What’s behind postpartum opioid prescribing patterns?
Multiple factors have contributed to the current opioid epidemic, with physician over-prescribing known to play a major role. A new study in Obstetrics and Gynecology reveals characteristics of health care providers—and patients—that may be linked with postpartum opioid prescribing.
The data are from a retrospective case-control study of all opioid-näive women who delivered at a large academic tertiary care center between December 1, 2015 and November 30, 2016. The authors accessed demographic and clinical information from outpatient and inpatient electronic medical records. Electronic medical and pharmacy records were used to determine the discharge health care provider, whether an opioid was prescribed at discharge, and if so, what type of opioid, what strength, and how many tablets.
The primary objective of the study was receipt of a high quantity of prescribed opioids at discharge, or morphine milligram equivalents (MME) ≥ 90thpercentile for the cohort, which was 300 MME for vaginal and 500 MME for cesarean delivery. The authors also included women patients who were not prescribed opioids at discharge for a comparison group. Women whose deliveries were vaginal were analyzed separately from those who had cesareans.
Of the 12,320 women included in the analysis, 73.6% (n=9,038) underwent vaginal delivery and 26.6% (n=3,288) underwent cesarean delivery. The majority of women were non-Hispanic white (58.3%) and privately insured (52.5%). Approximately two-thirds (67.4%) of the participants were discharged by an attending physician, one-fourth (24.8%) were discharged by an advanced practitioner and 7.9% were discharged by a trainee physician. Female health care providers made up the majority (87.5%) of discharging physicians.
Just under half (45.3%) of postpartum women received an opioid prescription on discharge. This included 30.3% (n=2,749) women who had a vaginal delivery and 86.7% (n=2,849) of women who had a cesarean delivery. Among women who had a vaginal delivery, 636 (7.0%) received high quantities of prescribed opioids at discharge and 241 (7.3%) of women who underwent cesarean delivery received a high amount at discharge.
In terms of demographics, women who received high quantities of opioids were older and were more likely to be married, non-Hispanic white, and nulliparous. They were also more likely to have a history of depression and anxiety. Patient-specific factors associated with prescription of a high quantities of opioids included nulliparity, intrapartum neuraxial anesthesia, major laceration, and infectious complication. Patients who received the drugs at that level also were less likely to be discharged by a trainee physician (8.5% vs 1.9%; odds ratio [OR] 0.18, 95% CI 0.10-0.32). For women who underwent cesarean delivery, the only factor associated with high quantities of opioids was hemorrhage.
The authors identified a few limitations to their study. The retrospective nature of the research made it susceptible to incomplete data and misclassification. The number of trainee physicians in the opioid prescription group was very low and the exact odds ratio may be imprecise. The data also lacked information regarding specific group differences in rounding practices or postpartum care. Finally, the study was limited to one academic institution. Despite these limitations, the authors believe that while patient factors account for some variation in postpartum prescribing habits for opioids at discharge, discharge by a trainee physician is independently associated with lower odds of high opioid prescribing.