Resources

  1. non-opioid combinations having equivalent or superior pain controlling ability (Systematic Review: Swed Dent J. 2014;38(1):1-14.)
  2. Chronic pain begins as acute pain, and the long-term use of opioids fell to many in the primary care world, so do not for a moment believe I blame our surgical peers alone.  We continued a bad thing.  Even worse, there is no evidence that chronic pain is successfully treated with opioids. Ann Intern Med. 2015;162(4):276-286.:

Transcript

Dr. Frank Domino:
George presents to your office five weeks following his elective hip replacement. He states he feels well and is doing the home exercises that he was prescribed the physical therapy. As you review his medication list, he asks, "What should I do with all of these leftover pain pills?" He produces a bottle of 45 oxycodone-acetaminophen tablets.

Hi, this is Frank Domino, Professor in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School. Joining me today is Dr. Jill Terrien, Associate Professor and Director of Nurse Practitioner Programs at the University of Massachusetts Medical School's Graduate School of Nursing. Welcome to the episode, Jill.

Jill Terrien:

Thank you, Frank. 

Dr. Frank Domino:
So, George and his hip, this really happened to me, and I didn't know where to begin.

Jill Terrien:

Well, I'm sure, Frank, that this is probably just not George, but it's happened a few times. I know that you looked at a recent study. Can you tell me what you found?

Dr. Frank Domino:
Sure. Well, this was a cohort study published in the anesthesia literature, and it looked at patients who were postop joint or spine surgery. And it followed them over time to see what they did with their pills, with their pain pills in particular. They did phone surveys at two weeks, one month, and six months. And what they found was that 73% of patients had unused opioids at one month, and 44% had unused opioids in their home at six months. This was really concerning, because you would think by one month, they wouldn't be needing more opioid pain medicine from their surgery. And it worries me a great deal that there might be some dependence forming.

The other interesting thing, the thing that I think is most important for those of us in primary care, is that 82% of the patients were told, were not offered non-opioid pain medication to use either alone or in conjunction with their opioids. They found that, at one month, only 6% had used a non-opioid agent to control their pain, and that the vast majority, 96% of patients at six months, reported unsafe storage practices of their opioids.

Jill Terrien:

Wow. There actually is just so much that we can do here, and when you think about the opioid crisis, this is one facet of it, right? Because if George, your patient, has these in his home and he's not using them, and they're unsafely stored, does he have grandchildren, does he have children?

Dr. Frank Domino:
Sure

Jill Terrien:

And what's gonna happen with these unused opioids? So, here he is, he's postop. As a primary care provider, what are you gonna tell George? He's got these opioids, is he taking them? What's your recommendation?

Dr. Frank Domino:

I think you make an excellent point. The first question is, are you still using them and are you using some non-opioid methods to control whatever pain you have. And since alone or in combination with acetaminophen are as effective as opioids for acute pain, and they have much lower risk and they're very safe, so I certainly wanna query him about what he's doing for pain control and try to encourage him to not use the opioids, use the non-opioid methods. The other thing I would ask him is, if he's still using the opioids, we have to find out what's going on. It could be that something has gone wrong with the surgery. He has an abscess, he has some chronic pain, he had some neuralgia following the surgery. There's a host of reasons why we need to investigate what his pain needs are at this point in time. And if he's not using the opioid, certainly congratulate him but at least counsel him a little bit on what might be proper ways to use pain medication if he still needs it.

Jill Terrien:

Those are all great points. I'm just wondering, George is five weeks postop, and if he is still taking opioids, you have to be concerned about the possible tolerance of that. So, it's great to hear that you're going to talk with him about a plan that is gonna be tailored to his needs, which I think it needs to be individualized. And the education piece is so important. If we take a patient of yours in primary care that's going to have surgery, what are you gonna be telling your patients that are on their way to a surgical procedure?

Dr. Frank Domino:

I think that's where our job is very important. If we're recommending a patient to have any sort of surgery, beforehand, we wanna give them a little bit of anticipatory guidance about what they should expect pre-op, postop, immediately and down the line. And what this study tells me is I need to do a much better job at telling patients, "Listen, use pain medication in this manner." Maybe try to treat the acute pain with a non-opioid treatment, and if that doesn't work, save the opioid for that. Now, in this case, George received a combination agent with an opioid and acetaminophen. So, I might say, "Listen, postoperatively, use an anti-inflammatory, something like naproxen 500 mg twice a day, and then if you still need something else, you can add in the combination agent to help control the symptoms without any worry about acetaminophen toxicity.

Jill Terrien:

Right. And I think maybe, in talking with George, you might find out that positioning in bed at night might be something for him. It might be something that you can talk about using pillows, and other things to support him, depending on when he's having... When he feels he's having his trouble with pain.

Dr. Frank Domino:
Sure. Ice and heat and just a host of things that are unlikely to hurt him and potentially to help him.

Jill Terrien:

Absolutely. Now, you have George and he's got these pills, and let's just say he's not taking them and they're leftover. What's your recommendation to patients about what they do with their leftover opioids?

Dr. Frank Domino: 

Well, this study told us that 96% of the patients were acting in an unsafe manner. And as you mentioned earlier, that means leaving them around in a way that small children could get them or someone with an opioid problem could steal them. There's a variety of opinions about how to get rid of medications, and if you go to the CDC, they first recommend that typically most communities once a month will offer a pill take-back program, where you can take your pills to the local health department, and even some pharmacies offer those options. But it turns out my assumption was that you couldn't flush them down the toilet, and that actually turns out to be not true.

The CDC states that if you have leftover medication, you have a variety of options. One is try to turn them in, but if not, you can flush them down the toilet. The fear that most of us had was that it might contaminate the water supply. It turns out that the vast majority of opioids in the water supply come from patients using opioids and not from flushing them down the toilet, so flushing them down the toilet is a very safe option that's not going to harm anyone. The third recommendation was, they suggested mixing it with something that would make the pills inactive, so mixing it with coffee grounds. They recommend mixing it with an acid, like some vinegar, or something that's going to break down the characteristic of the medication to make it clinically ineffective and then just throwing it out in your trash.

Jill Terrien:

That's great, Frank. I guess that we have to have great anticipatory guidance before we send our patients to surgery, 'cause we're gonna get them back in our practice. And so it's really good to be full circle with and knowing what they're taking for their pain and how we can advise them.

Dr. Frank Domino: 
I agree with you completely. This is the role of those of us in primary care, is that we can help prevent problems, like an opioid addiction, a death or even just a fall, from being under the influence of a pain medication that may be overly aggressively being used, and give patients a better set of options so that we don't have to then complicate matters with treating opioid dependence and all the complications that go with it.

Jill Terrien:

Sounds great, Frank.

Dr. Frank Domino: 

Jill, thanks so much for discussing this with me.

Jill Terrien:

It was my pleasure.

Dr. Frank Domino: 

Practice pointer. The majority of patients postoperatively do not store their unused medications properly. Please counsel patients, both before and after surgery, on proper usage of pain medication and proper disposal methods. 

Join us next time when we discuss the serious condition of binge drinking in adolescents. And for more timely, relevant and practical medical education, check out pri-med.com.