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Research Letter |

Leftover Prescription Opioids After Minor Procedures An Unwitting Source for Accidental Overdose in Children FREE

Terri Voepel-Lewis, PhD1; Deborah Wagner, PharmD1,2; Alan R. Tait, PhD1
[+] Author Affiliations
1Department of Anesthesiology, The University of Michigan Hospital and Health Systems, C. S. Mott Children’s Hospital, Ann Arbor
2Department of Surgical Pharmacy, The University of Michigan Hospital and Health Systems, C. S. Mott Children’s Hospital, Ann Arbor
JAMA Pediatr. 2015;169(5):497-498. doi:10.1001/jamapediatrics.2014.3583.
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Published online

Increasing rates of opioid misuse, adverse events, and deaths from opioids have paralleled prescription patterns,1 suggesting that physician efforts to alleviate pain have contributed to this public health crisis. Children and adolescents are particularly vulnerable to prescription opioid overdose and misuse, given high rates of exposure in this group.24 Unintentional opioid deaths are estimated at 0.1 and 3.7 per 100 000 children and adolescents/young adults, respectively,1 and nearly all unintentional childhood exposures to opioids are to other family members’ medications.4 Half of adolescents who misuse prescription opioids acquire them from their own previous prescriptions, friends, or family members and 8% share their prescriptions with others.3,5 Given increasing public health concerns, the American College of Physicians recommends that an evidence-based defined maximum opioid dosage and duration of treatment be developed and followed,6 which, in part, could reduce the amounts of unused drugs available for adverse events and misuse. Therefore, we compared the opioid doses dispensed to children with the amount used following minor outpatient procedures to estimate the unused drugs remaining in children’s homes and inform future opioid prescribing.

METHODS

This study was part of a larger study on parental analgesic decision making approved by the Institutional Review Board at the University of Michigan. Parents provided written informed consent and prospectively recorded all analgesics they gave their children (aged 3-17 years) as well as pain scores across 4 days following elective procedures at a tertiary care children’s hospital from March 1, 2013, to August 31, 2013. Leftover opioids were estimated by calculating the number of doses and treatment days remaining from the dispensed amount if parents continued giving the opioid at the day 3 dosing frequency.

RESULTS

Of the 223 parents who returned diaries, 14% gave zero doses of the dispensed opioid. Opioid dosing significantly decreased each day (mean difference, −0.7) in concert with decreasing pain intensity (mean difference, −1.22; P < .001). By day 3, 34% of parents gave only 1 to 2 doses and 39% had discontinued the opioid altogether and provided only over-the-counter analgesics. The Table shows leftover opioid doses and estimated weeks of treatment remaining by drug and service (nonsignificant differences). Given decreasing pain, early tapering, and discontinuation, most children (79%) had enough leftover opioid doses after day 3 to treat their acute pain for more than 2 to 3 additional weeks.

Table Graphic Jump LocationTable.  Leftover Opioid Doses and Estimated Days of Treatment Remaining

DISCUSSION

Our findings showed the potential mismatch between the amounts of opioids prescribed/dispensed and the amounts used following minor pediatric ambulatory procedures associated with acute pain. Most children received less than 50% of their prescribed opioid doses because parents quickly tapered opioids, switched to nonopioids, or discontinued analgesics during the first few postprocedure days. This left a considerable amount of unused prescribed opioids in the homes of children who were prescribed these agents for acute pain. This suggested mismatch between dispensed and used prescription opioids can inadvertently contribute to risky behavior and, therefore, begs for broad intervention.

The recommendation by the American College of Physicians that physicians develop guidelines to limit the amount of opioids prescribed is a step in the right direction. Furthermore, because it was unclear whether parents in our setting were informed about the risks of how to dispose of unused opioids, such education is clearly needed. The Drug Enforcement Agency recently expanded their drug take-back program and legally authorized pharmacies to accept and dispose of patients’ unused prescription medications. In accordance with recommendations from the US Food and Drug Administration, pediatric prescribers and pharmacists should educate parents and adolescents of the importance of proper use, storage, and disposal of these medications. Better alignment of opioid prescriptions with the pain needs of patients and disposal education is warranted to appropriately manage pain while limiting the amounts of unused opioids available for accidental overdose, diversion, and misuse.

ARTICLE INFORMATION

Corresponding Author: Terri Voepel-Lewis, PhD, Department of Pediatric Anesthesiology, The University of Michigan Hospital and Health Systems, C. S. Mott Children’s Hospital, Ann Arbor, 1540 E Hospital Dr, Room 4917, Ann Arbor, MI 48109-4245 (terriv@umich.edu).

Published Online: March 23, 2015. doi:10.1001/jamapediatrics.2014.3583.

Author Contributions: Dr Voepel-Lewis had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Voepel-Lewis, Tait.

Acquisition, analysis, or interpretation of data: Voepel-Lewis, Wagner.

Drafting of the manuscript: Voepel-Lewis, Wagner.

Critical revision of the manuscript for important intellectual content: Voepel-Lewis, Tait.

Statistical analysis: Voepel-Lewis.

Study supervision: Voepel-Lewis.

Conflict of Interest Disclosures: None reported.

REFERENCES

Paulozzi  LJ, Jones  C, Mack  K, Rudd  R; Centers for Disease Control and Prevention (CDC).  Vital signs: overdoses of prescription opioid pain relievers. United States 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492.
PubMed
Fortuna  RJ, Robbins  BW, Caiola  E, Joynt  M, Halterman  JS.  Prescribing of controlled medications to adolescents and young adults in the United States. Pediatrics. 2010;126(6):1108-1116.
PubMed   |  Link to Article
McCabe  SE, West  BT, Boyd  CJ.  Motives for medical misuse of prescription opioids among adolescents. J Pain. 2013;14(10):1208-1216.
PubMed   |  Link to Article
Bailey  JE, Campagna  E, Dart  RC; RADARS System Poison Center Investigators.  The underrecognized toll of prescription opioid abuse on young children. Ann Emerg Med. 2009;53(4):419-424.
PubMed   |  Link to Article
Johnston  LD, O'Malley  PM, Bachman  JG, Schulenberg  JE, Miech  RAMonitoring the Future: National Survey Results on Drug Use, 1975-2012: 2013 Volume 1. Secondary School Students. Ann Arbor: The University of Michigan; 2013
Kirschner  N, Ginsburg  J, Sulmasy  LS; Health and Public Policy Committee of the American College of Physicians.  Prescription drug abuse: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2014;160(3):198.
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable.  Leftover Opioid Doses and Estimated Days of Treatment Remaining

References

Paulozzi  LJ, Jones  C, Mack  K, Rudd  R; Centers for Disease Control and Prevention (CDC).  Vital signs: overdoses of prescription opioid pain relievers. United States 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492.
PubMed
Fortuna  RJ, Robbins  BW, Caiola  E, Joynt  M, Halterman  JS.  Prescribing of controlled medications to adolescents and young adults in the United States. Pediatrics. 2010;126(6):1108-1116.
PubMed   |  Link to Article
McCabe  SE, West  BT, Boyd  CJ.  Motives for medical misuse of prescription opioids among adolescents. J Pain. 2013;14(10):1208-1216.
PubMed   |  Link to Article
Bailey  JE, Campagna  E, Dart  RC; RADARS System Poison Center Investigators.  The underrecognized toll of prescription opioid abuse on young children. Ann Emerg Med. 2009;53(4):419-424.
PubMed   |  Link to Article
Johnston  LD, O'Malley  PM, Bachman  JG, Schulenberg  JE, Miech  RAMonitoring the Future: National Survey Results on Drug Use, 1975-2012: 2013 Volume 1. Secondary School Students. Ann Arbor: The University of Michigan; 2013
Kirschner  N, Ginsburg  J, Sulmasy  LS; Health and Public Policy Committee of the American College of Physicians.  Prescription drug abuse: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2014;160(3):198.
PubMed   |  Link to Article

Correspondence

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