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¹ Preparation of a manuscript describing this study was in progress at the time of the workshop. It has since been accepted for publication.

• “Confusion about ‘best’ disposal option immobilizes patients.” Egan said study participants often reported keeping opioids in the home because they did not feel there was a suitable option for disposal (e.g., some did not feel flushing was acceptable).
• “Desire to choose the disposal option that is best for them,” despite reported confusion. Factors participants reported taking into consideration included “convenience and accessibility, cost, distrust in law enforcement agencies, [and] environmental concerns.”
• Perception that disposing of unused opioids protects household members. Egan noted that some participants who were more motivated to dispose had children, pets, or a person at risk for substance misuse in the home.
• Desire to retain unused opioid analgesics “just in case.”

Studying Interventions to Facilitate Disposal

Distribution of In-Home Disposal Systems

Egan elaborated on a pilot study focused on distribution (Otufowora et al., 2023). Community health workers distributed in-home disposal systems through a local community outreach program and provided education about use. Of the 124 individuals who reported use of opioid medication, 100 percent accepted the offered in-home disposal system, and 98 percent of those said they “expected use to be very easy or somewhat easy.” However, “only about 50 percent intended to use it to dispose of opioid medication,” Egan said.

Raising Awareness of Disposal Boxes

Another study assessed public response to proposed interventions intended to increase awareness of the need to dispose of opioids promptly in drop boxes (Egan et al., 2020). To inform a communications campaign by local health departments, campaign materials were pretested in focus groups using a “forced exposure, cross-sectional survey design,” Egan said. The development of eight messages with visuals was informed by the health beliefs identified in the study by Helme and colleagues (2020). Egan emphasized the importance of including key partners and said experts in health communication were engaged in developing the materials to be tested.

Egan shared study findings for three of the visual messages, which illustrate the importance of engaging patients as partners as well. Showing study participants messaging centered on a photo of a small child with medications loose on a table in front of them “elicited the strongest

perceptions and beliefs that disposal would be beneficial to their household,” Egan reported. Messaging with an image of someone using a local disposal box scored well in promoting beliefs of self-efficacy (i.e., participants had confidence they knew how to dispose) but did not motivate interest in disposing. Messaging with a photo of an adolescent taking pills from a medicine cabinet was not perceived as intended (i.e., as diversion), and participants believed the person in the photo could be an adult or could be about to take their own prescribed medication. The campaign has now been implemented, but data on any impact are not available.

Text-Based Prompts to Encourage Secure Storage and Disposal of Opioids

Egan is currently designing an RCT to assess the efficacy and feasibility of using text messaging to prompt opioid storage and disposal behaviors after patients have filled a prescription. The RCT will leverage the automated text messaging systems used by pharmacies to send messages about secure storage, followed by messages that prompt disposal of unused opioids at some yet-to-be defined point.

The development of the study intervention is participant-driven, Egan said, with the text messages informed by focus groups and pretested using a cross-sectional forced exposure design. Focus groups considered proposed text messages relating to disposal through iterative rounds of review, responding to questions about their understanding of a message, how it impacted their perceptions, and whether it would motivate them to dispose. Egan pointed out that the five final messages chosen for pretesting based on user input were not the messages the research team used at the start. She emphasized that developing messaging for the public without consumer feedback can result in a campaign with “messages that don’t end up resonating with our end user.”

Three text messages pertaining to disposal were selected from the pretesting to be included in the RCT. Based on focus group input, Egan said that text-based disposal prompts will also include an embedded image with information about how to dispose. “Participants said they don’t want to click on a link to a website to go find this information,” she reported. She added that, in the absence of a standard of care, the control group in the RCT will receive a delayed intervention.

From Policy to Implementation: Lessons from Pharmacy-Based Disposal Boxes

A study by Egan found that the number of pharmacies with drug disposal boxes in North Carolina increased from 1.7 percent in 2016 to 13.5 percent in 2021 (Egan et al., 2022). She said, however, that

“13.5 percent is not enough for the populations that need these disposal boxes.” She reported that uptake of disposal boxes in 2016 was predominantly by independently owned pharmacies, done in partnership with substance use prevention coalitions. Today, the pharmacies most likely to have disposal boxes are corporate chain pharmacies. Egan observed that deimplementation of disposal boxes is occurring in all types of pharmacies. In the case of independently owned pharmacies, the boxes tend to be deimplemented when external funding support for them runs out.

Egan shared findings from interviews with pharmacists about disposal boxes, which she said could translate to in-home disposal systems should pharmacists be responsible for dispensing. Pharmacists believed that “disposal options meet patients’ needs” and that “their patients benefit from these programs,” she reported. Some pharmacists believed disposal efforts were “part of their scope of work” and that they benefited from these programs as well. Pharmacists in corporate-owned pharmacies said there is no cost or operational burden to them, while independent pharmacists and small chains face cost burdens that can make continued implementation unsustainable. When looking to partner with pharmacies to implement disposal boxes, it is important to recognize that pharmacists in corporate pharmacies are unable to make any changes to their pharmacy. Independently owned and operated pharmacies expressed interest in working with community partners to implement disposal boxes, Egan said, but showed concern about expiration of funding. From an implementation perspective, Egan summarized, it is important to consider what assistance those who will be implementing disposal policies might need to successfully provide disposal options, such as funding or educational materials. If disposal systems are dispensed in the context of care, she noted the need to consider whether dispensing might need to have a protocol or whether an ICD (International Classification of Diseases)-10 code would be needed.

In closing, Egan said there is no one-size-fits-all solution to reducing the risk of opioids in the home. A comprehensive approach is needed that incorporates education, disposal systems for patients who have unused opioids, and secure storage options for patients who need to retain opioids.

CONSIDERING THE ROLES OF IN-HOME DISPOSAL

Following the presentation, Egan was joined by four panelists for further discussion of the role of an ideal in-home opioid disposal system in mitigating the risk of prescription opioid misuse or overdose. Panelists included Christopher Gaw, a pediatric emergency medicine fellow and associate fellow at the Center for Injury Research and Prevention

at the Children’s Hospital of Philadelphia; Jeff Horwitz, chief executive officer of the Stop the Addiction Fatality Epidemic (SAFE) Project; Susan Sherman, Bloomberg Professor of American Health in the Department of Health, Behavior and Society at Johns Hopkins Bloomberg School of Public Health; and Wilson Compton, deputy director of the National Institute on Drug Abuse (NIDA) at the National Institutes of Health. The discussion was moderated by Robert Morones, area injury prevention specialist at Indian Health Service (IHS) Phoenix Area.

Preventing Pediatric Injury and Death

The Poison Prevention Packaging Act in 1970 required systematic changes to medication packaging, which led to “a 40 to 50 percent reduction in injury exposures and fatalities in the pediatric population,” Gaw said. However, data from CDC, the National Poison Data System, and child death reviews show that an increasing number of pediatric injuries and fatalities are associated with opioids (Gaw et al., 2023). In young children, exposure to opioids is generally associated with exploratory behavior, while exposure in teens is frequently experimental. Most pediatric injury from opioid exposure is accidental, although Gaw added that some cases of pediatric opioid injury are intentional or associated with child abuse.

Gaw said in-home drug disposal systems could play a role in pediatric injury prevention efforts. “If you have no exposure to an opioid, you should theoretically have no injury or fatality from an opioid,” he said. However, to be effective they must be used. Furthermore, the risk persists until the drug is disposed of, which cannot be done until use as prescribed is completed. He highlighted the need for “a multifaceted and a multipronged approach” that includes education and safe storage options. Effecting a shift in cultural and social norms around storage and disposal behaviors will require repeated, targeted, easy-to-understand messaging provided by different sources, Gaw said. As an example, he said the use of seatbelts and child car seats is now a social norm and essentially automatic behavior, but it took decades of public health messaging. Morones likened a parent/guardian protecting children by securing them in a motor vehicle to protecting them by securing and disposing of drugs in the home.

As discussed by Egan, there can be challenges in moving from policy to implementation. Gaw said that policies around pediatric injury prevention can be ineffective or potentially harmful if stakeholders do not understand them or do not believe they are necessary. Current data on pediatric injury from opioid exposure are primarily raw epidemiologic data. Additional research is needed to better understand the pathways

to pediatric exposure and injury, and whether and how parents will use in-home disposal systems.

Preventing Fatal Opioid Overdoses

In 2022, more than 100,000 people in the United States died from overdoses, Horwitz said, or nearly 300 people per day.² A recent study found that having an opioid in the home is associated with a 60 percent increased risk of overdose by someone for whom it was not prescribed (Hendricks et al., 2023). Furthermore, Horwitz said that “the majority of 12th graders will say they’ve experimented … in their own medicine cabinet,” and “80 percent of heroin users today will self-admit that they started out with misuse in their home.” Many are under the misperception that because a drug is a prescription drug, it is safe for them.

The SAFE Project was created by a family following the fatal overdose of their son and operates under the premise that creating change requires collaboration and collective action.³ Horwitz said the SAFE Project considers in-home opioid disposal solutions to have a role in expanding the number of options available for patients to remove opioid drugs from their home.

With support from in-kind donations from manufacturers, the SAFE Project has distributed about 140,000 in-home disposal systems over the past 5 years, Horwitz said. Through follow-up surveys, he said that 80 to 90 percent of those who accepted a disposal system reported using it. He added that in cases where a disposal pouch had been offered and declined, providing an explanation of why it is needed and how to use it frequently leads to acceptance.

Harm Reduction

Sherman defined harm reduction as “a set of practical strategies and ideas aimed at reducing the negative consequences associated with drug use.” A principle of harm reduction is acknowledging that people misuse drugs. Programs and tools are aimed at reducing the risks of associated harms, such as overdose or becoming infected with HIV or hepatitis C. Examples of harm reduction programs and tools mentioned by Sherman include “syringe service programs, naloxone, [and] drug-checking technologies like fentanyl test strips.”

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² See https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm (accessed November 11, 2023).

³ See https://www.safeproject.us/ (accessed November 11, 2023).

posal to other approaches are also needed. Compton agreed with Egan that there will not be a one-size-fits-all solution and said, “Having a broad range of approaches provides the best approach to public health.”

The extent to which a disposal approach reduces diversion is another question for empirical research to inform public health decisions about implementation of disposal options. Diversion will be a concern regardless of disposal approach, Compton said, and the issue is how much we can minimalize it. Some current in-home disposal systems might make opioids inaccessible for use. While it is “theoretically possible to reconstitute substances from at least some approaches to in-home disposal,” there is no empirical data on the extent to which that happens. It will take a significant amount of expertise to retrieve or reconstitute the drug after disposal, but Compton said more research is needed here as well. In his experience as an addiction specialist, Compton said he has observed surprising creativity by patients seeking drugs. He suggested monitoring communication modalities used by illicit drug markets, and drug-using communities could provide information about new approaches to undermine the effectiveness of disposal strategies.

From a primary prevention perspective, Egan said, the goal of disposal is to remove unneeded opioids from the home in a timely manner, and disposal systems can do that. Assessing the outcomes of primary prevention is much more difficult and occurs over the longer term. In this case, research is needed to determine the extent to which disposing of unused opioids prevents substance misuse. She added that there is anecdotal evidence on the unintended consequences of using different disposal options (e.g., the impact of flushing), but quantitative data are lacking.

Messaging and Education

Much of the panel discussion expanded on messaging about the role of in-home disposal of opioids. Panelists discussed the need to educate providers and the public about currently available disposal options while continuing to develop and assess a range of new options.

Horwitz said education is needed, not just about how to use the disposal system but to raise awareness and provide a unified message that having opioid medications in the home presents a risk for everyone there (including pets), and people can reduce that risk by removing the medications from the home. Sherman agreed with the need for practitioners to incorporate unified messaging about opioid use and disposal into their practice. She clarified that unified does not mean the same. Messaging can be tailored to the population and context. Morones agreed and said that for Tribal communities, “water is a precious resource” and people are

generally unwilling to flush medications. Messaging about disposal needs to take this context into account.

Horwitz also emphasized the need to consider what message is being conveyed when providing education about current disposal options. He suggested that it is somewhat dismissive to tell people opioids are dangerous drugs but that they can just flush them down the toilet, put them out at the street with the trash mixed into some kitty litter, or send them back through the USPS. In response to a question, Horwitz acknowledged that mail-back envelopes can be an option for those without access to other take-back options, such as those living in rural areas or those who choose not to go to a take-back site, but added that in-home disposal could be an option for them as well. He said a range of options should be made available to enable patients to be successful at disposing of unused opioids.

Egan observed that current messaging asks patients to choose a disposal option based on what is available to them. She suggested that messaging might be better framed around having patients choose which disposal approach best reduces the potential risk to their household. That choice might be based on whether there are young children or someone with substance use disorder in the home, for example.

Gaw said although the clinician and pharmacist are logical potential counseling points, there are practical challenges. An adult primary care encounter with the physician can last 15 to 25 minutes, while a pediatric well check can include only 10 to 15 minutes with the pediatrician, he said. Given the many other competing priorities, including addressing patient and parent concerns, this might not be the most effective venue for fitting in general messaging about opioid safety. Gaw said pediatricians do screen children for risks in the home and provide education and resources accordingly (e.g., pediatric screening for access to a gun in the home is now a protocol at the Children’s Hospital of Philadelphia). Pediatric practices are becoming increasingly aware of the need to provide counseling and interventions to mitigate the risks of medications in the home. He noted that no single approach is sufficient, and injury prevention works best in layers.

Pharmacists face similar time constraints on patient interactions. Gaw and Compton both observed that a prescription pickup is often reduced to a card swipe, tapping acknowledgment of a paragraph on a screen that few people read, and a signature. Horwitz acknowledged the challenges but emphasized the importance of taking all opportunities to impart the message that unused opioids present a serious risk. Physicians can mention when prescribing an opioid that they are also going to make sure the patient has an in-home disposal system or whatever option is available regionally, and pharmacists can mention again when dispensing that

disposal is important. If everyone reinforces the message, “the behavior will follow,” he said.

In addition to identifying communication opportunities across the life cycle of prescribed opioids (e.g., the prescriber, someone else in the prescriber’s office, the health care system, the dispenser), Compton said broad community-based communication strategies about opioid risks are also needed to prime the public for more successful uptake of messaging from health care providers. Gaw agreed that community partners have a role to play in providing effective messaging about opioids and preparing patients to discuss concerns with a trusted provider. He suggested leveraging social media to engage target audiences and looking to other novel communication approaches. Sherman also agreed with the need to intervene at multiple points across the opioid prescribing pathway and with the need to engage a range of community partners. She suggested engaging harm reduction outreach workers, syringe service programs, or homeless organizations as well. While this might seem counterintuitive, she said that they often work with people who quit using opioids and would need disposal options.

Panelists also discussed the complex association of messaging, perceptions, and behavior. Hanz Atia, a policy and programs associate at the Product Stewardship Institute (PSI), raised the issue of children exploring in-home disposal pouches before the opioids have been fully deactivated, and whether perceptions that the system is non-toxic might lead parents to be less careful with the used pouch. Gaw said that having the opioids in a disposal system, even if not yet fully unavailable for use, is generally still better than the alternative of a child having access to intact drug. Parental perception of the safety of disposal systems is an important factor in willingness to use them. The final product–drug mixture should be non-toxic. A challenge is addressing the potential lack of understanding of the time that might be required for full deactivation and the potential for real or perceived harm. If there is widespread perception that the system or end mixture is harmful, efforts to implement in-home disposal could be hampered. Conversely, the product–drug mixture is intended to be non-toxic, but it is not known if this information might impart a false sense of security prior to full drug deactivation and lead some to be less cautious with the used disposal system.

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