New persistent opioid use after acute opioid prescribing in pregnancy: a nationwide analysis

Abstract

To evaluate the association between opioid prescribing during pregnancy and new persistent opioid use in the year following delivery. MATERIALS AND METHODS: This nationwide retrospective cohort study included patients aged 12À55 years in Optum's deidentified Clinformatics Data Mart Database who were undergoing vaginal delivery or cesarean delivery from 2008 to 2016, with continuous enrollment from 2 years before birth to 1 year postdischarge. Women were included if they were opioid naive in pregnancy (ie, did not fill an opioid prescription 2 years to 9 months before delivery) and did not undergo a procedure within the year after discharge. The exposure was filling an opioid prescription in pregnancy. The primary outcome was new persistent opioid use, defined as a pharmacy claim for !1 opioid prescription between 4 and 90 days postdischarge and !1 prescription between 91 and 365 days postdischarge. Clinical and demographic covariates were included. Analyses included descriptive statistics and multivariable logistic regression, adjusting for clinical and demographic covariates. RESULTS: Of 158,425 childbirths identified, 101,013 (63.8%) were by vaginal delivery and 57,412 (36.2%) cesarean delivery. Among all patients, 6.0% (9429) filled an opioid prescription during pregnancy. The factors associated with filling an opioid in pregnancy were having a nondelivery procedure in pregnancy (adjusted odds ratio, 9.60; 95% confidence interval, 8.81À10.47) and having an emergency room visit during pregnancy (adjusted odds ratio, 2.48; 95% confidence interval, 2.37À2.59). Of women who received an opioid in pregnancy, 4% (379) developed new persistent opioid use. The factors most associated with new persistent opioid use were receiving an opioid prescription during pregnancy (adjusted odds ratio, 3.45; 95% confidence interval, 3.04À3.92) and filling a peripartum opioid prescription (1 week prior to 3 days postdischarge) adjusted odds ratio, 2.28, 95% confidence interval (2.02À2.57). Though having a procedure during pregnancy was associated with increased receipt of an opioid prescription, it was also associated with reduced new persistent opioid use (adjusted odds ratio, 0.72; 95% confidence interval, 0.52À0.99). CONCLUSION: Women who receive an opioid prescription during pregnancy are more likely to experience new persistent opioid use. Maternity care providers must balance pain management in pregnancy with potential risks of opioids.

Opioid Prescribing Practices for Women Undergoing Elective Gynecologic Surgery

“…The exact rate of NPOU is highly dependent on the definition. Our data is consistent with other studies which utilized a similar methodology: Brummett et al NPOU rates between 5.9% to 6.5%; Wright et al 6.8%; Peahl et al 4% 7,16,22 . Not surprisingly, studies with more stringent definitions reported lower rates of NPOU 8,9,23 .…”

“…We were able to demonstrate that several patient characteristics are associated with risk of NPOU among women with perioperative opioid use. We showed that patients who have a mental health diagnosis, have a history of substance use disorder, or high amounts of prescribed OMEs had higher rates of NPOU and these findings are consistent with findings from similar studies 5,9,16,29 . Given our large cohort, the magnitude of these risks is modest and likely merit further confirmation.…”

“…To limit the cohort to opioid-naïve patients, we excluded those who underwent additional surgery within 30-days prior to the index, those with previous hospital presentation for opioid toxicity and patients who filled an opioid prescription between 1 year to 31 days prior to the index. These definitions were consistent with methodology for similar studies 7,13,16 .…”

“…We also identified NPOU after gynecologic surgery, which was defined as having filled ≥1 opioid prescription between 91 to 180 days post-operatively. There is a consensus in the literature that post-operative pain related to surgery should have resolved by 90 days 7,13,16 .…”

The risk of serious opioid-related events associated with common opioid prescribing regimens in the postpartum period after cesarean delivery

“…[4][5][6][7][8][9] Increasing evidence indicates that for both vaginal and cesarean deliveries, opioid prescribing during the postpartum period is associated with an increased risk of SOREs. 5,6,10,11 Approaches that improve postpartum opioid prescribing, including after cesarean, are greatly needed. 12,13 Currently, opioid prescribing guidelines for acute pain among opioid naïve patients recommend the use of the lowest effective opioid dose for the shortest duration.…”