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

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.