By Rebecca H. Allen, MD, MPH

Associate Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI

Dr. Allen reports she is a Nexplanon trainer for Merck, and has served as a consultant for Bayer and Pharmanest.

SYNOPSIS: This cross-sectional survey of 720 women found that 85% filled an opioid prescription after cesarean delivery, and the median number of tablets dispensed was 40. The median number of tablets consumed was only 20 tablets and the number dispensed did not correlate with patient satisfaction, pain control, or the need for a refill.

SOURCE: Bateman BT, Cole NM, Maeda A, et al. Patterns of opioid prescription and use after cesarean delivery. Obstet Gynecol 2017; June 6. doi: 10.1097/AOG.0000000000002093. [Epub ahead of print].

This was a cross-sectional survey performed from September 2014 to March 2016 at six academic medical centers in the United States including Massachusetts General Hospital, Brigham and Women’s Hospital, the University of Michigan, Columbia University, Wake Forest Health Science Center, and Stanford University. Participants were a convenience sample of English-speaking adult women who had undergone elective or unplanned cesarean delivery and did not stay in the hospital longer than seven days after delivery. Women enrolled in the study were contacted two weeks after hospital discharge and completed an interview about their pain experience, use of opioids and other analgesics, medication side effects, and satisfaction with pain management. The type and number of opioids prescribed was obtained by asking women to read the medication bottle label. If this was not available, the information was abstracted from the medical record. Data on patient demographics and hospitalization also were obtained from the medical record. The number of leftover tablets, if any, was obtained by asking the women to count the number of pills left in the bottle. If the bottle was not available, subjects were asked to estimate the number. If subjects did not feel comfortable estimating, the data were considered missing. Investigators asked participants to rate their pain on discharge, during the first week postpartum, and during the second week postpartum, as well as their satisfaction with pain control.

A total of 1,065 women were approached for study participation: 55 did not consent, 35 did not meet inclusion criteria, three were excluded for other reasons, and 252 were not able to be reached by phone two weeks after delivery, resulting in a final sample size of 720 women. The mean age of participants was 32.7 years old, 60% were white, and 77% were privately insured. Three-quarters of the sample was recruited from the Boston and New York sites. Nearly all prescriptions were for 5 mg oxycodone (82.1%) or 5 mg hydrocodone (8.7%). The median maximum pain score upon discharge from the hospital was 5 (interquartile range [IQR] 3-6); the median score was 4 (IQR 2-5) during the first week; and the median score was 2 (IQR 1-3) during the second week. Of the 720 participants, 615 (85.4%) filled an opioid prescription. The median number of tablets dispensed was 40 (IQR 30-40), the median number consumed was 20 (IQR 8-30), and the median number left over was 15 (IQR 3-26). The vast majority (95%) had not disposed of the leftover tablets at the time of the interview. The sample was divided into tertiles based on number of tablets dispensed: 30, 31 to 40, and > 40. There was no difference across the groups in terms of satisfaction with pain relief, pain scores during the first two weeks post-discharge, and the proportion requiring a refill (5%). There was a correlation between the number of tablets dispensed and the number of tablets consumed.

COMMENTARY

It is well known that prescription opioid abuse is a major problem in the United States. Prescription opioid abuse often leads to subsequent heroin abuse, and we are in the midst of an epidemic of opioid overdose deaths.1 Leftover prescribed medication has been identified as an important source of diverted or misused opioids and accidental ingestion. Studies show that most patients fail to dispose of leftover opioids and some share leftovers with other people.2 The authors of this study aimed to determine the normative amounts of opioid prescriptions after cesarean delivery in the United States. This is important because cesarean delivery is the most common inpatient surgical procedure performed nationally, with 1.3 million surgeries performed annually.3

The strengths of this study included the attempt to survey women in different areas of the country. Nevertheless, only seven subjects were recruited from Stanford, 52 from the University of Michigan, and 94 from Wake Forest University, with the vast majority from Boston and New York. Therefore, the data likely only represent academic medical center practice in northeastern states. Other limitations include the fact that one-quarter of those approached were not able to be contacted for the survey, and these women may be different in important ways. In addition, I am not sure why the authors included women who were in the hospital postoperatively for more than four days, which is the typical number for cesarean delivery. Nevertheless, this is one of the first attempts to quantify opioid prescribing patterns after cesarean delivery. It seems that most patients are prescribed 40 tablets of Percocet or Vicodin (I assume the opioids were combined with acetaminophen but the authors did not state this explicitly) and only use 20 tablets. The authors also found that 15% of women did not fill their opioid prescriptions, citing reasons such as not needing or wanting opioids (87%), not liking the way opioids made them feel (11%), and negative side effects during prior exposure to opioids (9%). The authors did not find that the number prescribed affected patients’ satisfaction with pain control. Therefore, it seems reasonable that the number of tablets prescribed could be fewer initially and also could be individualized to patients based on their preferences.

Over-prescription of opioid analgesics is a problem because it potentially allows unused medication to be diverted. Several states have passed laws targeting initial prescriptions of opioids for acute pain. For example, in my state, Rhode Island, providers are required to check the Prescription Drug Monitoring Program website prior to prescribing opioids to patients. After this, providers are allowed to prescribe no more than 30 morphine milligram equivalents total daily dose per day for a maximum total of 20 doses. This translates to 20 tablets of Percocet for the initial opioid prescription.

Initially, when this law passed, I was concerned that our patients would be calling for Percocet refills after cesarean delivery. Since we cannot send opioid prescriptions electronically in our electronic medical record system, this would mean that patients physically would have to come to the clinic to pick up a new prescription. I felt that this would be a burden to our patients who recently went home with a newborn and depended on public transportation. Nevertheless, we have not found a marked increase in calls for Percocet refills.

Another recommendation instituted by our hospital was providing information on how to dispose of medications safely in the discharge instructions given to patients. (See Table 1.) These are specific to Rhode Island, but the Food and Drug Administration has recommendations on its website for safe drug disposal.4 Although I would not expect a woman only two weeks postpartum to have disposed of her leftover opioid medications given the demands of caring for a newborn, that is something that could be addressed at the postpartum visit. Just reminding our patients of the importance of safely disposing any leftover opioid medications would have a great effect.

Table 1: How to Dispose of Medicine Safely

If you are finished with a prescription medicine and you have pills left, or if you have any unused prescriptions around the house, it is important to get rid of them safely.

The best thing to do is to bring them to a drug disposal box or take-back event.

 

A list of sites for safe drug disposal can be found at http://noperi.org/drugdisposal.html or call your local police department for information on take-back events.

If you cannot get to a drug disposal site, here are the steps to safely dispose of any medicine:

  1. Take medicine out of its original container and mix it with cat litter or used coffee grounds.
  2. Put medicine into a disposable container with a lid or into a sealable plastic bag.
  3. Conceal or remove any personal information (including prescription number) on the empty containers.
  4. Put the sealed container or bag and the empty medicine bottles in the regular trash.

Please remember, it is your responsibility to safeguard all medicines and keep them in a secure location.

SOURCE: Women and Infants' Hospital, Providence, RI.

REFERENCES

  1. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths—United States, 2010-12015. MMWR Morb Mortal Wkly Rep 2016;65:1445-1452.
  2. Kennedy-Hendricks A, Gielen A, McDonald E, et al. Medication sharing, storage, and disposal practices for opioid medications among US adults. JAMA Intern Med 2016;176:1027-1029.
  3. Martin JA, Hamilton BE, Osterman MJ, et al. Births: Final data for 2015. Natl Vital Stat Rep 2017;66:1.
  4. US Food and Drug Administration. Disposal of unused medicines: What you should know. Available at: https://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuringsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm. Accessed June 12, 2017.