When Prescribed Opioids Go Unused
Question: Regarding the disposal of unused medications, what do you recommend your patients do?
Background Information for Question
A father took his 16-year-old son to an emergency room for acute ear pain. After examination, they were sent home with a prescription for ibuprofen and another for #30 hydrocodone/acetaminophen (Vicodin) 5 mg/325 mg and told to take 2 every 4 to 6 hours as needed. Twelve hours later, they returned, as the boy’s pain was not adequately controlled. The doctor gave the patient an intramuscular opioid injection and issued a second prescription for #30 hydrocodone 7.5 mg/325 mg, being told to take 2 every 4 to 6 hours as needed. When the father offered to return the unused hydrocodone tablets, the doctor advised him, “Don’t bother. Just keep what you don’t use and use it later if you ever have back pain.” Was this an appropriate response? Regarding the disposal of unused medications, what do you recommend your patients do?
Answer: There are two separate issues here: First is the safety of increasing the dose of hydrocodone/acetaminophen (APAP) 5 mg/325 mg. The maximum safe dose of APAP to avoid liver damage is considered to be 4,000 mg per day, or approximately 12 tablets per day at 325 mg per tablet for short-term use. The emergency room (ER) physician initially prescribed up to 12 tablets per day. If indeed the boy was taking 10 mg of hydrocodone (2 tablets) every 4 hours without adequate relief, then it makes sense to increase the dose. However, just increasing the number of tablets might exceed the recommended daily dose of APAP. One way to provide more pain relief safely is to supplement with oxycodone (OxyContin) 5 mg (without APAP). Another approach is to prescribe a different formulation, with an increased ratio of hydrocodone to APAP. Generic versions that provide 10 mg hydrocodone + 325 mg APAP per tablet (Norco) are available. This formulation provides the possibility of higher dosing of hydrocodone, plus more flexibility in dosing, including taking half a tablet. The physician chose an intermediate dose, 7.5 mg/325 mg. This too is a reasonable approach, but it then results in the patient having unused hydrocodone tablets.
The second issue is disposal of the unused hydrocodone. It is common practice for patients to hold onto remaining pills to use if the pain recurs, or for some other pain problem. The latter is not recommended, but not illegal. It is, however, illegal for another person to use controlled substances that were not prescribed for them. The ER doctor was giving an inappropriate suggestion to the father.
As to how to dispose of these pills, or other controlled substances, the US Food and Drug Administration advises the following guidelines1:
- Follow any specific disposal instructions on the drug label. Do not flush down the toilet.
- Take advantage of community drug take-back programs that allow the public to bring unused drugs to a central location for proper disposal. The Drug Enforcement Administration co-sponsors National Prescription Drug Take-Back Days.2
- If no instructions are given on the drug label and you do not have access to a take-back program, throw the drugs in the household trash, but first:
- Remove the drug from the original container and mix with an undesirable substance such as used coffee grounds or kitty litter.
- Place the drug in a sealable bag, empty can, or other container to prevent the medication from leaking or breaking out of a garbage bag.
Jennifer Schneider, MD, PhD
Internal Medicine, Addiction Medicine, and Pain Management