A new QuintilesIMS analysis found women use opioids far more than their male counterparts.
Although middle-aged women have the highest rate of opioid use, the report notes that “nearly one in five opioid prescriptions (18%) went to patients in another vulnerable population, those aged 20-39; this is the population most likely to misuse these drugs and the one that accounts for the greatest number of individuals entering treatment for opioid addiction.”
This is also the female age range most likely to be giving birth. A recent study in the journal Obstetrics and Gynecology examination of opioid use among women who had a C-section concluded that most women—especially those with normal in-hospital opioid use—are prescribed opioids in excess of the amount needed.
Given these factors, is it possible that OBs could be contributing to the opioid epidemic?
Most OBs prescribe opioids for their patients for one reason: to alleviate pain. Childbirth is traumatic to a woman’s body, and a C-section is a major operation. Recovery at home can be a lengthy process, and pain management is a necessary component.
But there is a larger sub-context. Reimbursement in value-based care has in part been predicated on patient satisfactions scores, including pain level satisfaction. It’s possible that on a subconscious level, OBs and Labor and Delivery staff have over-administered opioids out of fear of retribution.
Hospital and departmental administrators and OBs must work together on policies to bring down rates of over-prescribing, protect patient health and help curb the opioid epidemic. Here are four ways:
Pain management decisions should be in clinical hands. Opioids used to be considered the first line of defense against pain, and hospital and departmental policies reflected this perspective, supporting and even promoting opioid dispensing.
Policies should allow physicians selection appropriate to the need and must have enough flexibility that providers can deviate from the protocol to treat an unusual level of pain.
At Ob Hospitalist Group, we are examining our large database of OB clinical encounters to identify and promote best practices for clinician prescribing and pain management that can be incorporated at systems and facilities across the country. Because they are on-site 24/7 and collaborate closely with community physicians, OB hospitalists can also deflect some of the pressure on the night shift nursing staff, which must often solely determine pain management decisions or coordinate between different practicing physicians.
Acknowledge and address the intersection of patient satisfaction scores and issues of addiction. In 1996, the American Pain Society designated pain as the fifth “vital sign” that doctors should use to detect or monitor medical problems, and in 2001, the Joint Commission first published its Pain Management Standards, which required providers to ask every patient about his pain. These actions tied pain control to patient satisfaction (and ultimately, to compensation as well).
While overprescribing can’t be attributed to cause-and-effect, there has certainly been economic as well as clinical pressure to prescribe in the following two decades. Beginning a dialogue that acknowledges these factors opens the door to a different approach that recognizes the systemic problem and the societal issues at play.
Consider alternative approaches to pain management. The Obstetrics & Gynecology study found that 83 percent of women who filled their prescriptions used opioids after discharge for a median of eight days, but 75 percent did not use all of the prescribed medications. That suggests that the usual 30-day supply is too many, and that the number of pills prescribed is a significant problem.
In addition to using precaution in routine prescribing of opioids and limiting the number of tablets that are prescribed, hospitals should also promote holistic interventions such as sitz baths, yoga, breathing techniques, IV Tylenol, ice packs, and post-partum screening for depression to reduce likelihood of medication dependence.
Counsel patients on the risk of narcotic use. Physicians must be very sensitive, but very direct in dialogue with postpartum patients, clearly explaining risks and benefits. A recent study found that when clinicians and patients spoke for ten minutes about post-operative pain and opioids – including how much pain to expect, risks and benefits of opioid and non-opioid painkillers, and other factors -- opioid use after C-sections was reduced by 50 percent.
Slowly, the tide may be turning. In December 2016, the American Academy of Family Physicians Congress of Delegates voted to eliminate pain as the fifth vital sign, and a 2017 Medscape survey found almost half of physicians and half of nurses strongly agreed.
As of 2017, CMS removed pain management scores from the HCAHPS survey for hospital value-based purchasing “to eliminate any financial pressure clinicians may feel to overprescribe medications.” That’s an important start. Now, hospitals and OBs must do their part to best serve their patients: reduce needless pain and curtailing excess prescribing.
Dr. Charles Jaynes works for Ob Hospitalist Group as Senior Director of Medical Operations.
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