Obstetrical Providers’ Management of Chronic Pain in Pregnancy: A Vignette Study

Abstract

Objective. Describe obstetrical providers’ manage­ment of a hypothetical case on chronic pain in preg­nancy and determine whether practices differ based on patient race. Design and Setting. This was a self-administered survey at a clinical conference. Subjects. Seventy-six obstetrician-gynecologists and one nurse practitioner were surveyed. Methods. A case-vignette described a pregnant pa­tient presenting with worsening chronic lower back pain, requesting an opioid refill and increased dos­age. We varied patient race (black/white) across two randomly assigned identical vignettes. Providers in­dicated their likelihood of prescribing opioids, drug testing, and referring on a 0 (definitely would not) to 10 (definitely would) scale; rated their suspicions/ concerns about the patient on a 0–10 VAS scale; and ranked those concerns in order of importance. We calculated correlation coefficients, stratifying analyses by patient race. Results. Providers were not inclined to refill the opi­oid prescription (median = 3.0) or increase the dose (median = 1.0). They were more likely to conduct urine drug tests on white than black patients (P = 0.008) and more likely to suspect that white pa­tients would divert the medication (P =0.021). For white patients, providers’ highest-ranked concern was the patient’s risk of abuse/addiction, whereas, for black patients, it was harm to the fetus. Suspicion about symptom exaggeration was more closely related to decisions about refilling the opi­oid prescriptions and increasing the dose for black patients (r = -0.357, -0.439, respectively), whereas these decisions were more closely correlated with concerns about overdose for white patients (r = -0.406, -0.494, respectively). Conclusions. Provider suspicion and concerns may differ by patient race, which may relate to differ­ences in pain treatment and testing. Further study is warranted to better understand how chronic pain is managed in pregnancy.