The opioid epidemic continues to devastate the United States. In 2015, opioids killed a record 33,000 people, according to the Centers for Disease Control and Prevention. About half of those deaths involved a prescription opioid. Now, a new study drills down to one source of these drugs: wisdom-tooth extractions.
More than half of the opioid painkillers prescribed to patients after wisdom tooth removal surgery in a recent Drug and Alcohol Dependence study went unused. If those numbers were to play out for all practicing oral surgeons, that would translate to a startling annual figure:
100 million opioid pills, prescribed for wisdom-tooth extractions, go unused.
Which means they’re available for misuse and abuse by patients, their loved ones or others. But the study also found that offering information about a pharmacy-based drug-disposal program, plus a financial incentive, made patients more likely to properly dispose of their unused medication, or at least plan to do so.
Many patients keep unused opioids “for a rainy day,” explains study co-author Elliot Hersh of the University of Pennsylvania’s School of Dental Medicine. “They think they’re going to have pain again … or a family member is going to need them.” Diverting drugs in this way can lead to misuse (and is also illegal, by the way). To stem the supply of unused opioids, the DEA has hosted occasional drug take-back days at sites across the country. The rest of the time, patients need to trek to their local law enforcement drug-disposal box.
To investigate whether a pharmacy-based program and financial incentive would make patients more willing to dispose of unused opioids, Hersh and his team studied 72 patients who had filled opioid painkiller prescriptions after impacted wisdom-tooth removal surgery. The patients were randomly assigned to two groups. The control group received an instruction sheet listing side effects, the risks of keeping unused opioids and a drug-disposal information hotline. In addition to these instructions, the intervention group received information about a pharmacy-based buyback program — about 20 cents of store credit in exchange for each pill. Throughout the three-week study period, all patients responded to questions via text message about their pain, and the number of opioid and nonsteroidal anti-inflammatory drugs (NSAIDs) they had taken in the past 24 hours.
The 67 patients who didn’t experience complications received an average of 28 opioid-containing pills — with 15 left over, for a total of 1,010 leftover pills. Sure enough, one day post-surgery, they reported a pain score of just 5 out of 10, on average, while taking painkillers. By the second day, more than half of the patients reported a low pain score (0 to 3) and by the fifth day, nearly 80 percent did. (These scores were recorded while many of the patients were still on pain meds on the second, third and fourth day after surgery.) But offering information about a pharmacy-based disposal program and in-store credit boosted the proportion of patients who reported disposing of their unused drugs, or planned to do so, by around 30 to 52 percent.
To be sure, the increase wasn’t statistically significant, owing to the small sample size. And even with the financial incentive, half of the intervention group members still kept their unused meds. “Many might not care about the [financial] incentive, and it may not be enough,” says Terri Voepel-Lewis of the University of Michigan Health System. Plus, once they called the pharmacy-based disposal program information hotline, they were informed that no such programs existed in their neighborhood yet, so the researchers had to rely only on patients’ reports that they had disposed of the drugs, or intended to do so. But “we don’t know if they followed through on actual disposal.” Hersh also notes that the study looked at the prescribing habits of mainly three oral surgeons.
Still, the study highlights the need for policymakers to broaden the availability of drug-disposal sites at pharmacies and other places people routinely visit, possibly also with small financial incentives. Doctors, meanwhile, “have a moral responsibility” to educate their patients about the dangers of prescription opioids, Hersh says. His group’s findings also suggest they should prescribe NSAIDs alone or NSAIDs plus Tylenol to start out, and opioids only for severe cases — and in limited amounts. Doctors often prescribe more than patients typically need to hedge for the possibility that they do end up experiencing complications and request more later.
Patients, in turn, can request the smallest dose necessary, or ask about non-opioid alternatives. (Congress recently folded a provision into the Comprehensive Addiction and Recovery Act that allows for partial filling of opioid prescriptions.) Those with leftovers can use the DEA’s online tool to locate nearby authorized collectors.
Although prescription opioids have largely fueled the epidemic, “we’re going to keep prescribing these drugs because people will need them,” Voepel-Lewis says. “We have a long way to go. There’s a lot of health illiteracy. We need to give people information at a level they can understand.”
