Prescription Opioids and Pain Management: The Tennessee Guidelines _ ______________________________
PATIENT EDUCATION ON THE USE AND DISPOSAL OF OPIOIDS
be flushed down the toilet instead of thrown in the trash [50]. Patients should be advised to flush prescription drugs down the toilet only if the label or accompanying patient information specifically instructs doing so. The American College of Preventive Medicine has published best practice recommendations designed to avoid diversion of unused drugs and educate patients regarding drug disposal [49]: • Consider writing prescriptions in smaller amounts. • Educate patients about safe storing and disposal practices. • Give drug-specific information to patients about the temperature at which they should store their medications. Generally, the bathroom is not the best storage place. It is damp and moist, potentially resulting in potency decrements, and accessible to many people, including children and teens, resulting in potential theft or safety issues. • Ask patients not to advertise that they are taking these types of medications and to keep their medications secure. • Refer patients to community “take back” services overseen by law enforcement that collect controlled substances, seal them in plastic bags, and store them in a secure location until they can be incinerated. Contact your state law enforcement agency or visit https://www.dea.gov to determine if a program is available in your area. The state of Tennessee has developed two types of disposal activities designed to control access and promote safe, convenient, and responsible disposal of prescription drugs. The first is a system of permanent prescription drug collection boxes located within law enforcement agencies (in compliance with DEA regulations) where community members can safely deposit drugs in a secure manner. The goal is to establish at least one permanent prescription drug collection box in all 95 counties of the state. The second activity involves community one-day “take-back” events wherein the public is encouraged to discard unwanted and outdated medications including prescription drugs from their homes. These events serve to raise public awareness of the prescription drug epidemic and encourage the use of local permanent disposal sites available year-round. A map showing the locations of permanent drug collection boxes can be found online at https://tdeconline. tn.gov/rxtakeback. DISCONTINUING OPIOID THERAPY The decision to modify or terminate prescription opioid use is based on clinical progress and a physician-patient discussion of the realized benefits or adverse effects. Among the reasons to taper or discontinue an opioid regimen are resolution of the condition causing pain, intolerable side effects, inadequate analgesia, lack of improvement in quality of life despite dose titration, deteriorating function, and significant aberrant medication use [1; 10].
Patients and caregivers should be counseled regarding the safe use and disposal of opioids. As part of its mandatory Risk Evaluation and Mitigation Strategy (REMS) for extended-release/long-acting opioids, the U.S. Food and Drug Administration (FDA) has developed a patient counseling document with information on the patient’s specific medications, instructions for emergency situations and incomplete pain control, and warnings not to share medications or take them unprescribed [16]. A copy of this form may be accessed online at https://www.fda.gov/ media/86281/download. When prescribing opioids, clinicians should provide patients with the following information [16]: • Product-specific information • Taking the opioid as prescribed • Importance of dosing regimen adherence, managing missed doses, and prescriber contact if pain is not controlled • Warning and rationale to never break or chew/crush tablets or cut or tear patches prior to use • Warning and rationale to avoid other CNS depressants, such as sedative-hypnotics, anxiolytics, alcohol, or illicit drugs • Warning not to abruptly halt or reduce the opioid without physician oversight of safe tapering when discontinuing • The potential of serious side effects or death • Risk factors, signs, and symptoms of overdose and opioid-induced respiratory depression, gastrointestinal obstruction, and allergic reactions • The risks of falls, using heavy machinery, and driving • Warning and rationale to never share an opioid analgesic • Rationale for secure opioid storage • Warning to protect opioids from theft • Instructions for disposal of unneeded opioids, based on product-specific disposal information There are no universal recommendations for the proper disposal of unused opioids, and patients are rarely advised of what to do with unused or expired medications [49]. According to the Office of National Drug Control Policy, most medications that are no longer necessary or have expired should be removed from their containers, mixed with undesirable substances (e.g., cat litter, used coffee grounds), and put into an impermeable, nondescript container (e.g., disposable container with a lid or a sealed bag) before throwing in the trash [50]. Any personal information should be obscured or destroyed. The FDA recommends that certain medications such as oxycodone/ acetaminophen (Percocet), oxycodone (OxyContin tablets), and transdermal fentanyl (Duragesic Transdermal System), may
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