Opioids Spare Children from Severe Pain, but Leftovers May Fuel the Opioid Epidemic
Large amounts of leftover opioids remain in communities nationwide from prescriptions for children alone
Physicians and families believe children discharged from the hospital following surgery or an illness should be spared from pain during recovery. As a result, physicians often send families home with prescriptions for opioids such as oxycodone to treat moderate-to-severe pain. But research conducted at Johns Hopkins finds physicians often send children home with more opioids than they need. In a study of more than 300 children treated at Johns Hopkins, children were prescribed an average of 43 opioid doses. But 58 percent of the medication wasn’t taken, resulting in more than 3,000 oxycodone and 1,000 hydromorphone tablets left over. When asked what happened to the leftover opioids, only 19 percent of families said they were told how to dispose of them, and only 4 percent did so.
If this small sample is any indication, large amounts of leftover opioids remain in communities nationwide from prescriptions for children alone, and many more could result from prescriptions for adults. This is particularly worrisome as unused medicine can find its way into the wrong hands, helping fuel the opioid epidemic plaguing our nation. This risk is particularly concerning for families with teens, who are at the highest risk for opioid abuse.
Why Doctors Prescribe “Too Much” Opioid
In years past pain was often undermanaged, but alleviation of pain is considered fundamental to today’s practice of medicine. Given their effectiveness, opioids have become the gold standard for relieving severe pain, to the point that their risks have often been downplayed. As opioid use has increased, so has its misuse, leaving the United States in the midst of an epidemic affecting millions of people each year and resulting in addiction, hospitalizations and unnecessary deaths.
Part of this crisis involves the nonmedical use of legitimately prescribed opioids. While physicians don’t want to contribute to the supply of drugs available for misuse, they don’t have a simple formula to predict the exact amount of pain medicine a patient will require because needs vary with type of surgery, medical condition, pain level and other factors. Furthermore, little research has focused on pediatric pain, limiting the information available to guide physicians on how to care for children. Finally, Maryland and many other states require paper prescriptions for opioids and don’t allow telephone or electronic refills, which may promote more liberal prescribing to keep patients from returning to their doctor’s office if they run out.
What Should Be Done?
In response to the epidemic, federal and state governments have proposed regulations limiting opioid dispensing, sometimes to supplies of only three to seven days. These guidelines, generally designed for adults, could eventually apply to children. While physicians agree that the amount of opioids dispensed needs reducing, they don’t support a one-size-fits-all approach that could impede appropriate pain treatment and their ability to make informed decisions based on facts and science. The ongoing proliferation of these government attempts highlights the need for more research to develop specific prescribing guidelines for children so future policies don’t interfere with appropriate treatment.
In the meantime, one simple step to reduce leftover opioids involves providing families with recommendations on how to dispose of unused medication. Doing so would allow patients to go home with enough opioids to cover their needs while decreasing the risk of diversion of unused medicine. Until now, however, telling patients what to do with leftover opioids hasn’t been straightforward. Physicians often suggest returning unused opioids to local pharmacies, even though many pharmacies don’t accept them. And for a long time government agencies provided conflicting advice, with the Food and Drug Administration recommending flushing pills down the toilet while the Environmental Protection Agency – concerned about chemicals in the water supply – disagreed.
Within the Johns Hopkins Health System, the epidemic has spurred the opioid-prescribing community to change practices. Among the goals are creating prescribing recommendations and educational initiatives for staff, patients and families to promote safe opioid use. Educational resources promoting disposal of leftover opioids are under development, and pharmacies at the Johns Hopkins East Baltimore campus now accept unused opioids to provide patients and families with a convenient disposal option. Other hospitals nationwide should do the same.
There isn’t a single solution to this crisis, and most answers likely won’t be easy. Finding the proper balance in the amount of opioids to prescribe will require further research, but time is of the essence. Better disposal instructions and increased access to effective disposal methods are important and achievable first steps that can make a significant difference today.
Constance L. Monitto, M.D., assistant professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine in Baltimore, is lead author of “Opioid Prescribing for the Treatment of Acute Pain in Children on Hospital Discharge,” published in Anesthesia & Analgesia in December 2017.
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