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Original Contribution  |   July 2020
Effect of Opioid Prescribing Education for Obstetrics and Gynecology Residents in a Safety-Net Hospital
Author Notes
  • From the Departments of Obstetrics and Gynecology (Drs Evans, McCullough, and Best) and Surgery (Dr Yorkgitis) at the University of Florida College of Medicine in Jacksonville. This study was presented as an abstract at the 67th Annual Clinical and Scientific Meeting of the American College of Obstetrics and Gynecology on May 4, 2019 in Nashville, Tennessee.  
  • Financial Disclosures: None reported.  
  • Support: None reported.  
  •  *Address correspondence to Casey Evans, MD, Department of Obstetrics and Gynecology, University of Florida College of Medicine, 655 W 8th St, Jacksonville, FL 32209-6511. Email: casey.evans@jax.ufl.edu
     
Article Information
Medical Education / Obstetrics and Gynecology / Pain Management/Palliative Care / Graduate Medical Education / Opioids
Original Contribution   |   July 2020
Effect of Opioid Prescribing Education for Obstetrics and Gynecology Residents in a Safety-Net Hospital
The Journal of the American Osteopathic Association, July 2020, Vol. 120, 456-461. doi:https://doi.org/10.7556/jaoa.2020.073
The Journal of the American Osteopathic Association, July 2020, Vol. 120, 456-461. doi:https://doi.org/10.7556/jaoa.2020.073
Abstract

Context: The number of deaths due to opioid overdose has steadily increased in the United States since the early 2000s. The US opioid epidemic calls for an urgent need to evaluate physician prescribing habits.

Objective: To educate obstetrics and gynecology residents about opioid abuse, the quantity typically prescribed postoperatively, and strategies to decrease adverse outcomes.

Methods: Obstetrics and gynecology residents at an urban safety-net hospital were given a preintervention evaluation to understand their opioid prescribing patterns and use of resources like prescription drug monitoring programs and opioid risk tool. Residents then attended a didactic session reviewing rates of adverse outcomes from overprescribing, resources to reduce adverse outcomes, and the number of opioids considered appropriate postoperatively. Residents completed an immediate postintervention evaluation to reevaluate prescribing patterns.

Results: Pre- and postintervention evaluations were completed by 13 residents. In the preintervention evaluation, all participants reported that they would prescribe at least 30 opioid pills for patients after cesarean delivery, but in the postintervention evaluation, none reported that they would prescribe more than 20 opioid pills (P=<.0001). Similar but less distinct shifts can be seen in laparoscopic hysterectomy and the use of preoperative gabapentinoids (ie, gabapentin and pregabalin). Before the intervention, 7 residents (54%) reported that they currently prescribed 20 opioid pills or more for patients after laparoscopic hysterectomy, whereas after the intervention, 1 resident (7.7%) reported that he or she would prescribe more than 20 opioid pills in (P=.0382). Before the intervention, 2 residents (15.4%) reported that they would consider gabapentinoids compared with 13 residents (100%) after the intervention.

Conclusion: Focused opioid education can reduce the intended number of opioid pills prescribed in a postoperative setting. This study highlights the effect that educational curricula can have on physician prescribing patterns to help mitigate the current epidemic and help optimize stepwise multimodal analgesia to avoid overprescribing opioids.

Since the early 2000s, the number of deaths due to opioid overdose has continuously increased and created an epidemic across the United States, which suggests the need to evaluate physician prescribing habits.1 Studies2-5 have indicated that patients frequently take fewer opioid pills than prescribed after major procedures and are left with excess pills.2-5 Obstetrics and gynecology (OB/GYN) physicians have a unique opportunity to affect prescribing patterns because cesarean delivery and laparoscopic hysterectomy are 2 of the most common surgeries performed in women.6 One study4 reported that 53% of patients took fewer than 5 pills after cesarean delivery, and 83% of patients took less than half of the total amount prescribed. Another study5 indicated that physicians frequently prescribed twice the number of opioids that patients used after a hysterectomy.5 One study7 found that physicians may be unaware of the degree to which overprescribing has played a role in the opioid epidemic. These patterns highlight the need for a change in current prescribing practices, and enhancing physician education may lead to improved opioid prescribing habits.7,8 
Evidence-based opioid quantity prescribing could decrease potential diversion and misuse of these medications. The purpose of this study was to educate OB/GYN residents about the increasing rates of opioid abuse and overdose, the number of opioid pills typically used by patients postoperatively, and the strategies to decrease adverse outcomes. We hypothesized that residents would make a change in their prescribing recommendations after the intervention. 
Methods
The study was exempt by the institutional review board at the University of Florida Health Science Campus in Jacksonville, Florida. 
An opioid-prescribing education (OPE) lecture was developed as an institutional response to changes in opioid-prescribing regulations in Florida and comprised evidence-based information from a general surgeon and institutional leader in surgical opioid prescribing safety (B.Y.) at the safety-net hospital. The OPE was conducted in June 2018 as a lecture given during the residents' didactic time period as an institutional effort to improve opioid prescribing safety. Participating residents at the lecture were asked to complete anonymous pre- and postintervention evaluations to gauge achievements in learning objectives and serve as a quality tool for further educational sessions. These evaluations were retrospectively compiled for the study. The evaluation assessment was adapted from Yorkgitis et al.9 The lecture focused on the Getting it RIGHTT (risk for an adverse event, insight into pain, going over pain plan, halting opioids, tossing unused opioids, trouble identification) best-practice strategy (Figure).10 The scope of opioid misuse and deaths, risk factors for misuse, evidence-based guidelines about the OB/GYN procedure-specific opioid prescribing quantity recommendations, and nonopioid adjuncts (eg, nonsteroidal anti-inflammatory drugs, acetaminophen, gabapentin, pregabalin) were also addressed. 
Figure.
The opioid prescribing educational lecture for residents at a safety-net hospital was based on the Getting it RIGHTT (risk for adverse event, insight into pain, going over pain plan, halting opioids, tossing unused opioids, trouble identification) best-practice strategy. Abbreviation: NSAID-non-steroidal anti-inflammatory drugs.
Figure.
The opioid prescribing educational lecture for residents at a safety-net hospital was based on the Getting it RIGHTT (risk for adverse event, insight into pain, going over pain plan, halting opioids, tossing unused opioids, trouble identification) best-practice strategy. Abbreviation: NSAID-non-steroidal anti-inflammatory drugs.
The OPE was delivered to a group of OB/GYN residents at an urban safety-net hospital in the form of a 1-hour didactic lecture. Before and immediately after the OPE lecture, residents completed anonymous pre- and postintervention evaluations that assessed topics such as prescription drug monitoring programs and use of the opioid risk tool,9 the number of opioid pills commonly prescribed following vaginal delivery, cesarean delivery, and laparoscopic hysterectomy for benign disease, appropriate opioid disposal, and prescription of perioperative gabapentinoids (ie, gabapentin and pregabalin). In addition to descriptive statistics, evaluation results were compared using the Fisher exact test, with P<.05 considered statistically significant. 
Results
Thirteen of 26 (50%) OB/GYN residents attended the OPE lecture and completed both the pre- and postintervention evaluations. The postintervention evaluations reflected what the residents intended to prescribe after attending the OPE lecture. Four of 14 participants (30.8%) reported having had prior controlled substance education. In the preintervention evaluation, 10 participants (76.9%) reported that they would never use prescription drug monitoring programs, and none had used the opioid risk tool. None of the residents reported prescribing opioids for patients at discharge for routine vaginal deliveries. For cesarean deliveries, 13 participants (100%) reported in the preintervention evaluation that they would prescribe at least 30 pills, but none would prescribe more than 20 pills in the postintervention evaluation. After the OPE lecture, 10 participants (76.9%) reported that they would prescribe 20 pills, and 3 participants (23.1%) reported that they would prescribe 15 pills. 
Before the OPE, 7 participants (53.8%) said that they would prescribe 20 opioid pills or more for a patient undergoing laparoscopic hysterectomy for benign disease, and after the OPE, 1 participant (7.7%) said that he or she would prescribe more than 20 pills. Postintervention results were found by dividing the total number of preintervention evaluations by the total number of postintervention evaluations. These results showed a relative reduction of 37.1% of pills that would be prescribed after cesarean delivery and a relative reduction of 27.1% of pills that would be prescribed after laparoscopic hysterectomy. The prescription of perioperative gabapentinoids was characterized as always, mostly, sometimes, and never. Eleven participants (84.6%) reported that they would never prescribe gabapentinoids before the OPE lecture, and 11 residents (84.6%) reported that gabapentinoids would be “always” or “mostly” used after the OPE lecture. The Table provides a comparison of results using the Fisher exact test. 
Table.
Postsurgical Analgesic Prescribing Intentions Among OB/GYN Residents Before and After an Opioid Educational Intervention (N=13)
Prescription recommendation Preintervention evaluation, No. (%) Postintervention evaluation, No. (%) Total P valuea
Cesarean delivery, No. of opioids <.0001
 15 0 3 (23.1) 3 (11.5)
 20 0 10 (76.9) 10 (38.5)  
 30 13 (100) 0 13 (50)  
Laparoscopic hysterectomy, No. of opioids .0382
 5 1 (7.7) 1 (7.7) 2 (7.7)
 10 0 3 (23.1) 3 (11.5)  
 15 5 (38.5) 8 (61.5) 13 (50)  
 20 2 (15.4) 1 (7.7) 3 (11.5)  
 30 5 (38.5) 0 5 (19.2)  
Gabapentinoids <.0001
 Always 0 3 (23.1) 3 (11.5)
 Mostly 0 8 (61.5) 8 (30.8)
 Sometimes 2 (15.4) 2 (15.4) 4 (15.4)
 Never 11 (84.6) 0 11 (42.3)

a Fisher exact test.

Abbreviation: OB/GYN, obstetrics and gynecology.

Table.
Postsurgical Analgesic Prescribing Intentions Among OB/GYN Residents Before and After an Opioid Educational Intervention (N=13)
Prescription recommendation Preintervention evaluation, No. (%) Postintervention evaluation, No. (%) Total P valuea
Cesarean delivery, No. of opioids <.0001
 15 0 3 (23.1) 3 (11.5)
 20 0 10 (76.9) 10 (38.5)  
 30 13 (100) 0 13 (50)  
Laparoscopic hysterectomy, No. of opioids .0382
 5 1 (7.7) 1 (7.7) 2 (7.7)
 10 0 3 (23.1) 3 (11.5)  
 15 5 (38.5) 8 (61.5) 13 (50)  
 20 2 (15.4) 1 (7.7) 3 (11.5)  
 30 5 (38.5) 0 5 (19.2)  
Gabapentinoids <.0001
 Always 0 3 (23.1) 3 (11.5)
 Mostly 0 8 (61.5) 8 (30.8)
 Sometimes 2 (15.4) 2 (15.4) 4 (15.4)
 Never 11 (84.6) 0 11 (42.3)

a Fisher exact test.

Abbreviation: OB/GYN, obstetrics and gynecology.

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Discussion
Our data suggest that an OB/GYN-specific OPE intervention may reduce the number of opioids prescribed to patients. Residents were able to make reductions in the anticipated number of opioid pills that they would prescribe postoperatively for both cesarean delivery and laparoscopic hysterectomy after the OPE intervention. Also, residents reported that they would increase their use of perioperative gabapentinoid. 
Previous studies7,8 support our results and suggest that physicians are often undereducated regarding the current opioid epidemic and the role that overprescribing plays. A study12 surveying 267 OB/GYN residents across the United States showed significant variability in prescribing practices among patients after cesarean delivery and laparoscopic hysterectomy, and factors affecting the variability included the region of the country, program type, and personal insight.12 Studies performed by Griffin et al2 in gynecologic surgery patients and Bateman et al13 in cesarean delivery patients provided evidence on the expected number of opioid pills used by patients after their respective procedures and found that patients took less than what was prescribed in the majority of cases. This finding highlights the importance of appropriate opioid prescription quantities. 
Additionally, prescribers should use a stepwise approach, with an emphasis on nonopioid therapies.10,14 The use of nonopioid adjuncts can assist in pain control after OB/GYN procedures. Dinis et al15 compared opioid vs nonopioid pain regimens of ibuprofen and acetaminophen after cesarean delivery and found that the mean pain score on a visual analog scale was lower in the nonopioid group at 2 to 4 weeks. This study found new persistent opioid use in 1.7% of women after vaginal delivery and 2.2% of women after cesarean delivery. Another study16 found new persistent opioid use in 0.5% of women after vaginal delivery and 1.0% of women after cesarean delivery who did not receive a peripartum opioid prescription. 
Gabapentinoids have been effective in decreasing opioid use in hysterectomy patients.17,18 In a study by Hasting et al,19 osteopathic manipulative treatment use led to improvements in visual analog scale scores in postpartum patients. The use of an OPE tool could improve the standardization of opioid prescribing as well as multimodal analgesia by increasing awareness of best prescribing practices and minimizing overprescribing, as found in the current study. 
The limitations of our study include the small sample size and the self-reported survey design, which relied on the ability of participants to correctly recall the typical amount of pills prescribed for various procedures. Although there was a reduction by all residents in the intended number of opioid pills prescribed after the intervention, variability in the number of pills prescribed continued to exist. Hill et al20 described a similar variability after educating general surgeons about opioid use and encouraged the use of medications such as ibuprofen and acetaminophen. Further work on standardizing procedure-specific opioid recommendations is needed. Future research should expand the OPE to broader populations of physicians and other residency programs to fully assess the potential effects of an OPE. Future studies exploring the actual quantity of opioid pills, gabapentinoids, and nonopioid pain relievers prescribed after attending an OPE lecture could define the real-life clinical effect of this intervention. 
Conclusion
Specialty-specific opioid education among OB/GYN residents reduced the intended quantity of opioid pills prescribed to patients in a postoperative setting. This study highlights the effect of educational intervention on prescribing patterns by helping physicians better understand the current opioid epidemic and learn to optimize stepwise multimodal analgesia to avoid overprescribing opioids. 
Author Contributions
All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. 
References
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Griffith KC, Clark NV, Zuckerman AL, Ferzandi TR, Wright KN. Opioid prescription and patient use after gynecologic procedures: a survey of patients and providers. J Minim Invasive Gynecol. 2018;25:684-688. doi: 10.1016/j.jmig.2017.11.005 [CrossRef] [PubMed]
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Yorkgitis BK, Paffett C, Brat G, Crandall . Effect of surgery-specific opioid-prescribing education in a safety-net hospital. J Surg Res. 2019;243:71-74. [CrossRef] [PubMed]
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Baruch AD, Morgan DM, Dalton VK, Swenson C. Opioid prescribing patterns by obstetrics and gynecology residents in the United States. Subst Use Misuse. 2018;53(1):70-76. doi: 10.1080/10826084.2017.1323928 [CrossRef] [PubMed]
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Commonwealth of Pennsylvania. Obstetrics & gynecology opioid prescribing guidelines. Overdose Free PA; 2015. http://www.overdosefreepa.pitt.edu/wp-content/uploads/2015/12/OB-GYN-FINAL-12-14-15.pdf. Accessed August 2, 2019.
Dinis J, Soto E, Pedroza C, Chauhan SP, Sibai B. Nonopioid versus opioid analgesia after hospital discharge from a cesarean delivery: a randomized clinical trial. Am J Obstet Gynecol. 2019;222(5):488.e1-488.e8. doi: 10.1016/j.ajog.2019.12.001 [CrossRef]
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Figure.
The opioid prescribing educational lecture for residents at a safety-net hospital was based on the Getting it RIGHTT (risk for adverse event, insight into pain, going over pain plan, halting opioids, tossing unused opioids, trouble identification) best-practice strategy. Abbreviation: NSAID-non-steroidal anti-inflammatory drugs.
Figure.
The opioid prescribing educational lecture for residents at a safety-net hospital was based on the Getting it RIGHTT (risk for adverse event, insight into pain, going over pain plan, halting opioids, tossing unused opioids, trouble identification) best-practice strategy. Abbreviation: NSAID-non-steroidal anti-inflammatory drugs.
Table.
Postsurgical Analgesic Prescribing Intentions Among OB/GYN Residents Before and After an Opioid Educational Intervention (N=13)
Prescription recommendation Preintervention evaluation, No. (%) Postintervention evaluation, No. (%) Total P valuea
Cesarean delivery, No. of opioids <.0001
 15 0 3 (23.1) 3 (11.5)
 20 0 10 (76.9) 10 (38.5)  
 30 13 (100) 0 13 (50)  
Laparoscopic hysterectomy, No. of opioids .0382
 5 1 (7.7) 1 (7.7) 2 (7.7)
 10 0 3 (23.1) 3 (11.5)  
 15 5 (38.5) 8 (61.5) 13 (50)  
 20 2 (15.4) 1 (7.7) 3 (11.5)  
 30 5 (38.5) 0 5 (19.2)  
Gabapentinoids <.0001
 Always 0 3 (23.1) 3 (11.5)
 Mostly 0 8 (61.5) 8 (30.8)
 Sometimes 2 (15.4) 2 (15.4) 4 (15.4)
 Never 11 (84.6) 0 11 (42.3)

a Fisher exact test.

Abbreviation: OB/GYN, obstetrics and gynecology.

Table.
Postsurgical Analgesic Prescribing Intentions Among OB/GYN Residents Before and After an Opioid Educational Intervention (N=13)
Prescription recommendation Preintervention evaluation, No. (%) Postintervention evaluation, No. (%) Total P valuea
Cesarean delivery, No. of opioids <.0001
 15 0 3 (23.1) 3 (11.5)
 20 0 10 (76.9) 10 (38.5)  
 30 13 (100) 0 13 (50)  
Laparoscopic hysterectomy, No. of opioids .0382
 5 1 (7.7) 1 (7.7) 2 (7.7)
 10 0 3 (23.1) 3 (11.5)  
 15 5 (38.5) 8 (61.5) 13 (50)  
 20 2 (15.4) 1 (7.7) 3 (11.5)  
 30 5 (38.5) 0 5 (19.2)  
Gabapentinoids <.0001
 Always 0 3 (23.1) 3 (11.5)
 Mostly 0 8 (61.5) 8 (30.8)
 Sometimes 2 (15.4) 2 (15.4) 4 (15.4)
 Never 11 (84.6) 0 11 (42.3)

a Fisher exact test.

Abbreviation: OB/GYN, obstetrics and gynecology.

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