About 1% of mothers had new persistent opioid use in the first postpartum year

Caitlin E. Martin, MD, MPH, FACOG, FASAM

It is well known that we are in the midst of an overdose crisis in North America. Overdose-related deaths continue to be a leading cause of mortality, including for women in the year after pregnancy.

While other drugs and alcohol play a role in this epidemic, opioids remain the most significant contributor. Opioids, in this context, include both prescription opioid medications, like oxycodone, that can be used as prescribed by a clinical provider or misused, as well as other opioid substances, like heroin and fentanyl.

When considering the contribution of prescription opioids to the overdose crisis and increasing prevalence of opioid use disorder, it is well established that the provision of these medications in large quantities, one-size-fits-all approach, especially in the early 2000s and beyond, served as a pinnacle catapult for the years of rising overdose-related mortality and morbidity. Thus, research and changes in standards of medical care focused on responsible opioid prescribing have been hot topics in medicine, with numerous studies and proposed clinical guidelines coming out with proposed avenues to decrease opioid prescribing while still providing appropriate pain management.

Zipursky and colleagues presented an elegant study using Canadian data to supplement existing literature illustrating the risk of persistent opioid use among postpartum women undergoing vaginal and cesarean deliveries. While 1% seems small, the authors appropriately point out that 1% can add up to thousands of women accumulating risk factors for poor health outcomes related to opioid use. Long-term opioid use can have side effects on the body, like changes in gastrointestinal health and cognition.

Further, and most importantly, people can develop a physiologic dependence on opioids, where their nerves and brain evolve to need exposure to opioids to “function normally.” This physiologic dependence can unfortunately set someone up to subsequently take more prescription opioids than prescribed or not in the way it was prescribed to avoid withdrawal symptoms, and ultimately develop the signs and symptoms indicative of opioid use disorder.

Thus, focusing our research and clinical efforts on advancing responsible opioid prescribing after common events, like surgery, delivery and other conditions, is important, which is why these efforts have been supported by national strategies and funding sources.

As these efforts evolve over time, it is important to continue to evaluate the problem within the broader context to avoid bigger public health problems down the road. For example, the numbers presented in this study by Zipursky and colleagues should not be interpreted as no one should get opioid prescriptions at birth hospitalization discharge. Cesarean sections are major abdominal surgeries, and many patients require opioids as part of a multimodal pain management plan to ensure they can function after discharge, especially when having to care not only for themselves, but also for a newborn child. Instead, research like this study should continue to support new efforts to expand responsible opioid prescribing, where the type, number and duration for use of opioids given at discharge match what the individual patient will need and include shared decision-making.

Taking drastic actions can cause more harm, like dramatically eliminating or reducing opioid prescriptions like what we have seen in the past decade with many patients telling me about how they were “cut off” by their opioid prescriber, leading them to turn to more dangerous behaviors like fentanyl use. Instead, we need to use data like those presented by Zipursky and colleagues to push forward implementation and investigations of smart actions aimed at individualizing clinical care, like opioid prescribing.