Opioid-related deaths recently exceeded motor vehicle accidents as the leading cause of injury-related death in the United States.1 In 2015, 2 million Americans had a prescription opioid use disorder, and more than half of those who reported prescription opioid misuse obtained the drugs through diversion of prescribed medications.2
To address the evolving opioid epidemic that parallels an increase in opioid prescriptions, federal and state agencies developed guidelines to promote judicious opioid-prescribing practices.3–5 As well, the American College of Obstetricians and Gynecologists (ACOG) published recommendations to screen for nonmedical use of prescription drugs, follow suggestions to limit abuse or diversion, and educate patients on safe use, storage, and disposal.6,7 Although the content of the published guidelines differs, they have common recommendations that include tailoring prescriptions to individuals, providing the lowest dose for the shortest amount of time, counseling patients on risks and benefits, and discussing proper use, storage, and disposal of opioids with patients.3–7
Obstetrician–gynecologists (ob-gyns) perform two of the most common surgical procedures nationwide (cesarean delivery and hysterectomy) and often treat pelvic pain conditions, yet little is known about their awareness regarding misuse of prescription opioids or individual opioid-prescribing practices. This information could help identify areas for improvement and inform the development of educational interventions designed to mitigate excessive opioid prescriptions. The primary objective of this study was to describe American ob-gyns' knowledge and prescribing practices regarding opioid analgesics. The secondary objective was to determine whether there are differences in prescribing practices based on physician characteristics.
MATERIALS AND METHODS
We performed a survey-based study of a national sample of ACOG Fellows and Junior Fellows to describe their knowledge of and prescribing practices for opioid analgesics. The study was conducted from April 25, 2016, to September 30, 2016, and was part of a larger survey assessing knowledge and prescribing patterns for common medications for gynecologic and obstetric patients. The study was determined to be exempt by the institutional review board at Women & Infants' Hospital of Rhode Island because the survey was anonymous and contained no personal identifiers or health information.
The study population included a random sample of ACOG Fellows and Junior Fellows who volunteered to receive research surveys as part of the Collaborative Ambulatory Research Network. ACOG is a national society of more than 58,000 members that represent 90% of practicing ob-gyns in the United States, including both specialists and subspecialists. There are currently approximately 1,400 Collaborative Ambulatory Research Network members located throughout the United States. Detailed demographic information is not available for all ACOG Fellows or all Collaborative Ambulatory Research Network members. However, the proportion of men compared with women and the geographic distribution are comparable between the Collaborative Ambulatory Research Network and the general ACOG member population. There were no exclusion criteria for this study.
Online and paper surveys were developed by the research team and tested on a group of volunteer physicians before distribution to correct wording errors, clarify any questions that were difficult to understand, and determine the time required to complete the survey. There were no changes to the content of the questions based on volunteer feedback. The survey included multiple-choice and single-answer questions about the physician, opioid-prescribing patterns, and knowledge regarding proper use and misuse of opioid analgesics. The survey also collected data on beliefs, knowledge, and practices regarding antidepressants and antiemetics during pregnancy, which were analyzed for other studies.
We distributed the surveys using a sequential mixed-method approach to a total of 300 Collaborative Ambulatory Research Network members. Because Collaborative Ambulatory Research Network members are asked to complete multiple surveys per year, a sample size of 300 was chosen to limit oversampling and survey fatigue. First, a sample of randomly selected Collaborative Ambulatory Research Network members received an email message from the survey platform Real Magnet that oriented them to the study, provided information for informed participation, and contained a personalized link to the survey. These surveys have unique identification numbers linked to the email so respondents can only submit a single survey. Informed consent was implied by clicking on the link to the electronic survey. After the original email, five weekly email reminders to participate were sent to nonresponders. For Collaborative Ambulatory Research Network members who did not have an email address or who did not respond within 2 weeks of the final online survey reminder, a short-form paper version of the survey was sent by mail. After 5 weeks, a second (final) reminder mailing was sent to those who had not responded to any of the previous emailed or mailed survey requests. Data collection ended 9 weeks after the final mailing. A short-form paper version of the survey was developed and distributed to increase the likelihood of survey response. This short form included fewer questions related to prescribing practices for nonsurgical indications and did not include the questions on knowledge of opioid misuse. Data collected only on the online survey are denoted throughout the article and in the tables. Surveys sent by mail included a unique identification number that corresponded to a specific participant. Returned surveys were given a new identification number that was not associated with any personal information. This method maintained confidentiality while ensuring duplicate surveys were not received.
Based on a review of published prescribing guidelines, we identified four recommended practices for outpatient opioid-prescribing (which also pertains to opioid-prescribing at hospital discharge) (Table 1).3–7 We assessed adherence to these practices with a series of true and false questions. These were embedded in a series of questions on prescribing practices and were not labeled as “recommended practices” in the survey. We then compared the number of opioid tablets prescribed for gynecologic and postsurgical indications between physicians who did compared with those who did not report practicing in accordance with the individual recommended prescribing practices.
Online and paper survey responses were imported into a statistical software package (Stata 13.1). An initial data analysis was performed to screen for implausible and inconsistent answers and to check randomly selected questionnaire items for data entry accuracy. We performed bivariate comparisons for categorical variables using Pearson χ2 or Fisher exact test where appropriate. Continuous variables were compared using t test or analysis of variance. Nonparametric tests (Wilcoxon rank-sum and Kruskal-Wallis) were used for data not normally distributed. We categorized respondents by national region (Northeast, South, Midwest, West) (Box 1). We grouped indications into laparotomy (cesarean delivery and abdominal hysterectomy), minimally invasive surgery (laparoscopic and vaginal hysterectomy), acute nonsurgical pain (ovarian cysts and vaginal birth), and chronic pain (endometriosis and chronic pelvic pain of unknown cause). We compared the number of pills prescribed by the ob-gyns' demographic characteristics (including national region) and indication for prescription using a repeated-measures analysis of variance. P values <.05 were considered statistically significant, and all tests were two-sided.
We obtained responses from 179 Collaborative Ambulatory Research Network members (response rate 60%), 102 online and 77 by mail. The demographic characteristics of respondents are described in Table 2. Respondents represented all national regions, although a greater proportion was from the South (35%) compared with the West (19%), Midwest (21%), and Northeast (26%). Respondents represented a variety in both practice setting and number of years in practice postresidency. Compared with mail respondents (short form), a higher proportion of online respondents (long form) was female (76% vs 52%, P=.002) and maternal-fetal medicine subspecialists (22% vs 3%, P=.01). Online respondents were in practice for a shorter duration than mail respondents (median 19 years [range 1–41 years] vs 26 years [range 2–52 years]). There were no other significant differences between online and mail-based respondents.
Ninety-eight percent of respondents reported they typically prescribed opioid pain medication for outpatient pain control after surgery (94% after cesarean delivery, 97% after abdominal hysterectomy, 89% after laparoscopic hysterectomy, and 86% after vaginal hysterectomy) (Table 3). Fewer ob-gyns reported that they typically prescribed opioids for ovarian cysts (30%), endometriosis (24%), and chronic pelvic pain of unknown cause (18%) or after vaginal birth (22%). Among the respondents who endorsed prescribing opioids for each listed indication, a greater proportion reported they were comfortable prescribing opioids for acute pain-related indications (postsurgical 92%, postvaginal birth 90%, ovarian cysts 80%) than reported they were comfortable prescribing opioids for gynecologic problems associated with chronic pain-related indications (endometriosis 68%, chronic pelvic pain of unknown cause 41%). More respondents endorsed “usually or always” prescribing the combined opioid-acetaminophen medications than endorsed “usually or always” prescribing opioid agents alone; 34% prescribed acetaminophen with hydrocodone, 29% prescribed acetaminophen with oxycodone, 13% prescribed acetaminophen with codeine, 8% prescribed oxycodone, 3% prescribed hydrocodone, and 1% prescribed hydromorphone.
Respondents overall prescribed a median of 26 (range 5–80) opioid pills per patient across all indications combined. The number of opioid pills typically prescribed varied by indication and between respondents. Respondents reported typically providing more pills after laparotomies for cesarean delivery and abdominal hysterectomy (median 30, range 8–80) followed by minimally invasive surgeries of laparoscopic and vaginal hysterectomy (median 25, range 6–60) and acute nonsurgical pain resulting from ovarian cysts and vaginal birth (median 20, range 5–40) (P<.001 for each pairwise comparison). Respondents' reported opioid prescriptions varied the greatest for chronic conditions of endometriosis and chronic pelvic pain of unknown cause (range 9–60 pills). There were no significant regional differences in prescribing practices (Fig. 1). There were no differences in reported prescribing practices based on ob-gyns' gender, specialty, number of years in practice, or practice type.
We also evaluated whether reported prescribing practices were consistent with published recommendations (Tables 1 and 4). Only 19% percent (n=30/161) reported adherence to three or more recommendations. Twenty-two percent reported they typically performed opioid dependence screens and 17% typically counseled patients on proper disposal of unused opioids. When we compared respondents who reported adhering to at least one of the four recommended practices listed previously with those who did not, there was no significant difference in the median number of pills prescribed (25 [interquartile range 25–30] vs 28 [interquartile range 20–30], P=.58; Table 4). In terms of other relevant prescribing practices, the majority of respondents reported they review inpatient pain medication use (67%); however, only 47% stated that they base the outpatient prescription on how much pain medication the patient needed during her hospitalization. Most respondents reported they prescribed a standard dose (75%) and number of pills (69%).
In Table 5, we included ob-gyns' responses to questions related to knowledge about opioid misuse with a description of the correct response. The majority (73%) of respondents knew that swallowing pills whole is the most common route for abusing opioids. Almost half (44%) did not know how to properly dispose of unused prescription opioids. Eighty-one percent of respondents did not know that the majority of individuals who misuse prescription opioids obtain them from family or friends.2,6 Ob-gyns endorsed fairly neutral levels of concern (on a scale of 1 being no concern and 10 being greatest concern) regarding opioid misuse (median 7, range 1–10) and diversion (median 5, range 2–10) in their communities and practice.
United States Categorized into Geographic Regions Cited Here...
Connecticut, Delaware, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont
Alabama, Arkansas, District of Columbia, Florida, Georgia, Kansas, Louisiana, Maryland, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia
Illinois, Indiana, Iowa, Kentucky, Michigan, Minnesota, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin
Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, Wyoming
Excessive prescriptions contribute to opioid-related morbidity and mortality by making opioids available for misuse and diversion.2,8,9 Our study showed that current opioid-prescribing practices vary widely among ob-gyns and many are not adhering to published recommendations. It is a cause for concern that 81% of respondents were unaware that diversion of friends' and family members' prescription opioids is the primary source of these drugs. These findings highlight the need to further develop and promote ongoing educational efforts and to stress the prescribers' role in fighting the opioid epidemic.
Current guidelines recommend tailoring prescriptions to provide the “briefest, least invasive, and lowest dose regimen that minimizes pain and avoids dangerous side effects.”4 Most respondents reported that they prescribe the smallest number of pills needed, review inpatient use, and tailor prescriptions, yet also reported that they provide a standard number (75%) and dose (69%) of opioids. We compared the number of opioid tablets prescribed between respondents who reported adherence and nonadherence with guidelines to examine this apparent conflict in responses and found no clinically meaningful differences between groups in the amount of opioids they prescribed. One possible explanation for this finding is that respondents perceive they provide the smallest number of pills possible, and that is their standard prescription. Another possible explanation is a misinterpretation of the question; respondents may have reported that they provide a standard number and dose for all, or nearly all, patients despite tailoring opioid prescriptions in very specific situations (although the question asked about typical practice).
In providing a standard number or dose of pills to patients, ob-gyns may be overprescribing opioids to patients in an attempt to ensure adequate pain control. However, most postsurgical and obstetric patients consume only a fraction of the opioids prescribed for outpatient pain control.10–14 In a recent study of opioid prescriptions and use after cesarean delivery, Bateman et al10 showed that, on average, only half of prescribed opioid tablets were consumed (median prescribed 40, median consumed 20). Two studies examined opioid use after urogynecologic procedures; one showed that in a practice that typically prescribed 30 opioid tablets per patient after major surgery (laparotomy), a median of 15 tablets per patient was left over.11 Similarly, in a study of minimally invasive urogynecologic procedures, approximately one third of the opioids prescribed (median 40 tablets) were consumed (median 13 tablets).12
Excessive opioid prescriptions are vulnerable to misuse or diversion. In our study, only 17% of surveyed physicians counsel their patients on proper disposal and only 56% knew how to properly dispose of excess opioids. Given that up to 20% of patients share their unused opioids with others and 54–71% of individuals who misuse opioids receive them from a friend or relative, educating both patients and health care providers on the importance and mechanisms of proper disposal is another step that could be taken to reduce excess opioids in society.2,8,15
In our study of selected ACOG Fellows and Junior Fellows, the number of prescribed opioid pills varied widely (5–80 pills) with differences seen only between indications for prescriptions. This is consistent with literature that reports a wide range in prescribing practices for minimally invasive gynecologic surgery, cesarean delivery, and procedures in other surgical specialties.10–15 Such wide variations in practice highlight inconsistencies in health care delivery and present opportunities for evaluation of clinical practice guidelines and continuing medical education.
The main strength of this study is the nationwide sample of ACOG Fellows and Junior Fellows with representation across all geographic regions. Despite a lower response rate than anticipated and desired, overall, this study provides new and very much needed information about physician-reported opioid-prescribing practices and can be used to guide research and educational efforts.
Because this study involved a self-completed physician survey, it is limited by nonresponse bias and the ability of physicians to correctly recall the amount of opioid medication they typically prescribe. Data are not available in this study to allow comparisons between the study sample and the general ACOG fellow population or between responders and nonresponders. Although previous studies have shown that Collaborative Ambulatory Research Network and ACOG Fellow populations are comparable, our sample still represents a very small subset of the ACOG membership.16 Survey responders do not adequately represent rural practices, where opioid use disorder may be a greater issue. It is possible that Collaborative Ambulatory Research Network survey responders are a subset of engaged fellows who are more knowledgeable than the general ACOG Fellow population, which would underestimate the lack of knowledge and adherence to recommended practices. Additionally, this is part of a larger study and the full survey was lengthy. We used a shorter form of the survey for the mailed version compared with the online version with the goal of improving overall survey response at the expense of having a smaller denominator for a subset of questions. We were also limited in our ability to ask more questions regarding the ob-gyns' background, practice, and patient population. We queried “typical” and “routine” use, assuming that ob-gyns do not consider patients with opioid use disorders to be their “typical” patient. Therefore, we are unable to determine whether variations in prescribing practices are associated with differences in the prevalence of patients with an opioid use disorder.
Our study shows a wide variation in typical opioid-prescribing among ob-gyns, which was associated only with the indication, but not with overall reported adherence to recommended prescribing practices. Recognizing the role of ob-gyns in the opioid crisis and its effect on women's health, ACOG joined the American Medical Association Taskforce to Reduce Opioid Abuse to create online resources for health care providers.17,18 Our findings highlight the need to further develop and promote such educational resources for prescribers and to inform ob-gyns of the patient resources that are available regarding proper use, storage, and disposal of excess opioid medications.
1. National Center for Injury Prevention and Control. Causes of injury death, highlighting unintentional injury. Available at: http://www.cdc.gov
/injury/wisqars/pdf/leading_causes_of_injury_deaths_highlighting_unintentional_injury_2014-a.pdf. Retrieved January 24, 2017.
2. Hughes A, Williams MR, Lipari RN, Bose J, Copello EAP, Kroutil LA. Prescription drug use and misuse in the United States: results from the 2015 national survey on drug use and health. NSDUH data review. Available at: http://http://www.samhsa.gov
/data/. Retrieved September 21, 2017.
3. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep 2016;65:1–49.
4. Washington State Agency Medical Directors' Group. Interagency guideline on prescribing opioids for pain 2015. Available at: http://http://www.agencymeddirectors.wa.gov
/Files/2015AMDGOpioidGuideline.pdf. Retrieved September 21, 2017.
5. Alexander GC, Frattaroli S, Gielen AC, editors. The prescription opioid epidemic: an evidence-based approach. Available at: http://www.jhsph.edu
/research/centers-and-institutes/center-for-drug-safety-and-effectiveness/research/prescription-opioids/JHSPH_OPIOID_EPIDEMIC_REPORT.pdf. Retrieved April 2, 2017.
6. Nonmedical use of prescription drugs. Committee Opinion No. 538. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:977–82.
7. Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e81–94.
8. Jones CM, Paulozzi LJ, Mack KA. Sources of prescription opioid pain relievers by frequency of past-year nonmedical use: United States, 2008-2011. JAMA Intern Med 2014;174:802–3.
9. Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep 2011;60:1487–92.
10. Bateman BT, Cole NM, Maeda A, Burns SM, Houle TT, Huybrechts KF, et al. Patterns of opioid prescription and use after cesarean delivery. Obstet Gynecol 2017;130:29–35.
11. Hota LS, Warda HA, Haviland MJ, Searle FM, Hacker MR. Opioid use following gynecologic and pelvic reconstructive surgery. Int Urogynecol J 2017 Sep 9 [Epub ahead of print].
12. Swenson CW, Kelley AS, Fenner DE, Berger MG. Outpatient narcotic use after minimally invasive urogynecologic surgery. Female Pelvic Med Reconstr Surg 2016;22:377–81.
13. Bates C, Laciak R, Southwick A, Bishoff J. Overprescription of postoperative narcotics: a look at postoperative pain medication delivery, consumption, and disposal in urologic practice. J Urol 2011;185:551–5.
14. Hill MV, McMahon ML, Stucke RS, Barth RJ Jr. Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg 2017;265:709–14.
15. Kennedy-Hendricks A, Gielen A, McDonald E, McGinty EE, Shields W, Barry CL. Medication sharing, storage, and disposal practices for opioid medications among US adults. JAMA Intern Med 2016;176:1027–9.
16. Leddy MA, Lawrence H, Schulkin J. Obstetrician-gynecologists and women’s mental health: findings of the Collaborative Ambulatory Research Network 2005–2009. Obstet Gynecol Surv 2011;66:316–23.
17. American Medical Association. Reversing the opioid epidemic. Available at: http://ama-assn.org/delivering-care/reversing-opioid-epidemic. Retrieved July 26, 2017.
18. American College of Obstetricians and Gynecologists. Tobacco, alcohol, and substance abuse: opioids. Available at: http://www.acog.org
/About-ACOG/ACOG-Departments/Tobacco--Alcohol--and-Substance-Abuse/Opioids. Retrieved September 26, 2017.
19. Chasnoff IJ, Wells A, McGourty RF, Bailey LK. Validation of the 4P’s Plus screen for substance use in pregnancy. J Perinatol 2007;27:744–8.
20. National Institute on Drug Abuse (NIDA) Resource Guide. Screening for drug use in general medical settings. Available at: http://www.drugabuse.gov
/publications/resource-guide-screening-drug-use-in-general-medical-settings/nida-quick-screen/. Retrieved September 28, 2017.
21. Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med 2002;156:607–14.
22. Centers for Disease Control and Prevention. Opioid factsheet for patients. Available at: http://www.cdc.gov
/drugoverdose/pdf/aha-patient-opioid-factsheet-a.pdf. Retrieved September 26, 2017.
23. American Medical Association.End the epidemic: safe storage and disposal resources for physicians and patients. Available at: http://www.end-opioid-epidemic.org
/storage-and-disposal. Retrieved September 27, 2017.
24. U.S. Food and Drug Administration. Disposal of unused medicines: what you should know. Available at: http://www.fda.gov
/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm#Flush_List. Retrieved September 27, 2017.
25. U.S. Department of Justice Drug Enforcement Administration. National drug threat assessment summary 2016. Available at: http://www.dea.gov
/resource-center/2016%20NDTA%20Summary.pdf. Retrieved September 21, 2017.
26. Kirsh K, Peppin J, Coleman J. Characterization of prescription opioid abuse in the United States: focus on route of administration. J Pain Palliat Care Pharmacother 2012;26:348–61.
27. Gasior M, Bond M, Malamut R. Routes of abuse of prescription opioid analgesics: a review and assessment of the potential impact of abuse-deterrent formulations. Postgrad Med 2016;128:85–96.