Opioid prescribing after childbirth: overprescribing and chronic use

Abstract

Purpose of review-Over-prescribing opioids contributes to the epidemic of drug overdoses and deaths in the United States. Opioids are commonly prescribed after childbirth especially after cesarean, the most common major surgery. This review summarizes recent literature on patterns of opioid over-prescribing and consumption after childbirth, the relationship between opioid prescribing and chronic opioid use, and interventions that can help reduce over-prescribing. Recent findings-It is estimated that more than 80% of women fill opioid prescriptions after cesarean birth and about 54% of women after vaginal birth, although these figures vary greatly by geographical location and setting. After opioid prescriptions are filled, the median number of tablets used after cesarean is roughly 10 tablets and the majority of opioids dispensed (median 30 tablets) go unused. The quantity of opioid prescribed influences the quantity of opioid used. The risk of chronic opioid use related to opioid prescribing after birth may seem not high (annual risk: 0.12-0.65%) but the absolute number of women who are exposed to opioids after childbirth and become chronic opioid users every year is very large. Tobacco use, public insurance, and depression are associated with chronic opioid use after childbirth. The risk of chronic opioid use among women who underwent cesarean and received opioids after birth is not different from the risk of women who received opioids after vaginal delivery. Summary-Women are commonly exposed to opioids after birth. This exposure leads to an increased risk of chronic opioid use. Physician and providers should judiciously reduce the amount of opioids prescribed after childbirth, although more research is needed to identify the optimal method to reduce opioid exposure without adversely affecting pain management.

Trends in Postpartum Opioid Prescribing: A Time Series Analysis

“…Safety concerns regarding postpartum opioid use have historically focused on the nursing neonate, and there are limited data regarding the maternal harms of opioid use following childbirth, including the potential for persistent opioid use 1,12,15,16,38,39 . Previously identified risk factors for ongoing opioid use after childbirth include prior substance use, certain psychiatric conditions, and concomitant use of benzodiazepines and antidepressants 38,39 .…”

“…However, the consequences of its original publication have not been studied. A shift from codeine to more potent opioids, for example, may place mothers at heightened risk of persistent opioid use, opioid use disorder, and overdose, while unused tablets of more potent opioids may pose a hazard to other young children in the home 15–17 . Importantly, there is no reason to believe maternal use of more potent opioids is safer for breastfeeding neonates than codeine.…”

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

“…While severe opioid-related events such as opioid use disorder, opioid-related overdose and death remains relatively rare among American women, these tragic, but preventable, events represent a public health challenge due to the large number of cesarean deliveries in the US each year (>1.2 million). 4,26 Reductions in opioid prescribing after cesarean delivery could reduce the incidence of persistent opioid use and other SOREs.…”

“…Such exposure is a potential precipitating event for the development of serious opioid-related events (SOREs), including persistent opioid use, opioid use disorder and opioid-related overdose and death. [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.…”

“…Baseline 1 and follow-up characteristics of women with cesarean birth stratified by Baseline included covariates measured during pregnancy through day 4 after birth; 2 Individual categories for severe maternal morbidity included myocardial infarction, aneurysm, renal disease, acute respiratory distress syndrome, AFE, liver disease, arrythmia, DIC, eclampsia, heart failure, CVA, edema, anesthesia complication, sepsis, shock, sickle cell disease, embolism, transfusion, hysterectomy, tracheal intubation, cardiomyopathy, and ventilation;3 Categories created a priori based on the quartile distribution of visits during pregnancy only (180 days before delivery through 3 days before delivery). Clustering at specific values led to only 3 categories for each variable;4 Outpatient visits includes but are not limited to prenatal care visits…”