Safe opioid storage, tapering, and disposal

Introduction

Opioids are used to treat pain. They may be given by your physician to help relieve pain after surgery or an injury.1 Opioids may also be used in certain situations for chronic pain.

Taking Opioids

Opioids include codeine, fentanyl, hydrocodone, oxycodone, oxymorphone, morphine, and many others.2 Opioids come in pill or tablet form.3 Opioids also can be given by injection or intravenously. Some opioids can be taken as lozenges or lollipops. Others are delivered through a patch placed on the skin or with a suppository.

You may experience side effects on opioids. These may include constipation, nausea, vomiting, dry mouth, sleepiness, dizziness, confusion, and increased sensitivity to pain.4-7 In cases of overdose, opioids can cause more serious life-threatening side effects such as shallow or slowed breathing, slowed heart rate, and loss of consciousness.2,8

Opioid Abuse

Opioids are powerful, highly addictive drugs. They should never be shared with anyone, as this is highly dangerous and can cause great harm. In fact, opioid abuse has become a major public health concern.9 There are many risks with ongoing opioid use.2,4,5 You can develop a tolerance to opioids. Tolerance means needing higher doses to achieve the same effect. You can become dependent, which means having symptoms of withdrawal when the medication is stopped. You can also become addicted. Addiction means losing control and getting involved in other harmful behaviors. Having any of these conditions increases your risk of opioid overdose and death.4,8,10 

Safe Opioid Storage

Opioids are controlled substances. The possession and use of controlled substances are regulated by state and federal laws.11 Opioids should be stored in their original packaging inside a locked cabinet, a lockbox, or other secure locations.12 Unfortunately, anyone you know may seek out drugs like opioids for illegal use. Don’t keep opioids in obvious places like bathroom cabinets or on kitchen counters where others might find them.

Note when and how much medication you take as this will help you keep track of the amount left.12 If you think someone has taken your medications, you should contact the police to file a report. With opioids, even a small dose can sometimes be fatal. That’s one of the many reasons why you should never share your medications. More than 70 percent of people who are misusing or abusing opioids get them from family and friends.13,14 Sharing medications is dangerous and can contribute to addiction and overdose.7 It’s important to take opioids responsibly. This requires not selling or sharing them to prevent illegal use.

Tapering Opioids

There are many different reasons for stopping opioids.1 If you are taking opioids for acute pain after major surgery or an injury and did not take them beforehand, you will no longer need them as you heal. You can typically stop your prescribed opioid medication within a few days or whenever you feel you don’t need them anymore.

For chronic painful conditions, you may want to stop your opioids so you don’t end up taking them long-term. Certain chronic pain syndromes respond better to other medications or procedures. You may also want to stop your prescribed opioids if your pain doesn’t get better despite opioid therapy. You may have bothersome side effects from you prescribed opioids. You may also be worried about or even show signs of substance use disorder. Substance use disorder can include work or family problems related to opioid use or difficulty in controlling use. Maybe you or someone you trust has shown warning signs for overdose risk such as confusion, sedation, or slurred speech.15

Although these are good reasons to stop taking opioids, you should not stop taking them all of a sudden if you have been on them a long time. Speak with your physician first and be aware of possible withdrawal symptoms. These can depend on the type and dose of medication you’re taking and your medical conditions.2,6 

Withdrawal symptoms may include:

  • Flu-like symptoms (sweating, chills, goose bumps, headache, generalized muscle or joint aches).
  • Fatigue, restlessness, anxiety, trouble sleeping, hallucination, or tremors.
  • Nausea, vomiting, abdominal cramps, or diarrhea.

Withdrawal symptoms can be severe.1 To avoid this, it’s necessary to work together with your physician when it’s time to stop your opioid medication.2 Your physician can help you develop a plan to safely taper off of your opiod prescription. Tapering your medication will gradually reduce the amount of medication you take, until you enitrely stop use.1 It may take weeks or even months to get off opioids if you have been taking them for a long time.

For chronic opioid users especially, your tapering plan should be tailored to you.1,6 The timeline for tapering varies from person-to-person and for each medication. This will ensure that individual medical needs are addressed while minimizing the harmful effects of opioid withdrawal.

The following are tapering recommendations from various organizations:

  • Department of Veterans Affairs and the Department of Defense:16
    • Slower tapering schedule (for chronic opioid users): Dosage reductions of 5 to 20 percent of the original dose every 4 weeks.
    • Faster tapering schedule (for acute/postoperative opioid users): Daily decreases of 20 to 50 percent of the initial dose down to a threshold dose. This is followed by a decrease every 2 to 5 days.
  • Mayo Clinic:17
    • For chronic opioid users: decrease of 10 percent of the original dose every 5 to 7 days until 30 percent of the original dose is reached. This is followed by a weekly decrease by 10 percent of the remaining dose.
  • CDC:15
    • For chronic opioid users: decrease of 10 percent of the original dose per week. Some patients who have taken opioids for a long time might find even slower tapers easier.

During your opioid taper your physician may:1

  • Regularly monitor your pulse, blood pressure and temperature.
  • Request urine or blood samples to check the type and amount of medication or other substances in your system.
  • Ask for your permission to speak with your other healthcare providers, pharmacist, or family members to obtain information that may help with your medication taper.
  • Introduce other pain therapies as needed.
  • Prescribe other types of medications to help you manage withdrawal signs and symptoms such as sleep, appetite, and mood disturbances.

Here are a few tips to minimize withdrawal symptoms:6

  • Stay hydrated by drinking plenty of water.
  • Eat regularly and choose healthy meals.
  • Stay active with moderate exercise, including walking, stretching, and deep-breathing exercises.
  • Use relaxation techniques, which can include breathing exercises, music therapy, guided imagery, meditation, and reading.
  • Keep a positive outlook and surround yourself with people who can help keep your mood positive.
  • Do not substitute alcohol or other substances for the medication you are tapering down.

Safe Opioid Disposal

When your opioid medication has expired or you've stopped using it, you need to safely dispose of any unused medication as quickly and properly as possible.18 See http://michigan-open.org/safe-drug-disposal/ for more details.

  • Don’t keep your unused medications in your home “just in case.” One study found that almost 60 percent of Americans have opioid medications they no longer use stored in their homes.19
  • Use safe, approved disposal techniques:
    • Check for your community drug take-back program or your pharmacy mail-back/return program.1,7 Many local law enforcement agencies have medicine take-back programs. Registered sites can be searched through the Drug Enforcement Agency (DEA) website. These may include retail, hospital or clinic pharmacies, and law enforcement facilities.20 Throughout the year many communities offer free drives to take back unused medications.
    • Methods such as throwing away your medications with your household trash or flushing medications down the toilet, are not preferred disposal methods. However, these may be the only options for some people in certain situations. The Food and Drug Administration (FDA) website offers the following advice if using these options:21
      • If garbage is your only option, please mix with an unpalatable substance (kitty litter, dirt, or used coffee grounds) before throwing in the trash. Place the mixture in a container such as a sealed plastic bag. Remember to delete all personal information on the empty pill bottles or packaging.
      • Opioids are included on the FDA list of medications which may be flushed when there is no other option. If flushing opioid patches down the toilet, fold each patch in half with the sticky sides together before flushing.

References

  1. Mayo Clinic. Tapering off opioids. https://www.mayoclinic.org/diseases-conditions/prescription-drug-abuse/in-depth/tapering-off-opioids-when-and-how/art-20386036. Accessed August 6, 2018.
  2. American Society of Anesthesiologists. What are opioids? https://www.asahq.org/whensecondscount/pain-management/opioid-treatment/what-are-opioids/. Accessed August 6, 2018.
  3. American Chronic Pain Association. ACPA Resource Guide To Chronic Pain Management. https://www.theacpa.org/wp-content/uploads/2018/03/ACPA_Resource_Guide_2018-Final-v2.pdf. Accessed August 6, 2018.
  4. US Department of Health and Human Services Centers for Disease Control and Prevention. Prescription Opioids: What You Need to Know Fact Sheet. 2016. www.cdc.gov/drugoverdose/pdf/aha-patient-opioid-factsheet-a.pdf. Accessed August 6, 2018.
  5. Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. Patient Information Guide: Long-term Opioid Therapy for Chronic Pain. June 2017. https://www.healthquality.va.gov/guidelines/Pain/cot/PatientGuideOpioidTherapyFINAL2017.pdf. Accessed August 6, 2018.
  6. Hospital for Special Surgery. A Patient’s Guide to Opioid Tapering. https://www.hss.edu/conditions_patient-guide-opioid-tapering.asp. Accessed August 6, 2018.
  7. Surgeon General of the United States. About opioids. https://turnthetiderx.org/for-patients/. Accessed August 6, 2018.
  8. National Institute on Drug Abuse. Prescription opioids. June 2018. https://www.drugabuse.gov/publications/drugfacts/prescription-opioids. Accessed August 6, 2018.
  9. White House Council of Economic Advisers. The Underestimated Cost of the Opioid Crisis. The White House Council of Economic Advisers. https://www.whitehouse.gov/sites/whitehouse.gov/files/images/The Underestimated Cost of the Opioid Crisis.pdf. Accessed August 6, 2018.
  10. Opioid Therapy for Chronic Pain Working Group, Department of Veterans Affairs & Department of Defense. VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain (Version 3.0). 2017. https://www.healthquality.va.gov/guidelines/Pain/cot/VADoDOTCPG022717.pdf. Accessed August 6, 2018.
  11. Drug Enforcement Administration. Controlled Substances Security Manual. https://www.deadiversion.usdoj.gov/pubs/manuals/sec/index.html. Accessed August 6, 2018.
  12. American Academy of Family Physicians. Safe use, storage, and disposal of opioid drugs. 2018. https://familydoctor.org/safe-use-storage-and-disposal-of-opioid-drugs/. Accessed August 6, 2018.
  13. American Medical Association. Promote safe storage and disposal of opioids and all medications. March 2017. http://www.aafp.org/dam/AAFP/documents/patient_care/pain_management/safe-storage.pdf. Accessed August 6, 2018.
  14. Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: mental health findings. http://www.samhsa.gov/data/sites/default/files/NSDUHmhfr2013/NSDUHmhfr2013.pdf. Published November 2014. Accessed August 6, 2018.
  15. Centers for Disease Control and Prevention. Pocket guide: tapering opioids for chronic pain. www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf. Accessed August 6, 2018.
  16. Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. Tapering and discontinuing opioids. https://www.qmo.amedd.army.mil/OT/OpioidTaperingBooklet_FINAL_508.pdf. Accessed August 6, 2018.
  17. Berna C, Kulich RJ, Rathmell JP. Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice. Mayo Clin Proc. 2015; 90(6):828-842.
  18. Mayo Clinic. How to use opioids safely. https://newsnetwork.mayoclinic.org/discussion/how-to-use-opioids-safely/. Accessed August 6, 2018.
  19. 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.
  20. US Food & Drug Administration. Disposal of Unused Medicines: What You Should Know. July 2018. https://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuringsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm. Accessed August 6, 2018.
  21. US Food & Drug Administration. List of medicines recommended for disposal by flushing. https://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/UCM588196.pdf. Accessed August 6, 2018.