In this study, we detected no difference in inpatient postpartum opioid use by race. Despite statistically significant differences in age, insurance status, perineal lacerations, and BMI at time of delivery, inpatient postpartum use of oxycodone 5 mg tablets was nearly identical between Black and White patients. This is in contrast to the findings of other institutions, which note significant differences in opioid prescription practices both in the postpartum period and in numerous other specialties and situations between Black and White patients [8, 10, 11]. In addition, we found that the amount of opioid tablets prescribed at discharge were not associated with patient race. These findings persisted even in patients who did not request or receive inpatient opioids for pain control despite being able to receive them. To our knowledge, this is the first study to compare opioid prescriptions at discharge stratified by patient race and inpatient usage.
There are multiple possible explanations for why there was a lack of association identified between patient race and opioids prescribed at discharge in this study [8, 12]. First, it may reflect a difference in patient population, as the study by Badreldin et al. included over 9900 patients but only 10.6% of whom identified as non-Hispanic Black, whereas 66% of women in our study population identified as Black. In a similar study by Johnson et al., 25% of patients identified as non-Hispanic Black and received fewer opioid doses in the immediate postpartum period compared to their White counterparts, despite higher pain scores . These studies reported on primarily White populations, and neither reported on the amount of opioids provided at discharge, which in this study made up the bulk of opioids prescribed. Another possible explanation is that at our academic institution, intern or resident physicians (of which there are 36; 77% female, 83% White) prescribe the vast majority of discharge opioids. All residents train and provide care in both outpatient and inpatient environments which serve a predominantly Black patient population and receive formal training on techniques to reduce implicit bias, which may have effectively decreased racial disparities in opioid prescription. Lastly, our primary findings may also simply reflect that at the time of this study, there were no specific institutional guidelines for discharge opioid prescriptions. In the absence of guidelines, residents prescribe varying, largely arbitrary numbers of tablets from 0–30, based on the resident’s discretion. This may have translated into a lack of racial or ethnic inequity in opioid prescribing, though may also be insensitive to cultural differences in the temporal experience of pain and risks over- or under-prescribing for some patients.
This study is strengthened by its inclusion of all routine vaginal and cesarean deliveries with an inpatient postpartum opioid order from six different obstetric practices with a diverse payer mix at a large institution for the analyzed period. Obstetric care providers at our institution order opioids for all patients who have undergone cesarean delivery without a contraindication to opioids, as well as patients who have undergone vaginal delivery with BTL or without BTL if they experience moderate-severe or persistent pain, when non-narcotic analgesics fail or are contraindicated, or per patient request, making this a diverse sample of patients experiencing postpartum pain. The medical records of all patients included in the study were also reviewed and abstracted by obstetricians, adding validity to our findings.
This study is not without limitations, particularly its small sample size in the setting of overall decreased postpartum opioid prescribing. We also did not incorporate postpartum pain scores as, though these values are collected by bedside nurses, obstetric providers do not reliably utilize these metrics during throughout admission or review them at the time of patient discharge. Instead, patient requests for additional analgesia and safe dosing interval- not an arbitrary pain threshold- are the determining factors for initial opioid administration and subsequent frequency. Nevertheless, pain scores may have added a dimension of quantification to the outcome of our study, perhaps identifying patients with undertreated pain despite receiving equivalent doses of opioids. It is important to note that pain scores do not account for patient preference or beliefs about opioid analgesia and goals for pain management, and they may be insensitive to cultural differences in the perception or reporting of pain, so may also be misleading .
In summary, this study contributes an important addition to the literature regarding racial disparities in postpartum practices. In our diverse patient population, we did not note significant differences in inpatient postpartum opioid usage or discharge prescribing practices by patient race. In light of recent nationwide, professional, and institutional efforts to stem the tide of opioid use disorder and opioid related deaths, this study provides a baseline for our institution and others like it by which to measure the racial equity of these interventions. As postpartum opioid prescribing practices change, it will be important to be mindful of implicit and explicit biases and to specifically study interventions in predominantly minority populations to prevent these changes from unequally affecting minority women.