Leftover Opioid Analgesics and Disposal Following Ambulatory Pediatric Surgeries in the Context of a Restrictive Opioid-Prescribing Policy

Abstract

BACKGROUND: Opioid analgesics are commonly prescribed for postoperative analgesia following pediatric surgery and often result in leftover opioid analgesics in the home. To reduce the volume of leftover opioids and overall community opioid burden, the State of Tennessee enacted a policy to reduce initial opioid prescribing to a 3-day supply for most acute pain incidents. We aimed to evaluate the extent of leftover opioid analgesics following pediatric ambulatory surgeries in the context of a state-mandated restrictive opioid-prescribing policy. We also aimed to evaluate opioid disposal rates, methods of disposal, and reasons for nondisposal. METHODS: Study personnel contacted the parents of 300 pediatric patients discharged with an opioid prescription following pediatric ambulatory surgery. Parents completed a retrospective telephone survey regarding opioid use and disposal. Data from the survey were combined with data from the medical record to evaluate proportion of opioid doses prescribed that were left over. RESULTS: The final analyzable sample of 185 patients (62% response rate) were prescribed a median of 12 opioid doses (interquartile range [IQR], 12–18), consumed 2 opioid doses (IQR, 0–4), and had 10 opioid doses left over (IQR, 7–13). Over 90% (n = 170 of 185) of parents reported they had leftover opioid analgesics, with 83% of prescribed doses left over. A significant proportion (29%, n = 54 of 185) of parents administered no prescribed opioids after surgery. Less than half (42%, n = 71 of 170) of parents disposed of the leftover opioid medication, most commonly by flushing down the toilet, pouring down the sink, or throwing in the garbage. Parents retaining leftover opioids (53%, n = 90 of 170) were most likely to keep them in an unlocked location (68%, n = 61 of 90). Parents described forgetfulness and worry that their child will experience pain in the future as primary reasons for not disposing of the leftover opioid medication. CONCLUSIONS: Despite Tennessee’s policy aimed at reducing leftover opioids, a significant proportion of prescribed opioids were left over following pediatric ambulatory surgeries. A majority of parents did not engage in safe opioid disposal practices. Given the safety risks related to leftover opioids in the home, further interventions to improve disposal rates and tailor opioid prescribing are warranted after pediatric surgery.

Postoperative Pain Medication Utilization in Pediatric Patients Undergoing Sports Orthopaedic Surgery: Characterizing Patient Usage Patterns and Opioid Retention

“…A systematic review by Sheth et al 20 found that overprescription of opioids was common after sports medicine procedures, with more than one-third of prescribed opioids remaining after utilization after surgery. Similar to the results of our study, Stone et al 21 described opioid utilization patterns after pediatric ambulatory surgery and reported over 90% of individuals having leftover opioids, with only 42% reporting disposal of these medications. The aforementioned studies all provide similar results to this study, demonstrating that patients undergoing orthopaedic surgery vastly underutilize their prescribed opioids based on typical prescribing patterns, which opens up the potential for community retention and illicit diversion.…”

Opioid prescription rates associated with surgery among adolescents in the United States from 2015 to 2020

“…However, state‐level PMP's were not associated with reduction in opioid misuse and opioid use disorder in a study of adults taking part in the National Survey of Drug use and Health 17 . Other studies have found that restricting of opioid prescribing to children and adolescents, have been much less successful in reducing leftover opioids 16,18,19 …”

“…Indeed, some studies suggest that opioid prescribing patterns after pediatric surgeries indicate that there are more opioids provided than what is needed for appropriate recovery 24–26 . Stone et al found that restricting postsurgical opioids to a 3‐day supply, still resulted in the vast majority of opioids going unused with >50% of parents retaining leftover opioids for future use 19 . There is an urgent need for research aimed at matching postsurgical opioid prescription with actual patient demand, in order to reduce the prevalence of leftover medication.…”

Impact of state legislation and institutional protocols on opioid prescribing practices following pediatric tonsillectomy

“…Yet recommendations from an expert surgical panel, also published in 2021, list pediatric adenotonsillectomy as a procedure in which “opioid‐free postoperative analgesia may be possible for some patients under some circumstances.” 3 Practical applications of national guidelines through The National Tonsil Surgery Registry in Sweden showed that half the departments surveyed prescribed rescue medications, including opioids, while the other half did not 25 . Literature has shown that children often receive more opioid doses than are needed to treat postoperative pain and that these left‐over medications are routinely left undisposed of with the potential for misuse and diversion 28–32 . However, the risk of over‐prescribing medications must be carefully balanced by the risks of the undertreatment of post‐tonsillectomy pain which include poor oral intake, dehydration, and prolonged recovery time 33 .…”