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Opioids over prescribed after cesarean delivery

Two separate studies recently published in Obstetrics and Gynecology suggest women are being prescribed excess opioids after cesarean delivery, and offer suggestions to health care professionals on ways to curb excess prescriptions, particularly for oxycodone.

“We know that leftover medications are fueling our current opioid epidemic," Brian Bateman, MD, chief of obstetric anesthesia, Brigham and Women's Hospital, Boston, said in a press release. “Quantifying the amount of medication that a woman needs to control her pain following cesarean delivery and finding ways to reduce unnecessary prescribing can reduce unused opioid pills that end up in medicine cabinets at home.”

Researchers in the first study surveyed 720 women 2 weeks after they had been discharged from the hospital following a cesarean section on: pain scores immediately after discharge, the first week after discharge, and the second week after discharge; opioid and other analgesic use; medication-related side effects at any time point; and overall satisfaction with their pain management. Chart reviews, as well as information on the type of opioid dispensed, its strength, and the number of tablets, were also obtained.

Bateman and colleagues found that of the women surveyed, 615 filled an opioid prescription. The median number of dispensed opioid tablets was 40 (interquartile range 30–40), the median number consumed was 20 (interquartile range 8–30), and leftover was 15 (interquartile range 3–26). Of those with leftover opioids, 95.3% had not disposed of the excess medication at the time of the interview. In addition, the number of opioids dispensed did not correlate with patient satisfaction, pain control, or the need to refill the opioid prescription. There was an association between a larger number of tablets dispensed and the number consumed independent of patient characteristics.

“Obstetricians ... should adopt more judicious prescribing patterns and counsel women about the importance of safe leftover medication disposal,” Bateman and colleagues wrote.

In the second study, Malavika Prabhu, MD, department of obstetrics and gynecology, Massachusetts General Hospital, and colleagues observed 50 women who had recently had a cesarean delivery as they viewed a tablet-based decision aid with a health care professional. The tool included information on anticipated patterns of pain in the first 2 weeks after cesarean delivery; expected outpatient opioid use after cesarean delivery; risks and benefits of opioid and nonopioid analgesics, and information on opioid disposal and access to refills if needed. At session’s end, the women chose to be prescribed a quantity of 5 mg oxycodone ranging from zero to 40 tablets. Two weeks after enrollment, follow-up interviews were conducted with the women.

Researchers found that the use of the shared decision-making tool was associated with a 50% decrease in the number of opioid pills prescribed after the procedure, 90% of the women reported being satisfied or very satisfied with their pain control and the refill rate was 8%.

“[This] study demonstrates that shared decision-making is a promising strategy to align opioid prescribing with patient needs after cesarean delivery and thus may reduce the number of unused opioid tablets in the community while still ensuring adequate pain control and patient satisfaction,” Prabhu and colleagues wrote.

Other researchers recently outlined some research priorities for addressing opioid use in women who are pregnant, including gaining a better understanding of the problems that can accompany opioid use disorder in pregnancy as well as addressing pain management for women with opioid use disorder during labor and on special interventions after delivery.

Earlier this year, the AMA provided suggestions on ways to safely store and dispose of opioids, such as urging patients to use local “take back” programs, mail back program or medication drop box at a police station, DEA-authorized collection site or a pharmacy that has a secure drop-box program to dispose of unused medications.. – by Janel Miller

Disclosure: Bateman is supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the NIH. Please see the study for the other author’s relevant financial disclosures.