Leftover prescription opioids pose big risks to kids, yet most parents keep their own and their child’s unused painkillers even after they’re no longer medically necessary for pain.
But a new University of Michigan study suggests that convenient disposal paired with tailored risk education can improve those numbers.
Terri Voepel-Lewis, U-M associate professor of nursing, and colleagues, found that prompt disposal of leftover medications improved if parents received a disposal packet at the time the medications were prescribed.
3 Further, parents who saw tailored online messages about the risks opioids pose to children and teens were less likely to report that they intended to keep leftover medications.
The study included 517 parents of children ages 7-17 who were prescribed a short course of opioids. Parents were placed in one of three groups: some received a take-home pill disposal packet; some received the packet and an interactive web-based program asking them to make opioid dosing decisions for their children in different real-life scenarios; and some received neither intervention.
Of the parents, 93% had leftover medications but only 19% in the control group promptly disposed of them. However, prompt disposal doubled (38.5%) for parents who received both interventions.
Further, the number of parents in the web intervention group who planned to keep leftover opioids was half the number in the control group.
Higher risk perception lowered the odds of parents keeping the leftover opioids, while parental past opioid misuse increased them.
The takeaway for parents is that leftover opioids pose the risk of poisoning and death for children.
The only way to completely avoid this risk is to get rid of leftovers as soon as possible, said Voepel-Lewis, principal investigator on the project.
The takeaway for prescribers is that the best way to improve prompt disposal rates is to give parents a simple way to dispose of the drugs, paired with information that boosts their understanding of the risk that keeping leftover medications poses to their children.
Several findings in the study surprised the researchers, Voepel-Lewis said.
“The high rate of parental misuse (11.8%) was a surprise – and that this and past retention behaviors were so predictive of intention to keep the drug around,” she said. “This is something that prescribers need to know and assess for.”
Nor did the team expect that intention-to-dispose rates would be as high, given past findings, Voepel-Lewis said.
“We believe that the opioid crisis awareness in our community may have falsely increased parents’ reports of intention to dispose, knowing that many people in Michigan have died from accidental overdose,” she said.
Though prescribing rates have recently decreased for opioids, leftover medications are still common for opioids and other risky drugs, like sedatives and stimulants.
“Many hospitals are now beginning to give disposal packets, mostly marketed and costly ones, with opioids,” Voepel-Lewis said. “They are not doing this with other risky drugs and the risk enhancement information is lacking. We will make our educational information available at the end of our studies.”
The study, “Behavioral Intervention and Disposal of Leftover Opioids: A Randomized Trial”, is scheduled to appear online Dec. 23 in the journal Pediatrics.
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The number of prescription opioids dispensed to adolescents and young adults in the United States quadrupled over just one decade [1], likely due to an emphasis on pain management during that period.
This surge in prescribing was accompanied by increased rates of opioid-related adverse events [2–4], poisonings [5], opioid misuse [6], and opioid use disorder [7]. These adverse event rates have continued to soar despite the recent plateauing and even declining prescribing rates for children and adolescents [8], suggesting a lingering and worrisome undertow of the prescription opioid epidemic.
Exposure to prescribed opioids for medical reasons poses both immediate and long-term risks. Following surgery or injury, 5%–12.5% of opioid-naïve children and adolescents persistently or recurrently use a prescribed opioid [9,10] presenting a high risk for ongoing opioid-related adverse events and dependence. Furthermore, legitimate use during adolescence has been associated with higher rates of opioid misuse and substance use disorder symptoms during adulthood [11,12].
The term prescription opioid misuse (POM) encompasses several risky behaviors including “medical misuse” (e.g., non–compliant use such as taking larger or more frequent doses or taking it for an unintended purpose), “non–medical misuse” (e.g., taking someone else’s prescription), and “diversion” (sharing with others) [13].
Each of these subtypes of misuse poses increased risk for serious adverse outcomes including drug dependence (when drugs are taken longer than intended or over time), drug addiction and accidental overdose, particularly when the inherent risks of prescribed opioids are not known or are underestimated.
A primary motivation for POM for a majority (84%–88%) of adolescents and young adults is to treat pain [14], and 71% of those motivated by self-treatment of pain reported using a past personal prescription [15].
While these and other less common motivations for POM are well described, the decisional factors that may help explain these risky behaviors have not been well explored. Since many misusers are motivated by a desire to self-treat pain, it may be that a large portion of misuse behavior reflects a deliberative process involving a consideration of expected benefits (e.g., pain relief) and expected risks [16]. Higher perceptions of benefit, which are common among adolescents considering risky behavior [16], combined with lower risk perceptions may, thus, promote opioid misuse. Such deliberations are likely influenced by past experiences and the mental models formed in response [16,17].
For instance, experience with opioid use or misuse might leave an impression of the subjective benefits (“I used it this way before”, “Something good happened”) and lessen the perception of risk, particularly if no negative consequences occurred [16,17]. A better understanding of the cognitive and experiential factors associated with POM decisions is needed to optimize interventions to prevent future misuse.
This observational, cross-sectional study, therefore, examined the associations between adolescents’ and young adults’ prescription opioid risk knowledge, risk perceptions, their past experiences with prescription opioids, and their decisions to misuse a prescription opioid to treat pain. We hypothesized that (1) greater knowledge of serious opioid-related risks and higher risk perceptions would be associated with less willingness to misuse an opioid, and (2) past experience with prescription opioid use and misuse would be associated with an increased willingness toward future misuse.
Results
Sample description
One thousand thirteen volunteers were surveyed from May through September 2017, but 41 (4%) were incomplete due to Internet connection problems or time constraints, leaving 972 for analyses. Our convenience sample was representative of the community at large with the exception of sex (69% female in our sample compared to 52% for the community; that is, 2015 university census demographics include 52% female, 13% Asian, 5% black, 5% Hispanic, 66% white, 4% >two, and 7% other/unknown; City of Ann Arbor 2016 data include 49% female, 16% Asian, 7% black, 4% Hispanic, 68% white, 4% >two, and 1% other/unknown).
Table 1 depicts the past pain history and analgesic preferences of respondents who had previously used a prescribed opioid compared to those who did not. Notably, 90% of respondents overall reported at least monthly pain and 96% reported past analgesic use (mostly over-the-counter nonopioids).
Table 1
Characteristics of the sample (n = 972)
| Previously used a prescription opioid (n = 432) | Never used a prescription opioid (n = 540) | Univariate comparisons between groups | |
|---|---|---|---|
| Age (years) | 19.91 ± 1.3 | 19.4 ± 1.5 | MD −0.51 (CI −.69 to −.33) |
| Female sex | 289 (67%) | 381 (71%) | OR .84 (CI .64–1.12) |
| Race | |||
| White | 342 (79%) | 331 (61%) | OR 2.4 (CI 1.8–3.2) versus all |
| Asian | 42 (10%) | 130 (24%) | Others |
| Black | 15 (4%) | 33 (6%) | |
| Hispanic | 14 (3%) | 23 (4%) | |
| Other | 19 (4%) | 23 (4%) | |
| Substance use within 30 days | |||
| Tobacco | 78 (18%) | 62 (12%) | OR 1.71 (CI 1.19–2.45) |
| Alcohol | 380 (89%) | 379 (71%) | OR 3.37 (CI 2.36–4.81) |
| Illegal drugs | 127 (30%) | 131 (24%) | OR 1.31 (CI .98–1.75) |
| Pain and analgesic use history | |||
| Pain types | |||
| Headache | 393 (91%) | 469 (87%) | OR 1.53 (CI 1.01–2.31) |
| Abdominal | 342 (79%) | 415 (77%) | OR 1.15 (CI .84–1.56) |
| Muscular-Skeletal | 371 (86%) | 384 (71%) | OR 2.47 (CI 1.78–3.43) |
| Frequent analgesica use (≥once or twice a month) | 365 (85%) | 374 (69%) | OR 2.42 (CI 1.76_3.32) |
| Used marijuana for pain | 69 (16%) | 39 (7%) | OR 2.43 (CI 1.6_3.7) |
| Pain relief preference score (normally distributed) | −47 ± 3.87 | −1.22 ± 3.67 | MD −.77 (CI −1.23 to −.28) |
MD = Mean difference; OR = Odds ratio; CI = 95% confidence interval.aIndicates overall analgesic use that includes over-the-counter agents.
Importantly, 32% of past prescription opioid users reported POM, and 99% of these did so to relieve pain. Other reasons for past POM included the following: to sleep (n = 33 [8%]), relieve anxiety (n = 7 [2%], get high (n = 8 [2%]), or experiment (n = 6 [1%]). Pain relief preference scores were significantly lower (i.e., more risk averse) for respondents who had never misused a prescription opioid compared to those who had (MD −.76 [95% CI −1.24 to −.28]).
Analgesic knowledge and risk perceptions
Table 2 shows the differences in opioid risk awareness and perceptions between those who had previously used an opioid compared to those who had not. In addition to the noted differences between these groups, the sample overall rated the riskiness of sharing an opioid with others (i.e., diversion) significantly higher than the risk of misusing one’s own past prescription (i.e., medical misuse; MD 2.08 [95% CI 2.01–2.05]). Additionally, participants who reported past POM had significantly lower risk perceptions of medical misuse (i.e., misusing one’s own prescription; MD −0.497 [95% CI −0.76 to −0.24]) and diversion (i.e., MD −0.449 [95% CI −0.68 to −0.22]) compared to those who had never misused.
Table 2
Opioid risk knowledge and perceptions among past prescription opioid users and nonusers
| Past prescription opioid users (n = 432) | Nonusers (n = 540) | Univariate comparisons between groups | |
|---|---|---|---|
| n (%) | n (%) | Odds ratio (95% confidence interval); p value | |
| Aware of serious opioid-related risks | |||
| Addiction | 362 (84%) | 356 (66%) | 2.71 (2.0–3.71); <.001 |
| Over-sedation | 368 (86%) | 298 (56%) | 4.74 (3.45–6.52); <.001 |
| Slowed breathing | 219 (52%) | 199 (37%) | 1.83 (1.41–2.37); <.001 |
| Know all three | 215 (51%) | 186 (35%) | 1.94 (1.49–2.51); <.001 |
| Risk perceptions (measured from 0 to 5, where 0 = not risky/serious and 5 = most risky/serious) | |||
| Mean ± SD | Mean ± SD | Mean difference (95% confidence interval); p value | |
| Perceived seriousnessa of opioid-related risks | |||
| Addiction | 3.27 ± 2.14 | 3.61 ± 1.92 | .34 (.08–.60); .011 |
| Over-sedation | 2.85 ± 1.48 | 2.56 ± 1.48 | −.29 (−.48 to −.09); .004 |
| Slowed breathing | 3.03 ± 2.02 | 3.21 ± 1.84 | .18 (−.07−.43); .168 |
| Perceived riskinessa of taking over-the-counter analgesics | .84 ± .86 | 1.05 ± .93 | .20 (.09–0.32); .001 |
| Perceived riskinessa of taking a prescribed opioid | 2.02 ± 1.19 | 2.29 ± 1.30 | .26 (.10–.41); .001 |
| Perceived riskinessa of taking one’s own past prescription for an unrelated condition (medical misuse) | 3.81 ± 1.16 | 3.93 ± 1.18 | .12 (−.03−.26); .128 |
| Perceived riskinessa of sharing one’s own opioid left-overs with a friend (diversion) | 4.23 ± 1.04 | 4.26 ± 1.06 | .03 (−.10−.17); .643 |
aSeriousness and riskiness rated from 0 (not serious or risky) to 5 (extremely serious or risky).
Willingness to misuse a prescribed opioid
Overall, 249 respondents (26%) indicated a willingness to misuse an opioid for one or more of the scenarios. Past prescription opioid users were significantly more likely to indicate this willingness compared to nonusers (29% vs. 23%; OR 1.34 [95% CI 1.001–1.79]). More specifically, 56 (6%) would medically misuse a prescribed opioid for the first scenario (unrelenting headache), 167 (17%) would medically misuse their own and 55 (6%) would non-medically misuse someone else’s drug for unrelieved toothache in the second scenario, and 25 (3%) would share a prescribed opioid with a friend in pain. In addition, one respondent would use marijuana or “dank kush” for headache, another would use “cold water extraction of the hydrocodone” for either headache or toothache (this latter description coded as willing to misuse).
Discussion
Findings from this large community survey of adolescents and young adults suggest that perceptions of opioid misuse riskiness, pain relief preferences (i.e., analgesic benefit), and past opioid misuse experience help to explain what may be deliberative prescription opioid misuse decisions among those considering self-treatment of pain. These findings have significant implications for strategizing better interventions to mitigate prescription opioid misuse among transitional aged youth.
Importantly, we found no association between simple awareness of serious opioid-related adverse outcomes (e.g., addiction, excessive sedation, respiratory depression) and willingness to misuse a prescription opioid.
This finding suggests that provision of simple risk information alone, such as that included in newly mandated opioid consent forms, is likely to be insufficient toward mitigating the potential for later prescription opioid misuse. In contrast, we found that stronger preferences for analgesic benefit (i.e., pain relief) and lower risk perceptions were strongly associated with misuse intention.
These findings align with studies of risky decision-making among adolescents and young adults who respond more to the possibility of short-term benefit than to the potential long-term and rare risks, and whose risk perceptions are strongly associated with behavioral willingness [30]. Together, these findings suggest a need to heighten opioid risk perception and strengthen risk aversion preferences.
Of note, past prescription opioid users in our sample ranked the riskiness of addiction (a long-range outcome) lower compared to past nonusers but ranked the excessive sedation risk higher. This risk appraisal may reflect a mental model derived from personal experience with the more immediate adverse effect, sedation.
These findings are not surprising since adolescents’ risk perceptions are often reappraised downward after experience with a risky behavior [17,30]. Indeed, longitudinal data show how experience with drinking and driving, unprotected sex, or heroin use together with failure to experience negative outcomes leads to lowered risk perceptions [16,31].
Since adolescents exhibit cognitive appraisal during risky decision-making, some suggest that behaviors may be best modified by discouraging deliberative analysis of risks and benefits and, rather, by enhancing risk perceptions and risk avoidance values [30]. Giving verbatim or quantitative information about low rates of negative outcomes (e.g., overdose, dependence, and addiction) could provide a “rational calculus of risk promotion” that endorses risk-taking and intentions among youth who focus on potential benefits [16].
Conversely, enhancing gist risk perceptions (i.e., simple global perceptions) has been found to decrease risky intentions [16]. Devising the most effective health-risk messaging for adolescents is complex given the impact of “unpunished” experiences and that gist-based risk perceptions develop slowly as experience matures [17].
Novel prevention strategies aimed at strengthening the perceived benefits of health-promoting behaviors may, therefore, end up being more successful in reducing risk-taking among adolescents. For instance, promoting healthier approaches to pain management (e.g., non-opioid analgesics and non-pharmacologic methods) in combination with messages that enhance prescription opioid risk perceptions may better prevent intentional POM for self-treatment of pain.
Notably, more respondents in our sample indicated a willingness to misuse a personal prescription than to use a friend’s or share with a friend (non-medically misuse or diversion), reflecting common misconceptions about the safety of prescribed opioids [32]. Additionally, similar to others [33–35], we found an association between substance use behavior and willingness to misuse a prescription opioid.
Together, these findings suggest a need to better assess past prescription opioid behaviors and substance use and to introduce preventive interventions at the time of prescribing before the slippery slope of misuse and subsequent risk reappraisal has the chance to emerge.
Our findings must be considered in light of the following limitations. Our convenience sample was drawn from one university community and our sample included primarily older, white and female adolescents. Thus, our sampling limits the potential generalizability to other population. Next, the data reflect self-report of potentially sensitive information.
However, surveys were anonymous and the questions were carefully worded to be nonjudgmental to promote honest disclosure and reduce the potential for response bias. Additionally, our findings are validated, in part, by previous, broader-based community data showing similar rates of self-reported pain [36], analgesic use [37], prescription opioid use (including racial differences in use) and misuse [38].
Despite some external validation, the ability to generalize to other populations of youth is limited by our sampling. Next, although we did not directly measure perceived personal vulnerability, we did find that riskiness of personal opioid misuse was ranked lower than riskiness of sharing or diversion which is in line with data regarding personal invulnerability among youth [39].
Our study explored decisional factors related to intentional risk taking specifically for treatment of pain, and thus, factors related to impulsive POM may differ. Indeed, recent data suggest that perceived harmfulness was not associated with non-medical prescription opioid use in college students who scored high in sensation-seeking [26]. Such differences suggest a need for differing interventional strategies for different target populations.
Last, it could be argued that hypothetical decision-making may not align with real-world decision-making. Yet, empirical studies have shown that hypothetical decisions are highly correlated with real behavior and provide the opportunity to manipulate key variables that are otherwise difficult to ascertain in the real world [40].
Despite these limitations, this study identified important risk perception and experiential factors that may contribute to adolescents’ and emerging adults’ risky decisions to misuse prescription opioids. Our findings have important implications given that millions of prescriptions are dispensed to this group annually, posing ongoing and potentially significant risks of misuse and adverse events.
Our data can also inform recent policy mandates for parental consent and youth education. We find the likely targets for intervention include the need to heighten opioid misuse risk perceptions (not simple risk awareness alone) and strengthen analgesic risk aversion values when prescribing opioids to treat pain in adolescents and young adults.
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More information:Pediatrics (2019). DOI: 10.1542/peds.2019-1431
