We are in the midst of an opioid epidemic; one issue is the presence of excess prescription circulating. How do we know this and who is at fault? 

We know prescription opioid medication is being used for unintended purposes, and often by unintended parties. The best data source available detailing this is the National Survey on Drug Use and Mental Health that the Substance Abuse and Mental Health Services Administration conducts yearly. The survey asks users where they obtained their last dose of pain relievers. Rather than from a dealer, the most common source is from a friend or relative followed by personal prescription. As far as fault, it is not easy to place blame on any singular party. There is extensive research on physicians prescribing in excess of what is used, however, pain is subjective and experienced differently by each individual and outcomes based healthcare increasingly pressures physicians to minimize re-admittance (which can happen for uncontrolled pain), and increase patient satisfaction. There is also research indicating that other health practitioners, nurses, pharmacists, technicians, who interact with patients are not efficiently educating patients on safe use and disposal of opioid medication. Finally, prescriptions are made in good faith that the patient will use the medication themselves and as prescribed.  The blame can actually fall to many tiers.

How does the cost of your intervention compare to other interventions? 

Our intervention is very low cost. The original brochures were printed for 20 cents each and cost no time for faculty or staff.  Many current interventions focus on training programs or days for residents and fellows. These focus only on the physician tier of overprescribing, and are more costly in terms of labor time and likely in terms of hiring trainers or purchasing computer software.

Background—so this is not only affecting patient health in terms of morbidity and mortality, but also healthcare costs as a whole? 

Correct, a study by Hsu published last year in Addiction states the health care cost for prescription opioid overdoses has risen proportionally to morbidity and mortality from 2001-2012 up to over 700 million annually.

Short-term use of opioids can lead to long-term dependence. What is considered short-term? 

Short term use in literature often refers to prescriptions that are intended to cover acute pain situations, like after surgery. Being that nerve pain can be severe, in our clinic, two weeks is considered an appropriate amount of time to allow for acute postsurgical pain. CDC guidelines for acute pain opioid prescriptions state in general over 7-9 days will rarely needed. Long term opioid use would be for patients in chronic pain such as cancer or hospice situations. (often in medicine over 6 months is considered chronic, but that depends on diagnosis)

What are some of the conflicts among different disposal guidelines? 

The conflicting recommendations by the FDA, EPA, DEA, and APA can not only be challenging for patients to follow, but also for providers who are attempting to educate patients on proper disposal methods. The Food and Drug Administration recommends certain opioids may be flushed and others may not, while the Environmental Protection Agency discourages flushing of any medication to protect water systems. The Drug Enforcement Agency’s rule for disposal is return to a pharmacy or police take back station, which may be difficult to locate or far away depending on the patient’s location. Written in comments on surveys in our study also demonstrate difficulties with returning opioids to pharmacies (ie. inability of pharmacy to accept medication (many, including ours, are not DEA approved to do so) or requirement to wait until a specified day to return medication). The American Pharmacists Association recommends mixing unused medication with an unpalatable substance and disposing of the mixture in the trash. This method is consistently accepted by all regulatory bodies and is also very simple and straightforward. A large part of the problem is that patients are never instructed in a clear manner on what they should do with their excess opioids. Many have been personally affected by the opioid crisis facing the US today and want to help. Knowledge is power.

What is the evidence of the link between unused opioids and opioid abuse?

In the absence of clear instruction on what to do with unused prescription opioid medication, the majority of patients are keeping the medications in their homes. This was shown in our studies and in previous literature (Bates C, 2011; Wieczorkiewicz SM, 2013). Unfortunately, the surplus of medication becomes available for unintended consumption or illegal sale by the patient or others, most frequently friends and relatives.  A national survey conducted by Substance Abuse and Mental Health Administration found that approximately 69% of “user” respondents obtained their most recently non-medical use pain-reliever or sedative divergently from a friend or relative, some given freely, some bought, and some taken without their knowledge. By reducing the number of excess pills left in households, we can reduce the number available for users to obtain from friends and relatives.

There is strong data indicating that prescription opioid use is a risk for heroin use. For example, 86% of IV drug users reported having misused opioid pain relievers prior to using heroin. Initiation of misuse was via three main sources: family, friends, or personal prescriptions (Lenkenau et al., 2012).