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Badreldin N, DiTosto JD, Leziak K, Niznik CM, Yee LM. Understanding the Postpartum Cesarean Pain Experience Among Individuals With Publicly Funded Insurance: A Qualitative Investigation. J Midwifery Womens Health 2024; 69:136-143. [PMID: 37394901 PMCID: PMC10758503 DOI: 10.1111/jmwh.13540] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/21/2023] [Indexed: 07/04/2023]
Abstract
INTRODUCTION Pain is the most common postpartum concern and has been associated with adverse outcomes, such as difficulty with neonatal bonding, postpartum depression, and persistent pain. Furthermore, racial and ethnic disparities in the management of postpartum pain are well described. Despite this, less is known regarding patients' lived experiences regrading postpartum pain. The purpose of this study was to assess patient experiences related to postpartum pain management after cesarean birth. METHODS This is a prospective qualitative study of patients' experiences with postpartum pain management after cesarean birth at a single large tertiary care center. Individuals were eligible if they had publicly funded prenatal care, were English or Spanish speaking, and underwent a cesarean birth. Purposive sampling was used to ensure a racially and ethnically diverse cohort. Participants underwent in-depth interviews using a semistructured interview guide at 2 time points: postpartum day 2 to 3 and 2 to 4 weeks after discharge. Interviews addressed perceptions and experiences of postpartum pain management and recovery. Data were analyzed using the constant comparative method. RESULTS Of 49 participants, 40.8% identified as non-Hispanic Black and 40.8% as Hispanic. The majority (59.2%) had experienced a cesarean birth with a prior pregnancy. Thematic analysis yielded 2 overarching domains: (1) experience of pain after cesarean birth and (2) pain management and opioid use after cesarean birth. Themes related to the experience of pain included pain as a meaningful experience, pain not aligned with expectations, and limitations caused by pain. All participants discussed limitations caused by their pain, voicing frustration with pursuing activities of daily living, caring for home and family, caring for neonate, and impact on mood. Themes related to pain management and opioid use addressed a desire for nonpharmacologic pain management, positive and negative experiences using opioids, and hesitancy and perceived judgement regarding opioid use. Several participants described experiences of judgement regarding the request for opioids and needing stronger pain medications, such as oxycodone. DISCUSSION Understanding experiences regarding postpartum cesarean pain management and recovery is essential to improving patient-centered care. The experiences identified by this analysis highlight the need for individualized postpartum pain management, improved expectation counseling, and the expansion of multimodal pain management options.
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Affiliation(s)
- Nevert Badreldin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University School of Medicine, Chicago, Illinois
| | - Julia D DiTosto
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University School of Medicine, Chicago, Illinois
| | - Karolina Leziak
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University School of Medicine, Chicago, Illinois
| | - Charlotte M Niznik
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University School of Medicine, Chicago, Illinois
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University School of Medicine, Chicago, Illinois
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Premkumar A, Oler AM, Cai SW, Nilsen AM, Miller ES. The association of out-of-hospital postpartum NSAID use and post-discharge hypertension control for people with hypertensive disorders of pregnancy. Pregnancy Hypertens 2023; 33:34-38. [PMID: 37473678 DOI: 10.1016/j.preghy.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE To evaluate the relationship between amount of NSAID use postpartum and outpatient blood pressure (BP) control. STUDY DESIGN This is a prospective, single-site, cohort study of postpartum people diagnosed with HDP from 2018 to 2020 using the American College of Obstetrician and Gynecologists criteria. All participants were provided an electronic BP cuff for daily evaluation after discharge. Those who provided at least 7 days of data within the first 14 days after discharge were included. Standard PP pain management included ibuprofen 600 mg every 6 h as needed. The exposure was self-reported amount of NSAIDs used within the first 14 days after discharge. The primary outcome was median mean arterial pressure (MAP) over the first 14 days after hospital discharge. Secondary outcomes included median and maximum systolic and diastolic BPs and need for PP readmission for HDP. Regression models were created, controlling for a propensity score for highest quartile of NSAID use. RESULTS 103 participants were approached, of whom 60 met inclusion criteria. Those who had a history of a cesarean delivery were more likely to be in the highest quartile of NSAID use; no other significant differences were noted across quartiles of NSAID use. There was no association between NSAID amount used and median MAP (adjusted β coefficient 0.03, 95% CI: -0.17 to 0.22). There were no significant associations between NSAID amount used and all other secondary outcomes. CONCLUSION Out-of-hospital NSAID use is not associated with worsened PP BP control after hospital discharge among people diagnosed with HDP.
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Affiliation(s)
- Ashish Premkumar
- Department of Obstetrics and Gynecology, Pritzker School of Medicine, University of Chicago, Chicago, IL, USA.
| | - Ann M Oler
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Stephanie W Cai
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Annika M Nilsen
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Emily S Miller
- Department of Obstetrics and Gynecology, The Warren Alpert School of Medicine, Brown University, Providence, RI, USA
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Badreldin N, Ditosto JD, Grobman WA, Yee LM. Maternal psychosocial factors associated with postpartum pain. Am J Obstet Gynecol MFM 2023; 5:100908. [PMID: 36809840 PMCID: PMC10121962 DOI: 10.1016/j.ajogmf.2023.100908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/06/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND The experience of pain is shaped by a host of psychological, cultural, and social factors. Although pain is the most common postpartum complaint, data on its relationship with psychosocial factors and postpartum pain are limited. OBJECTIVE This study aimed to examine the relationship between self-reported postpartum pain scores and patient-level psychosocial factors, including relationship status, pregnancy intendedness, employment, education, and psychiatric diagnosis. STUDY DESIGN This was a secondary analysis of data from a prospective observational study of postpartum patients at 1 institution (May 2017 to July 2019) who used an oral opioid at least once during their postpartum hospitalization. Enrolled participants completed a survey, which included questions regarding their social situation (including relationship status), psychiatric diagnoses, and perceptions of their pain control during their postpartum hospitalization. The primary outcome was self-reported overall pain during the postpartum hospitalization (score of 0-100). Multivariable analyses accounted for age, body mass index, nulliparity, and mode of delivery. RESULTS In this cohort of 494 postpartum patients, most patients (84.0%) underwent cesarean delivery, and 41.3% of patients were nulliparous. In a pain score of 0 to 100, participants reported a median pain score of 47. On bivariable analyses, there was no significant difference in pain score between patients with and without an unplanned pregnancy or a psychiatric diagnosis. Patients who were unpartnered, those without a college education, and those who were unemployed reported significantly higher pain scores (57.5 vs 44.8 [P<.01], 52.6 vs 44.6 [P<.01], and 53.6 vs 44.6 [P<.01], respectively). In multivariable analyses, patients who were unpartnered and unemployed reported significantly higher adjusted pain scores than patients who were partnered and employed (adjusted beta coefficients: 7.93 [95% confidence interval, 2.29-13.57] vs 6.67 [95% confidence interval, 2.28-11.05]). CONCLUSION Psychosocial factors, such as relationship and employment statuses, which are indicators of social support, are associated with the experience of pain postpartum. These findings suggest that addressing social support, such as via enhanced support from the health care team, warrants exploration as a nonpharmacologic means of improving the postpartum pain experience.
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Affiliation(s)
- Nevert Badreldin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL (Dr Badreldin, Ms Ditosto, and Dr Yee).
| | - Julia D Ditosto
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL (Dr Badreldin, Ms Ditosto, and Dr Yee)
| | - William A Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH (Dr Grobman)
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL (Dr Badreldin, Ms Ditosto, and Dr Yee)
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Bougie O, Blom J, Zhou G, Murji A, Thurston J. Use and misuse of opioid after gynecologic surgery. Best Pract Res Clin Obstet Gynaecol 2022; 85:23-34. [PMID: 35973919 DOI: 10.1016/j.bpobgyn.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/25/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
Postoperative opioid use following gynecologic surgery may be necessary for effective treatment of pain; however, it can result in significant side effects, adverse reactions, and negative health consequences, including prolonged problematic use. Surgeons and healthcare providers of patients recovering from gynecologic procedures should be aware of effective strategies that can decrease the need for opioid use, while providing high-quality pain management. These include adherence to Enhanced Recovery After Surgery Protocols, particularly the use of multimodal analgesia management. When prescribing opioids, providers should adhere to responsible prescribing practices to minimize the risk of inappropriate and/or long-term opioid use.
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Affiliation(s)
- Olga Bougie
- Department of Obstetrics & Gynecology, Queen's University, Kingston Health Sciences Centre, Kingston, ON, USA.
| | - Jessica Blom
- Department of Obstetrics & Gynecology, Queen's University, Kingston Health Sciences Centre, Kingston, ON, USA
| | - Grace Zhou
- Department of Obstetrics & Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, ON, USA
| | - Ally Murji
- Department of Obstetrics & Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, ON, USA
| | - Jackie Thurston
- Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, USA
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How Can We Get to Equitable and Effective Postpartum Pain Control? Clin Obstet Gynecol 2022; 65:577-587. [PMID: 35703219 DOI: 10.1097/grf.0000000000000731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Postpartum pain is common, yet patient experiences and clinical management varies greatly. In the United States, pain-related expectations and principles of adequate pain management have been framed within established norms of Western clinical medicine and a biomedical understanding of disease processes. Unfortunately, this positioning of postpartum pain and the corresponding coping strategies and pain treatments is situated within cultural biases and systemic racism. This paper summarizes the history and existing literature that examines racial inequities in pain management to propose guiding themes and suggestions for innovation. This work is critical for advancing ethical practice and establishing more effective care for all patients.
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Loomis BR, Yee LM, Hayes L, Badreldin N. Nurses' Perspectives on Postpartum Pain Management. WOMEN'S HEALTH REPORTS 2022; 3:318-325. [PMID: 35415715 PMCID: PMC8994431 DOI: 10.1089/whr.2021.0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 11/13/2022]
Abstract
Introduction: There is variation in postpartum opioid use by prescriber characteristics that cannot be explained by patient or birth factors. Thus, our objective was to evaluate nursing training, clinical practices, and perspectives on opioid use for postpartum pain management. Materials and Methods: In this survey study, postpartum bedside nurses at a single, large academic center were asked about training, factors influencing clinical decisions, and viewpoints regarding pain management and opioid use. Findings were summarized using descriptive analyses. Results: A total of 92 nurses completed the survey. A majority (77%) reported having received some formal training on opioid use for pain management. About a quarter (25.7%) felt their training was not adequate. Regarding clinical practices, the majority (71% and 70%, respectively) reported that “routine habit” and “patient preference” most influenced the type and amount of pain medication they administered. Finally, nurses' perspectives on pain management demonstrated a wide range of beliefs. Most nurses strongly agreed with the importance of maximizing nonopioid pain medication before opioid administration. The majority agreed that patient-reported pain score is important to consider when deciding to administer opioids. Conversely, most nurses disagreed that patients should be encouraged to endure as much pain as possible before using an opioid. Similarly, beliefs about the reliability of use of vital signs in assessing pain intensity varied widely. Conclusions: Bedside nurses rely on routine habits, patient preference, and patient-reported pain score when administering opioids for postpartum pain management. Increased training opportunities to improve consistency and standardization of opioid administration may be beneficial.
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Affiliation(s)
- Benjamin R. Loomis
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lynn M. Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lauren Hayes
- Department of Obstetrics and Gynecology, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Nevert Badreldin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Badreldin N, DiTosto JD, Grobman WA, Yee LM. Association Between Patient-Prescriber Racial and Ethnic Concordance and Postpartum Pain and Opioid Prescribing. Health Equity 2022; 6:198-205. [PMID: 35402767 PMCID: PMC8985536 DOI: 10.1089/heq.2021.0130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 11/12/2022] Open
Abstract
Objective: To evaluate whether patient-prescriber racial and ethnic concordance is associated with postpartum opioid prescribing patterns and patient-reported pain scores. Methods This is a retrospective cohort study of patients who delivered at a tertiary care center between December 1, 2015 and November 30, 2016. Self-identified non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, or Asian patients were included. Patient-prescriber pairs were categorized as racially and ethnically concordant if they shared the same racial and ethnic identity; the prescriber was defined as the obstetrical provider who was responsible for the postpartum discharge of the patient. Multivariable regression models controlling for demographic and clinical confounders were used to assess the relationship of patient-prescriber racial and ethnic concordance with receipt of an opioid prescription and patient-reported pain score at discharge. Results Of 10,242 patients included in this analysis, 62.3% identified as NHW, 19.1% Hispanic, 9.7% NHB, and 8.9% Asian. About half (52.8%) of patients were discharged by a racially and ethnically concordant prescriber. Patient-prescriber racial and ethnic concordance was not associated with receipt of an opioid prescription (adjusted odds ratio [aOR] 0.82, confidence interval [95% CI] 0.67–1.00) or reporting a pain score ≥5 (aOR 0.90, 95% CI 0.69–1.16). However, NHB and Hispanic patients were less likely to receive an opioid prescription (aOR 0.73, 95% CI 0.56–0.95; aOR 0.73, 95% CI 0.57–0.92, respectively) and significantly more likely to report a pain score ≥5 (aOR 2.13, 95% CI 1.51–3.00; aOR 1.48 95% CI 1.08–2.01, respectively) than NHW patients, even when accounting for concordance. Conclusion Disparities in postpartum opioid prescribing and pain perception are not ameliorated by patient-prescriber racial and ethnic concordance.
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Affiliation(s)
- Nevert Badreldin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University School of Medicine, Chicago, Illinois, USA
| | - Julia D. DiTosto
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University School of Medicine, Chicago, Illinois, USA
| | - William A. Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University School of Medicine, Chicago, Illinois, USA
| | - Lynn M. Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University School of Medicine, Chicago, Illinois, USA
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Badreldin N, Grobman WA, Niznik CM, Yee LM. Association of Inpatient Postpartum Opioid Use with Bedside Nurse. J Midwifery Womens Health 2022; 67:251-257. [PMID: 35076172 DOI: 10.1111/jmwh.13316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 10/18/2021] [Accepted: 10/21/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Our objective was to assess the association between the nurse providing bedside care and women's postpartum opioid use. METHODS Retrospective study of all women who birthed at a single center (December 2015 to November 2016). Patient, prescriber, and clinical data were abstracted. The postpartum nurse and total opioid use during the first 12-hour postpartum shift after birth were determined. A high amount of opioid use was defined as morphine milligram equivalents greater than or equal to 90% for this population (stratified by vaginal and cesarean births). A logistic regression model was fit with covariates entered in a step-wise manner to identify the extent to which individual nurses were associated with a greater likelihood of high opioid use by establishing one model in which the only covariate was nurse (model 1) and assessing whether the addition of patient (model 2), birth (model 3), and prescriber factors (model 4) altered the association. Kendall rank correlation assessed rank changes between models. RESULTS Of the 8376 and 2957 women who had vaginal and cesarean births, 17.9% and 10.2%, respectively, had high opioid use. In the vaginal cohort, women cared for by 46 of 200 nurses were significantly less likely to have high opioid use. Following adjustment, patients cared for by 53 of 200 bedside nurses (model 4) had significantly lower odds of having high opioid use. The rank order of nurses, with respect to the likelihood of opioid use, remained similar after adjustment for patient, birth, and prescriber factors (Τ = 0.84). Findings were similar for the cesarean cohort: 35 of 113 nurses were associated with a significantly lower likelihood of their patients having high opioid use, and the rank order remained similar after covariate adjustment (Τ = 0.78). DISCUSSION There is significant variation in postpartum women's opioid use based on the nurse that is not explained by patient, birth, or prescriber factors.
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Affiliation(s)
- Nevert Badreldin
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - William A Grobman
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Charlotte M Niznik
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lynn M Yee
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Yee LM, Kacanek D, Brightwell C, Haddad LB, Jao J, Powis KM, Yao TJ, Barr E, Broadwell C, Siminski S, Seage GR, Chadwick EG. Marijuana, Opioid, and Alcohol Use Among Pregnant and Postpartum Individuals Living With HIV in the US. JAMA Netw Open 2021; 4:e2137162. [PMID: 34860242 PMCID: PMC8642784 DOI: 10.1001/jamanetworkopen.2021.37162] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/14/2021] [Indexed: 11/15/2022] Open
Abstract
Importance Amid the opioid epidemic and evolving legal and social changes with marijuana, little is known about substance use among pregnant and postpartum people living with HIV. Objectives To evaluate trends in marijuana, alcohol, and opioid use during pregnancy and the first year postpartum among US people living with HIV and the differences in substance use based on marijuana legalization status. Design, Setting, and Participants Data from the Surveillance Monitoring for Antiretroviral Toxicities (SMARTT) study of the Pediatric HIV/AIDS Cohort Study were analyzed. SMARTT-enrolled, pregnant people living with HIV at 22 US sites from January 1, 2007, to July 1, 2019, with self-reported substance use data available in pregnancy, 1 year postpartum, or both were assessed. Exposures Calendar year and state marijuana legalization status. Main Outcomes and Measures The prevalence of any use of each of the following substances was calculated by calendar year, separately for pregnancy and postpartum: marijuana, alcohol, opioid, and concomitant alcohol and marijuana. Log binomial models were fit using general estimating equations to evaluate the mean annual change, accounting for repeat pregnancies. The study also evaluated differences in substance use by state recreational or medical marijuana legalization status. Results Substance use data were available for 2926 pregnancies from 2310 people living with HIV (mean [SD] age, 28.8 [6.1] years; 822 [28.1%] Hispanic, 1859 [63.5%] non-Hispanic Black, 185 [6.3%] White, 24 [0.8%] of more than 1 race, 24 [0.8%] of other race or ethnicity [individuals who identified as American Indian, Asian, or Native Hawaiian or other Pacific Islander], and 12 [0.4%] with unknown or unreported race or ethnicity). Between 2007 and 2019, marijuana use during pregnancy increased from 7.1% to 11.7%, whereas alcohol and opioid use in pregnancy were unchanged. Postpartum alcohol (44.4%), marijuana (13.6%), and concomitant alcohol and marijuana (10.0%) use were common; marijuana use increased from 10.2% to 23.7% from 2007 to 2019, whereas postpartum alcohol use was unchanged. The adjusted mean risk of marijuana use increased by 7% (95% CI, 3%-10%) per year during pregnancy and 11% (95% CI, 7%-16%) per year postpartum. Postpartum concomitant alcohol and marijuana use increased by 10% (95% CI, 5%-15%) per year. Differences in substance use were not associated with recreational legalization, but increased marijuana use was associated with medical marijuana legalization. Conclusions and Relevance In this cohort study, opioid use among pregnant people living with HIV remained stable, whereas marijuana use during pregnancy and postpartum increased over time and in states with legalized medical marijuana. These patterns of increasing marijuana use among pregnant and postpartum people living with HIV suggest that enhanced clinical attention is warranted, given the potential maternal and child health implications of substance use.
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Affiliation(s)
- Lynn M. Yee
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Deborah Kacanek
- Center for Biostatistics in AIDS Research, Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Chase Brightwell
- Center for Biostatistics in AIDS Research, Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Lisa B. Haddad
- Center for Biomedical Research, Population Council, New York, New York
| | - Jennifer Jao
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kathleen M. Powis
- Departments of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Tzy-Jyun Yao
- Center for Biostatistics in AIDS Research, Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Emily Barr
- Department of Pediatric Infectious Diseases, University of Colorado School of Medicine, Aurora
| | - Carly Broadwell
- Center for Biostatistics in AIDS Research, Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - George R. Seage
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ellen G. Chadwick
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Kahn KM, Demarco K, Pavsic J, Sangillo J. A Quality Improvement Project to Reduce Postcesarean Opioid Consumption. MCN Am J Matern Child Nurs 2021; 46:190-197. [PMID: 34016836 DOI: 10.1097/nmc.0000000000000721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The opioid epidemic is a public health emergency in the United States, stemming in part from widespread misuse and overprescribing of opioids following surgery. Approximately 1 in 300 women with no prior exposure to opioids develops an opioid use disorder following cesarean birth. Effective management of postcesarean pain requires individualized treatment and a balance of the woman's goals for optimal recovery and ability to safely care for her newborn. The American College of Obstetricians and Gynecologists recommends a multimodal approach to pain management after cesarean birth. METHODS In April 2019, a multidisciplinary team was formed at New York University Langone Health to study opioid use postcesarean. The team used the Plan, Do, Study, Act process model for continuous quality improvement to launch a postcesarean pathway called "Your Plan After Cesarean," a standardized visual tool with quantifiable milestones. It facilitates integration of women's preferences in their postcesarean care, and emphasizes providers' routine use of nonpharmacological interventions to manage pain. RESULTS During the pilot period of the project, postcesarean high consumption of 55 to 120 mg of opioids was reduced from 25% to 8%. By January 2020, 75% of women postoperative cesarean took little-to-no opioids during their hospital stay. By February 2021, the total number of opioids consumed by women after cesarean birth in-hospital was reduced by 79%. Satisfaction among women with pain management after cesarean continued to be high. CLINICAL IMPLICATIONS Reduction in postcesarean opioid administration and the number of opioids prescribed at hospital discharge can be accomplished without having a negative effect on women's perceptions of post-op pain relief. These changes can potentially be a factor in helping to avoid an opioid-naive woman who has a cesarean birth from developing an opioid use disorder.
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Opioid Prescribing Practices for Women Undergoing Elective Gynecologic Surgery. J Minim Invasive Gynecol 2021; 28:1325-1333.e3. [PMID: 33503472 DOI: 10.1016/j.jmig.2021.01.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 01/07/2023]
Abstract
STUDY OBJECTIVE To describe the opioid prescribing practices in opioid-naive women undergoing elective gynecologic surgery for benign indications and identify risk factors associated with increased perioperative opioid use. We also explored factors associated with new persistent opioid use in women with perioperative opioid use. DESIGN Retrospective, population-based cohort study. SETTING We used linked administrative data from a government-administered single-payer provincial healthcare system in Canada. This study was undertaken at ICES, a not-for-profit research institute in Ontario, Canada. PATIENTS We followed opioid-naive adult women who underwent benign elective gynecologic surgery between 2013 and 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was perioperative opioid use defined as ≥1 opioid prescription from 30 days before to 14 days after surgery. New persistent opioid use after gynecologic surgery was defined as having filled 1 or more opioid prescriptions between 91 days and 180 days postoperatively. Multivariable log-linear regression analyses were employed to adjust for clinical and demographic data. Of the 132 506 patients included in our cohort, most (74.3%) underwent minor gynecologic procedures. Perioperative opioid use was documented in 27 763 (21.0%) patients, and there was a significant decreasing trend (p <.001) in the proportion of patients with perioperative opioid use from 21.8% in 2013 to 18.5% in 2018. Factors associated with increased perioperative opioid use included younger age; higher income quintile; urban dwellers; and diagnosis of infertility, endometriosis, or adnexal mass. Perioperative opioid use was an independent risk factor for persistent use (adjusted relative risk 1.40; 95% confidence interval, 1.13-1.72) and for every 65 patients prescribed opioids associated with gynecologic surgery, one developed new persistent opioid use. The highest risk factor for developing persistent use was filling a high-dose opioid prescription (adjusted relative risk5th quintileOME 2.33; 95% confidence interval, 1.83-2.96). CONCLUSION One in 5 women who undergo a gynecologic procedure has a new exposure to opioids. For every 65 patients who fill an opioid prescription after their gynecologic surgery, one will experience prolonged opioid use.
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Nidey N, Carnahan R, Carter KD, Strathearn L, Bao W, Greiner A, Jelliffee-Pawlowski L, Tabb KM, Ryckman K. Association of Mood and Anxiety Disorders and Opioid Prescription Patterns Among Postpartum Women. Am J Addict 2020; 29:463-470. [PMID: 32249527 DOI: 10.1111/ajad.13028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/24/2020] [Accepted: 03/20/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Postpartum women represent a large population with opioid exposure who also have an increased risk of experiencing mood and anxiety disorders. However, the effect that mood and anxiety disorders have on opioid use postpartum has received little attention in the literature. Therefore, the objective of this study was to examine the association of mood and anxiety disorders with filling opioid prescriptions within the first 3 months postpartum. METHODS A retrospective cohort study (n = 25 279) was completed using claims data for a sample of privately insured women who gave birth in the state of Iowa. The interactive effects of mood and anxiety disorders and delivery mode on filling at least one and two or more opioid prescriptions were examined in logistic regression models. RESULTS The presence of mood and anxiety disorders among women who delivered vaginally increased their odds of filling at least one opioid fill by nearly 50% (odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.35-1.63) and by 20% (OR: 1.20, 95% CI: 1.00-1.43) among women with cesarean delivery. DISCUSSION AND CONCLUSION Postpartum women with mood and anxiety disorders were more likely to fill opioid prescriptions postpartum compared to women without these conditions. SCIENTIFIC SIGNIFICANCE This study extends prior research by examining the intersection of risk of mood and anxiety disorders and opioid use postpartum. Findings from this study support the need for future research to identify the drivers of increased opioid use among postpartum women with mood and anxiety disorders. (Am J Addict 2020;29:463-470).
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Affiliation(s)
- Nichole Nidey
- Department of Pediatrics, Division of Biostatistics and Epidemiology, Division of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ryan Carnahan
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
| | - Knute D Carter
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa
| | - Lane Strathearn
- Stead Family Department of Pediatrics, Division of Developmental and Behavioral Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa.,Center for Disabilities and Development, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - Wei Bao
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
| | - Andrea Greiner
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Laura Jelliffee-Pawlowski
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California
| | - Karen M Tabb
- School of Social Work, University of Illinois at Urbana-Champaign, Urbana, Illinois
| | - Kelli Ryckman
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
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Carrico JA, Mahoney K, Raymond KM, McWilliams SK, Mayes LM, Mikulich-Gilbertson SK, Bartels K. Predicting Opioid Use Following Discharge After Cesarean Delivery. Ann Fam Med 2020; 18:118-126. [PMID: 32152015 PMCID: PMC7062496 DOI: 10.1370/afm.2493] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/23/2019] [Accepted: 08/14/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Although cesarean delivery is the most common surgical procedure in the United States, postoperative opioid prescribing varies greatly. We hypothesized that patient characteristics, procedural characteristics, or both would be associated with high vs low opioid use after discharge. This information could help individualize prescriptions. METHODS In this prospective cohort study, we quantified opioid use for 4 weeks following hospital discharge after cesarean delivery. Predischarge characteristics were obtained from health records, and patients self-reported total opioid use postdischarge on weekly questionnaires. Opioid use was quantified in milligram morphine equivalents (MMEs). Binomial and Poisson regression analyses were performed to assess predictors of opioid use after discharge. RESULTS Of the 233 patients starting the study, 203 (87.1%) completed at least 1 questionnaire and were included in analyses (86.3% completed all 4 questionnaires). A total of 113 patients were high users (>75 MMEs) and 90 patients were low users (≤75 MMEs) of opioids postdischarge. The group reporting low opioid use received on average 44% fewer opioids in the 24 hours before discharge compared with the group reporting high opioid use (mean = 33.0 vs 59.3 MMEs, P <.001). Only a minority of patients (11.4% to 15.8%) stored leftover opioids in a locked location, and just 31 patients disposed of leftover opioids. CONCLUSIONS Knowledge of predischarge opioid use can be useful as a tool to inform individualized opioid prescriptions, help optimize nonopioid analgesia, and reduce opioid use. Additional studies are needed to evaluate the impact of implementing such measures on prescribing practices, pain, and functional outcomes.
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Affiliation(s)
- Jacqueline A Carrico
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Katharine Mahoney
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Kristen M Raymond
- Department of Psychiatry, Division of Substance Dependence, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Shannon K McWilliams
- Department of Psychiatry, Division of Substance Dependence, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Lena M Mayes
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Susan K Mikulich-Gilbertson
- Department of Psychiatry, Division of Substance Dependence, University of Colorado, Anschutz Medical Campus, Aurora, Colorado.,Department of Biostatistics & Informatics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Karsten Bartels
- Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado .,Department of Psychiatry, Division of Substance Dependence, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
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14
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15
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Sanchez Traun KB, Schauberger CW, Ramirez LD, Jones CW, Lindberg AF, Molero Bravo RA, Wright TE, Traun BD, Peterson SE, Rudolf VP. Opioid prescribing trends in postpartum women: a multicenter study. Am J Obstet Gynecol MFM 2019; 1:100055. [PMID: 33345845 DOI: 10.1016/j.ajogmf.2019.100055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The postpartum period can be a particularly vulnerable time for exposure to opioid medications, and there are currently no consensus guidelines for physicians to follow regarding opioid prescribing during this period. OBJECTIVE The purpose of this study was to evaluate inter- and intrahospital variability in opioid prescribing patterns in postpartum women and better understand the role of clinical variables in prescribing. STUDY DESIGN Data were extracted from electronic medical records on 4248 patients who delivered at 6 hospitals across the United States from January 2016 through March 2016. The primary outcome of the study was postpartum opioid prescription at the time of hospital discharge. Age, parity, route of delivery, and hospital were analyzed individually and with multivariate analyses to minimize confounding factors. Statistical methods included χ2 to analyze frequency of opioid prescription by hospital, parity, tobacco use, delivery method, and laceration type. An analysis of variance was used to analyze morphine equivalent dose by hospital. RESULTS The percentage of women prescribed postpartum opioids varied significantly by hospital, ranging from 27.6% to 70.9% (P <0.001). Oxycodone-acetaminophen was the most commonly prescribed medication (50.3%) with each hospital having its preferred opioid type. Median number of tablets prescribed ranged from 20 to 40 (P < .0001). Primiparous women were more likely to receive opioids than multiparous women when broken down by a parity of 1, 2, 3, 4, and ≥5 (52.8%, 48.0%, 47.6%, 40.1%, and 45.8%, respectively, P = .0005). Among women who had vaginal deliveries, opioid prescription rates were higher in women who experienced either a second-degree laceration (35.5%, P = .0002) or a third-/fourth-degree laceration (59.3%, P < .001). CONCLUSION Postpartum opioid prescription rates vary widely among hospitals, but providers within the same hospital tend to follow similar prescribing trends. The variation in prescribing found in our study illustrates the need for clear consensus guidelines for postpartum pain management.
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Affiliation(s)
| | | | - Luis D Ramirez
- Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI
| | - Cresta W Jones
- Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, MN
| | - Alisha F Lindberg
- Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, MN
| | | | - Tricia E Wright
- Department of Obstetrics and Gynecology, University of Hawaii, Honolulu, HI
| | - Benjamin D Traun
- Department of Family Medicine and Community Health, University of Wisconsin, Madison, WI
| | - Suzanne E Peterson
- Department of Obstetrics and Gynecology, Swedish Medical Center, Seattle, WA
| | - Vania P Rudolf
- Addiction Recovery Services, Swedish Medical Center, Seattle, WA
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Badreldin N, Grobman WA, Chang KT, Yee LM. Reply. Am J Obstet Gynecol 2019; 220:208-209. [PMID: 30315786 DOI: 10.1016/j.ajog.2018.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 10/02/2018] [Indexed: 10/28/2022]
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