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Smid MC, Clifton RG, Rood K, Srinivas S, Simhan HN, Casey BM, Longo M, Landau R, MacPherson C, Bartholomew A, Sowles A, Reddy UM, Rouse DJ, Bailit JL, Thorp JM, Chauhan SP, Saade GR, Grobman WA, Macones GA. Optimizing Opioid Prescription Quantity After Cesarean Delivery: A Randomized Controlled Trial. Obstet Gynecol 2024; 144:195-205. [PMID: 38857509 PMCID: PMC11257794 DOI: 10.1097/aog.0000000000005649] [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: 03/24/2024] [Accepted: 04/25/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVE To test whether an individualized opioid-prescription protocol (IOPP) with a shared decision-making component can be used without compromising postcesarean pain management. METHODS In this multicenter randomized controlled noninferiority trial, we compared IOPP with shared decision making with a fixed quantity of opioid tablets at hospital discharge. We recruited at 31 centers participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Study participants had uncomplicated cesarean births. Follow-up occurred through 12 weeks postdischarge. Individuals with complicated cesarean births or history of opioid use in the pregnancy were excluded. Participants were randomized 1:1 to IOPP with shared decision making or fixed quantity (20 tablets of 5 mg oxycodone). In the IOPP group, we calculated recommended tablet quantity based on opioid use in the 24 hours before discharge. After an educational module and shared decision making, participants selected a quantity of discharge tablets (up to 20). The primary outcome was moderate to severe pain (score 4 or higher [possible range 0-10]) on the BPI (Brief Pain Inventory) at 1 week after discharge. A total sample size of 5,500 participants was planned to assess whether IOPP with shared decision making was not inferior to the fixed quantity of 20 tablets. RESULTS From September 2020 to March 2022, 18,990 individuals were screened and 5,521 were enrolled (n=2,748 IOPP group, n=2,773 fixed-quantity group). For the primary outcome, IOPP with shared decision making was not inferior to fixed quantity (59.5% vs 60.1%, risk difference 0.67%; 95% CI, -2.03% to 3.37%, noninferiority margin -5.0) and resulted in significantly fewer tablets received (median 14 [interquartile range 4-20] vs 20, P <.001) through 90 days postpartum. CONCLUSION Compared with fixed quantity, IOPP with shared decision making was noninferior for outpatient postcesarean analgesia at 1 week postdischarge and resulted in fewer prescribed opioid tablets at discharge. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT04296396.
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Affiliation(s)
- Marcela C Smid
- Departments of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah, The Ohio State University, Columbus, Ohio, University of Pennsylvania, Philadelphia, Pennsylvania, University of Pittsburgh, Pittsburgh, Pennsylvania, University of Alabama at Birmingham, Birmingham, Alabama, Brown University, Providence, Rhode Island, Columbia University, New York, New York, University of Texas Medical Branch, Galveston, Texas, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston, Texas, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, Northwestern University, Chicago, Illinois, and University of Texas at Austin, Austin, Texas; the Department of Anesthesiology, Columbia University, New York, New York; the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Hart K, Medvecz AJ, Vaidya A, Dusetzina S, Leech AA, Wiese AD. Opioid and non-opioid analgesic regimens after fracture and risk of serious opioid-related events. Trauma Surg Acute Care Open 2024; 9:e001364. [PMID: 39021730 PMCID: PMC11253739 DOI: 10.1136/tsaco-2024-001364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 05/31/2024] [Indexed: 07/20/2024] Open
Abstract
Background Non-opioid analgesics are prescribed in combination with opioids among patients with long bone fracture to reduce opioid prescribing needs, yet evidence is limited on whether they reduce the risk of serious opioid-related events (SOREs). We compared the risk of SOREs among hospitalized patients with long bone fracture discharged with filled opioid prescriptions, with and without non-opioid analgesics. Design We identified a retrospective cohort of analgesic-naïve adult patients with a long bone fracture hospitalization using the Merative MarketScan Commercial Database (2013-2020). The exposure was opioid and non-opioid analgesic (gabapentinoids, muscle relaxants, non-steroidal anti-inflammatory drugs, acetaminophen) prescriptions filled in the 3 days before through 42 days after discharge. The outcome was the development of new persistent opioid use or opioid use disorder during follow-up (day 43 through day 408 after discharge). We used Cox proportional hazards regression with inverse probability of treatment weighting with overlap trimming to compare outcomes among those that filled an opioid and a non-opioid analgesic to those that filled only an opioid analgesic. In secondary analyses, we used separate models to compare those that filled a prescription for each specific non-opioid analgesic type with opioids to those that filled only opioids. Results Of 29 489 patients, most filled an opioid prescription alone (58.4%) or an opioid and non-opioid (22.0%). In the weighted proportional hazards regression model accounting for relevant covariates and total MME, filling both a non-opioid analgesic and an opioid analgesic was associated with 1.63 times increased risk of SOREs compared with filling an opioid analgesic only (95% CI 1.41 to 1.89). Filling a gabapentin prescription in combination with an opioid was associated with an increased risk of SOREs compared with those that filled an opioid only (adjusted HR: 1.84 (95% CI1.48 to 2.27)). Conclusions Filling a non-opioid analgesic in combination with an opioid was associated with an increased risk of SOREs after long bone fracture. Level of evidence Level III, prognostic/epidemiological. Study type Retrospective cohort study.
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Affiliation(s)
- Kyle Hart
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew J Medvecz
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Avi Vaidya
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stacie Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashley A Leech
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew D Wiese
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Chua KP, Brummett CM, Kelley-Quon LI, Bicket MC, Gunaseelan V, Waljee JF. Pediatric Surgical Opioid Prescribing by Procedure, 2020-2021. Pediatrics 2024; 154:e2024065814. [PMID: 38919985 PMCID: PMC11211692 DOI: 10.1542/peds.2024-065814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 04/19/2024] [Accepted: 04/23/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Surgery is one of the most common indications for opioid prescribing to pediatric patients. We identified which procedures account for the most pediatric surgical opioid prescribing. METHODS We conducted a cross-sectional analysis of commercial and Medicaid claims in the Merative MarketScan Commercial and Multi-State Medicaid Databases. Analyses included surgical procedures for patients aged 0 to 21 years from December 1, 2020, to November 30, 2021. Procedures were identified using a novel crosswalk between 3664 procedure codes and 1082 procedure types. For each procedure type in the crosswalk, we calculated the total amount of opioids in prescriptions dispensed within 3 days of discharge from surgery, as measured in morphine milligram equivalents (MMEs). We then calculated the share of all MMEs accounted for by each procedure type. We conducted analyses separately among patients aged 0 to 11 and 12 to 21 years. RESULTS Among 107 597 procedures for patients aged 0 to 11 years, the top 3 procedures accounted for 59.1% of MMEs in opioid prescriptions dispensed after surgery: Tonsillectomy and/or adenoidectomy (50.3%), open treatment of upper extremity fracture (5.3%), and removal of deep implants (3.5%). Among 111 406 procedures for patients aged 12 to 21 years, the top 3 procedures accounted for 33.1% of MMEs: Tonsillectomy and/or adenoidectomy (12.7%), knee arthroscopy (12.6%), and cesarean delivery (7.8%). CONCLUSIONS Pediatric surgical opioid prescribing is concentrated among a small number of procedures. Targeting these procedures in opioid stewardship initiatives could help minimize the risks of opioid prescribing while maintaining effective postoperative pain control.
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Affiliation(s)
- Kao-Ping Chua
- Susan B. Meister Child Health Evaluation and Research Center, and Departments of Pediatrics
| | - Chad M. Brummett
- Overdose Prevention Engagement Network, Institute for Healthcare Policy and Innovation
- Anesthesiology
| | - Lorraine I. Kelley-Quon
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, and Departments of Surgery
- Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Mark C. Bicket
- Overdose Prevention Engagement Network, Institute for Healthcare Policy and Innovation
- Anesthesiology
| | - Vidhya Gunaseelan
- Overdose Prevention Engagement Network, Institute for Healthcare Policy and Innovation
- Anesthesiology
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Horn A, Adgent MA, Osmundson SS, Wiese AD, Phillips SE, Patrick SW, Griffin MR, Grijalva CG. Risk of Death at 1 Year Following Postpartum Opioid Exposure. Am J Perinatol 2024; 41:949-960. [PMID: 35640619 PMCID: PMC9708936 DOI: 10.1055/s-0042-1745848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Opioids are commonly prescribed to women for acute pain following childbirth. Postpartum prescription opioid exposure is associated with adverse opioid-related morbidities but the association with all-cause mortality is not well studied. This study aimed to examine the association between postpartum opioid prescription fills and the 1-year risk of all-cause mortality among women with live births. METHODS In a retrospective cohort study of live births among women enrolled in Tennessee Medicaid (TennCare) between 2007 and 2015, we compared women who filled two or more postpartum outpatient opioid prescriptions (up to 41 days of postdelivery discharge) to women who filled one or fewer opioid prescription. Women were followed from day 42 postdelivery discharge through 365 days of follow-up or date of death. Deaths were identified using linked death certificates (2007-2016). We used Cox's proportional hazard regression and inverse probability of treatment weights to compare time to death between exposure groups while adjusting for relevant confounders. We also examined effect modification by delivery route, race, opioid use disorder, use of benzodiazepines, and mental health condition diagnosis. RESULTS Among 264,135 eligible births, 216,762 (82.1%) had one or fewer maternal postpartum opioid fills and 47,373 (17.9%) had two or more fills. There were 182 deaths during follow-up. The mortality rate was higher in women with two or more fills (120.5 per 100,000 person-years) than in those with one or fewer (57.7 per 100,000 person-years). The risk of maternal death remained higher in participants exposed to two or more opioid fills after accounting for relevant covariates using inverse probability of treatment weighting (adjusted hazard ratio: 1.46 [95% confidence interval: 1.01, 2.09]). Findings from stratified analyses were consistent with main findings. CONCLUSION Filling two or more opioid prescriptions during the postpartum period was associated with a significant increase in 1-year risk of death among new mothers. KEY POINTS · Opioid prescribing in the postpartum period is common.. · Prior studies show that >1 postnatal opioid fill is associated with adverse opioid-related events.. · > 1 opioid fill within 42 days of delivery was associated with an increase in 1-year risk of death..
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Affiliation(s)
- Arlyn Horn
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Margaret A. Adgent
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Sarah S. Osmundson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Andrew D. Wiese
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Sharon E. Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Stephen W. Patrick
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Marie R. Griffin
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Veterans’ Health Administration Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Nashville, TN
| | - Carlos G. Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
- Veterans’ Health Administration Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Nashville, TN
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Varney B, Zoega H, Gillies MB, Gisev N, Weston Shand A, Pearson SA, Havard A. Prevalence and Persistence of Prescription Opioid Use Following Hospital Discharge After Childbirth: An Australian Population-Based Cohort Study. Anesth Analg 2024; 138:970-979. [PMID: 37319031 DOI: 10.1213/ane.0000000000006582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND Opioid analgesics are used for acute postpartum pain relief but carry risks, including persistent long-term opioid use. Our primary objective was to estimate the prevalence of persistent use following hospital discharge after childbirth. METHODS We conducted a population-based cohort study of women discharged from public or private hospitals in New South Wales, Australia, between 2012 and 2018 following vaginal birth (VB) or cesarean delivery (CD). We used linked hospitalization and medicine dispensing data to calculate the prevalence of opioid use within 14 days of hospital discharge for childbirth using an external estimate of the total number of hospital admissions for childbirth per year as the denominator. Among women dispensed an opioid postdischarge, we estimated the prevalence of persistent use defined as ≥3 dispensings between 30- and 365-days postdischarge. To calculate the odds of persistent opioid use, we performed a series of logistic regressions each including a single characteristic of interest. Included characteristics were maternal and birth characteristics, maternal medical conditions, prior use of certain medicines, and the initial opioid dispensed following discharge for childbirth. RESULTS The final cohort comprised of 38,832 women who were dispensed an opioid in the 14 days following discharge after childbirth. Between 2012 and 2018, the prevalence of opioid use was increased following CD (public hospital 16.6%-21.0%; private hospital 9.8%-19.5%) compared with VB (public hospital 1.5%-1.5%; private hospital 1.2%-1.4%) and was higher following discharge from public hospitals compared with private. The most commonly dispensed opioids following discharge for childbirth were oxycodone (44.8%; 95% confidence interval [CI], 44.3-45.3), codeine (42.1%; 95% CI, 41.6-42.6), and tramadol (12.9%; 95% CI, 12.6-13.2). Among women dispensed an opioid, the prevalence of persistent opioid use was 5.4% (95% CI, 5.1-5.6). This prevalence was 11.4% (95% CI, 10.5-12.3) following a VB as compared with 4.3% (95% CI, 4.1-4.6) among those who underwent a CD ( P < .001). Characteristics associated with persistent opioid use included smoking during pregnancy, age <25 years, living in remote areas, discharged from a public hospital, history of opioid use disorder, other substance use disorder, mental health diagnosis, or prior use of prescription opioids, nonopioid analgesics, or benzodiazepines. CONCLUSIONS The results of this cohort study indicate that Australian women have a higher prevalence of opioid use following CD compared to VB. One in 19 women dispensed an opioid postdischarge used opioids persistently. Careful monitoring of opioid therapy following childbirth is warranted, particularly among women with characteristics we identified as high risk for persistent opioid use.
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Affiliation(s)
- Bianca Varney
- From the School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Helga Zoega
- From the School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Malcolm Bjørn Gillies
- From the School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Antonia Weston Shand
- Department of Maternal Fetal Medicine, Royal Hospital for Women, Randwick, Sydney, Australia
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Sallie-Anne Pearson
- From the School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Alys Havard
- From the School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- National Drug and Alcohol Research Centre, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
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Zipursky JS, Everett K, Calzavara A, Gomes T, Juurlink DN. New Persistent Opioid Use After Childbirth. Obstet Gynecol 2023; 142:1440-1449. [PMID: 37917933 DOI: 10.1097/aog.0000000000005432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/14/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE To examine factors associated with new persistent opioid use after childbirth. METHODS We conducted a population-based cohort study of individuals who initiated opioid therapy within 7 days of discharge from hospital after delivery between September 1, 2013, and September 30, 2021. The primary outcome was new persistent opioid use , which was defined as one or more prescriptions for an opioid within 90 days of the first postpartum prescription and one or more subsequent opioid prescriptions in the 91-365 days afterward. We used multivariable logistic regression to assess patient-, pregnancy-, and prescription-related factors associated with new persistent opioid use after delivery. RESULTS We identified 118,694 unique deliveries after which opioids were initiated, including 99,399 cesarean (83.7%) and 19,295 vaginal (16.3%) deliveries. Among mothers who initiated an opioid after delivery, 1,282 (10.8/1,000 deliveries) met our definition of new persistent opioid use in the subsequent year. Rates of new persistent opioid use were appreciably higher after vaginal (16.0/1,000) compared with cesarean (9.8/1,000) deliveries. Each additional 30 morphine milligram equivalents in the initial opioid prescription was associated with an increased risk of new persistent use after cesarean (adjusted odds ratio [aOR] 1.06, 95% CI 1.04-1.08) and vaginal (aOR 1.05, 95% CI 1.02-1.08) delivery. A concomitant benzodiazepine prescription after cesarean delivery was associated with a markedly increased risk of persistent opioid use (aOR 2.69, 95% CI 1.60-4.52). CONCLUSION Among people who filled an opioid prescription after delivery, about 1% displayed evidence of persistent opioid use in the subsequent year. Initial prescriptions for large quantities of opioids and a concurrent benzodiazepine prescription may be important modifiable risk factors to prevent new persistent opioid use after delivery.
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Affiliation(s)
- Jonathan S Zipursky
- Department of Medicine, Sunnybrook Health Sciences Centre, ICES, the Sunnybrook Research Institute, the Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, and the Leslie Dan Faculty of Pharmacy and the Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Zipursky JS, Gomes T, Everett K, Calzavara A, Paterson JM, Austin PC, Mamdani MM, Ray JG, Juurlink DN. Maternal opioid treatment after delivery and risk of adverse infant outcomes: population based cohort study. BMJ 2023; 380:e074005. [PMID: 36921977 PMCID: PMC10015218 DOI: 10.1136/bmj-2022-074005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
OBJECTIVE To examine whether maternal opioid treatment after delivery is associated with an increased risk of adverse infant outcomes. DESIGN Population based cohort study. SETTING Ontario, Canada. PARTICIPANTS 865 691 mother-infant pairs discharged from hospital alive within seven days of delivery from 1 September 2012 to 31 March 2020. Each mother who filled an opioid prescription within seven days of discharge was propensity score matched to a mother who did not. MAIN OUTCOME MEASURES The primary outcome was hospital readmission of infants for any reason within 30 days of their mother filling an opioid prescription (index date). Infant related secondary outcomes were any emergency department visit, hospital admission for all cause injury, admission to a neonatal intensive care unit, admission with resuscitation or assisted ventilation, and all cause death. RESULTS 85 675 mothers (99.8% of the 85 852 mothers prescribed an opioid) who filled an opioid prescription within seven days of discharge after delivery were propensity score matched to 85 675 mothers who did not. Of the infants admitted to hospital within 30 days, 2962 (3.5%) were born to mothers who filled an opioid prescription compared with 3038 (3.5%) born to mothers who did not. Infants of mothers who were prescribed an opioid were no more likely to be admitted to hospital for any reason than infants of mothers who were not prescribed an opioid (hazard ratio 0.98, 95% confidence interval 0.93 to 1.03) and marginally more likely to be taken to an emergency department in the subsequent 30 days (1.04, 1.01 to 1.08), but no differences were found for any other adverse infant outcomes and there were no infant deaths. CONCLUSIONS Findings from this study suggest no association between maternal opioid prescription after delivery and adverse infant outcomes, including death.
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Affiliation(s)
- Jonathan S Zipursky
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto ON M4N 3M5, Canada
- ICES, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Tara Gomes
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | | | | | - J Michael Paterson
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Peter C Austin
- ICES, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad M Mamdani
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Joel G Ray
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - David N Juurlink
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto ON M4N 3M5, Canada
- ICES, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Girard T, Dayan N, Wilson MG, Harris M, El-Messidi A, Gosselin S, Fleiszer D, Bonnici A, Villeneuve E, Lee TC, McDonald EG. A retrospective study comparing postoperative opioid prescribing practices in an academic medical centre. Can Pharm J (Ott) 2022; 155:277-284. [PMID: 36081921 PMCID: PMC9445502 DOI: 10.1177/17151635221110153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Background In the midst of the North American opioid crisis, identifying and intervening on drivers of high-risk opioid prescriptions is an important step towards reducing iatrogenic harm. Objectives We aimed to identify factors associated with variations in high-risk opioid discharge prescriptions, following select surgical procedures, to guide future quality improvement initiatives. Methods This retrospective cohort study analyzed 1322 patients who underwent select open pelvic and open abdominal surgeries between January 1 and December 31, 2017, in a tertiary health care centre in Montreal. Results Patients who underwent open abdominal surgeries were prescribed significantly higher daily doses of morphine milligram equivalents (MME) (45 mg; interquartile range, 30-60), than patients who underwent either a caesarean delivery (20 mg, 20-20) or a hysterectomy (30 mg, 22-30). After adjustment for multiple potential confounders, abdominal surgery was associated with 4 times the odds of receiving more than 50 MME at hospital discharge compared with pelvic surgeries (odds ratio, 3.96; 95% confidence interval, 1.31-11.97). The availability of postoperative preprinted order sets with fixed high doses of opioids was also highly associated with the outcome. Conclusion In our institution, some surgeries were more likely to receive high-risk opioid prescriptions at discharge. Efforts to optimize safer prescribing practices should address the creation and/or updating of preprinted order sets to reflect current best practice guidelines. This initiative could be overseen by hospital pharmacy and therapeutics committees.
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Osmundson SS, Halvorson A, Graves KN, Wang C, Bruehl S, Grijalva CG, France D, Hartmann K, Mokshagundam S, Harrell FE. Development and Validation of a Model to Predict Postdischarge Opioid Use After Cesarean Birth. Obstet Gynecol 2022; 139:888-897. [PMID: 35576347 PMCID: PMC9015028 DOI: 10.1097/aog.0000000000004759] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/03/2022] [Indexed: 11/26/2022]
Abstract
A model with three predictors readily found in the electronic health record—inpatient opioid use, tobacco use, and depression or anxiety—accurately estimated postdischarge opioid use. OBJECTIVE: To develop and validate a prediction model for postdischarge opioid use in patients undergoing cesarean birth. METHODS: We conducted a prospective cohort study of patients undergoing cesarean birth. Patients were enrolled postoperatively, and they completed pain and opioid use questionnaires 14 days after cesarean birth. Clinical data were abstracted from the electronic health record (EHR). Participants were prescribed 30 tablets of hydrocodone 5 mg–acetaminophen 325 mg at discharge and were queried about postdischarge opioid use. The primary outcome was total morphine milligram equivalents used. We constructed three proportional odds predictive models of postdischarge opioid use: a full model with 34 predictors available before hospital discharge, an EHR model that excluded questionnaire data, and a reduced model. The reduced model used forward selection to sequentially add predictors until 90% of the full model performance was achieved. Predictors were ranked a priori based on data from the literature and prior research. Predictive accuracy was estimated using discrimination (concordance index). RESULTS: Between 2019 and 2020, 459 participants were enrolled and 279 filled the standardized study prescription. Of the 398 with outcome measurements, participants used a median of eight tablets (interquartile range 1–18 tablets) after discharge, 23.5% used no opioids, and 23.0% used all opioids. Each of the models demonstrated high accuracy predicting postdischarge opioid use (concordance index range 0.74–0.76 for all models). We selected the reduced model as our final model given its similar model performance with the fewest number of predictors, all obtained from the EHR (inpatient opioid use, tobacco use, and depression or anxiety). CONCLUSION: A model with three predictors readily found in the EHR—inpatient opioid use, tobacco use, and depression or anxiety—accurately estimated postdischarge opioid use. This represents an opportunity for individualizing opioid prescriptions after cesarean birth.
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Zipursky J, Juurlink DN. Opioid use in pregnancy: An emerging health crisis. Obstet Med 2021; 14:211-219. [PMID: 34880933 PMCID: PMC8646213 DOI: 10.1177/1753495x20971163] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 10/07/2020] [Indexed: 04/17/2024] Open
Abstract
Opioid use in pregnancy has increased in parallel to the opioid crisis observed in the general population. Rising rates of peripartum opioid use pose a significant public health concern for both mothers and their children. Pregnancy also represents a unique opportunity for healthcare providers to screen women for opioid use disorder and engage them in appropriate care. In the present review, we describe patterns of opioid use in pregnancy and how this relates to maternal and neonatal health outcomes. We also examine screening for and treatment of opioid use disorder in pregnancy, neonatal outcomes following maternal opioid use, and breastfeeding recommendations for women taking opioids postpartum.
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Affiliation(s)
- Jonathan Zipursky
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - David N Juurlink
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
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The risk of serious opioid-related events associated with common opioid prescribing regimens in the postpartum period after cesarean delivery. Am J Obstet Gynecol MFM 2021; 3:100475. [PMID: 34455101 DOI: 10.1016/j.ajogmf.2021.100475] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 08/19/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Opioid analgesics are commonly prescribed to women after cesarean delivery. There is a growing effort to prescribe opioids judiciously; however, the risk of serious opioid-related events associated with specific prescribing patterns after cesarean delivery remains unclear. OBJECTIVE We examined the association between the dosage of the first opioid prescription filled after cesarean delivery and the risk of serious opioid-related events. STUDY DESIGN We identified opioid-naïve women with a cesarean delivery enrolled in Tennessee Medicaid (2007-2014). Pharmacy prescription fill data characterized opioids filled within 5 days after delivery. Patients were followed up from day 5 after delivery to the earliest of the following: serious opioid-related event (persistent opioid use, evidence of opioid use disorder [diagnosis or methadone or buprenorphine fill], overdose, or opioid-related death), non-opioid-related death, enrollment loss, or 365th day. We estimated the adjusted hazard ratios and 95% confidence intervals for the serious opioid-related event outcomes based on the dosage (morphine milligram equivalents) of the first filled opioid prescription, adjusting for baseline sociodemographic characteristics, delivery complications, multiple deliveries, comorbidities, and medication use. Secondary analyses examined the role of commonly prescribed opioid strengths and quantities. RESULTS The overall incidence rate of serious opioid-related events among women after cesarean delivery was 3.0 per 100 person-years. Compared with women who did not fill an opioid prescription, the rate of serious opioid-related events was higher among women who filled an opioid prescription, although only significantly higher among women who filled a total dosage of ≥100 morphine milligram equivalents (97.1% of opioid prescriptions). In the secondary analyses, women with a low prescribed daily opioid dosage and women with a low prescribed number of oxycodone (5 mg) tablets (<10 tablets) were not at increased risk of serious opioid-related events compared with women who did not fill an opioid prescription. CONCLUSION Opioid-naïve women who filled a postpartum opioid prescription at commonly prescribed doses after cesarean delivery had an increased risk of serious opioid-related events compared to women who did not fill a postpartum opioid prescription. Low opioid doses were not associated with a significant increase in the risk of serious opioid-related events.
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12
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Zipursky JS, Pang A, Paterson JM, Austin PC, Mamdani M, Gomes T, Ray JG, Juurlink DN. Trends in Postpartum Opioid Prescribing: A Time Series Analysis. Clin Pharmacol Ther 2021; 110:1004-1010. [PMID: 34032277 DOI: 10.1002/cpt.2307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/14/2021] [Indexed: 12/22/2022]
Abstract
Opioids are commonly prescribed following childbirth, but data are lacking on trends in postpartum opioid prescribing over time. We examined whether a highly publicized 2006 case report questioning the safety of codeine during lactation was associated with changes in postpartum opioid prescribing. We conducted a cross-sectional time series analysis of all publicly funded prescriptions for opioids to postpartum women in Ontario, Canada, from April 1, 2000, to March 31, 2017. The intervention was the publication of a case report in 2006 attributing the death of a breastfeeding neonate to maternal codeine use. The primary outcome was the rate of opioid prescribing to postpartum women. Among postpartum women eligible for prescription drug coverage, 17.5% filled an opioid prescription in the third quarter of 2006 (immediately prior to the intervention), with codeine representing 89.8% of all prescriptions. By the fourth quarter of 2010, only 12.2% of postpartum women filled an opioid prescription, representing a decline of 30% (P < 0.01), with codeine representing 71.9% of all prescriptions. During this period, we observed sizeable relative increases in the proportion of opioid prescriptions filled for morphine, hydromorphone, and oxycodone. By 2017, among women prescribed opioids post partum, 39.0% filled a prescription for codeine, while the remainder filled prescriptions for oxycodone (18.6%), morphine (25.5%), and hydromorphone (16.9%). A highly publicized case report questioning the safety of maternal codeine use during breastfeeding was associated with significant changes in opioid prescribing to postpartum women, including a decline in overall opioid prescribing and a shift from codeine to stronger opioids.
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Affiliation(s)
- Jonathan S Zipursky
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Pang
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - J Michael Paterson
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Peter C Austin
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Muhammad Mamdani
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada.,Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada.,Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Joel G Ray
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada.,Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - David N Juurlink
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
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13
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Anderson PO. Opioid Use in Breastfeeding. Breastfeed Med 2021; 16:366-369. [PMID: 33651950 DOI: 10.1089/bfm.2021.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Philip O Anderson
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California, USA
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14
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Wiese AD, Osmundson SS, Mitchel E, Adgent M, Phillips S, Patrick SW, Horn A, Samuels LR, Griffin MR, Grijalva CG. Prescription Opioid Dose After Vaginal Delivery and the Risk of Serious Opioid-Related Events: A Retrospective Cohort Study. Womens Health Issues 2021; 31:376-383. [PMID: 33865673 DOI: 10.1016/j.whi.2021.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/21/2020] [Accepted: 03/05/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE Postpartum opioid use remains common among women with uncomplicated vaginal delivery and may increase the risk of serious opioid-related events. Therefore, we examined the association between the dose of the first filled opioid prescription after vaginal delivery and the subsequent risk of serious opioid-related events. METHODS We conducted a retrospective cohort study among women enrolled in Tennessee Medicaid with a vaginal delivery (2007-2015). We used Cox proportional hazards regression to model adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for serious opioid-related events after delivery according to the dose (morphine milligram equivalents [MME]) of the first postpartum opioid prescription, accounting for comorbidities, medication use, parity, and delivery complications. Serious opioid-related events were defined as the occurrence of persistent opioid use, a methadone or buprenorphine fill, opioid use disorder diagnosis, opioid overdose, or opioid-related death. We used filled pharmacy data to characterize the dose of the first postpartum opioid prescription filled within 4 days after delivery. RESULTS More than one-half of women (53.2%; n = 147,598) filled an opioid prescription within 4 days of a vaginal delivery. After accounting for baseline risk factors, filling a postpartum opioid prescription was associated with an increased risk of serious opioid-related events across all dose categories, compared with women filling none (aHR 1-99 MME, 1.52; 95% CI, 1.33-1.74; aHR 100-149 MME, 1.41; 95% CI, 1.26-1.58; aHR 150-199 MME, 1.40; 95% CI, 1.26-1.57: and aHR ≥200 MME, 1.60; 95% CI, 1.43-1.78). CONCLUSIONS Filling a postpartum opioid prescription after a vaginal delivery was associated with an increased risk of serious opioid-related events, regardless of dose. Prescribing guidelines should discourage the routine prescribing of opioids after vaginal delivery.
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Affiliation(s)
- Andrew D Wiese
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Sarah S Osmundson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Edward Mitchel
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Margaret Adgent
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sharon Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen W Patrick
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Arlyn Horn
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lauren R Samuels
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marie R Griffin
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee; Mid-South Geriatric Research Education and Clinical Center, VA Tennessee Valley Health Care System, Nashville, Tennessee
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Feierman DE, Kim J, Bronstein A, Miller A, Dgheim C, London V, Alter A, Tyagaraj K. The use of bilateral transversus abdominis plane blocks with liposomal bupivacaine on postoperative cesarean delivery patients during COVID-19 pandemic is associated with reduced narcotics use and reduced length of stay. WOMEN'S HEALTH 2021; 17:17455065211058046. [PMID: 34775851 PMCID: PMC8591775 DOI: 10.1177/17455065211058046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The use of transversus abdominis plane blocks has been previously shown in both large-scale studies and our own institution to significantly reduce postoperative pain and opioid use. In addition, the use of bilateral transversus abdominis plane blocks using liposomal bupivacaine in combination with neuraxial morphine significantly reduced post-cesarean-delivery pain and opioid use. During the COVID-19 crisis, our anesthesia department in a collaborative effort with our obstetric colleagues thought that the use of bilateral transversus abdominis plane blocks with liposomal bupivacaine could reduce the use of opioids to treat postoperative pain and might result in decreased length of stay. Methods: After institutional review board approval, a retrospective study of 288 patients who underwent cesarean delivery under spinal or epidural (neuraxial) anesthesia at Maimonides Medical Center in Brooklyn, NY was conducted. Historical controls were from 142 consecutive patients from 1 January 2012 through 12 May 2012. An additional set of controls consisted of 30 consecutive patients from 10 March 2020 through 13 April 2020. The primary outcome data analyzed were the use of opioids and length of stay. Results: Post cesarean delivery, patients who received both bilateral transversus abdominis plane blocks with liposomal bupivacaine and neuraxial morphine was associated with a significant decrease in the number of patients using post operative opioids, 54%–60% decreased to 18% (p < 0.001), and a decreased length of stay; 3.1 days was reduced to 2.39 (p < 0.001). Conclusion: Neuraxial opioids combined with liposomal bupivacaine transversus abdominis plane blocks provided significant pain relief for patients post cesarean delivery, required less post operative opioids, and facilitated earlier discharge that may aid in reducing patient exposure and hospital burden secondary to COVID-19.
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Affiliation(s)
- Dennis E Feierman
- Department of Anesthesiology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Jason Kim
- Department of Anesthesiology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Aden Bronstein
- Department of Anesthesiology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Agnes Miller
- Department of Anesthesiology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Christein Dgheim
- Department of Anesthesiology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Viktoriya London
- Department of OB/GYN, Maimonides Medical Center, Brooklyn, NY, USA
| | - Avram Alter
- Department of Anesthesiology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Kalpana Tyagaraj
- Department of Anesthesiology, Maimonides Medical Center, Brooklyn, NY, USA
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Prescription opioid use after vaginal delivery and subsequent persistent opioid use and misuse. Am J Obstet Gynecol MFM 2020; 3:100304. [PMID: 33383232 DOI: 10.1016/j.ajogmf.2020.100304] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 12/19/2020] [Accepted: 12/23/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Vaginal delivery is the most common reason for hospitalization in the United States, and approximately 30% of women fill an opioid prescription after vaginal delivery, making this a common source of opioid exposure in women of reproductive age. OBJECTIVE This study aimed to evaluate the effect of receiving an opioid prescription after vaginal delivery on the risk of subsequent persistent opioid use, opioid use disorders, and overdose. STUDY DESIGN We assembled a nationwide cohort of Medicaid beneficiaries in the United States using the Medicaid Analytic eXtract 2009-2014. The study population included pregnant women who delivered vaginally between 2009 and 2013 and were continuously enrolled in Medicaid from 90 days before to 365 days after delivery. We identified patients with prescription opioids dispensed within 7 days of the date of vaginal delivery. Persistent opioid use was defined as ≥10 opioid fills or >120 days' supply dispensed from 30 to 365 days after delivery. Incident diagnoses of opioid use disorder and overdose were ascertained during the same interval. Propensity score matching was used to control for potential confounding factors. RESULTS Among 459,829 pregnancies ending in vaginal deliveries, 140,807 (30.62%) had an opioid dispensed within 7 days of delivery. Overall, 5770 of 140,807 (4.10%) women who filled an opioid prescription vs 2668 of 319,022 (0.84%) unexposed women had subsequent persistent opioid use, with an unadjusted relative risk of 4.90 (95% confidence interval, 4.68-5.13) and a risk difference of 3.26% (95% confidence interval, 3.15-3.37). After propensity score matching, the risk remained higher among pregnancies with an opioid prescription dispensed, with a relative risk of 2.57 (95% confidence interval, 2.43-2.72) and a risk difference of 2.21% (95% confidence interval, 2.08-2.33), which was confirmed by the instrumental variable analysis with a risk difference of 1.31% (95% confidence interval, 1.06-1.56) by using the rate of opioid prescribing at the delivery facility in a given geographic region as the instrument. The adjusted relative risk of newly diagnosed opioid use disorder and overdose was 1.48 (95% confidence interval, 1.40-1.57) and 1.92 (95% confidence interval, 1.20-3.09), respectively. CONCLUSION Opioid dispensing following vaginal delivery is associated with future persistent opioid use and misuse, independent of confounding factors. Opioid prescriptions to women after vaginal delivery should be avoided, except in rare circumstances.
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