More than 190 million opioid prescriptions are filled each year in the U.S., according to the Centers for Disease Control and Prevention, and providers are prescribing opioids in excess of patient need, John F. Kelly, MD, general surgery chief resident, University of Massachusetts (UMass) Medical School, Worcester, explained during The Opioid Problem: What a Surgeon Needs to Know.

He was part of a panel discussing the opioid addiction crisis in the United States, its effects on the practice of daily surgery, mitigation strategies for outpatient prescribing, and public health approaches to the solution Monday, October 5, at the Clinical Congress. The session will be available for on-demand viewing through the virtual Clinical Congress meeting platform through December 31.

In the Opioid Prescribing Optimization Study at UMass, recruited patients completed follow-up surveys after undergoing one of four elective surgeries with one of nine surgeons. Based on the 218 completed surveys, just 30 percent of opioids prescribed were actually taken by patients, leaving 70 percent of the drugs in the community at risk for abuse, misuse, or diversion if not properly disposed.

However, Dr. Kelly also reported that many patients are unaware of the proper disposal methods for unused opiates. Prior to the Drug Enforcement Administration (DEA) Disposal of Controlled Substances Act of 2014, which expanded the options for controlled substance disposal, only 9 percent of patients properly disposed of opioid medication. Dr. Kelly was instrumental in an effort to increase that number at UMass and detailed a process improvement program for installing a convenient, DEA-approved postoperative opioid collection box for safe medication disposal. Institutional approval, cost and model approval, the physical installation and location of the box, security risk management, and pharmacist training and availability are all necessary considerations, he explained. The 38-gallon UMass collection box is available outside the outpatient pharmacy, near the general surgery clinic, and under 24-hour video monitoring. From August 2019 to July 2020, more than 655 pounds of drugs have been collected. The amount of opioids in that total cannot be confirmed.

Kavita Babu, MD, chief, division of medical toxicology, and professor, department of emergency medicine, University of Massachusetts Medical School, explored opioid use, misuse, and postoperative pain control. She is also the chief opioid officer of the institution.

Massachusetts experienced a steady increase in opioid-related deaths from 2000 to 2016, when the number peaked at more than 2,100, Dr. Babu said. In the following three years, the number of deaths plateaued but continued to surpass 2,000 annually. She said the upward trend in opioid-related deaths was mirrored across the country.

Medical prescription opioid use, non-medical prescription opioid use, and illicit opioid use all factor into the opioid addiction crisis. Dr. Babu reported that individuals with exposure to non-physician prescribed opioids were 19 times more likely to initiate heroin use, making the case for the philosophy that the “opioid-naïve” patient should remain opioid naïve.

“Even short courses of opioids can have long-term impact,” Dr. Babu said. “We’re starting more and more to understand the fact that long-term opioid use can be a complication of surgery.”

She cited statistics published in 2017 suggesting that up to 71 percent of prescribed postoperative opioid doses go unused.

“When we think about these excess opioids in circulation, we’re creating a potential exposure for adolescents, for young adults, for other folks in the family, and not just harming our patients,” Dr. Babu said.

Half of opioid-related deaths are linked to prescribed opioids, said panelist Anghela Paredes, MD, MS, general surgery resident, Ohio State University Wexner Medical Center, Columbus. She addressed options for reducing inappropriate opioid prescriptions at the hospital level, including examining provider variance in prescribing practices and leveraging tools in the electronic medical record to consolidate data.