Leftover Prescription Opioids After Minor Procedures: An Unwitting Source for Accidental Overdose in Children

Increasing rates of opioid misuse, adverse events, and deaths from opioids have paralleled prescription patterns,¹ suggesting that physician efforts to alleviate pain have contributed to this public health crisis. Children and adolescents are particularly vulnerable to prescription opioid overdose and misuse, given high rates of exposure in this group.^2-4 Unintentional opioid deaths are estimated at 0.1 and 3.7 per 100 000 children and adolescents/young adults, respectively,¹ and nearly all unintentional childhood exposures to opioids are to other family members’ medications.⁴ Half of adolescents who misuse prescription opioids acquire them from their own previous prescriptions, friends, or family members and 8% share their prescriptions with others.^3,5 Given increasing public health concerns, the American College of Physicians recommends that an evidence-based defined maximum opioid dosage and duration of treatment be developed and followed,⁶ which, in part, could reduce the amounts of unused drugs available for adverse events and misuse. Therefore, we compared the opioid doses dispensed to children with the amount used following minor outpatient procedures to estimate the unused drugs remaining in children’s homes and inform future opioid prescribing.

This study was part of a larger study on parental analgesic decision making approved by the Institutional Review Board at the University of Michigan. Parents provided written informed consent and prospectively recorded all analgesics they gave their children (aged 3-17 years) as well as pain scores across 4 days following elective procedures at a tertiary care children’s hospital from March 1, 2013, to August 31, 2013. Leftover opioids were estimated by calculating the number of doses and treatment days remaining from the dispensed amount if parents continued giving the opioid at the day 3 dosing frequency.

Of the 223 parents who returned diaries, 14% gave zero doses of the dispensed opioid. Opioid dosing significantly decreased each day (mean difference, −0.7) in concert with decreasing pain intensity (mean difference, −1.22; P < .001). By day 3, 34% of parents gave only 1 to 2 doses and 39% had discontinued the opioid altogether and provided only over-the-counter analgesics. The Table shows leftover opioid doses and estimated weeks of treatment remaining by drug and service (nonsignificant differences). Given decreasing pain, early tapering, and discontinuation, most children (79%) had enough leftover opioid doses after day 3 to treat their acute pain for more than 2 to 3 additional weeks.

Our findings showed the potential mismatch between the amounts of opioids prescribed/dispensed and the amounts used following minor pediatric ambulatory procedures associated with acute pain. Most children received less than 50% of their prescribed opioid doses because parents quickly tapered opioids, switched to nonopioids, or discontinued analgesics during the first few postprocedure days. This left a considerable amount of unused prescribed opioids in the homes of children who were prescribed these agents for acute pain. This suggested mismatch between dispensed and used prescription opioids can inadvertently contribute to risky behavior and, therefore, begs for broad intervention.

The recommendation by the American College of Physicians that physicians develop guidelines to limit the amount of opioids prescribed is a step in the right direction. Furthermore, because it was unclear whether parents in our setting were informed about the risks of how to dispose of unused opioids, such education is clearly needed. The Drug Enforcement Agency recently expanded their drug take-back program and legally authorized pharmacies to accept and dispose of patients’ unused prescription medications. In accordance with recommendations from the US Food and Drug Administration, pediatric prescribers and pharmacists should educate parents and adolescents of the importance of proper use, storage, and disposal of these medications. Better alignment of opioid prescriptions with the pain needs of patients and disposal education is warranted to appropriately manage pain while limiting the amounts of unused opioids available for accidental overdose, diversion, and misuse.

Corresponding Author: Terri Voepel-Lewis, PhD, Department of Pediatric Anesthesiology, The University of Michigan Hospital and Health Systems, C. S. Mott Children’s Hospital, Ann Arbor, 1540 E Hospital Dr, Room 4917, Ann Arbor, MI 48109-4245 (terriv@umich.edu).

Published Online: March 23, 2015. doi:10.1001/jamapediatrics.2014.3583.

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

Study concept and design: Voepel-Lewis, Tait.

Acquisition, analysis, or interpretation of data: Voepel-Lewis, Wagner.

Drafting of the manuscript: Voepel-Lewis, Wagner.

Critical revision of the manuscript for important intellectual content: Voepel-Lewis, Tait.

Statistical analysis: Voepel-Lewis.

Study supervision: Voepel-Lewis.

Conflict of Interest Disclosures: None reported.