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 opioid availability as well as potential for abuse and misuse. A 2019 national survey in the US quoted over 10 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 opioids, including resident physicians under a faculty Drug Enforcement Administration (DEA), complete a three-hour online course entitled “Opioid Prescriber Training Program” by July 1, 2017 [4]. This course describes the various options for pain management in the outpatient and palliative care setting, the physiology of opioids, 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 resident physicians prescribing opioids 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 [5]. 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. Though most women receive an opioid prescription after cesarean section, only a small percentage of opioid naïve women (1 in 300) become persistent opioid users [6]. The trend in new persistent opioid use over the last decade has decreased [7]. Despite this low incidence, the large number of cesarean sections performed annually translates into a significant number of newly dependent patients and hence plays a role in this serious health problem.

Data regarding opioid prescriptions after cesarean section has revealed that for the most part, the amount of opioids prescribed surpasses the amount consumed [8, 9]. One prospective survey study showed only half the amount of prescribed opioid tablets was reportedly consumed by patients [8]. 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.

Our study suggests that this training course may have assisted in altering prescriber practices after January 1, 2018, at our institution. Post-intervention, we found that higher amounts of opioids were prescribed less often, and lower amounts of opioids were prescribed more often; prescriptions of moderate amounts of opioids remained unchanged. Additionally, though not statistically significant on the multivariate model, there was an association noted between inhouse opioid use, and the amount of opioids prescribed. Our data also suggests that amount of opioid prescribed did not correlate with patient demographics, and surgical and hospital factors.

The median amount of prescribed opioid was 150 MME (20 pills of 5mg oxycodone) both pre- and post-intervention. Though 150 MME remained the median amount of opioid prescribed, we observed a decline in the percentage of prescriptions $>$150 MME (21.3%) post-training as opposed to (45.1%) prior to training, a reduction that was particularly apparent in resident physicians. This apparent decline of prescriptions $>$150 MME especially in resident physicians is important because at many academic institutions, resident physicians may be responsible for discharge prescriptions. Although many states now require an opioid training course for providers prior to prescribing opioids, New York mandates resident physician training as well.

There was a significant difference in BMI and race between the groups. We hypothesized that this was because more than 40% of the patients in the cohorts were documented as race “unknown”. Therefore, it is unclear which racial groups were most affected by this category and makes it difficult to determine if the difference noted between the groups is truly significant. We are not aware of any data showing changes in the racial distribution of patients at our institution during the time period studied. Our post intervention group had a decrease in patients with BMI less than 25 and an increase in the overweight and obese categories. The BMI changes observed in the post-intervention group are consistent with the increase in obesity reported in adults living in the Bronx from 2015 to 2019 and therefore are not surprising [12]. Between the two groups there was a significant difference in surgery time, estimated blood loss and skin closure. Surgeries were longer post-intervention possibly due to an increase in new, young hires who frequently can have longer surgical times when compared to experienced faculty. The difference in estimated blood loss between groups may be explained by the implementation of “Quantitative Blood Loss” measurements where nurses calculated blood loss for deliveries using a standard formula. Though we used “Estimated Blood Loss” in our study, we understand the measurement of quantitative blood loss may bias providers’ estimations as well. The majority of cases were closed using sutures. Though the decrease in the use of staples post-intervention was significant, we do not believe that this is clinically relevant, and would have to perform future studies to determine a true association.

The main strength of our study is that we reviewed an extensive cohort of women in the pre, and post intervention groups and we were able to look at prescriber patterns for a large number of diverse providers of varying levels using a reliable EMR system.

This is a retrospective study with a high risk, urban patient population, which may not be generalizable of all cesarean deliveries in other states or countries. Our study only looked at our providers’ prescription habits, and this may not accurately depict which prescriptions were filled by the patients and/or amount of opioid consumed. There were a variable number of providers in each level, with the largest number of prescriptions being written by resident physicians. Our total analysis did not account for prescription habits between providers of different levels. However, we do not feel that controlling for provider level would alter the effect since in general PGY1–2 in the pre-intervention group were PGY3–4 in the post-intervention group.

Another limitation is that our institution briefly piloted an Enhanced Recovery After Surgery or ERAS protocol around the same time-period that we performed our chart review. This trial included 58 patients and used an inpatient only post-operative order set. Data from the protocol demonstrated that our ERAS pilot was not associated with a reduction in postoperative opioid use compared to standard of care [13]. There was an association between in-house opioid use and prescription patterns post-intervention with the univariate analysis and since ERAS was aimed to specifically decrease opioid use post-operatively there is the possibility it impacted our outcome.

Our study suggests a role in provider training and education in altering prescribing practices as a means of addressing the opioid epidemic. The positive shift in prescribing patterns in resident physicians supports that they be included in interventions to improve hospital practices and patient care. Opioid education should be included as part of the residency curriculum. This is especially significant since resident physicians will move on to become prescribing physicians themselves.

It is important to note that the observed changes in provider practices may not be solely related to this single intervention, but could be a combination of effects including the intervention as well as an overall increase in awareness through the media, news etc. Further studies would be needed to confirm causality.

There was an association between in house opioid use and prescribing patterns in the post-intervention group. Surprisingly, this association failed to be significant in the multivariate analysis. One would expect the amount of opioid use inhouse to predict use at home in the immediate post-operative setting, and therefore would be influential. More studies are needed to better elucidate this data. Patient demographic, surgical or hospital factors did not influence opioid prescriptions. Next steps would include a prospective study looking at the percentage of patients that filled their opioid prescriptions and actual patient consumption upon discharge.

TB was the primary investigator on this project. This author was involved in initial conceptualization and project planning. She supervised the initiation and progress of the entire project. She played a major role in writing final paper and was responsible for final review and editing. AC was involved in conceptualization of project with primary investigator. This author carried out the data research and recording in database. She played a large role in writing the original draft and in subsequent revisions. MF was the statistician on the project. This author provided formal statistical analysis and interpretation and wrote the statistical portions of the paper. GN assisted in data collection and input into the database. This author collaborated in writing the original draft. All authors read and approved the final manuscript.

The study was conducted in accordance with the Declaration of Helsinki and the protocol was approved by the Institutional Review Board at Montefiore Medical Center, Albert Einstein College of Medicine on July 15th, 2019. This was a chart review without direct patient contact, hence individual patient consent was not required. Institutional review board number is 2018-9111.

We would like to express gratitude to the department of Obstetrics and Gynecology at Montefiore Medical Center for their support and guidance during this project.

This research received no external funding.

The authors declare no conflict of interest.