Effect of Mailing an At-home Disposal Kit on Unused Opioid Disposal After Surgery: A Randomized Clinical Trial | Orthopedics | JAMA Network Open | JAMA Network
[Skip to Navigation]
Sign In
Table 1.  Participant Characteristicsa
Participant Characteristicsa
Table 2.  Self-reported Opioid Disposal
Self-reported Opioid Disposal
1.
Hill  MV, McMahon  ML, Stucke  RS, Barth  RJ  Jr.  Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures.   Ann Surg. 2017;265(4):709-714. doi:10.1097/SLA.0000000000001993 PubMedGoogle ScholarCrossref
2.
Bicket  MC, Long  JJ, Pronovost  PJ, Alexander  GC, Wu  CL.  Prescription opioid analgesics commonly unused after surgery: a systematic review.   JAMA Surg. 2017;152(11):1066-1071. doi:10.1001/jamasurg.2017.0831 PubMedGoogle ScholarCrossref
3.
Kennedy-Hendricks  A, Gielen  A, McDonald  E, McGinty  EE, Shields  W, Barry  CL.  Medication sharing, storage, and disposal practices for opioid medications among US adults.   JAMA Intern Med. 2016;176(7):1027-1029. doi:10.1001/jamainternmed.2016.2543 PubMedGoogle ScholarCrossref
4.
Agarwal  AK, Ali  ZS, Sennett  B,  et al.  An automated text messaging program to inform postoperative opioid prescribing.   NEJM Catal. 2021;2(3). doi:10.1056/CAT.20.0440Google ScholarCrossref
5.
Agarwal  AK, Lee  D, Ali  Z,  et al.  Patient-reported opioid consumption and pain intensity after common orthopedic and urologic surgical procedures with use of an automated text messaging system.   JAMA Netw Open. 2021;4(3):e213243. doi:10.1001/jamanetworkopen.2021.3243 PubMedGoogle ScholarCrossref
6.
Brummett  CM, Steiger  R, Englesbe  M,  et al.  Effect of an activated charcoal bag on disposal of unused opioids after an outpatient surgical procedure: a randomized clinical trial.   JAMA Surg. 2019;154(6):558-561. doi:10.1001/jamasurg.2019.0155 PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Views 2,491
    Citations 0
    Research Letter
    Orthopedics
    May 6, 2022

    Effect of Mailing an At-home Disposal Kit on Unused Opioid Disposal After Surgery: A Randomized Clinical Trial

    Author Affiliations
    • 1Department of Emergency Medicine, University of Pennsylvania, Philadelphia
    • 2Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
    • 3Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia
    • 4Division of Urology, Department of Surgery, University of Pennsylvania, Philadelphia
    • 5Department of Neurosurgery, University of Pennsylvania, Philadelphia
    • 6Penn Medicine, University of Pennsylvania Health System, Philadelphia
    • 7Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
    JAMA Netw Open. 2022;5(5):e2210724. doi:10.1001/jamanetworkopen.2022.10724
    Introduction

    Many prescription opioids after surgery are left unused and are at risk of being misused.1,2 Encouraging proper disposal is important, yet motivating this behavior remains challenging because patients must understand the risks of opioid use and the benefits of disposal and identify methods of safe disposal.3 We sought to test the effect of a mailed at-home disposal kit on disposal rates of unused opioids after surgery.

    Methods

    This 2-arm, randomized clinical trial compared usual care vs a mailed at-home disposal kit that was embedded in an existing postoperative text messaging program designed to capture patient-reported outcomes data and self-reported disposal.4 The trial protocol is available in Supplement 1. The study was approved by the University of Pennsylvania Institutional Review Board with a waiver of informed consent. The trial took place from April 19 to June 1, 2021, and followed the CONSORT reporting guideline.

    All patients 18 years or older undergoing an orthopedic or urologic procedure and prescribed an opioid replied through a text messaging platform using an established protocol.5 Patients without access to a short messaging service–capable device or who did not speak English were excluded. Participants were electronically block randomized in groups of 2 or 4 to usual care or a mailed at-home disposal kit immediately after consent (eMethods in Supplement 2). Usual care consisted of a text message hyperlink to nearby disposal locations. Intervention participants were mailed an at-home disposal kit timed to arrive on postoperative day 4 to 7 based on prior data and designed to provide patients with a disposal method when they were most likely to be finished taking opioids.5 The disposal kit (DisposeRx Inc.) sequesters tablets in a polymer gel. Patients self-reported disposal via text messaging. Baseline self-reported disposal rates were 25% to 30%. We estimated 75 patients per group, assuming a 2-sided α = .025, a β of 80%, and a 50% relative increase in self-reported disposal. The primary outcome of interest was self-reported disposal. All randomized participants were included in an intention-to-treat analysis, and statistical analyses were performed using Fisher exact and χ2 tests via R, version 3.60 (R Project for Statistical Computing).

    Results

    Of 657 patients invited to participate, 302 (46.0%) consented. Demographic information was obtained from the electronic health record to evaluate characteristics of respondents and nonrespondents. Participants had a median age of 56.5 (IQR, 40.0-65.8) years; 136 (45.0%) were women and 166 (55.0%) were men; 240 (79.5%) were White and 44 (14.6%) were Black; and 235 (77.8%) completed all questions. Consenting participants were younger than individuals who declined or did not respond (median age, 59.0 [IQR, 47.0-68.0] years), and more consenting participants than nonparticipants were White (215 of 355 [60.6%]). Participants were more likely than nonparticipants to be opioid naive (225 of 302 [74.5%] vs 225 of 355 [63.4%]) (Table 1). The odds of self-reported disposal were 2.01 (95% CI, 1.2-3.4) times higher in the intervention group. Among the 235 participants who completed all questions, 47 of 110 (42.7%) in the usual care group self-reported disposal, compared with 75 of 125 (60.0%) in the intervention group (Table 2). An estimated additional 480 unused opioid tablets were disposed of in the intervention group.

    Discussion

    Opioid disposal remains important, but motivating disposal remains challenging. In this randomized clinical trial, a mailed at-home disposal kit increased self-reported opioid disposal rates after common surgical procedures. Efforts to encourage disposal are growing, yet research in scalable and patient-centered approaches is lacking. The demonstrated impact has high potential for a low cost solution. This study is limited in that it relied on self-reported disposal and reflects a single center’s experience; in addition, consenting patients were more likely to be younger and White, which limits generalizability. However, the findings build on literature suggesting that providing patients with at-home disposal options can improve self-reported disposal rates.6 The process of mailing the disposal kit is simple, inexpensive (approximately $1.50 per mailed kit), and scalable.

    Back to top
    Article Information

    Accepted for Publication: March 19, 2022.

    Published: May 6, 2022. doi:10.1001/jamanetworkopen.2022.10724

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Agarwal AK et al. JAMA Network Open.

    Corresponding Author: Anish K. Agarwal, MD, MPH, MS, Department of Emergency Medicine, University of Pennsylvania, 423 Guardian Dr, 428 Blockley Hall, Philadelphia, PA 19104 (anish.agarwal@pennmedicine.upenn.edu).

    Author Contributions: Dr Agarwal had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Agarwal, Lee, Ali, Coniglio, Uritsky, Delgado.

    Acquisition, analysis, or interpretation of data: Agarwal, Lee, Wu, Delgado.

    Drafting of the manuscript: Agarwal, Lee, Wu.

    Critical revision of the manuscript for important intellectual content: Agarwal, Lee, Ali, Coniglio, Uritsky, Delgado.

    Statistical analysis: Agarwal, Wu.

    Obtained funding: Agarwal, Ali, Coniglio, Delgado.

    Administrative, technical, or material support: Agarwal, Lee, Coniglio.

    Supervision: Agarwal, Lee, Delgado.

    Conflict of Interest Disclosures: Dr Agarwal reported receiving grants from the US Food and Drug Administration (FDA), the Agency for Healthcare Research and Quality, the Patient-Centered Outcomes Research Institute, and the University of Pennsylvania Institute for Translational Medicine and Therapeutics during the conduct of the study. Dr Uritsky reported receiving a stipend for serving on the advisory board of AcelRx Pharmaceuticals Inc outside the submitted work. Dr Delgado reported receiving grants from the FDA, the National Institutes of Health, and Abramson Family Foundation during the conduct of the study. No other disclosures were reported.

    Funding/Support: This study was supported by grant HHSF223201810209C from the FDA (University of Pennsylvania Institute for Translational Medicine and Therapeutics). DisposeRx Inc previously provided disposal kits to the University of Pennsylvania Health System as an in-kind donation.

    Role of the Funder/Sponsor: DisposeRx and the sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Trial Registration: ClinicalTrials.gov Identifier: NCT05169281

    Data Sharing Statement: See Supplement 3.

    References
    1.
    Hill  MV, McMahon  ML, Stucke  RS, Barth  RJ  Jr.  Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures.   Ann Surg. 2017;265(4):709-714. doi:10.1097/SLA.0000000000001993 PubMedGoogle ScholarCrossref
    2.
    Bicket  MC, Long  JJ, Pronovost  PJ, Alexander  GC, Wu  CL.  Prescription opioid analgesics commonly unused after surgery: a systematic review.   JAMA Surg. 2017;152(11):1066-1071. doi:10.1001/jamasurg.2017.0831 PubMedGoogle ScholarCrossref
    3.
    Kennedy-Hendricks  A, Gielen  A, McDonald  E, McGinty  EE, Shields  W, Barry  CL.  Medication sharing, storage, and disposal practices for opioid medications among US adults.   JAMA Intern Med. 2016;176(7):1027-1029. doi:10.1001/jamainternmed.2016.2543 PubMedGoogle ScholarCrossref
    4.
    Agarwal  AK, Ali  ZS, Sennett  B,  et al.  An automated text messaging program to inform postoperative opioid prescribing.   NEJM Catal. 2021;2(3). doi:10.1056/CAT.20.0440Google ScholarCrossref
    5.
    Agarwal  AK, Lee  D, Ali  Z,  et al.  Patient-reported opioid consumption and pain intensity after common orthopedic and urologic surgical procedures with use of an automated text messaging system.   JAMA Netw Open. 2021;4(3):e213243. doi:10.1001/jamanetworkopen.2021.3243 PubMedGoogle ScholarCrossref
    6.
    Brummett  CM, Steiger  R, Englesbe  M,  et al.  Effect of an activated charcoal bag on disposal of unused opioids after an outpatient surgical procedure: a randomized clinical trial.   JAMA Surg. 2019;154(6):558-561. doi:10.1001/jamasurg.2019.0155 PubMedGoogle ScholarCrossref
    ×