If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
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.
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.
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.
Some countries, including the United States, Canada, and Australia experienced increased opioid abuse and misuse as the result of increased prescription for opioids.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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
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
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.
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.
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.
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.
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.
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.
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.
Several research studies have focused on whether providing specific written patient information would increase patient knowledge in opioid stewardship. de La Cruz et al
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
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.
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).
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
Reduction in the environmental exposure of pharmaceuticals through diagnostics, personalised healthcare and other approaches. A mini review and discussion paper.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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,
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.
References
Rudd R.
Seth P.
David F.
L S.
Increases in drug and opioid-involved overdose deaths—United States, 2010–2015.
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.
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.
A prospective evaluation of opioid utilization after upper-extremity surgical procedures: Identifying consumption patterns and determining prescribing guidelines.
Reduction in the environmental exposure of pharmaceuticals through diagnostics, personalised healthcare and other approaches. A mini review and discussion paper.
Jan Odom-Forren, who is co-editor of Journal of PeriAnesthesia Nursing, was not involved in the editorial review or decision to publish this article. The entire process from submission, referee assignment, and editorial decisions was handled by Vallire D. Hooper, the other co-editor of this journal.
30181-7&id=gr1.jpg){kind=link}