When Theresa Edwards, a freelance writer in Austin, Texas, was giving birth to her daughter in 2006, she had a cesarean delivery, or c-section. Afterwards, she was in immense pain, so her doctor prescribed Vicodin, an opioid painkiller.
“I felt awful,” Edwards said. “We went and filled a prescription. The first few days, it was like an alarm clock. I would be in pain, take the pill and feel better again.”
After three or four days, much of the pain subsided, so Edwards stopped taking the pills. Five days after her c-section, she returned to her college classes. But when she moved out of her apartment a couple of years later, she realized she still had leftover pills and was surprised to find she could’ve gotten a refill.
According to a study published in Obstetrics and Gynecology in July, women who received c-sections reported receiving twice as many opioid pills as they ended up taking. Of the 720 women surveyed at six U.S. medical centers between September 2014 and March 2016, nearly all patients failed to dispose of those excess pills properly.
Overprescribing can have consequences. Crucially, the study found that having leftover pills in the home increased the risk that other household members, such as children, could get their hands on them. Almost 2 percent of adolescents between ages 12 and 17 were nonmedical users of pain relievers in 2014.
There’s also the risk that patients with leftover pills might give them away to someone the prescription wasn’t written for, or become addicted to opioids themselves. Indeed, 1 in 300 people who had never taken opioids before continued to take those painkillers after they’d already recovered from a c-section, and according to the 2013 and 2014 National Survey on Drug Use and Health, about half of the people who misused prescription painkillers got them from a relative or friend for free.
When doctors prescribe more opioids than patients need, patients take more pills.
“Some of our work has shown that the greater the number of pills people have at home, the greater the number of pills they take,” said Lisa Rae Leffert, study co-author and chief of the obstetric anesthesia division at Massachusetts General Hospital. “There’s no basis that they have more pain.”
Overprescribing continues despite the opioid epidemic.
With an opioid epidemic plaguing the nation, overprescribing pills puts Americans, especially individuals with risk factors like chronic pain, substance abuse disorder and depression, at risk for addiction.
Doctors may overprescribe because they want to give patients enough medication to treat their pain and ensure that patients are satisfied, according to Chad Brummett, director of the pain research division at the University of Michigan. Some doctors may even overprescribe to avoid phone calls for refills, he said.
While most women do not become addicted after receiving an opioid prescription for a c-section, according to the researchers, failing to dispose of unused pills is still risky. The safe way to dispose of drugs is to return them to a hospital or bring them to a police or fire station. Patients can also take the drugs to some pharmacies, although not all pharmacies accept them. After they give birth, women usually have a six-week follow-up visit, and can bring unused pills back to the hospital. Patients can also check the Drug Enforcement Administration’s website for places to dispose of pills.
“Right now, many people don’t understand the risks of having unused opioids at home, and many people don’t have a locked cabinet,” Brummett said. “By keeping them unlocked, it makes them available to use by kids, family members and friends.”
Edwards now knows how to properly dispose of drugs, but as an undergraduate, she didn’t, so she kept the pills in her apartment. Looking back, she said, it was risky, since her roommate was addicted to heroin.
“I didn’t know anything about disposing of pills,” Edwards said. “I kept them because I do that with medication sometimes, which is dumb. Now as an [older] adult, I know you’re never supposed to do this. You’re supposed to turn them back in.”
Education and patient input can stem overprescription.
The researchers conducted a follow-up study on the steps doctors can take to prescribe the correct number of painkillers, such as by involving patients in deciding how many painkillers they need. Massachusetts General Hospital has already started taking these steps, and doctors are prescribing fewer pills.
“There needs to be more of a conversation with the patients,” said Malavika Prabhu, study co-author and obstetrician-gynecologist at Massachusetts General Hospital. “For many patients, having a c-section is the first major surgery they [have] ever experienced.”
Another important way to reduce the risk of overprescription is to educate doctors and nurses about situations in which over-the-counter drugs, such as Motrin and Tylenol, are more appropriate than opioids for treating pain.
C-sections don’t always require prescription painkillers.
Ruth Landau, study co-author and anesthesiology professor at Columbia University Medical Center, only took Tylenol and ibuprofen when she had her c-section. Since everyone has different pain needs, it’s important to make patients aware of their options, Landau explained.
“It will empower women to choose to be responsible to take ownership on what they feel and how they want to feel,” Landau said. “I’m not saying everyone should take nothing, but we’re each different … I really think the conversation needs to be between the provider and the woman.”
The next step for the researchers is studying opioid use disorder and opioid alternatives. More patients are struggling with opioid use disorder, and researchers want to find the best way to treat them. Currently, the recommended approach is for patients to receive a combination of drugs such as ibuprofen and Tylenol.
“There’s a tremendous amount of work being done on opioid alternatives: opioids that do not have the pleasurable effect, opioids that don’t have the same side effects,” Leffert said. “There’s a whole bunch of research being done about the possibility of addiction. It’s a really important area where a lot of impact can be made.”