1
|
Lim G, Xue L, Donohue JM, Junker S, Wilson JD, Suffoletto B, Lynch MJ, Pacella-LaBarbara ML, Chang CCH, Krans E, Jarlenski M. Associations between acute pain after vaginal delivery and postpartum opioid prescription fills: a retrospective case-controlled study. Br J Anaesth 2024; 132:978-981. [PMID: 38423825 DOI: 10.1016/j.bja.2024.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/16/2024] [Accepted: 01/22/2024] [Indexed: 03/02/2024] Open
Affiliation(s)
- Grace Lim
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Lingshu Xue
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Julie M Donohue
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Stefanie Junker
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - J Deanna Wilson
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Brian Suffoletto
- Department of Emergency Medicine, Stanford University, Palo Alto, CA, USA
| | - Michael J Lynch
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Chung-Chou H Chang
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Elizabeth Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Magee-Women's Research Institute, Pittsburgh, PA, USA
| | - Marian Jarlenski
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| |
Collapse
|
2
|
Peahl AF, Low LK, Langen ES, Moniz MH, Aaron B, Hu HM, Waljee J, Townsel C. Drivers of variation in postpartum opioid prescribing across hospitals participating in a statewide maternity care quality collaborative. Birth 2023. [PMID: 38158784 DOI: 10.1111/birt.12809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 10/06/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND We describe variation in postpartum opioid prescribing across a statewide quality collaborative and assess the proportion due to practitioner and hospital characteristics. METHODS We assessed postpartum prescribing data from nulliparous, term, singleton, vertex births between January 2020 and June 2021 included in the clinical registry of a statewide obstetric quality collaborative funded by Blue Cross Blue Shield of Michigan. Data were summarized using descriptive statistics. Mixed effect logistic regression and linear models adjusted for patient characteristics and assessed practitioner- and hospital-level predictors of receiving a postpartum opioid prescription and prescription size. Relative contributions of practitioner and hospital characteristics were assessed using the intraclass correlation coefficient. RESULTS Of 40,589 patients birthing at 68 hospitals, 3.0% (872/29,412) received an opioid prescription after vaginal birth and 87.8% (9812/11,177) received one after cesarean birth, with high variation across hospitals. In adjusted models, the strongest patient-level predictors of receiving a prescription were cesarean birth (aOR 899.1, 95% CI 752.8-1066.7) and third-/fourth-degree perineal laceration (aOR 25.7, 95% CI 17.4-37.9). Receiving care from a certified nurse-midwife (aOR 0.63, 95% CI 0.48-0.82) or family medicine physician (aOR 0.60, 95%CI 0.39-0.91) was associated with lower prescribing rates. Hospital-level predictors included receiving care at hospitals with <500 annual births (aOR 4.07, 95% CI 1.61-15.0). A positive safety culture was associated with lower prescribing rates (aOR 0.37, 95% CI 0.15-0.88). Much of the variation in postpartum prescribing was attributable to practitioners and hospitals (prescription receipt: practitioners 25.1%, hospitals 12.1%; prescription size: practitioners 5.4%, hospitals: 52.2%). DISCUSSION Variation in postpartum opioid prescribing after birth is high and driven largely by practitioner- and hospital-level factors. Opioid stewardship efforts targeted at both the practitioner and hospital level may be effective for reducing opioid prescribing harms.
Collapse
Affiliation(s)
- Alex F Peahl
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lisa Kane Low
- School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth S Langen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michelle H Moniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Bryan Aaron
- Medical School, University of Michigan, Ann Arbor, Michigan, USA
| | - Hsou Mei Hu
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer Waljee
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Courtney Townsel
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
3
|
Badreldin N, DiTosto JD, Grobman W, Yee LM. Temporal Trends in Postpartum Opioid Prescribing, Opioid Use, and Pain Control Satisfaction. Am J Perinatol 2022; 39:1151-1158. [PMID: 35253120 DOI: 10.1055/a-1788-5894] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The objective was to assess temporal trends in postpartum opioid prescribing, opioid use, and pain control satisfaction. STUDY DESIGN This is a prospective observational study of postpartum patients who delivered at a large tertiary care center (May 2017-July 2019). Inpatient patients were screened for eligibility; those meeting eligibility criteria who used inpatient opioids were approached for prospective survey participation which probed inpatient and outpatient postpartum pain control. The amount of opioids used during inpatient hospitalization and the amount of opioids prescribed at discharge were obtained from medical records. The primary outcome was the difference in opioid prescribing at discharge over time, measured by (1) the proportion of participants who received an opioid prescription at discharge and (2) for those who received an opioid prescription, the total morphine milligram equivalents of the prescription. Additional outcomes were inpatient and outpatient opioid use and patient-reported satisfaction with postpartum pain control. Trends over time were evaluated using nonparametric tests of trend. RESULTS Of 2,503 postpartum patients screened for eligibility, a majority (N = 1,425; 60.8%) did not use an opioid as an inpatient. Over the study period, there was a significant decline in the proportion of patients who used an opioid while inpatient (z-score = - 11.8; p < 0.01). Among these participants enrolled in the prospective survey study (N = 494), there was a significant decline over time in the amount of inpatient opioid use (z-score = - 2.4; p = 0.02), the proportion of participants who received an opioid prescription upon discharge (z-score = - 8.2; p < 0.01), and, when an opioid was prescribed at discharge, the total prescribed morphine milligram equivalents (z-score = - 4.3; p < 0.01). Both inpatient and outpatient satisfactions with pain control were unchanged over this time (z-score = 1.1, p = 0.27; z-score = 1.1, p = 0.29, respectively). CONCLUSION In this population, both the frequency and amount of opioid use in the postpartum period declined from 2017 to 2019. This decrease in opioid prescribing was not associated with changes in patient-reported satisfaction with pain control. KEY POINTS · From 2017 to 2019, there was a decrease in inpatient and outpatient postpartum opioid use.. · Both the proportion of postpartum patients receiving opioid prescriptions and the amount prescribed decreased.. · Patient satisfaction with postpartum pain control remained unchanged..
Collapse
Affiliation(s)
- Nevert Badreldin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julia D DiTosto
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - William Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
4
|
Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG Clinical Consensus No. 1. Obstet Gynecol 2021; 138:507-517. [PMID: 34412076 DOI: 10.1097/aog.0000000000004517] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
SUMMARY Pain in the postpartum period is common and considered by many individuals to be both problematic and persistent (1). Pain can interfere with individuals' ability to care for themselves and their infants, and untreated pain is associated with risk of greater opioid use, postpartum depression, and development of persistent pain (2). Clinicians should therefore be skilled in individualized management of postpartum pain. Though no formal time-based definition of postpartum pain exists, the recommendations presented here provide a framework for management of acute perineal, uterine, and incisional pain. This Clinical Consensus document was developed using an a priori protocol in conjunction with the authors listed. This document has been revised to incorporate more recent evidence regarding postpartum pain.
Collapse
|
5
|
Evaluation of a new departmental policy to decrease routine opioid prescribing after vaginal delivery. Am J Obstet Gynecol MFM 2020; 2:100156. [PMID: 33305251 DOI: 10.1016/j.ajogmf.2020.100156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND In line with a nationwide commitment to decrease opioid prescribing, in October 2017, our department implemented a new departmental policy to cease routine provision of opioid prescriptions at the time of discharge following vaginal delivery. OBJECTIVE This study aimed to evaluate the effect of this policy on the number of discharge opioid prescriptions provided and outpatient encounters observed postpartum. STUDY DESIGN This was a retrospective cohort study of patients who underwent vaginal delivery at our institution from November 2016 to January 2018. We reviewed delivery and postpartum records for patients 18 years or older, without chronic opioid use or contraindication to nonsteroidal antiinflammatory medication use. The primary outcome was the proportion of patients provided with an opioid prescription at the time of discharge following vaginal delivery. The secondary outcome was the number of unscheduled patient encounters related to pain in the 6-week postpartum period. Fisher's exact test was used to compare these outcomes before and after implementation of the new departmental opioid-prescribing policy. RESULTS A total of 1188 charts were reviewed; among those charts, 810 met the inclusion criteria. Notably, 405 patients delivered before the guideline, and 405 patients delivered after its implementation. After the implementation of the new departmental policy, there was a 10-fold decrease in opioid prescriptions provided from 323 (79.8%) to 29 (7.2%) (P<.01). Although the number of unscheduled outpatient encounters postpartum increased slightly from 22 to 37 encounters after the implementation of the new departmental policy, this difference was not statistically significant (P=.08). CONCLUSION Limiting opioid prescribing after vaginal delivery is associated with a considerable decrease in the number of discharge opioid prescriptions provided and does not significantly increase the number of outpatient encounters related to pain postpartum.
Collapse
|
6
|
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).
Collapse
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
| |
Collapse
|
7
|
Blitz MJ, Rochelson B, Prasannan L, Stoffels GJ, Pappas K, Palleschi GT, Marchbein H. Scheduled versus as-needed postpartum analgesia and oxycodone utilization. J Matern Fetal Neonatal Med 2020; 35:1054-1062. [PMID: 32193961 DOI: 10.1080/14767058.2020.1742318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: An optimal approach for providing sufficient postpartum analgesia while minimizing the risk of opioid misuse or diversion has yet to be elucidated. Moreover, there is scant literature on the efficacy of around-the-clock (ATC) scheduled dosing of opioid analgesia compared to pro re nata (PRN; as-needed) dosing for postpartum pain management. Here we evaluate a quality improvement intervention that aimed to proactively provide pain relief with a multimodal analgesic regimen that includes oxycodone at scheduled time intervals. This new protocol stands in stark contrast to many contemporary postpartum pain management regimens in which oral opioid medications are reserved for treating breakthrough pain.Objective: Our aim was to determine how inpatient oxycodone use is affected by as-needed compared to ATC scheduled dosing of acetaminophen, ibuprofen, and low-dose oxycodone, with the option to decline any of these medications. We also sought to determine the effect of each modality on patient satisfaction with pain control.Methods: Retrospective cohort study of singleton deliveries at ≥37 weeks of gestation at a tertiary hospital from 2013 to 2016. In month 21 of the 48-month study period, a new institutional protocol for postpartum pain management was implemented which consisted of scheduled dosing of a multimodal analgesic regimen. Prior to this, patients received pain relief only as needed, by reporting elevated pain scores to nursing staff. Patients were excluded for the following: NSAID or opioid allergies, protocol deviations, transition month deliveries, history of drug abuse, positive urine toxicology, delivery with general anesthesia, prolonged hospitalization, postpartum hemorrhage, hypertensive disorders of pregnancy, incomplete records. Outcomes evaluated were the percentage of patients receiving oxycodone and mean oxycodone use per inpatient day (milligrams). Segmented regression analysis of interrupted time series was performed to estimate linear time trends of oxycodone consumption pre- and post-protocol implementation. Results of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) standardized survey were also compared before and after implementation.Results: A total of 19,192 deliveries were included. After adjusting for confounders, a significant downward trend in the percentage of patients receiving oxycodone was noted among both cesarean (0.004% decrease per month; p < .006) and vaginal deliveries (0.005% decrease per month; p < .0001) before implementation of the scheduled pain management protocol. Among cesarean deliveries, there was no shift at the time of implementation, and no change in the slope of the trend after implementation. Among vaginal deliveries, there was an upward shift at implementation (+7.4%, p < .0001) but no change in the slope of the trend after implementation. Regardless of mode of delivery, no trend in monthly mean oxycodone consumption per day existed before or after implementation of the new protocol, and there was no shift at the time of implementation. Scheduled multimodal analgesia was associated with an improvement in HCAHPS scores for patient reported pain control after cesarean section (63 versus 71% reporting "Always" well controlled; p < .001) but had no effect after vaginal delivery.Conclusion: After cesarean delivery, scheduled multimodal analgesia that includes ATC dosing of acetaminophen, ibuprofen, and low-dose oxycodone, with the option to decline any of these medications, does not increase the percentage of women who receive oxycodone or mean oxycodone consumption per inpatient day compared to as-needed analgesia. After vaginal delivery, scheduled multimodal analgesia is associated with an increase in the percentage of women who receive oxycodone but no change in mean oxycodone consumption per inpatient day.
Collapse
Affiliation(s)
- Matthew J Blitz
- Division of Maternal-Fetal Medicine, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Burton Rochelson
- Division of Maternal-Fetal Medicine, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Lakha Prasannan
- Division of Maternal-Fetal Medicine, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Guillaume J Stoffels
- Biostatistics Unit, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Karalyn Pappas
- Biostatistics Unit, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Greg T Palleschi
- Department of Anesthesiology, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Harvey Marchbein
- Department of Obstetrics and Gynecology, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| |
Collapse
|
8
|
Martin CE, Terplan M, Krans EE. Pain, Opioids, and Pregnancy: Historical Context and Medical Management. Clin Perinatol 2019; 46:833-847. [PMID: 31653311 DOI: 10.1016/j.clp.2019.08.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Women are being disproportionately affected by the opioid crisis, including during pregnancy. Pain and other vulnerabilities to addiction differ between men and women. Management of opioid use disorder should be gender informed and accessible across the lifespan. During pregnancy, care teams should be multidisciplinary to include obstetrics, addiction, social work, anesthesia, pediatrics, and behavioral health. Pain management for women with opioid use disorder requires tailored approaches, including integration of trauma-informed care and addressing psychosocial needs. Thus, coordinated continued care by obstetric and addiction providers through pregnancy into postpartum is key to supporting women in recovery.
Collapse
Affiliation(s)
- Caitlin E Martin
- Department of Obstetrics and Gynecology, Virginia Commonwealth University, 1250 East Marshall Street, Richmond, VA 23298-0268, USA
| | - Mishka Terplan
- Friends Research Institute, 1040 Park Ave, Suite 103, Baltimore MD 21202, USA.
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Research Institute, 300 Halket Street, Pittsburgh, PA 15213, USA
| |
Collapse
|
9
|
|
10
|
Peahl AF, Dalton VK, Montgomery JR, Lai YL, Hu HM, Waljee JF. Rates of New Persistent Opioid Use After Vaginal or Cesarean Birth Among US Women. JAMA Netw Open 2019; 2:e197863. [PMID: 31348508 PMCID: PMC6661716 DOI: 10.1001/jamanetworkopen.2019.7863] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
IMPORTANCE Research has shown an association between opioid prescribing after major or minor procedures and new persistent opioid use. However, the association of opioid prescribing with persistent use among women after vaginal delivery or cesarean delivery is less clear. OBJECTIVE To assess the association between opioid prescribing administered for vaginal or cesarean delivery and rates of new persistent opioid use among women. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used national insurance claims data for 988 036 women from a single private payer from January 1, 2008, to December 31, 2016. Participants included reproductive age, opioid-naive women with 1 year of continuous enrollment before and after delivery. For participants with multiple births, only the first birth was included. EXPOSURES Peripartum opioid prescription (1 week before delivery to 3 days after discharge) captured by pharmacy claims, including prescription timing and size in oral morphine equivalents. Multivariable adjusted odds ratios were estimated using regression models. MAIN OUTCOMES AND MEASURES Rates of new persistent opioid use, defined as pharmacy claims for 1 or more opioid prescription 4 to 90 days after discharge and 1 or more prescription 91 to 365 days after discharge among women who filled peripartum opioid prescriptions. RESULTS In total, 308 226 deliveries were included: 195 013 (63.3%) vaginal deliveries and 113 213 (36.7%) cesarean deliveries. Participant mean (SD) age was 31.3 (5.3) years, and 70 567 (51.0%) were white patients. Peripartum opioid prescriptions were filled by 27.0% of women with vaginal deliveries and 75.7% of women with cesarean deliveries. Among them, 1.7% of those with vaginal deliveries and 2.2% with cesarean deliveries had new persistent opioid use. By contrast, among women not receiving a peripartum opioid prescription, 0.5% with vaginal delivery and 1.0% with cesarean delivery had new persistent opioid use. From 2008 to 2016, opioid prescription fills decreased for vaginal deliveries from 26.9% to 23.8% (P < .001) and for cesarean deliveries from 75.5% to 72.6% (P < .001), and fewer women had new persistent use (vaginal delivery, from 2.2% to 1.1%; P < .001; cesarean delivery, from 2.5% to 1.3%; P < .001). The strongest modifiable factor associated with new persistent opioid use after delivery was filling an opioid prescription before delivery (adjusted odds ratio, 1.40; 95% CI, 1.05-1.87). For vaginal deliveries, receiving a prescription equal to or more than 225 oral morphine equivalents was associated with new persistent opioid use (adjusted odds ratio, 1.25; 95% CI, 1.06-1.48). Women who underwent cesarean delivery and had a hysterectomy were more likely to develop persistence (AOR, 2.75; 95% CI, 1.33-5.70), although women who underwent a nonelective (AOR, 0.97; 95% CI, 0.88-1.07) or repeat cesarean (AOR, 1.45; 95% CI, 0.93-2.28) were not more likely. For cesarean deliveries, risk factors were associated with patient attributes such as tobacco use (adjusted odds ratio, 1.82; 95% CI, 1.56-2.11), psychiatric diagnoses, history of substance use (adjusted odds ratio, 1.43; 95% CI, 1.10-1.86), and pain conditions. CONCLUSIONS AND RELEVANCE The results of the present study suggested that opioid prescribing and new persistent use after vaginal delivery or cesarean delivery have decreased since 2008. However, modifiable prescribing patterns were associated with persistent opioid use for patients who underwent vaginal delivery, and risk factors following cesarean delivery mirrored those of other surgical conditions. Judicious opioid prescribing and preoperative risk screening may be opportunities to decrease new persistent opioid use after childbirth.
Collapse
Affiliation(s)
- Alex F. Peahl
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor
| | - Vanessa K. Dalton
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor
- Program on Women’s Healthcare Effectiveness Research, University of Michigan, Ann Arbor
| | | | - Yen-Ling Lai
- Michigan Opioid Prescribing Engagement Network, Department of Surgery, University of Michigan, Ann Arbor
| | - Hsou Mei Hu
- Michigan Opioid Prescribing Engagement Network, Department of Surgery, University of Michigan, Ann Arbor
| | - Jennifer F. Waljee
- Department of Surgery, University of Michigan, Ann Arbor
- Michigan Opioid Prescribing Engagement Network, Department of Surgery, University of Michigan, Ann Arbor
| |
Collapse
|