If a new study is any indication, most U.S. women who undergo a C-section leave the hospital with a prescription for about twice as many opioid pills as they need.
That’s a lot of leftover pills, especially for a country in the midst of an opioid epidemic.
With approximately 1.3 million performed each year, cesarean deliveries are the most common inpatient surgical procedure in the United States. In 2015, the most recent year for which data are available, nearly a third of all U.S. deliveries were by C-section.
For the new study, researchers conducted telephone surveys of 720 women who’d delivered by C-section at one of six academic medical centers scattered around the United States. The women had been discharged from the hospital about two weeks earlier.
Of the 720 women, 615, or about 85%, said they had filled a prescription for opioids to treat post-C-section pain. Nearly all of the prescriptions were for either oxycodone or hydrocodone.
"Opioids are thought to be safe for use in breastfeeding mothers," study coauthor Dr. Brian Bateman, chief of obstetric anesthesia at Brigham and Women’s Hospital, a Harvard teaching hospital, told me. "At higher doses, they can cause some sedation in infants."
The median number of pills prescribed to the women in Bateman's study—in other words, half of them got more, half got less--was 40, or about seven to 10 days’ worth. But the median number of pills consumed was only 20, with a median of 15 left over. And even though the women had stopped taking the pills, they hadn't yet disposed of the leftovers. The researchers published their findings online this week in the journal Obstetrics & Gynecology.
As far as the number of pills, "there's a lot of variation in what people are prescribing," Bateman said. "Traditionally, people wanted to prescribe at the top end of what the patient might reasonably require. The problem with that is you end up generating a lot of leftover medication."
Interestingly, the more pills women were prescribed, the more they took, the study found. Bateman attributed that to "expectation setting."
"If you're prescribed a large amount of a medication, then you think you should be taking a large amount," he explained. But the women who took more pills weren't any more likely to report that they were satisfied with their pain control. However, they were more likely to suffer opioid side effects, such as drowsiness, nausea or vomiting and constipation.
If their results were generalizable to the United States as a whole, Bateman and his coauthors wrote, that would mean prescriptions for C-section pain results in approximately 20 million leftover opioid pills each year, pills that could fall into the hands of people for whom they were not prescribed.
I was surprised to learn that doctors routinely prescribed opioids for C-section pain. "It's not true in most countries," Bateman noted. While women in those countries might get opioids when they undergo a C-section, he said, by the time they go home they're prescribed nonsteroidal anti-inflammatory drugs, or NSAIDs, such as naproxen, or acetaminophen, best-known by the brand name Tylenol.
Of course, I was also surprised to learn that women who deliver vaginally are being prescribed opioids for post-delivery pain. A recent analysis of Medicaid-enrolled Pennsylvania women who delivered a baby vaginally found that 12% filled a prescription for an opioid within five days of their baby's birth. Yet, little more than a quarter of them had undergone a painful procedure during the delivery, such as a tubal ligation ("tied tubes") or an episiotomy. (The researchers excluded from their analysis women who'd been taking opioids for reasons other than post-delivery pain.)
Here are two concerns about the prescribing of potentially too many opioid pills for C-section pain:
- Leftover tablets place even babies at risk for an overdose, according to a Canadian study I wrote about in February. The researchers found that young children were 2 1/2 times more likely to overdose if their mothers had been prescribed an opioid painkiller.
- Taking opioids for post-surgery pain can lead to continued use of the drugs long afterward. In a study published last September, Bateman and his coauthors found that among women who had not previously taken prescription opioid painkillers, one in 300 prescribed the drugs for C-section pain became persistent users.
The optimal number of opioid painkiller pills for post-cesarean pain isn't clear, although his research certainly suggests it's lower than typically prescribed, Bateman said.
In a related study of 50 women who delivered at Massachusetts General Hospital, he and his coauthors tested the effect of educational material about patterns of post-C-section pain and the risks and benefits of opioids and other pain medications.
The researchers found that women who reviewed the information with their doctor before discharge typically chose to be prescribed 20 pills instead of the hospital's standard 40, and the vast majority were satisfied with their pain control without needing a refill.
"In many ways, I think this is a decision that needs to be individualized," Bateman said. "Some patients know they require very little pain mredication, or they don't like the opioid side effects."
The take-home message, Bateman said, is don't take home a prescription for an excessive number of opioid tablets after you have a C-section. "NSAIDs and acetaminophen are good pain relievers, and they don't have the same side-effect profile and the same risks that opioids have."