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Potential for Harm Associated with Discharge Opioids After Hospital Stay: A Systematic Review

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Abstract

Introduction

Mounting evidence highlights the adverse effects of opioids. In spite of this, clinicians often prescribe excessive number of discharge opioids. The aim of this systematic review is to analyse the potential of harm from discharge opioids after inpatient care including excessive prescribing of discharge opioids, improper handling of unused opioids, and unintentional chronic opioid use.

Methods

A systematic search of MEDLINE, EMBASE, and Cochrane databases at the cut-off date of 1 December 2018 was conducted for studies reporting on various harmful effects of discharge opioids after inpatient care.

Results

Twenty-eight studies analysed the potential for harm of discharge opioids after various inpatient surgical or medical procedures. On average, patients consumed only 38% of the prescribed discharge opioid pills. Seventy-two percent of patients stored their leftover opioids in an unlocked location, and failure to dispose of unused opioids was reported in 94.5% of patients. These factors may contribute to the increasing rate of opioid misuse and diversion in the community. In addition, discharge opioids contribute to prolonged opioid use; the proportion of opioid-naïve patients still consuming opioids 3 months after hospital discharge is 10.4%. At 6 months, the proportion is 4.4%. Unintentional chronic opioid use is associated with pre-operative opioid use, history of substance use, specific comorbidities, and invasive surgical procedures.

Conclusion

This systematic review suggests that the current discharge opioid prescribing practices can be improved. Lack of patient education regarding storage and disposal of opioids also contributes to the increasing rate of opioid misuse, diversion, and unintended long-term use. More high-quality research with comparable outcomes is needed. Evidence-based hospital guidelines and public health policies are needed to improve opioid stewardship.

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References

  1. Macintyre PE, Huxtable CA, Flint SLP, Dobbin MDH. Costs and consequences: a review of discharge opioid prescribing for ongoing management of acute pain. Anaesth Intensive Care. 2014;42(5):558–74.

    Article  CAS  Google Scholar 

  2. Makary MA, Overton HN, Wang P. Overprescribing is major contributor to opioid crisis. BMJ. 2017;359:j4792. https://doi.org/10.1136/bmj.j4792.

    Article  PubMed  Google Scholar 

  3. Hah JM, Bateman BT, Ratliff J, Curtin C, Sun E. Chronic opioid use after surgery: implications for perioperative management in the face of the opioid epidemic. Anesth Analg. 2017;125(5):1733–40. https://doi.org/10.1213/ANE.0000000000002458.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Roughead EE, Lim R, Ramsay E, Moffat AK, Pratt NL. Persistence with opioids post discharge from hospitalisation for surgery in Australian adults: a retrospective cohort study. BMJ Open. 2019;9(4):e023990. https://doi.org/10.1136/bmjopen-2018-023990.

    Article  PubMed  PubMed Central  Google Scholar 

  5. CDC. QuickStats: number of deaths from poisoning, Drug Poisoning, and Drug Poisoning Involving Opioid Analgesics—USA, 1999–2010. In: Morbidity and Mortality Weekly Report (MMWR). CDC, Atlanta. 2013. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6212a7.htm. Accessed 29 Dec 2019.

  6. CDC. Vital signs: overdoses of prescription opioid pain relievers and other drugs among Women—USA, 1999–2010. In: Morbidity and Mortality Weekly Report (MMWR). CDC, Atlanta. 2013. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6226a3.htm. Accessed 29 Dec 2019.

  7. Roxburgh A, Bruno R, Larance B, Burns L. Prescription of opioid analgesics and related harms in Australia. The Medical journal of Australia. 2011;195(5):280–4.

    Article  Google Scholar 

  8. Blanch B, Pearson SA, Haber PS. An overview of the patterns of prescription opioid use, costs and related harms in Australia. Br J Clin Pharmacol. 2014;78(5):1159–66. https://doi.org/10.1111/bcp.12446.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Roxburgh A, Dobbins T, Degenhardt L, Peacock A. Opioid-, amphetamine-, and cocaine-induced deaths in Australia: August 2018. National Drug and Alcohol Research Centre, UNSW, Sydney. 2018. https://ndarc.med.unsw.edu.au/sites/default/files/Drug%20Induced%20deaths%20August%202018%20Drug%20Trends%20Bulletin.pdf. Accessed 11 Sep 2019.

  10. Kim B, Nolan S, Ti L. Addressing the prescription opioid crisis: potential for hospital-based interventions? Drug Alcohol Rev. 2017;36(2):149–52. https://doi.org/10.1111/dar.12541.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Monitto CL, Hsu A, Gao S, Vozzo PT, Park PS, Roter D, et al. Opioid prescribing for the treatment of acute pain in children on hospital discharge. Anesth Analg. 2017;125(6):2113–22. https://doi.org/10.1213/ANE.0000000000002586.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Furlan AD, Hassan S, Famiyeh IM, Wang W, Dhanju J. Long-term opioid use after discharge from inpatient musculoskeletal rehabilitation. J Rehabil Med. 2016;48(5):464–8. https://doi.org/10.2340/16501977-2080.

    Article  PubMed  Google Scholar 

  13. Juurlink DN, Gomes T, Guttmann A, Hellings C, Sivilotti MLA, Harvey M-A, et al. Postpartum maternal codeine therapy and the risk of adverse neonatal outcomes: a retrospective cohort study. Clin Toxicol (Phila). 2012;50(5):390–5. https://doi.org/10.3109/15563650.2012.681052.

    Article  CAS  Google Scholar 

  14. Calcaterra SL, Yamashita TE, Min SJ, Keniston A, Frank JW, Binswanger IA. [Not inpatient] Opioid prescribing at hospital discharge contributes to chronic opioid use. J Gen Intern Med. 2016;31(5):478–85. https://doi.org/10.1007/s11606-015-3539-4.

    Article  PubMed  Google Scholar 

  15. Bedard NA, Pugely AJ, Dowdle SB, Duchman KR, Glass NA, Callaghan JJ. Opioid use following total hip arthroplasty: trends and risk factors for prolonged use. J Arthroplasty. 2017;32(12):3675–9. https://doi.org/10.1016/j.arth.2017.08.010.

    Article  PubMed  Google Scholar 

  16. Goesling J, Moser SE, Zaidi B, Hassett AL, Hilliard P, Hallstrom B, et al. Trends and predictors of opioid use after total knee and total hip arthroplasty. Pain. 2016;157(6):1259–65. https://doi.org/10.1097/j.pain.0000000000000516.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Hadlandsmyth K, Vander Weg MW, McCoy KD, Mosher HJ, Vaughan-Sarrazin MS, Lund BC. Risk for prolonged opioid use following total knee arthroplasty in veterans. J Arthroplasty. 2018;33(1):119–23. https://doi.org/10.1016/j.arth.2017.08.022.

    Article  PubMed  Google Scholar 

  18. Hansen CA, Inacio MCS, Pratt NL, Roughead EE, Graves SE. Chronic use of opioids before and after total knee arthroplasty: a retrospective cohort study [has chronic user in the study pre-surgery]. The Journal of arthroplasty. 2017;32(3):811-7.e1. https://doi.org/10.1016/j.arth.2016.09.040.

    Article  Google Scholar 

  19. Hernandez NM, Parry JA, Taunton MJ. Patients at Risk: large Opioid Prescriptions After Total Knee Arthroplasty. The Journal of arthroplasty. 2017;32(8):2395–8. https://doi.org/10.1016/j.arth.2017.02.060.

    Article  PubMed  Google Scholar 

  20. Kim KY, Anoushiravani AA, Chen KK, Roof M, Long WJ, Schwarzkopf R. Preoperative chronic opioid users in total knee arthroplasty-which patients persistently abuse opiates following surgery? [has preop chronic and non-preopchronic. Include?]. J aArthroplaasty. 2018;33(1):107–12. https://doi.org/10.1016/j.arth.2017.07.041.

    Article  Google Scholar 

  21. Bartels K, Mayes LM, Dingmann C, Bullard KJ, Hopfer CJ, Binswanger IA. Opioid use and storage patterns by patients after hospital discharge following surgery. PLoS One. 2016;11(1):0147972. https://doi.org/10.1371/journal.pone.0147972.

    Article  CAS  Google Scholar 

  22. Al Dabbagh Z, Jansson KA, Stiller CO, Montgomery S, Weiss RJ. Long-term pattern of opioid prescriptions after femoral shaft fractures. Acta Anaesthesiol Scand. 2016;60(5):634–41. https://doi.org/10.1111/aas.12666.

    Article  CAS  PubMed  Google Scholar 

  23. Gangavalli A, Malige A, Terres G, Rehman S, Nwachuku C. Misuse of opioids in orthopaedic postoperative patients. J Orthop Trauma. 2017;31(4):e103–9. https://doi.org/10.1097/bot.0000000000000741.

    Article  PubMed  Google Scholar 

  24. Bicket MC, White E, Pronovost PJ, Wu CL, Yaster M, Alexander GC. Opioid oversupply after joint and spine surgery: a prospective cohort study. Anesth Analg. 2018. https://doi.org/10.1213/ane.0000000000003364.

    Article  Google Scholar 

  25. Sabatino MJ, Kunkel ST, Ramkumar DB, Keeney BJ, Jevsevar DS. Excess opioid medication and variation in prescribing patterns following common orthopaedic procedures. J Bone Jt Surg Am Vol. 2018;100(3):180–8. https://doi.org/10.2106/jbjs.17.00672.

    Article  Google Scholar 

  26. Griffith KC, Clark NV, Zuckerman AL, Ferzandi TR, Wright KN. Opioid prescription and patient use after gynecologic procedures: a survey of patients and providers. J Minim Invasive Gynecol. 2018;25(4):684–8. https://doi.org/10.1016/j.jmig.2017.11.005.

    Article  PubMed  Google Scholar 

  27. Hanson KT, Thiels CA, Polites SF, Gazelka HM, Ray-Zack MD, Zielinski MD, et al. The opioid epidemic in acute care surgery—Characteristics of overprescribing following laparoscopic cholecystectomy. J Trauma Acute Care Surg. 2018;85(1):62–70. https://doi.org/10.1097/ta.0000000000001834.

    Article  PubMed  Google Scholar 

  28. Stafford C, Francone T, Roberts PL, Ricciardi R. What factors are associated with increased risk for prolonged postoperative opioid usage after colorectal surgery? Surg Endosc. 2018;32(8):3557–61. https://doi.org/10.1007/s00464-018-6078-3.

    Article  PubMed  Google Scholar 

  29. Tan WH, Yu J, Feaman S, McAllister JM, Kahan LG, Quasebarth MA, et al. Opioid medication use in the surgical patient: an assessment of prescribing patterns and use. J Am Coll Surg. 2018. https://doi.org/10.1016/j.jamcollsurg.2018.04.032.

    Article  PubMed  Google Scholar 

  30. Bateman BT, Cole NM, Maeda A, Burns SM, Houle TT, Huybrechts KF, et al. Patterns of opioid prescription and use after cesarean delivery. Obstet Gynecol. 2017;130(1):29–35. https://doi.org/10.1097/AOG.0000000000002093.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Bateman BT, Franklin JM, Bykov K, Avorn J, Shrank WH, Brennan TA, et al. Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naive women. Ame J Obstet Gynecol. 2016;215(3):353.e1-.e18. https://doi.org/10.1016/j.ajog.2016.03.016.

    Article  Google Scholar 

  32. Osmundson SS, Schornack LA, Grasch JL, Zuckerwise LC, Young JL, Richardson MG. Postdischarge opioid use after cesarean delivery. Obstet Gynecol. 2017;130(1):36–41. https://doi.org/10.1097/aog.0000000000002095.

    Article  PubMed  Google Scholar 

  33. Lee JS, Hu HM, Edelman AL, Brummett CM, Englesbe MJ, Waljee JF, et al. New persistent opioid use among patients with cancer after curative-intent surgery. J Clin Oncol. 2017;35(36):4042–9. https://doi.org/10.1200/jco.2017.74.1363.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Pang J, Tringale KR, Tapia VJ, Panuganti BA, Qualliotine JR, Jafari A, et al. Opioid prescribing practices in patients undergoing surgery for oral cavity cancer. The Laryngoscope. 2018. https://doi.org/10.1002/lary.27215.

    Article  PubMed  Google Scholar 

  35. Hota LS, Warda HA, Haviland MJ, Searle FM, Hacker MR. Opioid use following gynecologic and pelvic reconstructive surgery. Int Urogynecol J. 2017. https://doi.org/10.1007/s00192-017-3474-5.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med. 2012;172(5):425–30. https://doi.org/10.1001/archinternmed.2011.1827.

    Article  PubMed  Google Scholar 

  37. Carroll I, Barelka P, Wang CK, Wang BM, Gillespie MJ, McCue R, et al. A pilot cohort study of the determinants of longitudinal opioid use after surgery. Anesth Analg. 2012;115(3):694–702. https://doi.org/10.1213/ANE.0b013e31825c049f.

    Article  PubMed  Google Scholar 

  38. Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ. 2014;348:g1251.

    Article  Google Scholar 

  39. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—USA, 2016. MMWR Recomm Rep. 2016;65(1):1–49. https://doi.org/10.15585/mmwr.rr6501e1.

    Article  PubMed  Google Scholar 

  40. Schug SA, Palmer GM, Scott DA, Halliwell R, Trinca J. Acute pain management: scientific evidence. 4th ed. Melbourne: ANZCA & FPMANZCA; 2015.

    Google Scholar 

  41. Allen ML, Leslie K, Parker AV, Kim CC, Brooks SL, Braat S, et al. Post-surgical opioid stewardship programs across Australia and New Zealand: current situation and future directions. Anaesth Intensive Care. 2019;47(6):548–52. https://doi.org/10.1177/0310057X19880904.

    Article  PubMed  Google Scholar 

  42. Wetzel M, Hockenberry J, Raval MV. Interventions for postsurgical opioid prescribing: a systematic review. JAMA surgery. 2018;153(10):948–54. https://doi.org/10.1001/jamasurg.2018.2730.

    Article  PubMed  Google Scholar 

  43. Stewart JE, Tuffin PH, Kay J, Mohamad AHT, Ritchie KL, Muthukuda G, et al. The effect of guideline implementation on discharge analgesia prescribing (two years on). Anaesth Intensive Care. 2019;47(1):40–4. https://doi.org/10.1177/0310057x18811746.

    Article  PubMed  Google Scholar 

  44. Stevens J, Trimboli A, Samios P, Steele N, Welch S, Thompson P, et al. A sustainable method to reduce postoperative oxycodone discharge prescribing in a metropolitan tertiary referral hospital. Anaesthesia. 2019;74(3):292–9. https://doi.org/10.1111/anae.14570.

    Article  CAS  PubMed  Google Scholar 

  45. Bicket MC, Long JJ, Pronovost PJ, Alexander GC, Wu CL. Prescription opioid analgesics commonly unused after surgery: a systematic review. JAMA Surg. 2017;152(11):1066–71. https://doi.org/10.1001/jamasurg.2017.0831.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Lipari RN, Hughes A. How People Obtain the Prescription Pain Relievers They Misuse. The CBHSQ Report. Rockville (MD) .2013; p. 1–7.

  47. Jones CM, Paulozzi LJ, Mack KA. Sources of prescription opioid pain relievers by frequency of past-year nonmedical use USA, 2008-2011. JAMA Intern Med. 2014;174(5):802–3. https://doi.org/10.1001/jamainternmed.2013.12809.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Belcher J, Nielsen S, Campbell G, Bruno R, Hoban B, Larance B, et al. Diversion of prescribed opioids by people living with chronic pain: results from an Australian community sample. Drug and alcohol review. 2014;33(1):27–32. https://doi.org/10.1111/dar.12084.

    Article  PubMed  Google Scholar 

  49. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011;171(7):686–91. https://doi.org/10.1001/archinternmed.2011.117.

    Article  CAS  PubMed  Google Scholar 

  50. Daoust R, Paquet J, Moore L, Emond M, Gosselin S, Lavigne G, et al. Recent opioid use and fall-related injury among older patients with trauma. CMAJ. 2018;190(16):E500–6. https://doi.org/10.1503/cmaj.171286.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Rolita L, Spegman A, Tang X, Cronstein BN. Greater number of narcotic analgesic prescriptions for osteoarthritis is associated with falls and fractures in elderly adults. J Am Geriatr Soc. 2013;61(3):335–40. https://doi.org/10.1111/jgs.12148.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Wilhelmi BG, Cohen SP. A framework for “driving under the influence of drugs” policy for the opioid using driver. Pain physician. 2012;15(3 Suppl):Es215-30.

    PubMed  Google Scholar 

  53. Li G, Chihuri S. Prescription opioids, alcohol and fatal motor vehicle crashes: a population-based case-control study. Inj Epidemiol. 2019;6:11. https://doi.org/10.1186/s40621-019-0187-x.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Dassanayake T, Michie P, Carter G, Jones A. Effects of benzodiazepines, antidepressants and opioids on driving: a systematic review and meta-analysis of epidemiological and experimental evidence. Drug Saf. 2011;34(2):125–56. https://doi.org/10.2165/11539050-000000000-00000.

    Article  CAS  PubMed  Google Scholar 

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  1. UWA Discipline of Anaesthesiology and Pain Medicine, Medical School, University of Western Australia, Level 4 MRF Building of RPH, GPO Box X2213, Perth, WA, 6847, Australia

    Gerardo A. Arwi & Stephan A. Schug

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Correspondence to Stephan A. Schug.

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Conflicts of interest

Gerardo Arwi has no conflicts of interest to declare. Unrelated to this study, the Anaesthesiology Unit of the University of Western Australia, but not Professor Schug personally, has received research and travel funding and speaking and consulting honoraria from Aspen, Biogen, Foundry, Grünenthal, Indivior, iXBiopharma, Komipharm, Luye Pharma, Mundipharma, Pfizer, Phosphagenics, Pierre Fabre, Seqirus and Xgene within the past three years. Since October 2019, again unrelated to this study, Professor Schug personally has received travel funding, speaking and consulting honoraria from Aspen, ESA, Grünenthal, HealthEd, Seqirus, Therapeutic Guidelines and WAPHA.

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Arwi, G.A., Schug, S.A. Potential for Harm Associated with Discharge Opioids After Hospital Stay: A Systematic Review. Drugs 80, 573–585 (2020). https://doi.org/10.1007/s40265-020-01294-z

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