

Two-group experimental design and convenience sample.

METHODS

Same-day surgery adults who received opioid orders were randomized to usual care or usual care plus a medication disposal pouch for opioid disposal. Opioid disposal and pain characteristics were collected by telephone at 30±10 days post discharge. Other data were abstracted from a hospital database. Data were compared using Kruskal-Wallis, Pearson's Chi-Square and Fisher's exact tests. Logistic regression models were built to identify predictors of disposal of unused opioids.

FINDINGS

Of 221 adults, mean age was 58.5 years and 50.2% were female. Overall, 121 received medication disposal pouches and 100 received usual care. Among those with a filled prescription, there was no between-group difference in the number of patients who used all of their opioid medication (disposal pouch group, 29.5%; usual care group, 21.7%). Of 74 disposal pouch and 65 usual care patients who did not use all opioid medications, 23.0% and 13.8%, respectively, disposed of opioids, and of the 23.0% of patients who disposed of medications in the disposal pouch group, 94.1% used the medication disposal pouch. After controlling for 7 factors, the odds of disposal of unused opioids increased among patients who received the intervention, had lower pain scores on the worst day of postoperative pain, and had a history of renal diagnoses (versus those with gastrointestinal diagnoses).

CONCLUSIONS

Although opioid medication disposal rates were higher in the medication disposal pouch group; overall rates of disposal of unused opioid medications were low. More research is needed to learn important factors and methods associated with opioid disposal.

Examining Age and Postoperative Opioid Use in the Urogynecology Population: A Prospective Study

IMPORTANCE

Surgeons must individualize postoperative pain management while also reducing the amount of unused prescribed opioids.

OBJECTIVES

This study compared postoperative opioid use in younger versus older women following urogynecologic surgery. We also assessed the likelihood of women returning unused opioids for safe disposal.

STUDY DESIGN

This was a prospective study of women undergoing pelvic reconstructive surgery divided into 2 cohorts: younger (<65 years) and older (≥65 years). Our primary outcome was total opioid use, measured in morphine milligram equivalents (MME). We also assessed the average pain score during the first week after surgery measured by a numerical pain scale (range, 0-10). Our secondary outcome was the rate of return of unused prescribed opioids at the 6-week postoperative visit utilizing a disposable drug deactivation system.

RESULTS

From April 2019 to September 2021, 152 participants were enrolled: 92 (61%) in the younger cohort (mean age, 51 ± 8 years) and 60 (39%) in the older cohort (mean age, 72 ± 6 years). For our primary outcome, younger women used significantly more opioids during the first postoperative week compared with older women (49 ± 71 vs 28 ± 40 MME, respectively, P = 0.04), despite no difference in average pain scores (4 ± 2 younger vs 3 ± 2 older, P = 0.05). For our secondary outcome, 23% of participants returned their opioids for disposal with the drug deactivation system.

CONCLUSIONS

Younger women had higher postoperative opioid use despite similar pain scores after urogynecologic surgery. Among those prescribed opioids, a quarter of participants returned their opioids for disposal at their postoperative visit.

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.