One in 10 Women Fill Opioid Prescription After Vaginal Delivery

Nicola M. Parry, DVM

February 08, 2017

Among Medicaid-enrolled women who experience a vaginal delivery and no opioid use during pregnancy, more than one in 10 fill an outpatient prescription for an opioid after delivery, a new study shows.

Marian Jarlenski, PhD, MPH, from the University of Pittsburgh, Pennsylvania, and colleagues published the results of their retrospective cohort study online February 8 in Obstetrics & Gynecology.

"Our results suggest that many opioid prescriptions after vaginal delivery in Medicaid are unexplained by clinical complications or observed pain-inducing conditions that occur during the delivery hospitalization," the authors write.

"National opioid-prescribing recommendations for common obstetrics procedures such as vaginal delivery are warranted."

According to Dr Jarlenski and colleagues, outpatient use of prescription opioids for acute pain could potentially lead to their long-term use or opioid use disorders. More than one third of Medicaid-enrolled women of reproductive age fill an outpatient prescription for opioids each year, they say. And among women in the United States, deaths from opioid overdoses increased fivefold between 1999 and 2010.

Although maternity care is the most common reason for hospitalization in the United States, little is known about clinicians' opioid-prescribing patterns to women after vaginal delivery.

The researchers therefore conducted a study of 164,720 Medicaid-enrolled women in Pennsylvania who vaginally delivered a live-born infant between 2008 and 2013. They excluded women who had used opioids during pregnancy and those who had an opioid use disorder.

The study's primary outcome was a filled outpatient prescription for an opioid within 5 days after delivery. The secondary outcome was a second filled opioid prescription between 6 and 60 days after delivery.

Overall, 12% (n = 18,131) of women filled an outpatient opioid prescription within 5 days after vaginal delivery. However, records suggest that only 28.2% of these had experienced a pain-inducing condition after delivery.

Moreover, of those women who had filled an opioid prescription within 5 days after delivery, 14.3% (n = 2592; 1.6% of the total) filled a second opioid prescription between 6 and 60 days after delivery. Only 26.2% of those patients had experienced a pain-inducing condition after delivery.

Compared with women who did not fill an opioid prescription after delivery, those who filled one within 5 days were more likely to have experienced a tubal ligation (1.4% vs 12.0%), a third- (1.5% vs 3.1%) or fourth-degree (0.3% vs 1.0%) laceration, or an episiotomy (7.6% vs 14.1%).

The prevalence of these three pain-inducing conditions did not significantly differ between women who did or did not fill a second opioid prescription between 6 and 60 days after delivery, the authors add.

However, among women who did not experience any pain-inducing condition at delivery, the researchers identified predictors that were associated with filling an outpatient opioid prescription. Tobacco use during pregnancy slightly increased the odds of filling a prescription within 5 days after delivery (adjusted odds ratio [aOR], 1.3; 95% confidence interval [CI], 1.2 - 1.4), and of filling a second prescription between 6 and 60 days after delivery (aOR, 1.4; 95% CI, 1.3 - 1.6).

Similarly, having a diagnosis of a mental health condition was associated with a slight increase in the likelihood of filling a prescription within 5 days (adjusted OR, 1.3; 95% CI, 1.2 - 1.4), as well as with a second prescription between 6 and 60 days (adjusted OR, 1.3; 95% CI, 1.1 - 1.5).

Although having a diagnosis of a substance (other than opioid) use disorder was not associated with filling an opioid prescription within 5 days after delivery, it was associated with filling a second prescription between 6 and 60 days after delivery (adjusted OR, 1.4; 95% CI, 1.3 - 1.6).

"Our results suggest that many opioid prescriptions after vaginal delivery in Medicaid are unexplained by clinical complications or observed pain-inducing conditions that occur during the delivery hospitalization," Dr Jarlenski and colleagues write.

Because of concerns about opioid use disorder in the perinatal period, they conclude that the findings "also suggest a need for improved clinical guidelines about pain management after vaginal delivery."

National Guidance Needed

In an accompanying podcast, Nancy C. Chescheir, MD, the editor-in-chief of Obstetrics & Gynecology, discusses the need for development of national guidelines to inform clinicians regarding prescription of opioids for outpatient pain management in women after vaginal delivery.

Despite the lack of national guidelines for this indication, she acknowledges the recent timely release of state-issued guidelines by the Commonwealth of Pennsylvania. These guidelines go some way toward helping address this issue, she says, by outlining a hierarchical pain management plan for clinicians who manage pain associated with vaginal delivery.

The pain management plan recommends that clinicians in the hospital should first treat patients using local therapies, such as heat or cold treatment, or application of topical lidocaine. If this approach is unsuccessful, they should then try nonsteroidal anti-inflammatory drugs, provided there are no contraindications for their use in a particular patient. Clinicians should only progress to opioid prescription, Dr Chescheir adds, if the earlier steps fail to relieve the patient's pain.

She emphasizes that clinicians must consider the risks involved in prescribing opioids in this patient population, highlighting the need to strike a balance between controlling the patient's pain and avoiding overprescribing opioids.

In moving toward a national agreement on opioid-prescribing for obstetric care, Dr Chescheir suggests that if the Commonwealth of Pennsylvania can demonstrate success with their stepwise approach, then this type of pain management plan should probably be adopted more broadly. Organizations such as the American Congress of Obstetricians and Gynecologists may also have a role to play in facilitating this, she adds.

In concluding, Dr Chescheir stresses that the study by Dr Jarlenski and colleagues produced very important findings about women's use of outpatient prescribed opioids after vaginal delivery, which she suspects "will inform some discussions at the local level in hospitals as to what we're doing and why we're doing it."

This study received funding from the University of Pittsburgh, the Pennsylvania Department of Human Services, the Building Interdisciplinary Research Careers in Women's Health Program, and the National Institute on Drug Abuse. The authors and Dr Chescheir have disclosed no relevant financial relationships.

Obstet Gynecol. Published online February 8, 2017.

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