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Delivery type, opioid prescribing, and the risk of persistent opioid use after delivery

Published:October 25, 2018DOI:https://doi.org/10.1016/j.ajog.2018.10.026

      Objective

      Cesarean delivery is associated with the persistent use of opioid pain relievers (OPRs), although whether this relates to the procedure or subsequent OPR prescribing is unclear.
      • Sun E.C.
      • Darnall B.D.
      • Baker L.C.
      • Mackey S.
      Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period.
      • Bateman B.T.
      • Franklin J.M.
      • Bykov K.
      • et al.
      Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naïve women.
      We examined OPR prescribing and persistent OPR use among women undergoing cesarean and vaginal delivery.

      Study Design

      We included pregnant women aged 15–44 years enrolled in Tennessee Medicaid and opioid-naïve ≥180 days prior to delivery (Jan. 1, 2007, through Sept. 30, 2015). We classified OPR exposure based on filled prescriptions during the postpartum period: no prescription, early only (≥1 fill from delivery to day 7 and none from days 8 through 42), early and late (≥1 fill from delivery to day 7 and days 8 through 42).
      Persistent OPR use was defined as ≥1 OPR fill in each 45 day period from days 43 through 365 after delivery. We compared the risk of persistent OPR use by OPR exposure group and delivery type using Poisson regression with robust standard errors to calculate relative risks and 95% confidence intervals (CIs) adjusted for patient demographics, rurality,

      Roehrich-Patrick L, Moreo B. Just how rural or urban are Tennessee’s 95 counties? Tennessee Advisory Commission on Intergovernmental Relations. Available at: https://www.tn.gov/content/dam/tn/tacir/documents/2016JustHowRuralOrUrban.pdf. Accessed November 27, 2018.

      smoking, depression, severe maternal morbidity, and pain conditions.

      Results

      Of 102,541 women, 89.0% with a cesarean (early-only: 70.2%; early-late: 17.1%) and 52.7% with a vaginal delivery (early-only: 42.9%; early-late: 6.3%) filled ≥1 OPR prescriptions during the postpartum period.
      The incidence of persistent OPR use was low overall (0.67%) and higher among women with cesarean vs vaginal delivery (0.84% vs 0.59%: adjusted relative risk [aRR], 1.26, 95% CI, 1.08–1.47). However, when examined by OPR exposure, persistent OPR use was similar by delivery type among those with no postpartum prescription (aRR, 0.70 [95% CI, 0.25–1.96]) or only an early prescription (aRR, 0.91 [95% CI, 0.67–1.24]) and lower among women with a cesarean delivery among those with an early and late prescription (aRR, 0.66 [95% CI, 0.54–0.81]).
      Among women with a vaginal delivery, persistent OPR use was higher among women with only early OPR prescriptions (aRR, 2.58, 95% CI, 1.80–3.71) and with early and late OPR prescriptions (aRR, 28.87, 95% CI, 20.37–40.91) compared with no prescription. Similarly, among women with a cesarean delivery, persistent OPR use was higher among women with only early OPR prescriptions (aRR, 2.75, 95% CI, 1.10–6.87) and with early and late OPR prescriptions (aRR, 23.22, 95% CI, 9.44–57.14) compared with no prescription (Figure) . The findings were similar if we excluded women with complicated vaginal deliveries (third- to fourth-degree lacerations and tubal ligations) or Centers for Disease Control and Prevention–defined severe maternal morbidity.
      • Callaghan W.M.
      • Creanga A.A.
      • Kuklina E.V.
      Severe maternal morbidity among delivery and postpartum hospitalizations in the United States.
      Figure thumbnail gr1
      FigurePersistent opioid use at year following delivery by postpartum prescription exposure and delivery type
      No prescription = 0 fills delivery day 42 (n = 3450 cesarean, n = 33,722 vaginal); early only = ≥1 fill from delivery day 7 and none from days 8 through 42 (n = 21,980 cesarean, n = 30,564 vaginal); early and late = ≥1 fill from delivery day 7 and day 8–42 (n = 5349 cesarean, n = 4482 vaginal); late only (not displayed) = 0 fill from delivery day 7 and ≥1 fill days 8 through 42 (n = 548 cesarean, n = 2446 vaginal).
      Osmundson et al. Risk of persistent opioid use after delivery. Am J Obstet Gynecol 2019.

      Discussion

      OPR prescribing after delivery was common and associated with persistent OPR use in the Tennessee Medicaid population, with only modest differences by delivery type. Women who filled early and late prescriptions were at highest risk for persistent OPR use. Persistent OPR use was higher for cesarean deliveries because of higher rates of OPR prescribing because no difference was observed within levels of postpartum OPR use. These findings suggest postpartum OPR exposure, not the delivery type, is the primary risk factor for persistent OPR use.
      Because of the high frequency of childbirth in the United States, even a small increased risk of persistent OPR use would affect a substantial number of US women. Based on our findings and assuming that postpartum OPR prescribing increases the risk of persistent OPR use, we estimated that postpartum OPR prescribing resulted in 21,576 new persistent OPR users annually (95% CI, 20,483–22,388).
      • Martin J.A.
      • Hamilton B.E.
      • Osterman M.J.K.
      • Driscoll A.K.
      • Mathews T.J.
      Births: final data for 2015.
      Study limitations included the inability to verify actual OPR use and the use of data from a single state. These findings highlight the need for judicious opioid prescribing during the vulnerable postpartum period, especially among women who require additional OPR prescriptions.

      Acknowledgement

      We are indebted to the Tennessee Division of TennCare of the Department of Finance and Administration, which provided data for the study. We are also indebted to the Tennessee Department of Health for providing data for the study.

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        Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period.
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        Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naïve women.
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