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16 Articles in Volume 20, Issue #5
20/20 with Drs. Carmen R. Green and Johnathan Goree: Racial Disparities in Pain Care
A Kratom Primer: Miracle Medicine or Herb of Abuse?
A Pilot Study: Incidence and Prediction of Diversion among Opioid Therapy Patients
Analgesics of the Future: G-Protein Biased Mu-Opioid Receptor Ligands
Application Note: Decellularized Human Placenta in the Treatment of Infracalcaneal Heel Pain
Are Clinicians Effectively Counseling Patients on Safe Opioid Storage and Disposal? Survey Results
Ask the PharmD: How to Manage Pain Meds During Pregnancy?
Behavioral Medicine: Managing Anxiety and Maladaptive Behaviors
Case Report: Spinal Cord Stimulation for the Treatment of Pain Associated with Chronic Pancreatitis
Differential Diagnoses: Inflammatory or Non-inflammatory Chronic Back Pain?
Pelvic Inflammatory Disease: Diagnosis, Education, and Treatment Options
Product Review: Non-Invasive Neuromodulation for the Treatment of the Most Difficult Pain Conditions
Provider Perspective: Carpal Tunnel's Association with Hypothyroidism
Research Insights: Opioid Use During the Peripartum Period – What to Expect
Special Report: Race, Pain Management, and the System
When Patients Become Pregnant: How to Maintain Chronic Pain Management

Are Clinicians Effectively Counseling Patients on Safe Opioid Storage and Disposal? Survey Results

Physicians' counseling appears to be affected by their perceived risk of diversion, patient’s pain type, medical specialty, and prescribing practices.

Prescription opioids play a vital role in the treatment of pain; however, unused pills may be diverted for nonmedical use, contributing to the abuse and misuse of opioid medications. Misuse is defined as taking prescription drugs for a different purpose than directed by the prescriber, and/or taking drugs more often, for a longer duration, or in greater amounts than prescribed.1

According to the 2018 National Survey on Drug Use and Health, nearly 9.9 million US residents age 12 or older misused prescription opioids in the previous year, of whom approximately 51% reported obtaining opioids from family or friends.Among surveyed individuals aged ≥65 years and 50 to 64 years who reported misusing opioids, 47.7% and 39.2%, respectively, reported obtaining opioids from physicians.Furthermore, among a nationally representative sample of surveyed high school seniors who reported nonmedical use of prescription opioids in the past year (n = 647), 36.9% reported leftover opioids from their own previous prescriptions as their source.4These data highlight the potential role of opioid-prescribing healthcare providers in curbing the misuse of these prescriptions.

Despite efforts that underscore the role of physicians in preventing prescription opioid misuse – as well as storage and disposal, current counseling practices of opioid-prescribing physicians in the US require further characterization (Image: iStock)

Federal, state, and industry-level actions to curb the opioid crisis include provisions intended to specifically mitigate prescription opioid misuse. The US Department of Health and Human Services includes “better pain management” in its 5-point Strategy to Combat Opioid Abuse, Misuse, and Overdose. Its aim is to ensure that patients receive appropriate, evidence-based care while reducing opioid misuse and harm.As of April 2019, the US DEA ran 6,258 authorized drug collection sites at which patients may safely dispose of prescription opioids.6,7 In addition, all 50 states, the District of Columbia, Guam, and Puerto Rico operate Prescription Drug Monitoring Programs (PDMPs).8,9 PDMPs track prescriptions for all controlled substances, which gives clinicians real-time ability to identify patients at risk for opioid misuse.Finally, the FDA has issued a guidance for industry for the development of abuse-deterrent formulations (ADF) of prescription opioids. As of 2019, the FDA had approved abuse-deterrent labeling for 10 prescription opioids although not all are commercially available.10

Another integral part of these efforts is the development of continuing education (CE) activities and guidelines highlighting healthcare providers’ role in educating and informing patients about proper opioid storage and disposal.11,12 The CDC’s 2016 Guideline for Prescribing Opioids for Chronic Pain attempted to address this in part.12 Additionally, the 2018 FDA Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS) required that all opioid analgesic companies provide accredited CE activities to healthcare providers who participate in pain treatment and monitoring.11 These activities continue to be available, including with remote/virtual options.13 Both the guideline and the REMS identified the need to counsel patients on proper opioid medication storage and disposal as key considerations for clinicians involved in pain management.

In addition, the FDA-required boxed warning on all opioids intended for outpatient use strongly encourages providers to complete a REMS-compliant education program and to counsel their patients on the storage and disposal of opioid products with every prescription.14,15 The DEA even runs an annual Prescription Drug Take Back day – scheduled to take place this year on October 24. However, despite efforts that underscore the role of physicians in preventing prescription opioid misuse, the current counseling practices of opioid-prescribing physicians in the US require further characterization.

The objective of this study was to assess opioid storage and disposal counseling practices and perceptions of opioid diversion among US physicians who prescribe opioids for the treatment of acute or chronic pain.

 

Methods

In this online cross-sectional survey, 300 physicians were recruited from an existing US market research panel of Research Now SSI in Plano, TX. The panel includes respondents who have indicated their willingness to participate in internet-based surveys by completing an opt-in process and enrolling in the panel. Once enrolled, physicians were able to view the survey invitation through the on-line portal and participate if they had the interest. The survey was designed to be 30 to 40 minutes in length and participants received a $75 honorarium. Physicians provided informed consent, and the study was approved by Institutional Review Board Company, Inc, in Buena Park, CA. 

To ensure representation across multiple medical specialties, physicians were recruited in the following areas of practice:

  • primary care (n = 120)
  • surgery (n = 40)
  • emergency medicine (n = 40)
  • neurology (n = 25)
  • rheumatology (n = 25)
  • pain medicine (n = 25)
  • physical medicine and rehabilitation (n = 25).

Recruitment remained open until quotas were met.

Physicians were eligible for participation if they graduated medical school between 2 and 35 years ago; had been practicing in their specialty for 2 to 30 years; had written ≥ 5 prescriptions for oral opioids in the preceding 7 days; and had initiated ≥ 2 patients on oral opioids in the preceding 30 days. Physicians were excluded if they were residing in Vermont, due to legislative restrictions on conducting research in that state.

For the purposes of the survey, each physician was asked to recall the last patient to whom they had issued a new prescription for an oral opioid to treat one of the following: acute pain resulting from surgery; acute pain resulting from injury; or chronic pain lasting > 90 days. Study objectives were to understand physician perceptions on opioid diversion and to assess physician counseling practices on safe opioid storage and disposal among patients treated for acute or noncancer chronic pain in the outpatient setting.

The sample size (n = 300) was calculated to capture statistically significant information and to detect a 10% difference in proportions with 95% confidence and 80% power. Descriptive statistics were used to summarize and compare participant data. Fisher’s exact tests and t tests were used to assess differences across proportions and means, respectively; P values < 0.05 were considered statistically significant. Analyses were performed using SAS version 9.2 (SAS Institute, Cary, NC). The survey was fielded between September 24, 2018, and October 15, 2018.

(Editor’s Note: An abstract of the findings was presented at the 2019 Academy of Physical Medicine and Rehabilitation Annual Assembly; this paper marks the full data publication.)

 

Results

Characteristics of Physicians

A total of 300 physicians, including 205 physicians who treated patients with acute pain and 95 who treated patients with chronic pain, completed the survey.

  • Mean age (SD): 46.1 (7.9) years
  • Sex: 76.3% male  
  • Practiced in medical specialty for a mean (SD) of  14.9 (6.8) years
  • The mean (SD) number of oral opioid prescriptions written in the week prior to the survey was higher among respondents treating patients for chronic versus acute pain (49.7 [52.3] vs 25.2 [23.7]; P < 0.0001)

See also Table I.

 

Characteristics of Patients Receiving a Prescribed Oral Opioid

  • Age: 59% were 35 to 54 years; patients with chronic pain tended to be older (P = 0.0005) (more details in Table II).
  • Sex: 71% male
  • 83% had received a hydrocodone- or oxycodone-containing oral opioid
  • Mean (SD) number of pills per prescription and expected days’ supply: 30.5 (21.5) and 13.0 (11.5), respectively; patients with chronic pain received twice the number of tablets and nearly triple the expected days’ supply versus those with acute pain (P < 0.0001 for both)
  • Abuse-Deterrent Formulations accounted for 16.7% of oral opioid prescriptions; they were more commonly prescribed to patients with chronic (vs. acute) pain (P = 0.04).
  • Immediate-Release Formulations accounted for 87% of oral opioid prescriptions; IR formulations were prescribed at a higher rate for patients with acute (vs. chronic) pain (P = 0.0014)

Physician Perception of Opioid Diversion Risk

Most physicians (87.0%) were aware of whether their patient lived alone or with others in the household (see Figure 1). Awareness of living arrangements for patients with acute pain or chronic pain was similar (P =0 .4640): approximately one-quarter lived alone and nearly two-thirds lived with others, while the living arrangements for 14.6% and 9.5%, respectively, were unknown.

In addition, nearly all physicians (94.4%) had knowledge of their patients’ substance abuse history. Physicians reported that: 0.7% of patients had prior abuse; 93.7% had no history of abuse; and the substance abuse history of 5.7% of patients was unknown (see Figure 2). This trend was similar for patients with both acute and chronic pain (P = 0.1063).

However, only 54.9% of physicians were aware of the substance abuse history of others living in the patients’ household. Unknown household history of substance abuse was numerically higher for physicians treating patients with acute versus chronic pain (49.6% vs 36.1%, respectively; P = 0.2098).  

When physicians were asked to rate on a scale from 1 to 5 (1 = low risk, 5 = high risk) the likelihood that the opioids they prescribed were at risk of diversion, the mean (SD) perceived risk was low overall (1.7 [0.9]). Physicians were slightly more concerned about diversion for patients with chronic versus acute pain (mean [SD]: 1.9 [1.0] vs 1.6 [0.8]; P = 0.02).

Figure 1Figure 1. Physician awareness of patient’s living arrangement. Q. Does this patient live alone?

Figure 2Figure 2. Physician awareness of patient and household history of substance abuse. Q. Does this patient have a personal history of substance abuse? Q. Do you know if anyone residing in the patient’s household has a history of substance abuse? Note: *Includes only patients who do not live alone.

Physician Counseling Practices on Safe Opioid Storage and Disposal

Physicians were asked whether they, or anyone else in their practice, discussed safe opioid storage or proper disposal of unused opioids with their patient. Patient counseling on opioid storage and/or disposal was reported by 44.7% and 30.0% of physicians, respectively. Nearly half of those surveyed (47.3%) indicated that no counseling was provided to their patients on either topic (Figure 3). Compared to patients treated for acute pain, those treated for chronic pain were more likely to be counseled on safe opioid storage (39.5% vs 55.8%; P = 0.0083) and disposal (25.9% vs 38.9%; P = 0.0213). Patients treated for acute pain were more likely to receive no counseling (54.1%) compared to patients treated for chronic pain (32.6%) (P = 0.0005).

Physicians (n = 234) cited the following reasons for not providing patient counseling (see also Figure 4):

  • 47.9% limited contact time
  • 39.3% patient does not exhibit any apparent risk factors
  • 36.8% counseling on other medical conditions took precedence 
  • 23.1% limited patient materials discussing opioid storage and disposal
  • 22.6% limited staffing
  • 10.7% other

 

Figure 3Figure 3. Physician counseling on opioid storage and disposal. Q. Did you discuss the following topics with the patient? Safe opioid storage; proper disposal of unused opioids; none of the above.

Figure 4Figure 4. Physician reasons for not counseling on opioid storage and disposal. Q. You indicated that neither you nor anyone in your practice provided information about storage and/or disposal. What were the reasons for not doing so? Note: *Includes physicians who reported that neither they, nor anyone in their practice, provided both storage and disposal counseling to patients.

Factors Associated With Opioid Storage and Disposal Counseling

Several factors were significantly associated with an increased likelihood of physicians, or someone in their practice, having provided opioid storage and/or disposal counseling (ie, any counseling) to their patient. Factors associated with the increased likelihood of counseling included:

  • a high perceived diversion risk (P = 0.0366)
  • treating a patient with chronic pain (P = 0.0007) (see also Table 3)
  • increased expected duration of therapy prescribed to the patient (P = 0.0001)
  • increased number of opioid prescriptions written by the physician in the week prior to survey (P = 0.0001)

The likelihood of counseling also varied by physician type (P < 0.0001):

  • 35.2% of surgeons counseled patients
  • 55.8% of primary care physicians counseled patients
  • 72% of other medical specialty physicians (combined emergency medicine, rheumatology, neurology, pain medicine, and physical medicine & rehabilitation) counseled their patients.

Other factors tested but found to have no significant associations (all P > 0.05) with patient storage and/or disposal counseling included:

  • physician age: 25to 34 [52.2%] vs 35to 44 [61.0%] vs 45to 54 [47.9%] vs 55-plus [46.2%]years
  • physician sex: male [55.7%] vs female [59.2%]
  • patient age: < 55 [50.0%] vs ≥ 55 [60.5%] years
  • patient sex: male [54.5%] vs female [48.3%]
  • living situation: alone [61.3%] vs with others [52.2%] vs unknown [38.5%]
  • physician knowledge of history of substance abuse : yes or unsure [52.6%] vs no [52.7%]
  • the opioid molecule prescribed: hydrocodone [53.2%] vs oxycodone [48.7%] vs other opioid [56.9%]
  • whether or not an ADF was prescribed: ADF [64.0%] vs non-ADF [50.4%])

Discussion

In this cross-sectional survey of US opioid-prescribing physicians, a low proportion of respondents reported providing patient counseling regarding the safe storage (44.7%) and disposal (30.0%) of unused opioid medications. Physician perception of opioid diversion risk among patients was also low overall, although physicians were more likely to counsel patients when they perceived a high risk for diversion.

Although the counseling rates reported in the current survey are low, they exceed the rates reported in recent studies with physician respondents. In a 2016 cross-sectional survey of a national sample of 179 obstetrician-gynecologists, only 17% reported counseling their patients on proper opioid disposal.16 Results from a 2019 survey of 127 orthopedic physicians found that, when presented with hypothetical scenarios, 79% did not provide patients with instructions on opioid disposal.17

Existing patient-based research, however, does suggest that actual counseling rates are similar to the current study. In a 2015 national survey of US adults with recent opioid prescriptions (n = 1,032), 48.7% and 45.3% did not recall receiving safe medication storage or disposal instructions, respectively, from any source, including their healthcare practitioner.18Similarly, in a 2016 cross-sectional survey of 152 patients who had received opioid prescriptions within the preceding 2 years, only 40.0% and 36.2% reported receiving information from a healthcare practitioner regarding the importance of and appropriate methods to dispose of their unused opioids.19 It is important to note, however, that study design (ie, the healthcare setting surveyed) may account for considerable differences across reported counseling rates.

In this survey, several factors appeared to increase the likelihood of physicians counseling their patients on opioid storage and disposal. These included:

  • prescribing to patients with chronic pain
  • prescribing a higher expected number of days of opioid supply
  • frequently prescribing opioids
  • higher perceived risk of opioid diversion

These factors may reflect a physician perception that the length of medication exposure within the home is positively associated with opioid diversion risk. Further research is warranted to fully understand these relationships, as well as to assess the impact of federal, state, and industry-level actions intended to mitigate prescription opioid misuse, including the recent addition of black box warnings on all prescription opioids.14,15

Counseling Provided by Specialty

The likelihood of patient counseling also appeared to be affected by medical specialty. Nonsurgical specialties were more likely to have counseled their patients, perhaps due to differences in training or experience. Indeed, surgeons were the least likely to counsel their patients. This is notable, as a 2016 systematic review concluded that surgical patients seldom stored and disposed opioids properly, with up to 77% storing opioids in unlocked locations, up to 92% having unused prescription opioids, and only 4% to 30% planning to or actually disposing of unused prescription opioids.20

Education on providing opioid storage and disposal counseling targeted to surgeons may therefore be beneficial. For example, the Michigan Opioid Prescribing Engagement Network has developed a brochure as well as a summary of best practices specifically for healthcare providers prescribing postsurgical pain medications.21,22 The brochure includes data intended to compel providers to alter their opioid prescribing practice, including increased provision of safe storage and disposal education.21 Such education is also listed as a best practice during preoperative patient counseling.22 More research is needed to assess the impact of such initiatives.

Time Constraints

Common physician-reported reasons for not providing opioid storage or disposal counseling appeared to be related to limited physician-patient contact time, and the need to prioritize the most pressing medical conditions. Limited patient contact time is common in the US.23,24 A recent evaluation in which family physicians and their ambulatory patients were directly observed over 982 visits found that providers spent an average of 18.5 minutes of face-to-face time with patients.25 Other studies report patient contact time lasting between 13.4 to 19.3 minutes,23,25-30 with a 2007 report indicating that a median of 6 topics were covered with patients over an average 17.4 minute visit.23 As such, time constraints may render opioid storage and disposal counseling a low priority, especially in light of competing medical conditions; this may be particularly the case for patients who are not perceived as high risk.

Pharmacists, Nurses Can Counsel, Too

Given the time constraints inherent in medical practice, and to help address this barrier, the role of pharmacists and nurses should not be overlooked. In a cross-sectional survey of 152 patients with opioid prescriptions, subgroup analyses revealed that patients who had received opioid disposal education from a healthcare provider, including pharmacists, disposed of their opioids at a higher frequency than those who received no education (56.4% vs 19.6%; P < 0.0001).19 Similarly, a case-control study surveyed 300 oncology outpatients who received opioid use, storage, and disposal educational materials, along with personalized counseling from a clinic staff member (nurse, pharmacist, or physician) with every opioid prescription, and 300 control patients who did not. After receipt of educational materials, more patients safely stored (hid or locked) their opioids (89.5% vs 79.4%; P = 0.0025) and fewer patients kept unused medication at home (38.1% vs 46.6%; P=0.0497) compared to the control group.31

Abuse History and Living Circumstances

Other noteworthy findings from this study are that patient substance abuse history and living situation were not associated with the likelihood of physician counseling regarding opioid storage and disposal. Only 6% of respondents reported having a patient with a history of substance abuse or being unsure of their patient’s status. It is possible that the lack of association between a patient’s substance abuse history and counseling status was a function of the low abuse/unknown rate rather than a reflection of current medical practice. The fact that patients lived with others in the household also did not appear to affect the likelihood of physician counseling; 62% of physicians reported that their patients resided with ≥ 1 other person and 25% were unsure.

Physicians may underestimate the risk of opioid diversion among patients who cohabitate, posing a danger to the household. A recent case-control study of individuals with opioid overdose (n = 2,303) and matched controls (n = 9,212) showed that the odds of opioid overdose nearly tripled (odds ratio 2.89, 95% confidence interval 2.59–3.23) across all age groups (children, adolescents, and adults) when family members had prescription opioids in the household.32 Therefore, any educational programs targeted to physicians to encourage opioid storage and disposal counseling should emphasize the risk of diversion among family members, as well as among those who come into the home.

Survey Strengths, Limitations

This survey research study has both strengths and limitations. A strength is that it assesses physician perception of opioid diversion risk and the frequency at which physicians provide counseling on safe opioid storage and disposal. Notably, this survey provides some rationale for physician’s decisions to not provide counseling, a topic that is insufficiently researched. This study also included a relatively large sample size, was powered to identify differences in proportions, and evaluated a range of physician types.

However, because this research relied upon physician-reported responses, results may be subject to recall bias. Further, due to the survey panel design, we could not assess differences between survey responders and nonresponders to assess for potential selection bias. It is uncertain whether and potentially how the honorarium provided to the physician participants may have biased the sample. This survey represented a geographically diverse sample of participants; however, they may not be representative of all US physicians who prescribe opioids. Finally, because this was an observational, cross-sectional study, cause and effect cannot be determined, only hypothesized.

 

Practical Takeaways

Safe opioid storage and the proper disposal of unused opioids may help to mitigate diversion risk. Results from this survey showed that almost one-half of physicians who prescribed an oral opioid did not provide their patient with counseling regarding drug storage or disposal. The likelihood of physicians providing counseling appeared to be affected by perceived risk of diversion, patient’s pain type, physician medical specialty, and opioid prescribing practices, suggesting that physicians are taking steps to prevent opioid diversion under certain circumstances. Limited time with patients, as well as the need to address other pressing medical conditions, may constrain physicians from providing such counseling.

 

Disclosures: Razmic Gregorian and Mariana Torgal are employees of Simon Kucher & Partners, Cambridge, MA, who completed the data analysis. Vivek Sivathanu and Sejal Shah are former employees of Simon Kucher & Partners, Cambridge, MA, who completed the data analysis. Elizabeth Marrett and Winghan Jacqueline Kwong are employees of Daiichi Sankyo, Inc., Basking Ridge, NJ.

Jeffrey Gudin received consulting fees from Daiichi Sankyo, Inc., related to the development of the study protocol and surveys.

This study was sponsored by Daiichi Sankyo, Inc.Medical editorial assistance was provided by Larry Radican, PhD, MPH, of Peloton Advantage, LLC, an OPEN Health company, and funded by Daiichi Sankyo, Inc. The abstract of this paper was presented at the American Academy of Physical Medicine and Rehabilitation 2019 Annual Assembly as a poster presentation.

Last updated on: October 16, 2020
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