An educational intervention coupled with a reliable option for opioid disposal resulted in a marked increase in disposal of opioids after surgery, for a simple but effective approach designed to help alleviate the ongoing opioid epidemic in this country.
“I think the public is becoming more aware of the opioid crisis,” said Rachael A. Haverland, MD, MS, a minimally invasive gynecologic surgery fellow at Mayo Clinic in Scottsdale, Ariz. “But we noticed that although our patients knew about the problem, they didn’t know what to do about or how to dispose of their medication.
“As it turns out, they had never been educated by anyone—not just a medical provider—about how to dispose of the medications,” Haverland said. “So, we thought we could implement a relatively simple intervention that might make a big impact.”
Currently, the FDA recommends several methods for disposal of unused medications. Among them is mixing medications with an unpalatable substance—such as dirt, cat litter or coffee grounds—and placing it in a sealed plastic bag. Previous research has shown that many people have a poor understanding of the proper means for disposing of medications, and that simply providing educational materials can increase proper disposal.
The feature that distinguishes the current effort is the inclusion of a charcoal drug deactivation bag (Deterra; Verde Technologies). Each disposal bag contains a carbon compound that neutralizes the active ingredient in the opioid. Patients put their unused medications in the bag, add water, and then seal the bag and place it in the garbage.
As Haverland explained, education was part of the researchers’ efforts. “These were all gynecologic surgery patients,” she said in an interview with Anesthesiology News. “At their preoperative visit, we gave them a pamphlet that explains how to dispose of the drugs, based on FDA and other recommendations.”
Cost of Disposal Bag Not an Impediment
As part of the prospective cohort study, Haverland and her colleagues, including principal investigator Johnny Yi, MD, first evaluated patients’ baseline understanding of medication disposal using a questionnaire. Patients were also given the medication disposal bag at this time, if they desired.
Of the 35 participants, 22 (71%) had never been educated by a medical provider regarding appropriate disposal. Tellingly, six patients (19%) said they had used a narcotic medication prescribed for someone else.
Participants again completed a questionnaire at their last postoperative visit, this time about how they disposed of their unused opioids. The researchers evaluated the success of the education and the rate of proper opioid disposal.
In an abstract approved for presentation at the pandemic-canceled annual meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract 830), the researchers noted that 31 patients successfully completed both surveys. Prior to the intervention, 52% (n=16) did not dispose of their narcotics. After the education and disposal bag were given, this rate increased to 93.5% (n=29) (P≤0.001). Results are shown in the Figure.
“We feel these are pretty impressive results,” Haverland said. “There have been a few randomized controlled trials that came out while our study was being conducted, but they didn’t implement both the education component and the bag simultaneously.”
The majority of patients who disposed of their opioids (24/29) used the drug disposal bag. Of note, these individuals said they would be willing to pay an average of $7.70 (up to $20) for each disposal bag.
“I think a lot of people keep their medications because they didn’t know what to do with them,” Haverland said. “But even if they knew how to dispose, it still required a time commitment. It’s not as easy to find a pharmacy that receives medication and then take it there. This [bag] made it much more convenient.”
Perhaps most telling about the initiative was that it helped get 477 tablets of 5-mg oxycodone properly disposed. Given these results, the researchers were quick to recommend that other institutions consider implementing similar programs, which they say will go a long way toward addressing the opioid epidemic.
“As we push for more outpatient surgeries with enhanced recovery protocols, there are more opioid prescriptions going home,” Haverland said. “So, we need to make sure we’re doing our part to keep these medications out of harm’s way. It doesn’t take a lot of time on the part of the provider.”
For Chad M. Brummett, MD, the senior associate chair for research and Bert N. LaDu Professor of Anesthesiology at the University of Michigan Medical School, in Ann Arbor, the safe and effective disposal of unused opioids is an important topic, particularly because these pills can linger in medicine cabinets for years, potentially becoming a source of misuse and abuse, particularly by adolescents and young adults. “As the authors noted, flushing is not recommended as the opioids can then move to our rivers and lakes.”
Indeed, Brummett and his colleagues previously demonstrated that receiving an activated charcoal disposal bag improved self-reported disposal (JAMA Surg 2019;154:558-561). “The disposal rate was extremely high, and it may be that the education provided or pathway was better than that which was previously stated,” he said. “While I appreciate that many would pay for the bag, my hope is that hospitals, pharmacies and payors can make these simple, effective tools more available as a part of standard clinical care.”