Elsevier

Drug and Alcohol Dependence

Volume 168, 1 November 2016, Pages 328-334
Drug and Alcohol Dependence

Full length article
Unused opioid analgesics and drug disposal following outpatient dental surgery: A randomized controlled trial

https://doi.org/10.1016/j.drugalcdep.2016.08.016Get rights and content

Highlights

  • Opioid analgesics that are unused after surgery may contribute to drug diversion.

  • 54% of opioids in this study remained unused 3 weeks after dental surgery.

  • Little research has examined pharmacy programs to promote safe drug disposal.

  • Patients in our intervention were more willing to dispose of unused opioids.

Abstract

Background

Individuals who abuse prescription opioids often use leftover pills that were prescribed for friends or family members. Dental surgery has been identified as a common source of opioid prescriptions. We measured rates of used and unused opioids after dental surgery for a pilot program to promote safe drug disposal. Methods: We conducted a randomized controlled trial of opioid use patterns among patients undergoing surgical tooth extraction at a university-affiliated oral surgery practice. The primary objective was to describe opioid prescribing and consumption patterns, with the number of unused opioid pills remaining on postoperative day 21 serving as the primary outcome. The secondary aim was to measure the effect of a behavioral intervention (informing patients of a pharmacy-based opioid disposal program) on the proportion of patients who disposed or reported intent to dispose of unused opioids. (NCT02814305) Results: We enrolled 79 patients, of whom 72 filled opioid prescriptions. On average, patients received 28 opioid pills and had 15 pills (54%) left over, for a total of 1010 unused pills among the cohort. The behavioral intervention was associated with a 22% absolute increase in the proportion of patients who disposed or reported intent to dispose of unused opioids (Fisher’s exact p = 0.11). Conclusion: Fifty-four percent of opioids prescribed in this pilot study were not used. The pharmacy-based drug disposal intervention showed a robust effect size but did not achieve statistical significance. Dentists and oral surgeons could potentially reduce opioid diversion by moderately reducing the quantity of opioid analgesics prescribed after surgery.

Introduction

The National Institute on Drug Abuse defines nonmedical use of prescription drugs as “use of a medication without a prescription, in a way other than as prescribed, or for the experience or feelings elicited” (National Institute on Drug Abuse, 2011). In 2014, it was estimated that 12 million Americans had used opioid analgesics nonmedically in the last year (Jones et al., 2014). Approximately 69% of individuals who misuse opioid analgesics obtain pills from family or friends in the community (Substance Abuse and Mental Health Services Administration, 2014). Unused opioids from prior prescriptions are a major source of these diverted pills (McCabe et al., 2013). Research suggests that 42–66% of opioid analgesics prescribed after outpatient surgical procedures are left unused (Bates et al., 2011, Harris et al., 2013, Rodgers et al., 2012). In one study of 250 patients undergoing elective hand and wrist surgery, more than 4600 opioid analgesic tablets (19 tablets per patient) remained unused two weeks after surgery (Rodgers et al., 2012).

In 2005, nearly 21 million surgical tooth extractions were performed on approximately 10 million patients in the United States (American Dental Association, 2007, Friedman, 2007). Postsurgical pain from this procedure is usually moderate to severe prior to initial analgesic intake, and it is considered a pivotal model by the Food and Drug Administration for evaluating new analgesic drugs (Hersh et al., 2004, Hersh et al., 2000). Most dental providers prescribe opioid combination drugs (acetaminophen with hydrocodone or oxycodone) together with nonsteroidal anti-inflammatory drugs (NSAIDs) for postsurgical analgesia (Baker et al., 2016, Denisco et al., 2011, Moore et al., 2006). Oral surgeons and general dentists prescribe an average of 20 opioid pills after tooth extraction (Baker et al., 2016, Denisco et al., 2011, Moore et al., 2006, Tufts Health Care Institute Program on Opioid Risk Management, 2010.).

Surveys suggest that opioids prescribed by dentists may be a significant source of drug diversion or misuse (Rigoni, 2003), especially among adolescents and young adults (McCabe et al., 2013). Forty-one percent of respondents in a survey of West Virginia dentists anticipated that patients would have leftover opioids after tooth extraction, yet no research has measured the quantity of unused opioids following dental surgery (Denisco et al., 2011). Historical data suggested that 12 percent of immediate-release opioid prescriptions came from dental practitioners (Rigoni, 2003); however, recent data from the South Carolina prescription drug monitoring program (PDMP) suggest that 45% of initial-fill (e.g., non-refill) opioid prescriptions during 2012–2013 came from dental practitioners (McCauley et al., 2016). The PDMP data also revealed that 11% of dental opioid prescriptions were for patients under age 21 (McCauley et al., 2016).

Many patients with unused opioid analgesics plan to keep them (Centers for Centers for Disease Control and Prevention, 2010, Harris et al., 2013, Kennedy-Hendricks et al., 2016, Lewis et al., 2014). The FDA recommends that patients dispose of unused opioids, but prescribers only rarely give instructions on how to do so (Bates et al., 2011, Wieczorkiewicz et al., 2013). Patients may return most unwanted medications to pharmacies for disposal, but until recently the Drug Enforcement Agency (DEA) prohibited return of controlled substances in this manner. The Safe and Responsible Drug Disposal Act of 2010 provided legislative authority to revise these restrictions, and regulations in October 2014 permitted retail pharmacies to serve as controlled substance disposal sites (Drug Enforcement Agency, 2014, Federal Register, 2014). There is little published research regarding pharmacies’ adoption of drug disposal programs or their impact on patient drug disposal.

In recent years, mobile device applications such as text messaging have been investigated as a means of collecting health data and administering health interventions (Burke et al., 2015, Garofalo et al., 2015, Spark et al., 2015). However, there is little published data regarding the use of mobile health tools in preventing, identifying, or treating prescription opioid abuse.

The primary aim of this study was to describe patterns of opioid prescribing and consumption after dental surgery, with a specific focus on measuring the quantity of opioids left unused. A secondary aim was to measure the impact of a behavioral intervention on patients’ willingness to dispose of unused opioids. We hypothesized that patients who received information about a pharmacy-based drug disposal program would be more likely to dispose of unused medications than patients who received routine discharge instructions. Another secondary aim was to measure patient utilization of a text messaging tool for gathering information on postoperative opioid use.

Section snippets

Study design and patient population

We performed a randomized controlled trial (RCT) of non-institutionalized patients aged 18 years and older who were scheduled for elective surgical extraction of one or more impacted teeth (e.g., third molar extractions) at a university-affiliated oral surgery practice during March-September 2015. Patients were invited to participate in a study described as an educational intervention to improve pain management. Exclusion criteria included pregnancy, significant cognitive impairment, a history

Results

The study enrolled 79 patients over six months. Demographic characteristics and procedural details for these patients are shown in Table 1. There were no statistically significant differences among the two study arms. A CONSORT diagram of RCT enrollment and analysis is shown in Fig. 1. Eight patients (10%) did not complete the follow-up interview and were lost to follow-up.

Discussion

This study is the first assessment of unused opioid analgesics following dental surgery, and it is the first investigation to measure the effect of offering a pharmacy-based drug disposal program on patients’ willingness to dispose of opioids. This study has three major findings.

Conclusions

More than half of opioid analgesics prescribed following surgical tooth extraction in this study were left unused by the patients for whom they were prescribed. Dentists and oral surgeons could substantially reduce the amount of prescription opioids available for diversion by reducing the quantity of opioids prescribed following these procedures; recently published recommendations in the dental literature highlight this opportunity. The availability of a pharmacy-based drug disposal program

Role of funding source

Nothing declared

Contributors

BCM developed the study concept, obtained funding, wrote the initial draft of the manuscript, and performed statistical analysis.

EVH contributed to study design, study oversight, and substantial manuscript revisions.

FSS performed statistical analysis and contributed to substantial manuscript revision.

KJW contributed to data collection and substantial manuscript revision.

EA contributed to data collection and substantial manuscript revision.

LRC contributed to data collection and substantial

Conflict of interests

No conflict declared

Acknowledgements

This research was supported by a Pilot Project Grant from the Leonard Davis Institute of Health Economics We wish to thank Breah Paciotti for her logistical and administrative support of the project.

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