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Persistent opioid use after delivery down, but more work is needed

Alex F. Peahl

Opioid prescribing and new persistent use following vaginal and cesarean delivery has declined since 2008, but maternity care clinicians can reduce new persistent use further with careful opioid prescribing, according to a study published in JAMA Network Open.

“This work confirms the high prevalence of opioid prescribing demonstrated in prior studies and the long-term impact of this prescribing: new persistent opioid use,” Alex F. Peahl, MD, of the department of obstetrics and gynecology at the University of Michigan, told Healio Primary Care. “Some women may be more at risk of new persistent opioid use, and providers can consider specific risk factors when counseling their patients on postpartum pain management.

“As some of the strongest predictors of new persistent opioid use are modifiable, specifically the size and timing of the prescription, providers have an opportunity to decrease the risk of new persistent opioid use through limited prescribing,” she continued.

Researchers conducted a retrospective cohort study using data from national insurance claims from private payers between Jan. 1, 2008, and Dec. 31, 2016. Women were included in the analysis if they were of reproductive age (12 to 55 years), opioid-naive and had at least 1 year of enrollment prior to and following delivery.

Pharmacy claims were used to identify peripartum opioid prescriptions from a week before delivery to 3 days after discharge.

Of the 308,226 deliveries included in the study, 195,013 (63.3%) were vaginal and 113,213 (36.7%) were cesarean. The mean age of women included in the study was 31.3 years.

Peripartum opioid prescriptions were filled by 27% (n = 52,710) of those who delivered vaginally, 1.7% (n = 893) of whom developed new persistent use. Opioid prescriptions were filled by 75.7% (n = 85,730) of those who had a cesarean delivery and 2.2% (n = 2,633) of them became persistent users.

The percentage of deliveries with filled opioid prescriptions decreased from 2008 to 2016 for both cesarean (75.5% to 72.6%; P < .001) and vaginal deliveries (26.9% to 23.8%; P < .001). New persistent opioid use also decreased during the study period in vaginal (2.2% to 1.1%; P < .001) and cesarean (2.5% to 1.3%; P < .001) deliveries.

Receiving an opioid prescription before delivery was the strongest risk factor tied to new persistent opioid use (adjusted OR = 1.4; 95% CI, 1.05-1.87).

Those with cesarean deliveries who also underwent hysterectomy were more likely to develop persistent use (adjusted OR = 2.75; 95% CI, 1.33-5.7), but those who underwent nonelective surgery or multiple cesarean deliveries were not.

Peahl explained that for postpartum pain management, guidelines recommend a stepwise approach starting with non-narcotics and adding opioids when necessary for breakthrough pain.

“Each woman’s delivery is a little different, and so it is important for providers and patients to work together to find the best regimen that maximizes pain control while minimizing risk,” Peahl said. “It is important to note that 25% of women who had a cesarean delivery and 72% of women who had a vaginal delivery in our cohort were able to navigate the postpartum period without opioids.”– by Erin Michael

Disclosures: Peahl reports no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures.