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. Author manuscript; available in PMC: 2024 Apr 1.
Published in final edited form as: Health Educ Behav. 2021 Dec 28;50(2):281–289. doi: 10.1177/10901981211057540

Promoting Disposal of Left-Over Opioids After Surgery in Rural Communities: A Qualitative Description Study

Lyen C Huang 1, Jordan E Johnson 1, Josh Bleicher 1, Allison N Blumling 1, Mark Savarise 1, David W Wetter 1, Jessica N Cohan 1, Alex AS Harris 2,3, Kimberly A Kaphingst 1
PMCID: PMC10473843  NIHMSID: NIHMS1927417  PMID: 34963358

Abstract

Background.

Patients rarely dispose of left-over opioids after surgery. Disposal serves as a primary prevention against misuse, overdose, and diversion. However, current interventions promoting disposal have mixed efficacy. Increasing disposal in rural communities could prevent or reduce the harms caused by prescription opioids.

Aims.

Identify barriers and facilitators to disposal in the rural communities of the United States Mountain West region.

Methods.

We conducted a qualitative description study with 30 participants from Arizona, Idaho, Montana, Nevada, Oregon, Utah, and Wyoming. We used a phronetic iterative approach combining inductive content and thematic analysis with deductive interpretation through the Precaution Adoption Process Model (PAPM).

Results.

We identified four broad themes: (a) awareness, engagement, and education; (b) low perceived risk associated with nondisposal; (c) deciding to keep left-over opioids for future use; and (d) converting decisions into action. Most participants were aware of the importance of disposal but perceived the risks of nondisposal as low. Participants kept opioids for future use due to uncertainty about their recovery and future treatments, breakdowns in the patient–provider relationship, chronic illness or pain, or potential future injury. The rural context, particularly convenience, cost, and environmental contamination, contributes to decisional burden.

Conclusions.

We identified PAPM stage-specific barriers to disposal of left-over opioids. Future interventions should account for where patients are along the spectrum of deciding to dispose or not dispose as well as promoting harm-reduction strategies for those who choose not to dispose.

Keywords: opioids, surgery, behavior change, qualitative, rural

Introduction

Every year, 56% to 70% of the patients undergoing surgery in the United States are prescribed opioids (Brat et al., 2018; Wunsch et al., 2016). Although prescribing has decreased in recent years, 67% to 92% of patients still have left-over opioid pills (Bicket et al., 2017; Robinson et al., 2020). Amid a crisis where 247,000 people died from prescription opioid overdoses between 1999 and 2019, the U.S. government has advocated for the secure storage of opioids followed by immediate disposal when treatment is complete (CDC, 2020, 2021a; FDA, 2020a). However, few patients store opioids securely, even in households with children, which may explain the three-fold national increase in opioid poisonings and deaths among U.S. children over the past two decades (Bartels et al., 2016; Gaither et al., 2018; McDonald et al., 2017). One-third of patients intentionally shared prescription opioids with others (Kennedy-Hendricks et al., 2016; Lewis et al., 2014) and nearly half of those misusing prescription opioids received them from friends or relatives (Han et al., 2017).

Without interventions, only 4% to 9% of patients will dispose of opioids after surgery (Bicket et al., 2017; Kennedy-Hendricks et al., 2016; Thiels et al., 2018). Most medications returned at take-back days or drop-boxes are not controlled substances (Gray et al., 2015; Ma et al., 2014). Other options include flushing down a toilet or disposal in trash (EPA, 2019; FDA, 2020b). Home disposal bags show the most promise for promoting disposal, but 28% to 86% of patients still do not dispose of leftover pills (Bicket et al., 2021; Brummett et al., 2019; Stokes et al., 2020). A recent single-institution trial bundled education, a drop-box, and close follow-up to achieve an 83% disposal rate (Porter et al., 2021). Whether this approach can be replicated in nontrial settings remains to be tested.

Several studies have examined barriers and facilitators to opioid disposal. Surveys suggest that awareness, convenience, lack of financial incentive, unexpired medications, and keeping opioids for future use are common barriers (Bicket et al., 2021; Buffington et al., 2019; Neill et al., 2020). Focus groups with Appalachian community members found that participants were aware of their communities’ susceptibility to the opioid crisis but unaware of disposal options (Helme et al., 2020). Mistrust of authorities also impeded disposal.

We conducted a qualitative description study with surgery patients from rural communities in the Mountain West region (Idaho, Montana, Nevada, Utah, and Wyoming). The Mountain West covers 17% of the continental U.S. landmass with 95% counties considered rural. The rural context is an independent risk factor for health inequities, and rural communities may suffer disproportionately from the opioid crisis (Lutfiyya et al., 2012; Palombi et al., 2018). While the current “third wave” of overdose deaths is driven by synthetic opioids like illicit fentanyl, 28% of deaths in 2019 involved prescription opioids (CDC, 2021b, 2021c). Until recently, death rates from short-acting prescription opioids were higher in rural counties (Hedegaard & Spencer, 2021). Prescription opioids remain the first exposure to opioids for many and can lead to future heroin use (often laced with synthetic opioids) (Cicero et al., 2018; Compton et al., 2016). Our goals for this study were (a) to identify the barriers and facilitators to opioid disposal in the Mountain West and (b) to select a theoretical framework for evaluating and developing opioid disposal interventions.

Methods

Study Design and Data Collection

We conducted semistructured interviews with a purposive sample of rural adult patients (age 18 or older) who traveled a significant distance for surgery at our institution. Inclusion criteria were (a) having undergone an elective general surgery operation, (b) home address located ≥100 miles driving distance from our institution, (c) home address located in a Rural–Urban Commuting Area census tract coded as 4 to 10, and (d) ability to complete interviews in English without assistance. Starting in October 2018, we prospectively identified patients using a weekly report generated from the electronic medical record (EMR). We reviewed patients’ EMR for demographics, diagnoses, surgical details, and current medications. One investigator with experience in rural community health (J.E.) recruited eligible patients by telephone or in-person (if still admitted). Patients were scheduled to complete 45- to 60-minute interviews in-person at their follow-up visit (typically 2–4 weeks after discharge) or by telephone after-wards. We sought to complete interviews within 2 months of discharge to reduce recall bias. Ten interviews were completed in-person and 20 by telephone. We confirmed demographics during the interviews. We subsequently collected discharge prescriptions and refills from the EMR. To capture a range of perspectives, we did not exclude participants discharged without an opioid prescription or who used opioids chronically. We did not screen for opioid use disorders. No renumeration was provided. We continued recruitment until the data collected were redundant (September 2019). All interviews were transcribed verbatim (Production Transcripts, Glendale, CA) and the accuracy verified by the interviewer. The study was approved by the University of Utah Institutional Review Board (IRB_00113552).

Interview Guide Development

We iteratively developed a semi-structured interview guide using input from experts in rural health, surgery, and communication. We conducted pilot-testing with 5 participants (included in the sample). The open-ended questions explored recovery after surgery; use and cessation of opioids; barriers and facilitators to disposal; and disposal practices. Probes were used to encourage in-depth responses.

Data Analysis

We used a phronetic iterative approach beginning with an emergent reading of the content followed by an inductive thematic analysis and a deductive analysis through the lens of the Precaution Adoption Process Model (PAPM) (Tracy, 2020; Weinstein & Sandman, 1992). We began with primary-cycle content coding. Two coders (J.E. and A.N.B.) randomly selected 3 (10%) transcripts and generated an initial codebook (Hsieh & Shannon, 2005). The codebook was further refined through a constant comparative methods using 3 (10%) additional transcripts (Crabtree & Miller, 1992). Throughout this process, investigators discussed code modification, addition, or removal until consensus was reached. The remaining transcripts were coded by one of the two coders. We then conducted secondary-cycle thematic coding and compared emergent themes and research goals against theoretical frameworks. During our thematic analysis, we considered our goal of selecting a framework to guide the development and evaluation of a patient-level intervention. Our data and the literature suggested the decision to dispose (or not) was not a single discrete decision but reflected progress through a series of stages starting with awareness and engagement, followed by indecision and a decision to dispose (or not) that precedes the action of disposal. PAPM is a preventive health psychology theory that posits that people who are unaware or unengaged by an issue will face different barriers from those who have decided not to act (Weinstein & Sandman, 1992). We used six of the seven stages of PAPM (Figure 1). PAPM has been used to address vaccination hesitancy, cancer screening, disaster preparation, and unnecessary medical treatments (Glik et al., 2014; Jin et al., 2019; Schefft et al., 2019; Tatar et al., 2019). Consistent with qualitative best practices and the use of semi-structured interviews, no counts or percentages were reported (Tracy, 2020).

Figure 1.

Figure 1.

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Emergent themes and subthemes mapped on to the corresponding stages of the Precaution Adopted Process Model.

Strategies for Trustworthiness

We used several strategies to address the trustworthiness of our findings (Morse, 2015). We generated thick descriptive interviews through open-ended questions with multiple probes. Interviews were conducted in a private setting with adequate time to establish trust. The interviewer debriefed regularly with other investigators to determine whether data collected were redundant. We developed a codebook with iterative discussions to resolve coding issues until consensus was reached. We sought to be reflexive about our biases by conducting our analysis with an interdisciplinary research team. Finally, we intentionally sought cases supporting or contradicting our emerging themes.

Results

Sample Characteristics

We interviewed 30 participants who hailed from seven states: Arizona, Idaho, Montana, Nevada, Oregon, Utah, and Wyoming. Half (n = 15) were female. The median age was 59 years (interquartile range [IQR] 51–67). Most (n = 24) underwent an intestinal procedure, typically colon resection (n = 18). Others underwent surgery for herniae (n = 2), breast cancer (n = 2), gallstones (n = 1), or a stomach tumor (n = 1). Nine surgeons performed the operations. Most operations were done minimally invasively (n = 26). Participants were prescribed a median of 17 tablets (IQR 10.5–30) of 5 mg oxycodone (or equivalent). All but one participant were prescribed opioids, and five used prescription opioids prior to their operations.

Barriers and Facilitators to Disposal

We identified four emergent themes and 14 subthemes which are reported in the results section. We mapped each theme and its subthemes onto the associated PAPM stage(s) (Figure 1).

Theme 1: Awareness, Engagement, and Education (Stages 1, 2, and 3)

Lack of Engagement.

Most participants were aware of the importance of disposal of left-over opioids, though one participant felt that their community would benefit from increased awareness. A more significant barrier was lack of engagement. Several participants expressed ambivalence or had not considered disposal prior to the interview. For some, lack of engagement stemmed from confidence in understanding the risks of opioids. For others, disposal was a low priority relative to their current ailments.

It’s just like my cancer medication. I don’t know. I just haven’t dealt with it [disposal].

The Quality and Delivery of Patient Education.

Participants had mixed experiences regarding their education from providers and health care staff regarding the appropriate use, risks, and disposal of opioids. Only one surgeon explained the use, risks, and effects of opioids. Several participants described how their pharmacist went through each prescription prior to discharge. However, other participants could not recall what, if any, education they had received. Instead, decisions about disposal were based on professional experience (e.g., working as a nurse), word-of-mouth advice from others in health care, knowing someone who misused or overdosed, or the internet.

By word of mouth … to get rid of your drugs, I’ve always heard… don’t throw them away, don’t flush them down your toilet, or put them down the sink.

The quality and delivery of education was often problematic. Participants described receiving a large amount of paperwork upon discharge. What education they did recall was generic, cursory, unengaging, or delivered at less-than-optimal times. Staff assumed that patients already knew about opioids and pain management. One participant expressed frustration that they were still recovering after anesthesia. A few participants described how providers and staff tailored their education to their surgery and individual needs, but this was not done for opioids or disposal.

But everybody kind of treated me as though I knew what I was doing anyway, so they kind of skimmed over it.

Theme 2: Low Perceived Risk Associated With Nondisposal (Stages 2, 3, 4, and 5).

Most participants generally saw little risk or consequence in nondisposal, independent of their own beliefs and practices about disposal. We identified four subthemes that comprised their overall risk assessment of (non) disposal.

Risk to Self.

No participant felt that they were at risk of misuse or overdose. Regardless of whether they were using opioids for the first time or had been using opioids to treat chronic conditions, participants expressed confidence in their ability to use opioids responsibly. Many participants justified their nondisposal by describing how they had the knowledge and innate characteristics (e.g., personality and rationality) to not misuse. In contrast, those who misused opioids were portrayed as lacking awareness or having innate flaws (e.g., weak character).

I’m responsible and I know when I need it and I won’t… I just don’t have the personality… to abuse medications.

Risk of Misuse or Overdose by Family and Friends.

Risk to others, particularly children or at-risk family and friends, was a facilitator for disposal. Those with children visiting or living in the household disposed to prevent misuse or overdose. Participants who knew specific individuals who had previously misused drugs or opioids or had been approached about sharing opioids generally were more open to disposal. In contrast, nondisposal was justified when others were perceived as low risk.

There’s no reason for me to throw it away because … none of my family misuses pain medication and they would not come here and go through my cabinets.

Storage Precautions.

Confidence in storage precautions often contributed to participants’ low perceived risk of nondisposal. Participants equated hidden or difficult-to-access storage as the same as disposal. The only participant who used locked storage did so because her brother was now asking her to share opioids.

I keep mine put away where I don’t think any kids would get into them. And I know my husband even has some relatives … they love getting left-over prescriptions from people. And if they were coming to my house, I would definitely hide everything better.

Targeted Theft of Opioids After Surgery.

Theft of opioids was described by several participants as common in their communities. Participants described thieves targeting the homes of those known to have recently undergone surgery. Intentional or opportunistic theft was also carried out by family members. While participants provided specific examples of theft, most ultimately judged that they were unlikely to be the victims thus justifying nondisposal. One participant described how theft was unlikely in his rural community where everyone lived far apart and his willingness to use guns to protect his property.

It’s a really tight-knit community… Those people that have been caught breaking into homes they were very selective… it was usually the elderly people that they knew were gonna be home alone after surgeries.

Theme 3: Deciding to Keep Left-Over Opioids for Future Use (Stages 3 and 4).

Many participants consciously chose to keep left-over opioids for future use. We identified five subthemes which drove these conscious decisions of nondisposal.

Uncertainty About Recovery and Future Treatments.

For some participants, keeping opioids was driven by uncertainty of the future. Many described a lack of expectation setting by their surgeon leading them to experience either far more or less pain than they anticipated. Expectations of pain were instead driven by their own research, experiences with past surgery or childbirth, or the experience of their friends and family. The gap between expectations and their recovery led to uncertainty about the future and skepticism that providers would be responsive to their future needs. Keeping left-over opioids provided participants with control.

I’ll keep it [opioids] because I don’t know what all else is going to happen to me … why should I throw it away when I already have some?

The Patient–Provider Relationship.

Participants generally acknowledged that the opioid crisis justified reduced opioid prescribing. Several participants were satisfied with their surgeons, the provided prescriptions, and were comfortable asking for refills. But for others, the decision to keep left-over opioids reflected mistrust and frustration with their surgeons. One participant perceived her surgeon’s unwillingness to prescribe refills as evidence that they should keep left-over opioids.

If I knew that they would prescribe something for me I probably would turn them back in right now. But I feel like I need to have my own personal stash.

Another participant expressed a sense of injustice and contrasted the ease with which their counseling clients acquired opioids with their prescription (perceived to be inadequate).

I couldn’t believe that’s all that was prescribed [20 oxycodone tablets] … I have clients that get pain meds all the time from pain clinics for minor stupid things and they sell the things. That just makes me so angry … But people, when they’ve had real surgeries, they give such a minor amount of whatever.

Chronic Illness or Pain Unrelated to Surgery.

Five participants used opioids prior to surgery for chronic illnesses or pain. Some felt justified using left-over opioids. One participant described how sometimes they needed a little extra, implying that the provider managing the chronic condition was not responsive to the needs. But another participant who used opioids chronically was vocal about increasing awareness on the use, risks, and disposal of opioids in their community. They expressed relief when they had returned to their baseline opioid needs after surgery.

I’ve known a couple people that have mixed opioids with alcohol and they’ve died… they could raise awareness about how to dispose properly of medications and how to store them properly in your home. And just raise awareness about not using pain medications when you don’t need them.

Financial.

One participant cited the difficulty of reaching doctors and medication costs as justification for keeping opioids. The other suggested money might incentivize patients to return left-over opioids.

It’s so hard to get to a doctor. Even at the beginning of the year where our deductible’s not met and we have to pay out-of-pocket.

Hypothetical Future Accidental Injury or Pain.

Several participants described hypothetical scenarios involving accidental injury as justification for nondisposal and viewed opioids as a potentially scarce but useful resource. Some were adamant on only using the opioids personally. Others were willing to share based on the severity of the situation, social ties, or perceived risk of misuse.

[The Oxycontins] were prescribed to me at a prior day so they’re not illegal… I have a guy that stuck an arrow in his thigh five miles back in there… I would keep it for necessary emergency use and maybe I shouldn’t share it with a friend, [but] I love my family, I love my friends, and I don’t care.

Theme 4: Converting Decisions Into Action (Stages 3 and 5).

The decision to dispose of opioids did not always result in carrying out the action of disposal. For participants who prioritized disposal, the action of disposal was deliberate and not difficult. But for others, the transition from decision to action encountered barriers.

Life in Rural Communities.

For some participants, the nearest disposal site was ≥30 miles away, and they often forgot to dispose because of infrequent trips into town. Converting decision into action required multiple steps of planning and action. Participants who disposed at home (e.g., flushing, trash, and burning) rather than using drop-boxes cited convenience as a major driver.

It’s not like most people can swing by on their way home from work and take a ten-minute detour past the hospital and drop off the extra medication. It’s something that you have to plan in your day when you’re going to be in town… remember to take the drugs and remember to make that stop at the pharmacy while you’re doing the grocery shopping [and] all the other stops that you have to do for the day. So, I know for a fact that people completely forget about it, even if they fully intend to dispose of the drugs.

Environmental Contamination.

Participants who disposed at home accompanied their decision with evaluations about environmental contamination of freshwater or soil. Some thought disposal in septic systems was safer than sewers or trash while others came to opposite conclusions. The detail provided suggested a surprising level of decisional burden where participants balanced convenience, cost, and the risk of environmental convenience.

I have actually dropped medication off at the police department, and I know that you can drop it off at the pharmacy but I think they charge you… I just put them in a garbage bag and take them to the dump. It’s better than putting it in the septic and then let it go into freshwater.

Reminders to Act.

Several participants who disposed after seeing visual cues, such as a drop-box or hearing announcements about upcoming take-back days. The action of disposal soon after the reminder suggesting that even passive nudges can convert decisions to action.

I was doing hyperbaric treatments… I noticed where they had deposit things where you could just deposit [left-over medications].

Discussion

In our qualitative description study of patients from rural Mountain West communities undergoing surgery, we identified four themes and 14 subthemes encompassing barriers and facilitators to disposal of left-over opioids after surgery. Our study found similar barriers to other studies such as unawareness, inconvenience, and keeping opioids for future use (Bicket et al., 2021; Buffington et al., 2019; Helme et al., 2020; Neill et al., 2020). However, our study identified several additional barriers such as lack of engagement, low perceived risk of nondisposal, breakdown of the patient–provider relationship, and the decisional burden resulting from rurality (e.g., environmental contamination). In contrast with Helme et al., lack of awareness or mistrust of authorities was not a barrier for most participants.

Improving Awareness, Patient Engagement, and Education (Stages 1, 2, and 3)

Current education interventions may focus too narrowly on raising awareness (which was not a common barrier in our study). The timing of education delivery may also be problematic if patients are preoccupied with their upcoming surgery or still recovering from anesthesia. Indifferent educators may also undermine educational efficacy. These issues may explain why existing education-only interventions have shown either no benefit, or modest improvements of 4% to 11% in disposal (Brummett et al., 2019; Cabo et al., 2019; Hasak et al., 2018). Future interventions should use evidence-based practices such as multimodal education reinforced through multiple sessions and personalized education (Fredericks et al., 2010; Kang et al., 2018).

Addressing the Low Perceived Risk Associated With Nondisposal (Stages 2, 3, 4, and 5)

Risk perception can facilitate or impede preventive health behaviors (Brewer et al., 2007). Our participants generally perceived the risks of opioids to be low, though risks were higher for others, particularly children. Messaging on the risks of opioids to children can effectively promote disposal (Egan et al., 2020). However, optimism about storage precautions may lead to an under-assessment of risk. Future interventions could counter patients’ optimism bias by having them define potential undesirable outcomes. Memorable stories could nudge patients into action by helping them imagine similar events occurring to them or their loved ones.

Deciding to Keep Left-Over Opioids for Future Use (Stages 3 and 4)

Patients deciding to keep left-over opioids has been a consistent finding identified in prior studies (Bicket et al., 2021; Buffington et al., 2019; Helme et al., 2020; Neill et al., 2020). Uncertainty about recovery or future treatments could be addressed through improved expectation setting and care coordination. However, a breakdown in the patient–surgeon relationship may contribute to nondisposal. Some participants lost trust in providers perceived as unresponsive. A recent study found opioid reduction interventions negatively affected the relationship between PCPs and some patients on chronic opioid therapy (Sherman et al., 2018). The patient–surgeon relationship, often lacking longitudinal contact and fraught with the risk of complications after surgery, may be even more fragile. Many patients meet with their surgeon only once before and after surgery. Patient trust is quickly eroded when expectations are not met or surgeons are unresponsive (Brooke et al., 2018). Open and frank discussions about pain and opioids may help reassure patients and promote disposal. Alternately, promoting harm-reduction strategies such as lock-boxes can support patients who have decided on nondisposal.

Converting Decisions Into Action (Stages 3 and 5)

Even well-intentioned patients do not always act. Passive cues to act such as visible drop-boxes increased patient awareness and consistent messaging by pharmacists (Ehrhart et al., 2020). Follow-up phone calls can also prompt disposal (Porter et al., 2021). However, the rural context still presents unique challenges. Drop-boxes remain inconvenient for rural patients who increasingly follow-up via telehealth. Contradictory messaging from federal agencies on environmental contamination may lead to confusion and inaction (EPA, 2019; FDA, 2020b). Home disposal bags could address rural concerns about convenience and contamination.

Limitations

A limitation of our study is the influence of social desirability on participant responses. Our sample also had the means to travel for surgery. A limitation of PAPM is the presumption that disposal is the only metric of success. However, rather than solely trying to transition all patients who have decided for nondisposal back to disposal, patient-centric interventions promoting both disposal and harm-reduction strategies may still achieve our public health goals of reducing overdoses, misuse, and diversion while respecting patient autonomy.

Conclusion

Disposal of prescription opioids after surgery can prevent overdose, misuse, and diversion. Interventions addressing stage-specific barriers to disposal in rural communities are needed to reverse the unintended contributions of surgeons to the opioid crisis. Further research rigorously evaluating and developing interventions using theoretical frameworks will improve opioid stewardship.

Impact Statement.

Many patients have left-over opioid pills following surgery, but few dispose of them. Disposal can prevent dependence, misuse, overdoses, and diversion. However, current interventions to increase disposal after surgery have shown mixed success. No interventions have been tested in rural communities that bear a disproportionate burden of the opioid crisis. We conducted interviews with 30 patients from rural communities in the United States Mountain West region after surgery to identify barriers and facilitators to disposal of left-over prescription opioids. We identified four themes and 14 subthemes encompassing the barriers and facilitators of disposal and propose a theoretical framework for disposal using the Precaution Adoption Process Model. The evaluation and development of opioid disposal interventions should leverage both evidence- and theory-based approaches.

Acknowledgments

The authors thank Brenna Kelly for the visual design of Figure 1.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (grant no. 5KL2TR002539; KL2 Scholars). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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