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.