Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naïve women

Abstract

Background The incidence of opioid-related death in women has increased five-fold over the past decade. For many women, their initial opioid exposure will occur in the setting of routine medical care. Approximately 1 in 3 deliveries in the U.S. is by Cesarean and opioids are commonly prescribed for post-surgical pain management. Objective The objective of this study was to determine the risk that opioid naïve women prescribed opioids after Cesarean delivery will subsequently become consistent prescription opioid users in the year following delivery, and to identify predictors for this behavior. Study Design We identified women in a database of commercial insurance beneficiaries who underwent Cesarean delivery and who were opioid-naïve in the year prior to delivery. To identify persistent users of opioids, we used trajectory models, which group together patients with similar patterns of medication filling during follow-up, based on patterns of opioid dispensing in the year following Cesarean delivery. We then constructed a multivariable logistic regression model to identify independent risk factors for membership in the persistent user group. Results 285 of 80,127 (0.36%, 95% confidence interval 0.32 to 0.40), opioid-naïve women became persistent opioid users (identified using trajectory models based on monthly patterns of opioid dispensing) following Cesarean delivery. Demographics and baseline comorbidity predicted such use with moderate discrimination (c statistic = 0.73). Significant predictors included a history of cocaine abuse (risk 7.41%; adjusted odds ratio 6.11, 95% confidence interval 1.03 to 36.31) and other illicit substance abuse (2.36%; adjusted odds ratio 2.78, 95% confidence interval 1.12 to 6.91), tobacco use (1.45%; adjusted odds ratio 3.04, 95% confidence interval 2.03 to 4.55), back pain (0.69%; adjusted odds ratio 1.74, 95% confidence interval 1.33 to 2.29), migraines (0.91%; adjusted odds ratio 2.14, 95% confidence interval 1.58 to 2.90), antidepressant use (1.34%; adjusted odds ratio 3.19, 95% confidence interval 2.41 to 4.23) and benzodiazepine use (1.99%; adjusted odds ratio 3.72, 95% confidence interval 2.64 to 5.26) in the year prior to Cesarean delivery. Conclusions A very small proportion of opioid-naïve women (approximately 1 in 300) become persistent prescription opioid users following Cesarean delivery. Pre-existing psychiatric comorbidity, certain pain conditions, and substance use/abuse conditions identifiable at the time of initial opioid prescribing were predictors of persistent use.

Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic

“…44,47,51–54 Even opioids prescribed for low-pain, outpatient, or short-stay surgeries increase the risk of persistent opioid use, 51,52 and over 60% of people receiving 90 days of continuous opioid therapy remain on opioids years later. 55 Patients receiving an opioid prescription after short-stay surgeries have a 44% increased risk of long-term opioid use.…”

“…56,59 Use of specific medications including preoperative benzodiazepines and antidepressants are also associated with persistent opioid use after surgery. 54,56,59 …”

Recovery after Nulliparous Birth

“…Recent population based studies that have investigated opioid utilization after surgery, have similarly found relatively short duration of opioid requirements after cesarean delivery. 11,12 In the study by Sun and colleagues, 12 chronic opioid use was defined as having filled 10 or more prescriptions or having obtained more than 120 days’ supply of opioids within 1-year after cesarean delivery. The absolute risk of opioid naïve women becoming a chronic opioid user was 0.12%, which was 28% higher risk than a matched non-surgical control population.…”

“…Bateman et al stratified opioid naïve women into 5 categories according to the pattern of medication filling after cesarean delivery to identify persistent opioid users. 11 They demonstrated that 0.36% of women fell into the category of persistent opioid users, who on average dispensed opioids in 6.1 out of 12 months following cesarean delivery. Our study is unique in providing daily opioid utilization data after cesarean delivery to outline use trajectories rather than just relative risk determinations.…”

“…Further, leftover opioid could be diverted and abused by somebody for whom the prescription is not intended. An estimated 1 in 300 opioid-naive women become persistent opioid users after cesarean delivery, 11 and cesarean delivery is associated with an increased risk of chronic opioid use compared to non-surgical controls (odds ratio 1.28 [1.12–1.46]). 12 Due to the large population at risk, opioid exposure in the postpartum period is a significant public health consideration.…”