Few patients maximise opioid-sparing medications after orthopaedic surgery

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Patients improperly store and dispose of unused opioids, study finds

A new study led by Johns Hopkins researchers adds to growing evidence that patients underuse non-opioid pain relievers to supplement opioid pain management after spine and joint surgery.

report on the findings, which also shows that patients improperly store and dispose of unused opioids, was published in the journal Anesthesia & Analgesia. The report highlights the need for physicians to better educate patients on non-opioid alternatives as well as how to properly store and dispose of opioids in the home, the investigators say.

“We found that a very small percentage of patients use non-opioid medications such as ibuprofen and acetaminophen in addition to opioids to help manager their pain,” says Mark Bicket (Department of anesthesiology and critical care medicine, John Hopkins University School of Medicine, Baltimore, USA), the paper’s first author.

“It’s clear we need to empower patients to ask their physicians about non-opioid pain management options, as well as call on prescribers to be more thoughtful of their prescribing practices,” says Bicket.

Bicket adds that if pain is more frequently managed with non-opioid options, fewer opioids will need to be prescribed and patients will have less available to be lost, sold, taken by error or accidentally discovered by a child.

In one of Bicket’s earlier studies (JAMA Surgery, 2017), he reviewed half a dozen studies and found that most opioid pills prescribed after surgery went unused, and almost all patients failed to properly dispose of the leftovers.

To further examine what happens to opioid pills after they are prescribed, as well as to determine whether patients used non-opioid medications in conjunction with their prescribed opioid prescriptions as recommended by evidence-based guidelines, the researchers recruited 140 inpatient adult spine and joint surgery patients at The Johns Hopkins Hospital from August to November 2016. Of the 140 patients in the study, 47% were women, the average age was 56, 58% reported a history of chronic pain and 74% were Caucasian.

Bicket and his team collected patient data such as history of substance abuse, self-reported pain scores and preoperative opioid use through in-person interviews and electronic health records. The researchers also conducted phone surveys after surgery at two days, two weeks, one month and six months to determine if and when patients stopped taking opioids, how many opioid tablets they had left, what other non-opioid pain treatments they used, and their knowledge and practice regarding safe opioid storage and disposal per the Food and Drug Administration’s (FDA) recommendations.

Of these patients, very few used non-opioid medications in conjunction with opioid products throughout the study period. Two days after surgery, 82% of patients reported not using nonsteroidal anti-inflammatory drugs (NSAIDs) and 44% reported not using acetaminophen. Only 5% used both NSAIDs and acetaminophen. One month post-surgery, only 6% of patients reported use of multiple non-opioid medications.

One month post-surgery, 73% of patients said they had unused opioids, 46% said they had 20 or more unused pills, and 37% said they had more than 200 morphine milligram equivalents (MMEs) of opioids.

While it is difficult to definitively say how many MMEs are dangerous to take at one time, Bicket says 200 MME is considered by some experts as the dosage at which a patient who has never had opioids would overdose.

The majority of patients also reported unsafe storage (91%) and failure to dispose of (96%) opioids one month after surgery, as suggested in FDA guidelines.

Six months post-surgery, the percentage of patients who had unused opioids fell to 34%. Many still reported unsafe storage and failure to dispose of opioids (92% and 47%, respectively), with a large majority reporting they had not received instructions on how to store or dispose of opioids (83% and 75%, respectively).

Other authors on this paper include Elizabeth White, Peter J Pronovost, Christopher L Wu and G Caleb Alexander of the Johns Hopkins University; and Myron Yaster of Children’s Hospital Colorado (Aurora, USA).

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