Introduction:
Opioid abuse in the United States has heightened to dangerous proportions in the past 15 years. According to the Centers for Disease Control and Prevention (CDC), the opioid-related death toll in the United States (US) increased five-fold from 1999 to 2016.1 As a result in 2017 the US Department of Human and Health Services called this “Opioid Crisis” a state of public emergency, and subsequently is funding research and issuing strategies to combat this ongoing problem.
A major contributing factor to this epidemic is the increase in opioid prescriptions. Per the CDC, from 1999 through 2014 opioid prescription sales increased four-fold, and of the 42,000-plus opioid related deaths in 2016, 40% were attributed to a prescription opioid.1 This rise in opioid prescriptions increases narcotic availability as well as potential for abuse and misuse. A 2014 national survey in the US quoted 10.3 million people taking prescription opioids for nonmedical reasons, commonly using opioids not prescribed to them or using their prescription for other indications than were initially prescribed.2 In addition, there is a correlation between prescription opioid use and future heroin abuse.3
In response to the opioid crisis in New York State, the New York State Department of Health (NYSDOH) mandated that all providers who prescribe narcotics, including residents under a faculty Drug Enforcement Administration (DEA), complete a three-hour online course entitled “Opioid Prescriber Training Program” by July 1, 2017. This course describes the various options for pain management in the outpatient and palliative care setting, the physiology of narcotics, evidence regarding opioid overuse and consequences of addiction. Most states have specific required coursework, lasting 1-3 hours, for opioid prescribers in this vane. However, no other state mandates residents prescribing narcotics to complete a mandatory online training course.
Cesarean section is the most common surgical procedure undergone by reproductive aged women. According to the CDC, there were 1,258,581 Cesarean Deliveries in the US in 2016.1 At our institution, Montefiore Medical Center, Weiler Campus there are approximately 4000 deliveries per year and our Cesarean Delivery rate is about 30%. According to a nationwide survey, 85% of women receive a prescription for opioids after their cesarean section.4 At our institution, Montefiore Medical Center, all patients undergoing cesarean section receive a prescription for opioids upon discharge unless there is a medical contraindication and/or patient declines.
Data regarding opioid prescriptions after cesarean section has revealed that for the most part, the amount of narcotics prescribed surpasses the amount consumed.5,6 One prospective survey study showed only half the amount of prescribed narcotic tablets was reportedly consumed by patients.5 However much of this data is prior to 2017, and there is an inadequate amount of knowledge on obstetrician prescriber habits after the NYSDOH mandated that all prescribers take an opioid course.
Our primary objective was to describe opioid prescriber practices at time of hospital discharge following cesarean section in a large cohort of women before and after the NYSDOH mandated the Opioid Prescriber Training Program. Secondary aims were to analyze opioid prescription habits by provider level as well as to identify trends in opioid prescription patterns related to the amount of inpatient opioid use as well as surgical and/or hospital specific factors.