Perianesthesia Patient Education for the Promotion of Opioid Stewardship

Published:December 15, 2020DOI:https://doi.org/10.1016/j.jopan.2020.06.012

      Abstract

      Opioid overdose deaths and opioid use disorders are a crisis in the United States and other western countries around the globe. Opioid prescriptions more than doubled after the turn of the century, particularly for postoperative patients. Unfortunately, many who have abused opioids were able to obtain those opioids from friends or family who had held on to prescribed, but unused opioids. One method to manage and decrease the opportunity for unused opioids to become black-market opioids is to educate patients and families regarding the safe use, safe storage, and proper disposal of unused prescription opioids. Perianesthesia nurses, particularly those who educate patients before and after surgery, have an excellent opportunity to educate patients and families who are discharged to home after surgery.

      Keywords

      Objectives—1. Describe contributing factors leading to the current US opioid crisis. 2. Discuss evidence related to postoperative misuse, storage, and disposal of opioids. 3. Review current directives (guidance, recommendations) for patient and family education regarding proper postoperative disposal of unused opioids.

      Overdose deaths from opioids in the United States increased from 28,647 in 2014 to 47,600 in 2017, which was 67.8% of all drug overdose deaths.
      • Rudd R.
      • Seth P.
      • David F.
      • L S.
      Increases in drug and opioid-involved overdose deaths—United States, 2010–2015.
      ,
      CDC/NCHS
      National vital statistics system, mortality.
      Currently, more than 130 deaths occur in the United States every day from opioid overdose.
      CDC/NCHS
      National vital statistics system, mortality.
      In 2017, an estimated 1.7 million people in the United States experienced substance use disorders related to prescription opioid analgesics.
      National Institute on Drug Abuse
      Opioid overdose crisis.
      In the 1990s, when assured by pharmaceutical companies that very few patients who required opioids for postoperative pain would become addicted, prescriptions for opioids increased dramatically.
      National Institute on Drug Abuse
      Opioid overdose crisis.
      Across the globe, the use of prescription opioids more than doubled from 2001 to 2013.
      • Berterame S.
      • Erthal J.
      • Thomas J.
      • et al.
      Use of and barriers to access to opioid analgesics: A worldwide, regional, and national study.
      Some countries, including the United States, Canada, and Australia experienced increased opioid abuse and misuse as the result of increased prescription for opioids.
      • Neuman M.D.
      • Bateman B.T.
      • Wunsch H.
      Inappropriate opioid prescription after surgery.
      The purpose of this article was to describe contributing factors leading to the current US opioid crisis; discuss evidence related to postoperative misuse, storage, and disposal of opioids; review current directives (guidance, recommendations) for patient and family education regarding proper postoperative disposal of unused opioids; and describe perianesthesia implications to promote the safe use, storage, and disposal of opioids after discharge.

      Contributing Factors

      The increased number of prescriptions in the perioperative arena is multifactorial: the focus of pain as the “fifth vital sign,” new pain assessment standards from the Joint Commission, the increasing number of ambulatory surgeries requiring outpatient management of pain, pressure on physicians to treat pain, and patient satisfaction scores and metrics.
      • Kumar K.
      • Lawrence V.
      • Dines J.
      • et al.
      Unused opioid pills after outpatient shoulder surgeries given current perioperative prescribing habits.
      Rummans et al
      • Rummans T.A.
      • Burton M.C.
      • Dawson N.L.
      How good intentions contributed to bad outcomes: The opioid crisis.
      believe that “good intentions” impacted the opioid crisis. In other words, the desire to lessen pain and distress (good intentions) led to an increase in opioids prescribed, which resulted in misuse of opioids and even death.
      • Rummans T.A.
      • Burton M.C.
      • Dawson N.L.
      How good intentions contributed to bad outcomes: The opioid crisis.
      After discovering that 42% to 71% of opioids were unused in 810 patients, Bicket et al
      • Bicket M.C.
      • Long J.J.
      • Pronovost P.J.
      • Alexander G.C.
      • Wu C.L.
      Prescription opioid analgesics commonly unused after surgery—A systematic review.
      recommended a data-driven approach to prescribing opioids after surgery.
      The most common drugs involved in prescription opioid overdose deaths are methadone, oxycodone, and hydrocodone,
      • Ossiander E.
      Using textual cause-of-death data to study drug poisoning deaths.
      which include two commonly prescribed opioids postoperatively: oxycodone and hydrocodone.
      • Odom-Forren J.
      • Hooper V.
      • Moser D.K.
      • et al.
      Postdischarge nausea and vomiting: Management strategies and outcomes over 7 days.
      In more than 36,000 privately insured patients, 6% were found to have new persistent opioid use after minor and major surgeries.
      • Brummett C.M.
      • Waljee J.F.
      • Goesling J.
      • et al.
      New persistent opioid use after minor and major surgical procedures in US adults.
      Although multimodal analgesia treatment plans have resulted in decreased perioperative opioid consumption, opioids are used when indicated to treat severe breakthrough pain and are frequently prescribed on discharge.

      Carroll J, Trent-Adam S, Scott M, Wick EC, Chappell D. Enhanced recovery after surgery (ERAS): Medical education engagement to support safe prescribing for patients needing surgery. [ERAS®USA webinar]. April 1, 2020.

      This is significant because perioperative patient education about proper opioid storage and disposal is lacking.
      • Bicket M.C.
      • Long J.J.
      • Pronovost P.J.
      • Alexander G.C.
      • Wu C.L.
      Prescription opioid analgesics commonly unused after surgery—A systematic review.

      Misuse, Storage, and Disposal of Opioids: What We Know

      Opioid misuse can be defined as the use of illegal drugs or the use of prescription drugs in a manner other than as directed by a prescriber, such as taking more medication than prescribed or taking it more often, or using someone else's prescription.
      Centers for Disease Control and Prevention
      Opioid overdose.
      Storage refers to securement of the prescribed medication. Prescriptions should be secured in a place only known by the person for whom the medication was intended. If possible, all medications should be kept in a safe place, such as a locked cabinet, particularly when children or adolescents are in the home.
      Partnership for Drug-Free Kids
      Take action to address medicine abuse.
      Opioid disposal refers to an appropriate method to dispose of expired, unwanted, and unused or leftover medications.

      Harris PA, Mukkamala B. Advocacy and Action to End the Opioid Epidemic by the AMA Opioid Task Force. Available at: https://journalofethics.ama-assn.org/article/advocacy-and-action-end-opioid-epidemic-ama-opioid-task-force/2020-08. Accessed September 22, 2020.

      Misuse of Opioids

      Misuse of opioids has been found in several different settings. Unsafe use by sharing or losing opioids was reported in 26% of 300 cancer patients receiving care in the outpatient setting.
      • Reddy A.
      • De La Cruz M.
      • Rodriguez E.
      • et al.
      Patterns of storage, use, and disposal of opioids among cancer outpatients.
      In 191 US veterans, 34% were involved in sharing of opioids, typically giving or receiving opioids from family or friends.
      • Lewis E.
      • Cucciare M.
      • Trafton J.
      What do patients do with unused opioid medications?.
      In a survey of 1,032 adults with opioid prescriptions, more than 20% had shared with family or friends.
      • Kennedy-Hendricks A.
      • Gielen A.
      • McDonald E.
      • Shields W.
      • Barry C.
      Medication sharing, storage, and disposal practices for opioids medications among US adults.

      Storage

      Studies have shown that patients have left opioids out in plain sight or hid the opioids in an unlocked place with only a small portion of patients keeping opioids in a locked container.
      • Bicket M.C.
      • Long J.J.
      • Pronovost P.J.
      • Alexander G.C.
      • Wu C.L.
      Prescription opioid analgesics commonly unused after surgery—A systematic review.
      ,
      • Reddy A.
      • De La Cruz M.
      • Rodriguez E.
      • et al.
      Patterns of storage, use, and disposal of opioids among cancer outpatients.
      ,
      • Bartels K.
      • Mayes L.
      • Dingmann C.
      • Bullard K.
      • Hopfer C.
      • Binswanger I.
      Opioid use and storage patterns by patients after hospital discharge following surgery.
      ,
      • Bicket M.
      • White E.
      • Wu C.
      • Pronovost P.
      • Yaster M.
      • Alexander G.
      Prescription opioid oversupply following orthopedic surgery: A prospective cohort study.
      Bartels et al found that 75% of patients who had undergone a Caesarian section (n = 30) or thoracic surgery (n = 31) did not keep their opioids in a secure or locked location.
      • Bartels K.
      • Mayes L.
      • Dingmann C.
      • Bullard K.
      • Hopfer C.
      • Binswanger I.
      Opioid use and storage patterns by patients after hospital discharge following surgery.
      Bicket et al also found that 75% of 101 orthopaedic patients did not store medication in a locked location.
      • Bicket M.
      • White E.
      • Wu C.
      • Pronovost P.
      • Yaster M.
      • Alexander G.
      Prescription opioid oversupply following orthopedic surgery: A prospective cohort study.
      In a systematic review of 6 studies with 810 distinctive patients, 54% to 70% of patients stored opioids in a medicine cabinet or some other type of box and 21% to 26% used a cupboard or wardrobe. A high percentage (73% to 77%) of patients stored opioids in unlocked places.
      • Bicket M.C.
      • Long J.J.
      • Pronovost P.J.
      • Alexander G.C.
      • Wu C.L.
      Prescription opioid analgesics commonly unused after surgery—A systematic review.

      Unused Opioids

      Postoperative opioids are commonly used after surgery to manage the most challenging pain. However, unused opioids may be misused and diverted for nonmedical use, contributing to opioid-related injuries and deaths.
      • Bicket M.C.
      • Long J.J.
      • Pronovost P.J.
      • Alexander G.C.
      • Wu C.L.
      Prescription opioid analgesics commonly unused after surgery—A systematic review.
      Bartels et al
      • Bartels K.
      • Mayes L.
      • Dingmann C.
      • Bullard K.
      • Hopfer C.
      • Binswanger I.
      Opioid use and storage patterns by patients after hospital discharge following surgery.
      found that 83% of patients who had undergone a Caesarian section and 71% of those who had undergone a thoracotomy took half or less of their prescribed opioids after discharge. Kumar et al
      • Kumar K.
      • Lawrence V.
      • Dines J.
      • et al.
      Unused opioid pills after outpatient shoulder surgeries given current perioperative prescribing habits.
      compared the number of pills that were prescribed versus the number of pills that remained unused in 100 outpatients who underwent shoulder surgery. These outpatients reported a median of 13 unused pills of a median of 60 prescribed pills. Bockman et al
      • Bockman C.
      • Dale R.
      • Dong J.
      • et al.
      Examination of opioid discharge prescription, consumption and disposal in an orthopedic population.
      also found in preliminary results of a descriptive study that orthopaedic patients had only used 10 to 20 tablets of 40 or more. In a study of 250 patients after ambulatory upper extremity surgery, Rodgers et al
      • Rodgers J.E.
      • Cunningham K.
      • Fitzgerald K.
      • Finnerty E.
      Opioid consumption following outpatient upper extremity surgery.
      found that patients had an average of 19 pills unused for a total of 4,639 pills. Bates et al
      • Bates C.
      • Laciak R.
      • Southwick A.
      • Bishoff J.
      Overprescription of postoperative narcotics: A look at postoperative pain medication delivery, consumption and disposal in urological practice.
      found that in 586 postoperative urology patients, 67% had unused opioids after 2 to 4 weeks. Thiels et al
      • Thiels C.A.
      • Ubl D.S.
      • Yost K.J.
      • et al.
      Significant numbers of patients require no opioids after discharge: Results of a prospective multicenter initiative aimed at developing opioid prescribing guidelines for 25 elective surgeries.
      conducted a survey in 1,907 patients undergoing 25 elective procedures. They found that 62.7% of prescribed opioids were unused and 31% of patients took no prescribed opioids. At one 4-hour drug take-back event, opioid prescriptions returned for disposal had 60% of the number of pills dispensed unused. The strongest predictor of unused opioids was the number of days of medication prescribed.
      • Welham G.
      • Mount J.
      • Gilson A.
      Type and frequency of opioid pain medications returned for disposal.
      All of these unused opioids are potential sources of diversion.
      • Rodgers J.E.
      • Cunningham K.
      • Fitzgerald K.
      • Finnerty E.
      Opioid consumption following outpatient upper extremity surgery.

      Disposal of Opioids

      Unfortunately, many studies have shown that a minority of patients appropriately dispose of unused opioids. In one study, more than 65% of the patients (N = 191) who saved unused opioid medications reported that they saved them in case they needed them in the future.
      • Lewis E.
      • Cucciare M.
      • Trafton J.
      What do patients do with unused opioid medications?.
      Patients have also told other researchers that they kept the unused opioids for possible future use.
      • Merrill K.C.
      • Haslam V.C.
      • Luthy K.E.B.
      • Nuttall C.
      Educating patients about opioid disposal: A key role for perianesthesia nurses.
      Egan et al
      • Egan K.
      • Gregory E.
      • Sparks M.
      • Wolfson M.
      From dispensed to disposed: Evaluating the effectiveness of disposal programs through a comparison with prescription drug monitoring program data.
      evaluated the effectiveness of disposal programs by comparing the number of controlled medications dispensed in a community to the number disposed through take-back events or drug donation boxes. They found that medications disposed were only a small portion of those dispensed.
      In a study of 586 urology patients, only 9% of patients disposed of their medication either with appropriate or non–Food and Drug Administration (FDA)-approved methods of disposal.
      • Bates C.
      • Laciak R.
      • Southwick A.
      • Bishoff J.
      Overprescription of postoperative narcotics: A look at postoperative pain medication delivery, consumption and disposal in urological practice.
      After same-day or inpatient orthopaedic surgery, 85% of 101 patients did not dispose of their medication.
      • Bicket M.
      • White E.
      • Wu C.
      • Pronovost P.
      • Yaster M.
      • Alexander G.
      Prescription opioid oversupply following orthopedic surgery: A prospective cohort study.
      In 1,907 postoperative patients only 7.5% of patients disposed of unused opioids.
      • Thiels C.A.
      • Ubl D.S.
      • Yost K.J.
      • et al.
      Significant numbers of patients require no opioids after discharge: Results of a prospective multicenter initiative aimed at developing opioid prescribing guidelines for 25 elective surgeries.
      This supports the findings of a systematic review where only 4% to 9% considered or used a method of disposal that is supported by the FDA.
      • Bicket M.C.
      • Long J.J.
      • Pronovost P.J.
      • Alexander G.C.
      • Wu C.L.
      Prescription opioid analgesics commonly unused after surgery—A systematic review.

      Education of Misuse, Storage, and Disposal of Opioids

      Many patients deny receiving education regarding misuse, storage, or disposal of opioids. In a survey of 1,032 adults with recent opioid prescriptions, 51.3% stated they had received education about safe storage from medication packaging (46.5%), a pharmacist (44.1%), or physician or nurse (32.3%). Almost 58% reported education regarding disposal of unused medication from the pharmacist, news channels, or reading the packaging.
      • Kennedy-Hendricks A.
      • Gielen A.
      • McDonald E.
      • Shields W.
      • Barry C.
      Medication sharing, storage, and disposal practices for opioids medications among US adults.
      In 100 outpatients after shoulder surgery, only 25% received education on the storage and disposal of opioids.
      • Kumar K.
      • Lawrence V.
      • Dines J.
      • et al.
      Unused opioid pills after outpatient shoulder surgeries given current perioperative prescribing habits.
      In 586 postoperative urology patients, only 8% of patients stated they received education on disposal.
      • Bates C.
      • Laciak R.
      • Southwick A.
      • Bishoff J.
      Overprescription of postoperative narcotics: A look at postoperative pain medication delivery, consumption and disposal in urological practice.
      In other studies, 69% of 101 patients after orthopaedic surgery,
      • Bicket M.
      • White E.
      • Wu C.
      • Pronovost P.
      • Yaster M.
      • Alexander G.
      Prescription opioid oversupply following orthopedic surgery: A prospective cohort study.
      88% of 34 patients after laparoscopic cholecystectomy,
      • Merrill K.C.
      • Haslam V.C.
      • Luthy K.E.B.
      • Nuttall C.
      Educating patients about opioid disposal: A key role for perianesthesia nurses.
      and 82% of 359 patients after surgical procedures
      • Fujii M.H.
      • Hodges A.C.
      • Russell R.L.
      • et al.
      Post-discharge opioid prescribing and use after common surgical procedure.
      did not know how to dispose of unused opioids. Almost 95% of 1,416 patients after upper extremity surgery did not receive disposal information from a physician, nurse, or pharmacist.
      • Kim N.
      • Matzon J.L.
      • Abboudi J.
      • et al.
      A prospective evaluation of opioid utilization after upper-extremity surgical procedures: Identifying consumption patterns and determining prescribing guidelines.
      The clear conclusion based on strong evidence is that leftover opioids are often kept at home in unsecured places and signify a source of opioids available for diversion.
      • Reddy A.
      • De La Cruz M.
      • Rodriguez E.
      • et al.
      Patterns of storage, use, and disposal of opioids among cancer outpatients.
      ,
      • Bartels K.
      • Mayes L.
      • Dingmann C.
      • Bullard K.
      • Hopfer C.
      • Binswanger I.
      Opioid use and storage patterns by patients after hospital discharge following surgery.
      ,
      • Harris K.
      • Curtis J.
      • Larsen B.
      • et al.
      Opioid pain medication use after dermatologic surgery: A prospective observational study of 212 dermatologic surgery patients.
      ,
      • Odom-Forren J.
      • Brady J.M.
      • Rayens M.K.
      • Sloan P.
      Perianesthesia nurses' knowledge and promotion of safe use, storage, and disposal of opioids.

      Interventions to Increase Knowledge of Patients

      Several research studies have focused on whether providing specific written patient information would increase patient knowledge in opioid stewardship. de La Cruz et al
      • de La Cruz M.
      • Reddy A.
      • Balankari V.
      • et al.
      The impact of an educational program on patient practices for safe use, storage, and disposal of opioids at a comprehensive cancer center.
      compared use, storage, and disposal of prescribed opioids in adult cancer patients who received educational material (n = 300) to those who did not receive the material (n = 300). The patients who received the educational material were significantly less likely to keep unused opioids at home (38.1% vs 46.6%) and more aware of appropriate opioid disposal methods (75.5% vs 28%). Rose et al
      • Rose P.
      • Sakai J.
      • Argue R.
      • Froehlich K.
      • Tang R.
      Opioid information pamphlet increases postoperative opioid disposal rates: A before versus after quality improvement study.
      conducted a quality improvement study of adult postoperative patients with one group (n = 86) receiving usual discharge instructions and the intervention group (n = 86) receiving an opioid education pamphlet in addition to usual care. The pamphlet included information on safe opioid storage, opioid weaning, and disposal. Those in the intervention group disposed of opioids significantly more often (27%) than the control group (5%). The researchers suggested that written literature with verbal reinforcement from health care providers may increase the rate of disposal and reduce the risk of diversion.
      • Rose P.
      • Sakai J.
      • Argue R.
      • Froehlich K.
      • Tang R.
      Opioid information pamphlet increases postoperative opioid disposal rates: A before versus after quality improvement study.
      In a randomized controlled trial of adult patients after third molar extraction, patients in the experimental group (n = 31; information regarding a disposal program) reported a 22% higher rate of proper disposal than the control group (n = 27; controlled substance information sheet).
      • Maughan B.
      • Hersh E.
      • Shofer F.
      • et al.
      Unused opioid analgesics and drug disposal following outpatient dental surgery: A randomized controlled trial.
      Use of a Web-based educational program has also been studied. McCauley et al
      • McCauley J.
      • Back S.
      • Brady K.
      Pilot of a brief, web-based educational intervention targeting safe storage and disposal of prescription opioids.
      conducted a pilot study (N = 62) of a brief, interactive, Web-based intervention in patients who were from a chronic pain clinic or dental clinic. The goal was to improve knowledge of safe medication use, storage, and disposal. At preintervention 45.2% of participants were aware of how to store opioid medications or properly dispose of unused pills and 67.7% of participants believed it was appropriate to save leftover opioids. After the Web-based intervention, patients were significantly less likely to save unused medication and were significantly more knowledgeable about disposal and proper storage. The authors concluded that there was a strong need for patient and provider (physicians, nurses, dentists, and pharmacists) education to decrease the opportunity for diversion and opioid misuse.
      • McCauley J.
      • Back S.
      • Brady K.
      Pilot of a brief, web-based educational intervention targeting safe storage and disposal of prescription opioids.
      A newer method of increasing the percentage of patients who correctly dispose of unused opioids is the use of in-home disposal activation systems. Brummett et al
      • Brummett C.M.
      • Steiger R.
      • Englesbe M.
      • et al.
      Effect of an activated charcoal bag on disposal of unused opioids after an outpatient surgical procedure: A randomized clinical trial.
      investigated the effect of an activated charcoal bag sent home with patients discharged with a prescription for opioids after outpatient surgery. The activated charcoal can make drugs inactive by adsorption with the addition of warm tap water in a biodegradable bag. The study had three arms: usual care, educational brochure that included information on how to locate disposal locations, and activated charcoal bags sent home with the patient. They reported that 28.6% of patients in the usual care group disposed of opioids compared with 33.3% who received the brochure and 57.1% who received a charcoal activated bag.
      • Brummett C.M.
      • Steiger R.
      • Englesbe M.
      • et al.
      Effect of an activated charcoal bag on disposal of unused opioids after an outpatient surgical procedure: A randomized clinical trial.
      Their findings suggest that in-home disposal, a simple, low-cost intervention could reduce the number of unused opioids available for diversion.

      Current Guidelines for Misuse, Safe Storage, and Disposal

      Several medical, governmental, and non-profit organizations have published guidelines or other information for patients and health care providers regarding the misuse, safe storage, and disposal of unused medications including opioids. The American Medical Association (AMA) Task Force on Opioids has three main goals: talk to patients about safe use, remind patients to store medication in a safe place, and urge patients to dispose of unused medications.

      Harris PA, Mukkamala B. Advocacy and Action to End the Opioid Epidemic by the AMA Opioid Task Force. Available at: https://journalofethics.ama-assn.org/article/advocacy-and-action-end-opioid-epidemic-ama-opioid-task-force/2020-08. Accessed September 22, 2020.

      Misuse or Safe Use

      Because the misuse of opioids is a leading cause of accidental death, the American Academy of Orthopaedic Surgeons suggests that patients need to know that (1) a combination of opioids with alcohol or other drugs increases risk of death, (2) medication should be taken as prescribed (not taken more than instructed, not given to another individual, or sold), and (3) a patient should never take someone else's prescription.
      American Academy of Orthopaedic Surgeons
      Safe use, storage, and disposal of prescription opioid medicines.
      The AMA Opioid Task Force states that patients should be instructed to take the medication as prescribed and not share with others.

      Harris PA, Mukkamala B. Advocacy and Action to End the Opioid Epidemic by the AMA Opioid Task Force. Available at: https://journalofethics.ama-assn.org/article/advocacy-and-action-end-opioid-epidemic-ama-opioid-task-force/2020-08. Accessed September 22, 2020.

      For example, taking an opioid to help one go to sleep at night when prescribed for postoperative pain is medication misuse.
      • Costello M.
      Prescription opioid analgesics: Promoting patient safety with better patient education.
      Misuse can also be illegal, harmful, or even deadly.

      Harris PA, Mukkamala B. Advocacy and Action to End the Opioid Epidemic by the AMA Opioid Task Force. Available at: https://journalofethics.ama-assn.org/article/advocacy-and-action-end-opioid-epidemic-ama-opioid-task-force/2020-08. Accessed September 22, 2020.

      Drug diversion to other individuals can occur when a person sells or shares their prescription medication, and through loss by theft.
      • Brummett C.M.
      • Steiger R.
      • Englesbe M.
      • et al.
      Effect of an activated charcoal bag on disposal of unused opioids after an outpatient surgical procedure: A randomized clinical trial.
      Taking or sharing prescription opioid medications is a federal crime in violation of the Controlled Substances Act.
      • Manworren R.
      • Gilson A.
      Nurses' role in preventing prescription opioid diversion.

      Safe Storage

      More than 70% of people who misuse opioids get them from family and friends and 79% of those family and friends had a prescription from a provider.

      Harris PA, Mukkamala B. Advocacy and Action to End the Opioid Epidemic by the AMA Opioid Task Force. Available at: https://journalofethics.ama-assn.org/article/advocacy-and-action-end-opioid-epidemic-ama-opioid-task-force/2020-08. Accessed September 22, 2020.

      ,
      • Shafer E.
      • Bergeron N.
      • Smith-Ray R.
      • Robson C.
      • O'Koren R.
      A nationwide pharmacy chain responds to the opioid epidemic.
      Opioids should be stored in a safe place, preferably locked to protect children, other family members, or visitors from taking them.

      Harris PA, Mukkamala B. Advocacy and Action to End the Opioid Epidemic by the AMA Opioid Task Force. Available at: https://journalofethics.ama-assn.org/article/advocacy-and-action-end-opioid-epidemic-ama-opioid-task-force/2020-08. Accessed September 22, 2020.

      The Safe Home Coalition's Keep Kids Safe program has tips for keeping medicines safe. The recommendations include keeping opioids separate from other medications, installing a lockbox on the medicine cabinet, and securing opioids when guests or others will be accessing your home.
      Safe Homes Coalition
      What you can do.
      Also, it is important that prescription medications are secured when a home is shown to potential buyers.
      Safe Homes Coalition
      What you can do.
      With researchers reporting that surgeons prescribe more doses of opioids than patients need and with patients having a tendency to keep unused opioids at home, the potential for misuse or diversion is high.
      • Kumar K.
      • Lawrence V.
      • Dines J.
      • et al.
      Unused opioid pills after outpatient shoulder surgeries given current perioperative prescribing habits.
      ,
      • Rodgers J.E.
      • Cunningham K.
      • Fitzgerald K.
      • Finnerty E.
      Opioid consumption following outpatient upper extremity surgery.
      ,
      • Bates C.
      • Laciak R.
      • Southwick A.
      • Bishoff J.
      Overprescription of postoperative narcotics: A look at postoperative pain medication delivery, consumption and disposal in urological practice.
      Keeping unsecured medications in the home is especially risky when a child is present in the home, including deaths from accidental ingestion of opioids. Children with an opioid overdose are far more likely to have had a mother using a combination of opioid and antidepressant prescriptions. The most common opioids involved in the overdoses were oxycodone, methadone, and codeine.
      • Finkelstein Y.
      • Macdonald E.
      • Gonzalez A.
      • et al.
      Overdose risk in young children.
      Pets are also at risk when prescription opioids are unsecured.
      American Academy of Orthopaedic Surgeons
      Safe use, storage, and disposal of prescription opioid medicines.

      Disposal of Unused Prescription Opioids

      The US FDA recommends conscientious disposal of unused opioids. The FDA priority method of disposal is through take-back programs or US Drug Enforcement Agency (DEA)-authorized collectors (Figure 1). DEA-authorized collectors include retail pharmacies, hospitals, and law enforcement agencies. Some pharmacies provide mail-back envelopes. Web sites are available at https://www.fda.gov/drugs/information-drug-class/opioid-medications that consumers can visit to find drug disposal information and to locate an authorized collector. The American Academy of Orthopaedic Surgeons and AMA suggest the DEA Web site, www.deadiversion.usdoj.gov/pubdispsearch, which allows patients to search for DEA-approved disposal sites in their area.

      Harris PA, Mukkamala B. Advocacy and Action to End the Opioid Epidemic by the AMA Opioid Task Force. Available at: https://journalofethics.ama-assn.org/article/advocacy-and-action-end-opioid-epidemic-ama-opioid-task-force/2020-08. Accessed September 22, 2020.

      ,
      American Academy of Orthopaedic Surgeons
      Safe use, storage, and disposal of prescription opioid medicines.
      Periodically, the DEA hosts a national prescription drug take-back event. If these events are unavailable, the FDA suggests disposing of uncontrolled drugs in the household trash. The medicines can be mixed with a substance such as dirt, kitty litter, or used coffee grounds, placed in a container, and then in the trash. Personal information should be scratched from the prescription container label so it is unreadable. However, for controlled substances that are particularly harmful, the FDA recommends these medicines can be disposed of by flushing. A list of medications that should be flushed are provided at https://www.fda.gov/drugs/safe-disposal-medicines/disposal-unused-medicines-what-you-should-know and include fentanyl patches, morphine, buprenorphine, meperidine, hydromorphone, hydrocodone, and oxycodone. However, the US Environmental Protection Agency warns against flushing medications to avoid contamination in the water supply unless the patient information specifically states to flush.
      United States Environmental Protection Agency
      How to dispose of medicines properly.
      The Environmental Protection Agency recommends take-back programs as a first choice option.
      United States Environmental Protection Agency
      How to dispose of medicines properly.
      Proper disposal is also a way to decrease the amount of trace pharmaceuticals found in the water in the United States.
      • Kinrys G.
      • Gold A.K.
      • Worthington J.J.
      • Nierenberg A.A.
      Medication disposal practices: Increasing patient and clinician education on safe methods.
      Although it is suggested that incorrect medication disposal only nominally adds to environmental damage, improving safe medication disposal is one way to reduce environmental risk.
      • Kinrys G.
      • Gold A.K.
      • Worthington J.J.
      • Nierenberg A.A.
      Medication disposal practices: Increasing patient and clinician education on safe methods.
      ,
      • Straub J.O.
      Reduction in the environmental exposure of pharmaceuticals through diagnostics, personalised healthcare and other approaches. A mini review and discussion paper.
      Kinrys et al
      • Kinrys G.
      • Goldsmith C.H.
      • Nierenberg A.A.
      Proper drug disposal: Studying a solution to household prescription and over-the-counter drug abuse.
      believe that increased education on appropriate disposal practices for patients, caregivers, and health care professionals is part of a three-part solution for future research and treatment decreasing drug abuse. The other two components to their solution are increased medication take-back programs and elimination of social stressors in the environment that contribute to misuse and abuse of medication. They also suggest that this solution can be applied toward reducing environmental damage because of improper disposal techniques.
      • Kinrys G.
      • Goldsmith C.H.
      • Nierenberg A.A.
      Proper drug disposal: Studying a solution to household prescription and over-the-counter drug abuse.
      Figure thumbnail gr1
      Figure 1Unused opioid medication disposal options.
      Adapted from US Food and Drug Administration (FDA) drug disposal instructions,
      U.S. Department of Health and Human Services
      How to safely dispose of drugs.
      US Environmental Protection Agency (EPA) household disposal steps,
      United States Environmental Protection Agency
      How to dispose of medicines properly.
      and FDA flush list.
      U.S. Food and Drug Administration
      Drug disposal: Flush potentially dangerous medicine.
      This image is available in color online at www.jopan.org.

      State Policy Trends

      One recent trend is for state legislatures to pass laws that require education of patients and caregivers regarding storage and disposal of prescription opioids. For example, the state of Michigan (Public Act 246 of 2017) requires that before an opioid is prescribed to a patient, a prescriber should provide the following information: dangers of opioid addiction and how to properly dispose of an expired, unused, or unwanted controlled substance, as well as other information.
      Department of Licensing and Regulatory Affairs (LARA), (DHHS) MDoHaHS
      Michigan opioid laws: Frequently asked questions (FAQs).
      After providing this information, the prescriber must obtain a signature from the patient or the patient's representative on a “start talking consent form” as described by section (4) of Public Act 246 of 2017. This consent form shall be kept in the patient's medical record. This law excludes completing this form for patients who receive opioids while within a facility such as a hospital or outpatient facility.
      Department of Licensing and Regulatory Affairs (LARA), (DHHS) MDoHaHS
      Michigan opioid laws: Frequently asked questions (FAQs).

      Perianesthesia Nurses' Role

      Perianesthesia nurses are well positioned to provide needed education or “anticipatory guidance”
      • Manworren R.
      • Gilson A.
      Nurses' role in preventing prescription opioid diversion.
      to patients before and after surgery. Discharge teaching typically includes information on the signs and symptoms to observe that would necessitate a return to the hospital or physician's office, appropriate diet, activity and medication regime, follow-up appointments, and warnings, such as not driving a car for 24 hours, decision making (signing legal documents), or other activity restrictions.
      • Ead H.M.
      Ensuring a smooth discharge home after ambulatory surgery.
      Instructions include when to take pain medication, when to call if pain is not relieved, bowel habits (use of fiber or stool softener), and wound care.
      • O'Brien D.
      Patient education and care of the perianesthesia patient.
      Perianesthesia nurses discuss the risk of acetaminophen toxicity when the patient is taking an acetaminophen-opioid combination, and to take the complete course of antibiotics.
      • Manworren R.
      • Gilson A.
      Nurses' role in preventing prescription opioid diversion.
      However, perianesthesia nurses and other providers do not routinely discuss safe use, safe storage, or safe disposal of medications, which is critical in reducing prescription opioid diversion.
      • Odom-Forren J.
      • Brady J.M.
      • Rayens M.K.
      • Sloan P.
      Perianesthesia nurses' knowledge and promotion of safe use, storage, and disposal of opioids.
      ,
      • Feliz J.
      New research uncovers disconnect in pain-related communications between prescribers of pain medications and patients.
      In a survey to explore registered nurses' knowledge of opioids, only 29% (N = 133) knew how to correctly store and dispose of unused opioids.
      • Costello M.
      • Thompson S.
      Preventing opioid misuse and potential abuse: The nurse's role in patient education.
      Perianesthesia nurses should educate patients not only on the adverse effects of opioids, but also include education for the patient's caregivers on how to recognize signs of oversedation (particularly in conjunction with other medications such as benzodiazepines), safe use, storage, and how to dispose of unused opioids.
      • Costello M.
      • Thompson S.
      Preventing opioid misuse and potential abuse: The nurse's role in patient education.
      In a recent study, researchers found that only 18% of perianesthesia nurses advised all patients they discharged on how to properly dispose of opioids on discharge and 23% discussed proper storage of opioids with all patients.
      • Odom-Forren J.
      • Brady J.M.
      • Rayens M.K.
      • Sloan P.
      Perianesthesia nurses' knowledge and promotion of safe use, storage, and disposal of opioids.
      They also found that 25% of perianesthesia nurses always taught patients the risks of opioid diversion, 40% discussed risks of misuse of opioids, and 82% taught all patients about side effects.
      • Odom-Forren J.
      • Brady J.M.
      • Rayens M.K.
      • Sloan P.
      Perianesthesia nurses' knowledge and promotion of safe use, storage, and disposal of opioids.

      Perianesthesia Implications

      Enhanced surgical recovery pathways encompass evidence-based perioperative patient management by the surgical team across the continuum of care to (1) individualize care and optimize comorbidities before surgery is performed, (2) decrease physiological stress through perioperative fluid optimization and multimodal analgesia plans, and (3) promote early feeding, mobilization, and appropriate multimodal medication weaning to minimize complication potential and expedite postoperative recovery.
      • Brown J.K.
      • Singh K.
      • Dumitru R.
      • Chan E.
      • Kim M.P.
      The benefits of enhanced recovery after surgery programs and their application in cardiothoracic surgery.
      Perioperative care teams in the United States have increasingly implemented enhanced surgical recovery pathways over the past decade, which also include patient-specific opioid sparing multimodal analgesia protocols (Table 1).

      Carroll J, Trent-Adam S, Scott M, Wick EC, Chappell D. Enhanced recovery after surgery (ERAS): Medical education engagement to support safe prescribing for patients needing surgery. [ERAS®USA webinar]. April 1, 2020.

      However, opioids are still used to treat severe breakthrough pain and frequently prescribed on discharge.

      Carroll J, Trent-Adam S, Scott M, Wick EC, Chappell D. Enhanced recovery after surgery (ERAS): Medical education engagement to support safe prescribing for patients needing surgery. [ERAS®USA webinar]. April 1, 2020.

      The US Department of Health and Human Services Inter-Agency Task Force states, “Public, patient, provider, and policymaker education is critical to the delivery of effective, patient-centered pain management and necessary for optimizing patient outcomes, promoting appropriate use of pain medication, and reducing the risk associated with prescription opioids.”
      U.S. Department of Health and Human Services
      Pain management best practices Interagency Task Force Report: Updates, gaps, inconsistencies, and recommendations.
      p 59 Because perianesthesia nurses care for patients across all perioperative phases in concert with a multidisciplinary surgical team, a unique opportunity exists for nurses to coordinate and consistently deliver comprehensive preoperative and postoperative opioid stewardship education.
      • Hasak J.M.
      • Roth Bettlach C.L.
      • Santosa K.B.
      • Larson E.L.
      • Stroud J.
      • Mackinnon S.E.
      Empowering post-surgical patients to improve opioid disposal: A before and after quality improvement study.
      ,
      The Joint Commission
      R3 Report Issue 14: Pain assessment and management standards for ambulatory care.
      Guided by the American Society of PeriAnesthesia Nurses' position statement on opioid stewardship, the nurse should provide patient- and family-centered education on appropriate use, safe home storage methods, custody of opioid medication, and recommended disposal methods for unused opioids.
      American Society of PeriAnesthesia Nurses
      Position statement on opioid stewardship in perianesthesia practice.
      Table 2 lists important patient and health care education information.
      Table 1Multimodal Perioperative Pain Treatment Plan
      Adapted from Chou R, Gordon DB, de Leon-Casasola OA, et al Management of postoperative pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016; 17(2):131-157; Carroll J, Trent-Adam S, Scott M, Wick EC, Chappell D. Enhanced recovery after surgery (ERAS): Medical education engagement to support safe prescribing for patients needing surgery. ERAS®USA Webinar. April 1, 2020. Accessed April 1, 2020. https://ems9.intellor.com/?i=901238x9204944; Cowell AQ. Pain management. In Odom-Forren J. Drain's Perianesthesia Nursing: A Critical Care Approach (7th ed). Elsevier: St. Louis, MO.
      Components of an Enhanced Recovery Multimodal Analgesia Plan are Individualized to Each Patient and Typically Include:
      Pharmacologic
      • Regional or central local anesthetic nerve blockade
      • Acetaminophen
      • Non-steroidal anti-inflammatory medication
      • Gabapentinoids
      • Opioids for severe breakthrough pain when alternative therapies are unavailable
      Nonpharmacologic
      • Transcutaneous electrical nerve stimulation
      • Cognitive-behavioral therapies
        • o
          Guided imagery and other relaxation methods
        • o
          Hypnosis
        • o
          Intraoperative suggestions
        • o
          Music
      • Acupuncture
      • Massage
      • Application of heat and cold
      • Essential oils (aromatherapy)
      Table 2Recommendations for Increased Knowledge About Opioid Stewardship
      Patient and Caregiver
       Misuse
      Saving leftover medication when no longer needed for the reason prescribed
      Giving medications to family or friends
      Taking medication more often than prescribed
      Taking the medication for another use than it was intended
      Borrowing pills from others
       Safe storage
      Locked in cabinet or box is safest, especially when children are present in the home
      Secure/hide in a place where only you know the location
       Disposal options
      Take-back programs—medication taken back by patient or member of household only
      Flush the medication using the list from the US FDA
      Mix medication with an inedible substance, seal the container, place in trash
      In-home drug disposal system
       Opioid weaning
       Acetaminophen and NSAID toxicity
       Signs of oversedation for the caregiver
      Patient interventions
       Engage early to educate, empower the patient; include his/her preferences in plan of care
       Written literature with verbal reinforcement
       Consider innovative alternatives for education, eg, on demand Web-based education
      Health care providers
       Provision of provider education (physicians, nurses, dentists, and pharmacists)
       Concerted effort to deliver patient education by nurses, physicians, and pharmacists
       Further research to identify strategies promote safe opioid stewardship
       Dissemination of well-defined recommendations
      FDA, Food and Drug Administration; NSAID, non-sterioidal anti-inflammatory drug.
      Qualitative responses in a recent study revealed that some confusion exists regarding the appropriateness of opioid disposal by flushing method.
      • Odom-Forren J.
      • Brady J.M.
      • Rayens M.K.
      • Sloan P.
      Perianesthesia nurses' knowledge and promotion of safe use, storage, and disposal of opioids.
      This identified gap in knowledge and practice indicates that perianesthesia nursing workforce education is needed to ensure that opioid stewardship measures are consistently disseminated to the postoperative patient population. Figure 1 provides a compilation of federal guidance on safe opioid disposal, including when to flush specific medications.
      United States Environmental Protection Agency
      How to dispose of medicines properly.
      ,
      U.S. Department of Health and Human Services
      How to safely dispose of drugs.
      ,
      U.S. Food and Drug Administration
      Drug disposal: Flush potentially dangerous medicine.
      ,
      U.S. Food and Drug Administration
      Disposal of unused medicines: What you should know.
      ,
      U.S. Environmental Protection Agency
      Collecting and disposing of unwanted medicines.
      Ideally, the patient or an adult member of his or her household only
      U.S. Drug Enforcement Administration
      Disposal act: General public fact sheet.
      will dispose of unused opioids at an organized drug take-back day or approved take-back location. This should be done as soon as the medication is no longer needed to control postoperative pain. An emerging practice in some health care facilities is to provide and instruct patients to use an in-home drug disposal drug deactivation system. One such system works by placing uncrushed tablets in the disposal pouch and adding warm water, which dissolves an inner pod, thereby releasing activated carbon that absorbs the drug. The pouch is then discarded in the household trash.
      Verde Technologies
      Deterra drug activation system.
      Another in-home drug disposal system acts by adding water to the medication container, adding a deactivation powder, and discarding the container in the trash.
      DisposeRx Inc
      DisposeRx.
      As more in-home drug disposal units may be developed for use, nurses should be familiar with the available options and instruct patients to follow disposal instructions located on the packaging for the particular drug disposal system being used.

      Online Resources

      Web-based resources are available from the US Department of Health and Human Services to augment patient education regarding safe opioid use, storage, and disposal.
      U.S. Department of Health and Human Services
      How to safely dispose of drugs.
      The FDA's Remove the Risk initiative aims to increase public recognition about the dangers of saving unused opioids in the home.
      U.S. Department of Health and Human Services
      Safe opioid disposal-remove the risk outreach toolkit.
      The Web site provides a toolkit with easily accessible resources that can be hyperlinked or downloaded and printed to promote safe opioid use, storage, and disposal strategies after discharge. The toolkit includes adult and pediatric educational fact sheets, videos, printable posters, graphics, audio public service announcements, and an authorized drug take-back location finder identified by zip code.
      U.S. Department of Health and Human Services
      Safe opioid disposal-remove the risk outreach toolkit.
      Perianesthesia nurses are strongly encouraged to review and integrate evidence-based educational resources to complement perioperative patient teaching strategies.

      Conclusions

      Deaths related to opioid misuse have increased exponentially in the United States over the past two decades. Opioids are routinely prescribed for the treatment of postoperative pain, with historically insufficient patient education provided regarding safe storage and disposal of opioids. Health care providers have advanced evidence-based practice through the development and implementation of clinical guidelines that inform best practice. Although some organizations have written a position statement, for example ASPAN,
      American Society of PeriAnesthesia Nurses
      Position statement on opioid stewardship in perianesthesia practice.
      no nursing guideline is available to promote safety and stewardship for surgical patients discharged with an opioid prescription. Because nurses deliver care across all phases of the perioperative spectrum, the opportunity exists for perianesthesia nurses to develop a strategy to address this gap in practice. Advocacy for the establishment of a perianesthesia clinical guideline that encompasses comprehensive patient- and family-centered education can serve to mitigate the dangers associated with improper opioid storage and the potential for drug diversion, and can increase the observance of timely appropriate disposal of unused opioids after surgery.

      Test ID W083120 – Expiration Date August 31, 2022

      Perianesthesia Patient Education for the Promotion of Opioid Stewardship

      1.5 Contact Hours
      Purpose of the Journal of PeriAnesthesia Nursing: To facilitate communication about and deliver education specific to the body of knowledge unique to the practice of perianesthesia nursing.
      Outcome of this CNE Activity: To enable the nurse to increase knowledge on patient education for opioid stewardship
      Target Audience: All perianesthesia nurses
      Article Objectives
      • 1.
        Describe contributing factors leading to the current US opioid crisis
      • 2.
        Discuss evidence related to postoperative misuse, storage and disposal of opioids
      • 3.
        Review current directives (guidance recommendations) for patient and family education regarding proper postoperative disposal of unused opioids
      Accreditation
      American Society of Perianesthesia Nurses is accredited with distinction as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation.
      Provider approved by the California Board of Registered Nursing, Provider Number CEP5197, for 1.5 contact hours.
      Additional provider numbers: Alabama #ABNP0074
      Contact hours: Registered nurse participants can receive 1.5 contact hours for this activity.
      Disclosure
      All planners and authors of continuing nursing education activities are required to disclose any significant financial relationships with the manufacturer(s) of any commercial products, goods or services. Any conflicts of interest must be resolved prior to the development of the educational activity. Such disclosures are included below.
      Planners and Author Disclosures
      The members of the planning committee for this continuing nursing education activity do not have any financial arrangements, interests or affiliations related to the subject matter of this continuing education activity to disclose.
      The authors for this continuing nursing education activity do not have any financial arrangements, interests or affiliations related to the subject matter of this continuing nursing education activity to disclose.
      Requirements for Successful Completion: To receive contact hours for this continuing nursing education activity you must complete the registration form and payment, read the article, complete the online posttest and achieve a minimum grade of 100%, and complete the online evaluation.
      Directions
      A multiple-choice examination, designed to test your understanding of Perianesthesia Patient Education for the Promotion of Opioid Stewardship according to the objectives listed, is available on the ASPAN website: https://learn.aspan.org/
      To earn contact hours from the American Society of Perianesthesia Nurses (ASPAN) Continuing Nursing Education Accredited Provider Unit go to the ASPAN website: (1) select the article, complete the registration form and payment; (2) read the article; (3) complete the posttest on the ASPAN Website and achieve a minimum score of 100%; and (4) complete the online evaluation.
      This all must be completed prior to the expiration date of August 31, 2022.
      Your certificate will be available for you to print upon successful completion of the activity and completion of the online evaluation.
      Online payment is required: ASPAN member: FREE per test; nonmember: $15.00 per test.

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