This retrospective cohort study took place at a single high-volume tertiary care center between December 1, 2015 and November 30, 2016. The cohort included opioid-naive women with no explicit evidence of recent opioid use who were hospitalized for delivery during the study period. The obstetric provider had discretion over discharge prescriptions and there were no standard order sets for pain prescriptions at discharge. During the study period, there were no hospital guidelines concerning postpartum opioid prescriptions. Patients were excluded if they experienced the following: hysterectomy; general anesthesia without neuraxial anesthesia; intensive care unit admission; or postpartum admission lasting >10 days. The amount of oral morphine milligram equivalents (MME) prescribed at discharge was the primary outcome. The outcomes for women with cesarean and vaginal deliveries were analyzed separately. Pain scores and inpatient MME use were compared in women who received an opioid prescription to those who did not at hospital discharge.
Of 12,326 women eligible for inclusion, 9038 women delivered vaginally and 3288 women delivered via cesarean. At discharge, opioids were prescribed to 30.3% (N=2749) of women who delivered vaginally and 86.7% (N=2849) of women who delivered via cesarean. Excluding women who did not receive opioid prescriptions, the median morphine equivalents received were 300 for cesarean delivery (interquartile range: 200 to 300) and 200 for vaginal delivery (interquartile range: 120 to 300). Of women receiving opioid prescriptions after hospital discharge, nearly half (45.7%) of women who delivered vaginally used 0 MME during the final 24 hours of their hospitalization, compared with 18.5% of postcesarean women. A pain score of 0 was reported before discharge by 26.5% of vaginal delivery patients and 18.5% of cesarean delivery patients. There was no difference in either delivery group in opioid prescription amounts between women who reported a pain score of 0 and those who reported a pain score of >0. Hydrocodone was the most commonly prescribed opioid in the cohort.
In summary, regardless of vaginal or cesarean delivery, women were commonly prescribed an opioid at hospital discharge. The wide range of prescribed opioid amounts at the time of discharge suggests a lack of standardization. Women also received similar amounts of MME despite varying objective and subjective measures of pain before discharge.
Delivery is the most common reason for hospital admission in women of child-bearing age, and opioid abuse is now the leading cause of injury-related death in the United States.1,2 Women hospitalized for birth, regardless of mode of delivery or delivery complications, are regularly prescribed opioids at hospital discharge. However, little is known regarding opioid prescribing patterns at the time of postpartum hospital discharge. In this retrospective study of all deliveries at a single high-volume tertiary care center, over a 1-year period from December 1, 2015 through November 30, 2016, Badreldin and colleagues sought to describe opioid prescribing patterns at the time of discharge following delivery. They also sought to describe the relationship of opioid prescribing patterns with objective and subjective measures of pain prior to hospital discharge. The primary outcome of this study was the amount of opioid MME prescribed at discharge, described separately for women after vaginal and cesarean deliveries.
Overall, they found 45.3% of postpartum women received an opioid prescription on hospital discharge, of which 30% received an opioid prescription following vaginal delivery, and 87% received an opioid prescription following cesarean delivery. Interestingly, nearly half (45.7%) of women after vaginal delivery and 18.5% of women after cesarean delivery who received an opioid prescription used 0 MME’s during the final hospital day. Similarly, 26.5% and 18.5% of women after vaginal and cesarean delivery, respectively, reported a pain score of 0 of 10 before discharge.
This study noted that providers prescribed the exact same MME quantities on average for >70% of women who underwent cesarean deliveries and >80% of women who underwent vaginal deliveries. Among women who received a discharge prescription, there was no significant correlation between the total amount of MME prescribed at discharge and the amount of MME used during inpatient hospitalization or between the total amount of MME prescribed at discharge and pain score. Furthermore, the amount of prescription opioids did not vary by objective or subjective reports of pain.
Study limitations are that it was retrospective in nature, limited to prescribed opioids (not filled prescriptions), and performed in a single high-volume tertiary care center where generalizability to all hospitals may not be valid.
The findings suggest providers may not modify their prescribing practices based on the degree of the patient’s pain at discharge. As the United States addresses the increasing opioid epidemic, provider awareness and education of best practices in prescribing is essential. The surplus of opioid tablets in communities and the diversion of excess tablets are known to contribute to the opioid crisis, where >50% of people abusing opioids report having received pills from friends and/or family.3 This study emphasizes postpartum women are commonly prescribed opioids at hospital discharge, there is a wide range of MME prescribed at discharge, the quantity of prescribed medications at discharge does not appear to be based on subjective or objective measures of pain, and there is a lack of standardization for pain control management at hospital discharge. Given that pain is the fifth vital sign, it is important to standardize how we prescribe medications at hospital discharge, which includes tailoring the opioid to the individual patient’s pain, incorporating multimodal pain medications such as nonsteroidal anti-inflammatory drugs and acetaminophen as well as including various other non-narcotic modalities.
Comment by Manuel C. Vallejo, MD, DMD
1. HCUP. Facts and Figures: Statistics on Hospital-based Care in the United States, 2009. Rockville, MD: Agency for Healthcare Research and Quality; 2011.
2. Rudd RA, Aleshire N, Zibbell JE, et al. Increases in drug and opioid overdose deaths-United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64:1378–1382.
3. Manchikanti L, Helm S II, Fellows B, et al. Opioid epidemic in the Untied States. Pain Physician. 2012;15(suppl):ES9–ES38.