Provider attitudes and current practice regarding the prescription of opioid-containing pain medication for vaginal delivery

Sarah Atkinson; Anna R. Whelan; Abigail Litwiller

doi:10.5055/jom.0836

Authors

Sarah Atkinson, MD
Anna R. Whelan, MD
Abigail Litwiller, MD

DOI:

https://doi.org/10.5055/jom.0836

Keywords:

analgesics, opioid, obstetric delivery, opioid abuse, post-partum

Abstract

Background: The epidemic of opioid misuse and abuse is rampant in the United States. A large percentage of patients who go on to misuse or abuse opioids were initially legally prescribed an opioid medication by their physician. One of the most common reasons patients of reproductive age seek medical care is for pregnancy and delivery. These patients are frequently prescribed opioids. Greater than one in 10 Medicaid-enrolled women fill an opioid prescription after vaginal delivery.

Objective: To assess the opioid prescribing patterns of obstetric providers following vaginal deliveries.

Study design: Obstetric physicians and certified nurse midwives (CNMs) from different practice backgrounds were administered a questionnaire regarding opioid prescribing practices for patients who undergo vaginal delivery. Providers were contacted via email and completed survey via REDCap.

Results: Ninety-nine providers completed the survey between October 2018 and January 2019. Eight percent of all providers reported prescribing opioids at discharge after vaginal deliveries. There was a statistically significant difference in the proportion of physicians who provided opioid prescriptions at discharge compared to CNMs (16.7 percent vs 1.8 percent, respectively, p < .05). Common reasons for prescribing opioids at discharge included post-partum tubal ligation (56.4 percent), third- and fourth-degree lacerations (59.6 and 73.4 percent, respectively), and operative deliveries (26.6 percent). Physicians were significantly more likely to prescribe an opioid after a second-degree laceration than CNMs (19.1 percent vs 5.3 percent, p < 0.05).

Conclusions: Practice patterns for opioid prescription vary by provider type as well as by delivery characteristics. Further study is necessary to delineate the optimal care while minimizing unnecessary opioid prescriptions.

Author Biographies

Sarah Atkinson, MD

Department of Obstetrics and Gynecology, Advocate Christ Medical Center, Oak Lawn, Illinois

Anna R. Whelan, MD

Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Women & Infants Hospital of Rhode Island, Alpert Medical School at Brown University, Providence, Rhode Island

Abigail Litwiller, MD

Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center, San Jose, California

References

Centers for Disease Control and Prevention: Vital signs: Overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011; 60(43): 1487-1492.

Hedegaard H, Minino AM, Warner M: Drug overdose deaths in the United States, 1999-2019. NCHS Data Brief. 2020; 394: 1-8.

Compton WM, Jones CM, Baldwin GT: Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med. 2016; 374(2): 154-163. DOI: 10.1056/NEJMra1508490.

Hagemeier NE: Introduction to the opioid epidemic: The economic burden on the healthcare system and impact on quality of life. Am J Manag Care. 2018; 24(10 Suppl.): S200-S206.

Olsen Y: The CDC guideline on opioid prescribing: Rising to the challenge. JAMA. 2016; 315(15): 1577-1579. DOI: 10.1001/jama.2016.1910.

Osmundson SS, Min JY, Grijalva CG: Opioid prescribing after childbirth: Overprescribing and chronic use. Curr Opin Obstet Gynecol. 2019; 31(2): 83-89. DOI: 10.1097/GCO.0000000000000527.

Manchikanti L, Abdi S, Atluri S, et al.: American society of interventional pain physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2–guidance. Pain Phys. 2012; 15(3 Suppl.): S67-S116.

American College of Obstetricians and Gynecologists' Committee on Clinical Consensus–Obstetrics: Pharmacologic stepwise multimodal approach for postpartum pain management: ACOG clinical consensus no. 1. Obstet Gynecol. 2021; 138(3): 507-517. DOI: 10.1097/AOG.0000000000004517.

Baruch AD, Morgan DM, Dalton VK, et al.: Opioid prescribing patterns by obstetrics and gynecology residents in the United States. Subst Use Misuse. 2018; 53(1): 70-76. DOI: 10.1080/10826084.2017.1323928.

Bateman BT, Cole NM, Maeda A, et al.: Patterns of opioid prescription and use after cesarean delivery. Obstet Gynecol. 2017; 130(1): 29-35. DOI: 10.1097/AOG.0000000000002093.

Jarlenski M, Bodnar LM, Kim JY, et al.: Filled prescriptions for opioids after vaginal delivery. Obstet Gynecol. 2017; 129(3): 431-437. DOI: 10.1097/AOG.0000000000001868.

Ko JY, D'Angelo DV, Haight SC, et al.: Vital signs: Prescription opioid pain reliever use during pregnancy—34 US Jurisdictions, 2019. MMWR Morb Mortal Wkly Rep. 2020; 69(28): 897-903. DOI: 10.15585/mmwr.mm6928a1.

Prabhu M, McQuaid-Hanson E, Hopp S, et al.: A shared decision-making intervention to guide opioid prescribing after cesarean delivery. Obstet Gynecol. 2017; 130(1): 42-46. DOI: 10.1097/AOG.0000000000002094.

ACOG Committee Opinion No. 742: Postpartum pain management. Obstet Gynecol. 2018; 132(1): e35-e43. DOI: 10.1097/AOG.0000000000002683.

Mourad M, Landau R, Wright JD, et al.: Oral opioid use during vaginal delivery hospitalizations. Am J Perinatol. 2020; 37(4): 390-397. DOI: 10.1055/s-0039-1678566.

Harris PA, Taylor R, Thielke R, et al.: Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009; 42(2): 377-381. DOI: 10.1016/j.jbi.2008.08.010.

Mack KA, Zhang K, Paulozzi L, et al.: Prescription practices involving opioid analgesics among Americans with Medicaid, 2010. J Health Care Poor Underserved. 2015; 26(1): 182-198. DOI: 10.1353/hpu.2015.0009.

Yang YT, Attanasio LB, Kozhimannil KB: State scope of practice laws, nurse-midwifery workforce, and childbirth procedures and outcomes. Womens Health Issues. 2016; 26(3): 262-267. DOI: 10.1016/j.whi.2016.02.003.

Badreldin N, Grobman WA, Chang KT, et al.: Opioid prescribing patterns among postpartum women. Am J Obstet Gynecol. 2018; 219(1): 103e1–103-e8. DOI: 10.1016/j.ajog.2018.04.003.