A majority of women who undergo a cesarean delivery are sent home from the hospital with more opioid pain medications than needed, according to a new study at Vanderbilt University Medical Center (VUMC).
The study, published in the journal Obstetrics and Gynecology, looked at 179 cesarean patients from VUMC over an eight-week period to examine the variation in opioid prescribing and consumption after cesarean delivery, the most common major surgical procedure performed in the United States.
“What we found is that prescribers, partly in order to expedite a patient’s release from the hospital, have kind of a one-size-fits-all prescription model for patients when they are discharged from the hospital,” said first author Sarah Osmundson, M.D., assistant professor of Obstetrics and Gynecology in the Division of Maternal-Fetal Medicine.
This method, say the researchers, may undertreat a few patients, but most likely overtreats the vast majority of patients.
“There’s so much attention around excess opioids and the growing problem with opioid addiction, and the question came up, how much are patients really using when they go home?” Osmundson said.
“Anecdotally, I was hearing that patients were using one to two tablets once they were home, but they went home with a prescription for 30 tablets. The big question for us is what is happening after discharge and can we modify that to reduce the amount of excess opioids prescribed.”
Opioid overdose deaths in the U.S. have quadrupled in 15 years, a dramatic result of the current opioid abuse epidemic. This increase correlates with a sharp rise in the number of legal prescription opioids dispensed.
Most individuals using prescription opioids for non-medical purposes have obtained them from family members or friends who have been prescribed the medications.
For the study, women were asked weekly about the number of opioid pills used, the amount remaining and their pain experience, beginning on day 14 after the surgery until they had stopped taking the medication. The state’s Substance Monitoring Program was used to confirm prescription-filling details.
Michael Richardson, M.D., associate professor of anesthesiology and a co-author, said more attention should be paid to patients’ opioid use while they are still in the hospital to better predict their use after going home.
“Our data suggest that providers are not currently considering in-hospital opioid use to determine the amount of opioid prescribed at discharge,” Richardson said. “If the patient is not using very much in the hospital, why should they go home with a prescription for 30 oxycodone tablets?”
In addition, many patients given a 30-day prescription think they are supposed to take the pills until they are all gone, when in fact, they only need to take them when absolutely needed. Typically, over-the-counter pain relievers such as ibuprofen or Tylenol are sufficient in controlling post-cesarean pain.
The findings show that, once home, most women (83 percent) used opioids for an average of eight days, and of the women who filled their prescriptions (92 percent) 74 percent had unused tablets. This added up to about 2,540 unused five mg oxycodone tablets over the study period, Richardson said, and about 19,000 excess oxycodone per year from cesareans at VUMC alone.
And the majority (63 percent) stored their pills in an unlocked location in their home, which is another cause for concern, Osmundson said.
“Large studies show that the most common source for misused opioids are ones that are prescribed legally and to the appropriate person. We know that these are falling into the wrong hands and that people frequently use opioids prescribed to a friend or family member.”
“One way to tackle the opioid epidemic is not to have excess opioids around, which is unlikely to happen, or to minimize what we’re currently prescribing, which is doable,” Osmundson said.
There’s a balance, though, Richardson added. “You don’t want to under-prescribe either. In Tennessee, a health care provider can’t just call in a refill for opioids, so if you under-prescribe when the patient is sent home from the hospital, someone has to pick up a paper prescription, and that’s inconvenient for many patients.”
The researchers say they are planning further research to determine whether in-hospital opioid use can guide post-discharge prescribing to reduce opioids without under treating pain.
“If we can find a more nuanced way to prescribe, we can do a lot to reduce the excess opioids out there,” Osmundson said.