EXECUTIVE SUMMARY

In a new national cohort study of more than 300,000 deliveries, findings indicate that women who received a peripartum opioid prescription had rates of new persistent opioid use of 1.7% for vaginal delivery and 2.2% for cesarean delivery.

• According to earlier studies, more than 33% of women give birth via cesarean delivery each year and 66% receive a peripartum opioid prescription. Two-thirds of women who give birth each year will have a vaginal delivery, of whom approximately one-quarter will receive an opioid prescription.

• National guidance calls for a three-step approach to postpartum pain relief, with nonopioid analgesics, such as acetaminophen or nonsteroidal anti-inflammatory drugs, to be used first.


A new mother delivered her first child six months ago via cesarean delivery. Her medication list indicates she is continuing to use her peripartum opioid prescription.

Such incidents are not uncommon. In a new national cohort study of more than 300,000 deliveries, findings indicate that women who received a peripartum opioid prescription had rates of new persistent opioid use of 1.7% for vaginal delivery and 2.2% for cesarean delivery.1

Results of earlier studies show that 33% of women who give birth each year have a cesarean delivery; 66% receive a peripartum opioid prescription.2,3 Two-thirds of women who give birth each year have a vaginal delivery, of whom approximately one-quarter receive an opioid prescription.4

University of Michigan (UM) obstetrician and health services researcher Alex Friedman Peahl, MD, and colleagues examined patterns of opioid prescribing to women with private insurance who had not received opioids for a year before delivering. The investigators limited the study to women who did not suffer major birth complications or have any other procedures in the year following a birth.

“Overall, we see rates of opioid persistence higher than previously documented for women having C-sections, at about 2%,” Peahl said in a press statement. “For women who delivered vaginally, one-quarter received opioid prescriptions, although current guidelines call for a stepwise approach to pain management, starting with non-narcotic medications such as ibuprofen and acetaminophen; 1% of vaginal birth mothers were still receiving opioids months later.” (The statement can be viewed at: https://bit.ly/2ZxOj6y.)

Peahl, a National Clinician Scholar at the UM Institute for Healthcare Policy and Innovation, collaborated with Institute members involved with the Michigan Opioid Prescribing and Engagement Network. Senior author Jennifer Waljee, MD, MPH, MS, worked with Peahl in using an approach previously used to study opioid prescriptions after inpatient surgery.

Study findings suggested that women who gave birth in their teens or early 20s, as well as those with more medical issues at time of delivery, such as those related to pain or mental health, had higher rates of persistence. Mothers in the South and Midwest and women who used tobacco during pregnancy also were at higher risk for persistence, data indicated.

Researchers found two key factors: The larger the vial, the more likely women were to refill multiple prescriptions in the months after giving birth. Also, women who filled prescriptions prior to delivery were more likely to develop new persistent use.

Similar findings have been noted in surgical patients, according to previous research conducted by Waljee and colleagues.5 The researchers created prescribing guidelines for surgical teams that are based on patient feedback on pain control. Their cesarean section recommendations call for women to receive up to 20 5-mg oxycodone tablets or the equivalent.

Check Prescribing Recommendations

While guidelines for postpartum prescribing from both the American College of Obstetricians and Gynecologists (ACOG) and the American Pain Society advocate for stepwise, multimodal approaches to pain management, neither guidance includes specific recommendations on whether women should be discharged with an opioid prescription after vaginal delivery or cesarean delivery and, if so, with how many tablets.5,6

Using long-lasting opioids for the height of birth pain as part of an epidural, and reserving oral opioids for “breakthrough” post-birth pain, is possible, according to Peahl.

Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can provide effective pain relief in the days after birth, Peahl said, especially if women receive education on proper use during birth preparation. This approach can reduce post-discharge opioid painkiller use, she noted. ACOG calls for a three-step approach to postpartum pain relief, with nonopioid analgesics, such as acetaminophen or NSAIDs, to be used first. Step two adds milder opioids such as codeine, hydrocodone, oxycodone, tramadol, and oral morphine, and step three incorporates stronger opioids, such as parenteral morphine, hydromorphone, and fentanyl. When pain cannot be managed adequately with step one nonopioid medications, milder, short-acting opioids are the preferred next option, ACOG guidance states.6

Peahl and colleagues are contacting new mothers who received opioid painkillers to find out how many pills they used out of the total prescribed number. The researchers also are examining a new protocol that includes more robust patient education and shared decision-making about opioid prescriptions at the time of discharge.

“No matter which way they deliver, women should be able to get up and spend time with their new baby,” Peahl said in the statement. “Pain, and the effects of pain control medications, should not get in the way of their birth experience and bonding with their infant.”

REFERENCES

  1. Peahl AF, Dalton VK, Montgomery JR, et al. Rates of new persistent opioid use after vaginal or cesarean birth among US women. JAMA Netw Open 2019;doi: 10.1001/jamanetworkopen.2019.7863.
  2. Torio CM, Andrews RM; Healthcare Cost and Utilization Project (HCUP) Statistical Briefs; Agency for Healthcare Research and Quality (US). National inpatient hospital costs: The most expensive conditions by payer, 2011: Statistical Brief #160. Rockville, MD: Agency for Healthcare Research and Quality; 2013.
  3. Bateman BT, Franklin JM, Bykov K, et al. Persistent opioid use following cesarean delivery: Patterns and predictors among opioid-naïve women. Am J Obstet Gynecol 2016;doi:10.1016/j.ajog.2016.03.016.
  4. Prabhu M, Garry EM, Hernandez-Diaz S, et al. Frequency of opioid dispensing after vaginal delivery. Obstet Gynecol 2018;132:459-465.
  5. Shen MR, Waljee JF. Enhanced recovery after surgery protocols: Can they reduce postoperative opioid use? Ann Surg 2019;doi: 10.1097/SLA.0000000000003475.
  6. ACOG Committee. ACOG Committee opinion No. 742 summary: Postpartum pain management. Obstet Gynecol 2018;132:252-253.
  7. Chou R, Gordon DB, deLeon Casasola OA, et al. Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain 2016;17:131-157.