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Prescription Opioid Analgesics Commonly Unused After SurgeryA Systematic Review

Educational Objective To quantify how commonly prescribed opioids are unused, why they are unused, and what happens to them as reported in the literature.
1 Credit CME
Key Points

Question  How commonly are prescription opioid analgesics unused among adult patients after a surgical procedure?

Findings  In this review of 6 studies involving 810 unique patients who underwent orthopedic, thoracic, obstetric, and general surgical procedures, 67% to 92% of patients reported unused opioids. Rates of safe storage and/or disposal of unused prescription opioids were low.

Meaning  Unused opioids prescribed for patients after surgery are an important reservoir of opioids available for nonmedical use and could cause injuries or even deaths.


Importance  Prescription opioid analgesics play an important role in the treatment of postoperative pain; however, unused opioids may be diverted for nonmedical use and contribute to opioid-related injuries and deaths.

Objective  To quantify how commonly postoperative prescription opioids are unused, why they remain unused, and what practices are followed regarding their storage and disposal.

Evidence Review  MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched from database inception to October 18, 2016, for studies describing opioid oversupply for adults after a surgical procedure. The primary outcome—opioid oversupply—was defined as the number of patients with either filled but unused opioid prescriptions or unfilled opioid prescriptions. Two reviewers independently screened studies for inclusion, extracted data, and assessed the study quality.

Findings  Six eligible studies reported on a total of 810 unique patients (range, 30-250 patients) who underwent 7 different types of surgical procedures. Across the 6 studies, 67% to 92% of patients reported unused opioids. Of all the opioid tablets obtained by surgical patients, 42% to 71% went unused. Most patients stopped or used no opioids owing to adequate pain control, and 16% to 29% of patients reported opioid-induced adverse effects. In 2 studies examining storage safety, 73% to 77% of patients reported that their prescription opioids were not stored in locked containers. All studies reported low rates of anticipated or actual disposal, but no study reported US Food and Drug Administration–recommended disposal methods in more than 9% of patients.

Conclusions and Relevance  Postoperative prescription opioids often go unused, unlocked, and undisposed, suggesting an important reservoir of opioids contributing to nonmedical use of these products, which could cause injuries or even deaths.

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Article Information

Corresponding Author: Mark C. Bicket, MD, Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287 (bicket@jhmi.edu).

Accepted for Publication: March 4, 2017.

Published Online: August 2, 2017. doi:10.1001/jamasurg.2017.0831

Author Contributions: Dr Bicket had full access to all 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: Bicket, Pronovost, Wu.

Acquisition, analysis, or interpretation of data: Bicket, Long, Alexander.

Drafting of the manuscript: Bicket, Long, Wu.

Critical revision of the manuscript for important intellectual content: Bicket, Pronovost, Alexander.

Statistical analysis: Bicket.

Administrative, technical, or material support: Bicket.

Study supervision: Bicket, Pronovost, Alexander, Wu.

Conflict of Interest Disclosures: Dr Alexander reported being chair of the US Food and Drug Administration’s Peripheral and Central Nervous System Advisory Committee and serving as a paid consultant to PainNavigator, a mobile startup to improve patients’ pain management; as a paid consultant to QuintilesIMS; and on a scientific advisory board of QuintilesIMS Health. This arrangement has been reviewed and approved by The Johns Hopkins University according to its conflict-of-interest policies. No other disclosures were reported.

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