VOS has long endorsed a controlled substance policy for use by its membership
The Virginia Orthopaedic Society (VOS) has an opioid prescribing policy for its membership and works closely with the Medical Society of Virginia to update and promote it.

While opioid analgesics play an essential role in the care of acute musculoskeletal injuries and postoperative management of pain, orthopaedic providers must balance this appropriate use with the risks if their patients misuse or divert these medications.

More than 60 percent of deaths due to medication overdose involve opioids. What is now recognized as a national epidemic of opioid misuse is reflected by the quadrupling of prescription opioid associated deaths from 1999 to 2015. Certain areas of the United States report regional overdose mortality primarily due to prescription opioid diversion and misuse as opposed to heroin or other nonprescription opioids.

As the opioid crisis continues, the Virginia Orthopaedic Society has been proactive and provided its membership with an opioid prescribing policy. Included in this policy is a recognition of the need for patient education as a component of responsible opioid prescribing and use.
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More than 65 percent of individuals misusing opioids obtained these drugs from nonprescription sources, including friends and family. Recent studies show that up to 90 percent of surgical patients (regardless of specialty or inpatient versus outpatient) keep their unused opioids, with 75 percent having no safe storage or plans for disposal.

One concern is the common practice of “stockpiling” unused narcotic prescription medication for future needs and self-prescribed use. However, even when there is intent to dispose of unused opioids, there is a general lack of information regarding safe methods of disposal or options for facility- or community-based return of these drugs.

As the third highest prescribers of opioid medications, it is the responsibility of the orthopaedic community to proactively confront the impact of the diversion of unused opioids prescribed as a component of acute musculoskeletal injury or postoperative orthopaedic patient care.

The VOS has long endorsed a controlled substance policy for use by its members. It outlines the rationale of prescribing for acute care needs, limits on duration of prescribing, morphine milligram equivalent (MME) limits on prescriptions, naloxone prescription for at-risk use of comedications, and the use of prescription monitoring programs.

Included in this policy is a recognition of the need for patient education as a component of responsible opioid prescribing and use. A deficiency in the policy was noted in regard to patient instruction for disposal or safe return of unused opioids. Although U.S. Food and Drug Administration information exists regarding safe disposal of opioids and site-specific or community single-day take-back programs exist, these options are often misunderstood, and return site information is often inaccurately listed, outdated, or cumbersome.

With the support of a grant from the AAOS to the VOS, Carilion Clinic Orthopaedics, and the Virginia Tech-Carilion School of Medicine, the involved parties are investigating patient and provider awareness; perceptions and misperceptions of appropriate use; and disposal of opioid medications for orthopaedic patients. This study is currently awaiting final approval from all the parties involved. The projected completion date is April 1, 2018.

Given the paucity of institutional opioid return sites and the limited availability of community take-back sites, a better understanding of patient perceptions and their impact on safe disposal or return of unused medication patterns may serve as a stimulus to improve and expand patient access to community-based opioid return programs.

As studies have shown, directed education addressing misperceptions regarding medication use or disposal have the potential to improve patient compliance with safe behavior. The immediate post study action will include the construction of improved patient-centric education materials, explaining the rationale of safe disposal or return and the risk of medication diversion.

VOS, in conjunction with other interested parties, will provide orthopaedic surgeons a wallet-sized card to give to patients when prescribing opioids. The card will highlight key points for storage, disposal, and community opioid return information. A follow-up study is planned to assess the retention of information provided through the course and measure patient knowledge on safe disposal or return of unused medications.

T.K. Miller, MD, is an associate professor of orthopaedic surgery at the Virginia Tech-Carilion School of Medicine and vice chair of orthopaedic surgery, section chief of sports medicine at Carilion Clinic.

Susan Giampalmo, BS, is an MS2 student at the Virginia Tech-Carilion School of Medicine.

Malek Bouzaher, BS, MS, is an MS2 student at the Virginia Tech-Carilion School of Medicine.

Joseph T. Moskal, MD, is a professor of orthopaedic surgery at the Virginia Tech-Carilion School of

Medicine and chair of orthopaedic surgery, section chief of adult reconstruction at Carilion Clinic.

References

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