Ob/Gyns Not Well Informed About Opioid Prescribing

Ricki Lewis, PhD

December 15, 2017

Obstetricians and gynecologists need to become better informed about prescribing opioids, including improved awareness of misuse and educating patients about proper disposal, new data show.

In the midst of the widespread opioid epidemic in the United States, physician prescribing habits are under scrutiny. Because hysterectomy and cesarean deliveries are two of the most commonly performed surgical procedures, gynecologists and obstetricians often prescribe the drugs.

To better understand ob/gyns' knowledge about opioids and their prescribing practices, Annetta M. Madsen, MD, from the Allina Health United Women's Health Clinic in St Paul, Minnesota, and colleagues conducted a cross-sectional survey of fellows and junior fellows of the American College of Obstetricians and Gynecologists (ACOG).

Of 300 physicians who received the survey, 179 (60%) responded, Dr Madsen and colleagues report in an article published online and in the January 2018 issue of Obstetrics & Gynecology.

Respondents prescribed a median of 26 (range, 5 - 80) pills per patient across all the indications. The most common indication was surgery, for which 98% of the practitioners prescribed opioids. Specifically, 97% prescribed opioids after abdominal hysterectomy, 94% after cesarean delivery, 89% after laparoscopic hysterectomy, and 86% after vaginal hysterectomy.

Nonsurgical indications included ovarian cysts (30%), endometriosis (24%), pain after vaginal birth (22%), and chronic pelvic pain of unknown cause (18%). Physicians were more comfortable prescribing opioids for acute pain than for chronic pain.

More physicians reported prescribing opioid combinations than opioids alone. Commonly used combinations included acetaminophen with hydrocodone (34%), acetaminophen with oxycodone (29%), acetaminophen with codeine (13%), oxycodone (8%), hydrocodone (3%), and hydromorphone (1%).

The number of pills prescribed varied by indication. The largest number of pills was prescribed after laparotomies for cesarean delivery and abdominal hysterectomy (median, 30; range, 8 - 80), followed by minimally invasive laparoscopic surgeries and vaginal hysterectomy (median, 25; range, 6 - 60), acute nonsurgical pain associated with vaginal birth or ovarian cysts (median, 20; range, 5 - 40; P < .001 per pairwise comparison). The largest variation was seen with prescriptions for chronic endometriosis and pelvic pain of unknown cause (range, 9 - 60 pills).

Dr Madsen and colleagues also examined adherence to four practices recommended by state and federal agencies as well as by ACOG: screening for dependence; prescribing the smallest effective dose; tailoring prescriptions; and counseling patients on risks and benefits and the proper use, storage, and disposal of the drugs.

Fifty-seven (19%) of the respondents reported adherence to at least three of the recommended practices. Just 22% of respondents said they typically performed an opioid dependence screen, and only 17% typically told patients about proper disposal for unused opioids.

The median number of prescribed pills didn't differ between physicians who reported adherence to at least one of the recommended practices and physicians who did not adhere to any of them (25 vs 28; P = .58).

Most (67%) physicians report that they typically review inpatient pain medication use, and 47% base the outpatient opioid prescription on level of pain medication required during hospitalization. Most respondents also said they prescribe standard doses (75%) and number of pills (69%).

Despite the frequent prescribing, relatively few doctors were well informed about opioids. The predominant sources of misused opioids are friends or relatives, but only 81% of the respondents knew this. In addition, almost half (44%) of the physicians didn't know how to properly dispose of unused prescription opioids.

"Our study showed that current opioid-prescribing practices vary widely among ob-gyns and many are not adhering to published recommendations…. These findings highlight the need to further develop and promote ongoing educational efforts and to stress the prescribers' role in fighting the opioid epidemic," the researchers conclude.

Limitations of the study include self-reporting, use of a small sample of ACOG members, and recall bias.

The investigators have disclosed no relevant financial relationships.

Obstet Gynecol. 2018;131:150-157. Abstract

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