OBJECTIVES:

To investigate prescription opiate usage, disposal rates, and methods of disposal after pediatric surgery.

METHODS:

This was a retrospective chart review of patients <18 years of age who underwent a surgical procedure at our institution and were given a postoperative opiate prescription between April 2017 and June 2018. A follow-up phone survey was conducted between 60 and 90 days postoperatively to ask about prescription opiate usage and disposal.

RESULTS:

A total of 290 patients with a mean age of 9.0 ± 4.7 years (62.8% male) met inclusion criteria. Sixty patients (20.7%) reported using all of their prescription opiate medication, whereas 230 patients (79.3%) did not use all of their pain medication. Of these 230 patients, 141 (61.3%) disposed of their leftover prescription opiates via flushing (56.4%), trash (28.6%), or take-back center (15.0%). At the time of phone survey between 60 and 90 days postoperatively, 88 patients (38.3%) still had leftover pain medication. By 7 days postoperatively, 234 of 290 patients (80.7%) had taken their last prescription opioid.

CONCLUSIONS:

In our study, 79.3% of patients were overprescribed opiate pain medication after pediatric surgery. Disposal rates at 60 to 90 days for leftover pain medication after pediatric surgery was just >60%. Pediatric patients are often overprescribed prescription opiates after surgery and typically only require a one-week supply of pain medication.

Prescription opioid abuse has become a major medical and social problem in the United States. In 2015, >245 million opiate prescriptions were written. That same year, >12.5 million people misused prescription opioids.1  The misuse of opioids resulted in 33 000 overdose deaths in 2015, with approximately half of these deaths involving prescription opioids. Prescription opioid abuse also poses a financial burden to society, costing the economy >$78.5 billion in 2015 alone.1 

A major problem is ease of access to opioid medications, as unused opioids pose a threat to patients and their families.24  In previous studies of high school seniors, researchers found that 25% reported some exposure to prescription opioids, and a previous opioid prescription increased their future risk of opioid misuse by >33%.2,3  From 1997 to 2012, hospitalizations in the pediatric population due to opioid poisonings nearly doubled.4 

In the adult population, 67% to 92% of patients report unused opioids after various surgical procedures.5,6  In the pediatric literature, there are few studies in which researchers have investigated prescription opiate usage and disposal rates after surgery. In one study used to investigate reported morphine prescription use at home after pediatric surgery, researchers found that only 9.2% of prescribed doses were administered and most patients required only 2 doses or less.7  In another pediatric study on opioid usage after spinal surgery for scoliosis, researchers found that on average 67% of the prescribed opioids were consumed.8  There remains a large gap in the pediatric literature to accurately define prescription opiate usage and disposal after surgery. Our purpose with this study was to investigate usage, disposal rates, and methods of disposal of prescription opiates written to pediatric patients after surgery.

The study population consisted of patients <18 years of age who underwent a surgical procedure at our 690-bed academic medical center in the southeastern United States (predominately rural catchment area) and were given a postoperative opiate prescription between April 2017 and March 2018. Patients underwent a variety of inpatient and outpatient surgical procedures during this period. Exclusion criteria included any patients <18 years of age who were not given an opiate prescription after surgery. The study was approved by our institutional review board.

This was a retrospective chart review involving a follow-up phone survey between 60 and 90 days after surgery to ask the parents (or legal guardian) about the patient’s prescription opiate usage and disposal. Patients were identified via a surgery database at our institution. The parents (or legal guardian) were contacted via phone call, verbal consent was obtained, and the parents were asked specific questions about prescription opiate usage and disposal. These questions included whether pain medication was prescribed, whether all the pain medication was used or if there was any leftover, and the actual and/or planned method of disposal with any leftover medication. If a guardian was unable to be contacted during this time frame, the patient was excluded. A limited chart review was conducted before the survey to identify the study population and patient contact information, age, date of surgery, insurance type, race, county and state of residence, and BMI.

The primary outcome was to evaluate prescription opiate usage and disposal rates after pediatric surgery. Secondary outcomes included evaluation of disposal methods, plans for disposal of leftover medication, and ascertainment of how many days after surgery the last prescription opiate pill was consumed. Patients were not counseled by study personnel on proper opioid disposal to eliminate potential bias.

Data collection was performed by using Research Electronic Data Capture, which is a secure Web-based application designed to facilitate secure data capture and collection for research studies.9  For statistical analysis, descriptive statistics including ratios and percentages were calculated. Logistic fit analysis was used to evaluate correlations between continuous demographic variables and the study outcomes. A χ2, 2-tailed t test, and analysis of variance were used to determine impact of categorical demographic variables where appropriate. A P value of .05 was used to determine statistical significance for all analyses.

Overall, 290 patients with a mean age of 9.0 ± 4.7 years (SD) met inclusion criteria. Parents (or legal guardian) were reached an average of 74.0 ± 9.8 days (SD) after surgery, with an approximate overall 15% to 20% survey completion rate. A summary of the demographics of the study population can be seen in Table 1. The majority of the patients were white (86.9%), followed by African American (1.7%), Hispanic (1.0%), and other (10.3%). The predominant insurance type was Medicaid (58.6%), and there were 89 (30.7%) inpatient surgeries versus 201 (69.3%) outpatient surgeries.

Sixty patients (20.7%) reported using all of their prescription opiate medication, whereas 230 patients (79.3%) did not use all of their pain medication. Of the 230 patients who did not use all of their opioid prescription, 141 patients (61.3%) disposed of their leftover prescription opiates. Eighty-eight patients (38.3%) still had leftover pain medication at the time of the follow-up phone survey. Patients disposed of their leftover pain medication via flushing (56.4%), trash (28.6%), or take-back center (15.0%). For the 88 patients with leftover pain medication at the time of the follow-up phone survey, plans for unused opiates included disposal (60.2%), keep it (13.6%), and unsure (26.1%). By postoperative day 7, 80.7% of patients had taken their last prescription opioid and no longer required opioids for pain control. A summary of these statistics is provided in Table 2.

There was no significant difference in disposal rates on the basis of age (P = .52), sex (P = .14), ethnicity (P = .46), insurance type (P = .67), or inpatient versus outpatient surgery (P = .23). There was no significant difference in disposal method or plans for disposal of leftover medication on the basis of age, sex, ethnicity, insurance status, inpatient versus outpatient surgery, county, or state of residency. No significant association existed for patients with remaining medication at the time of the follow-up survey on the basis of age, sex, ethnicity, insurance status, or inpatient versus outpatient surgery.

In our study, only 20.7% of patients used all of the opioid pain medication after surgery. A total 79.3% of pediatric patients had leftover pain medication after various surgical procedures. These numbers are similar to previous studies in which authors found between 67% and 92% of prescription opioids remain unused after surgery.5,8,10  In a study of 586 patients who underwent various urologic procedures, 67% of patients had leftover medication after surgery. Only 8% of patients in that study received any instructions on the disposal of unused opioids.5  This lack of patient education on proper methods of opioid disposal is of major concern. Currently, there are 3 US Food and Drug Administration–approved methods to dispose of opioid pain medication: (1) mix the medication with unpalatable substance and throw it in the trash, (2) flush the medication in the toilet, or (3) bring the medication to a proper take-back or disposal location.11  Prescribers should consider all patients to be equally at risk for inappropriate disposal and adopt disposal education as part of their standard practice when prescribing opioids to pediatric patients.

Opioid misuse is a major problem in our state and the entire country, prompting recent legislative changes. The Opioid Reduction Act went into effect in our state on June 7, 2018. With the passage of this act, surgeons in our state are now limited to prescribing a 7-day supply of the lowest effective dose of opioids. Patients may not get a prescription refill of opioids until at least 6 days after surgery. If a patient requires a second refill of prescription opioids after surgery, the surgeon must consider referral to a pain management specialist. Similar legislation has been passed in several other states.

Limitations of this study include the inherent nature of any retrospective case series. Another notable limitation is the possibility of recall bias because guardians were asked about prescription opiate usage, disposal, and methods of disposal between 60 and 90 days postoperatively, which could potentially make it difficult to accurately recall this information. Response bias may also be present and make it difficult to consider the results generalizable given that the follow-up phone survey had a 15% to 20% completion rate. Patients may tend to answer questions about opioid usage and disposal in a socially acceptable manner, which may overestimate disposal rates and underestimate patients with remaining opioids in the household. In this study, there is no correlation between opiate prescription usage habits and dose prescribed or type of surgery performed, which should be addressed in future studies.

In this study, 80% of patients were overprescribed opiate pain medication after pediatric surgery. Disposal rates for leftover pain medication after pediatric surgery was 61.3%. Pediatric patients are overprescribed prescription opiates after surgery and typically only require a one-week supply of pain medication. In future studies, researchers should target creating guidance for proper postoperative dosing and opioid disposal to decrease unused opioids that remain in the household with potential for misuse.

Drs Ray, Shackleford, Bronikowski, Lubicky, Lancaster, and Grant conceptualized and designed the study, drafted the initial manuscript, conducted the data collection and analysis, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.

FUNDING: Supported by the National Institute of General Medical Sciences of the National Institutes of Health under award U54GM104942. Funded by the National Institutes of Health (NIH).

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose