Physicians thinking about prescribing opioid painkillers for women around the time of delivery should think twice, a new study suggests, because some go on to “persistent” opioid use.
A report published Friday in JAMA Network Open examined opioid prescriptions among more than 300,000 women who gave birth between 2008 and 2016. Nearly half were given an opioid prescription shortly before or after giving birth. Among the women who filled the prescriptions, about 2% showed signs of “persistent” opioid use, defined as two subsequent refills within one year after the delivery. These prescriptions are short, on average about one to two weeks of medication.
During the study period, both the percentage of women who filled their prescriptions and the rate of persistent opioid use declined.
But because so many women deliver babies each year, even 2% of persistent opioid use is meaningful from a public health standpoint, said Rishi Desai, an epidemiologist at Brigham and Women’s Hospital, who was not involved in the study.
Dr. Alex Peahl, an OB-GYN from the University of Michigan who led the study, said she was surprised to see so many women prescribed opioids around the time of delivery. The research team expected few women to need subsequent refills because delivery-related pain generally resolves around four to six weeks after delivery.
“It’s of course a topic that is on many people’s minds because pregnancy is one of the most common reasons why a lot of young women without any sort of health conditions come into contact with the health care system,” said Desai.
Persistent opioid use was seen in 1.7% of women with vaginal deliveries and 2.2% of those with cesarean deliveries.
The narrow difference between persistence among women following vaginal birth or C-section “makes us think that there’s something inherent to the prescription rather than what women are going through that’s driving persistent use,” said Peahl.
The researchers chose delivery because pregnancy and delivery are often the first contacts many women have to be exposed to prescription opioids. It raises a concern, said Desai. Once you start a pregnant woman on one opioid prescription, what is the probability that she will go on to use opioids longer term?
In this study, the biggest factor associated with increased odds of developing persistent opioid use is the first fill of a prescription, not the type of delivery.
The authors compared their findings to those of a recent study on similarly young, healthy individuals who had never before taken opioids and who were having their wisdom teeth removed, which can also represent a first exposure to opioids. After oral surgery, 1.3% of those who filled opioid prescriptions showed persistent opioid use, similar to the odds following delivery. Another study comparing major and minor surgical procedures showed similar results about first exposure to opioids.
Peahl and colleagues studied claims from commercial insurance, often through employers, which covers half of women in the U.S. through their pregnancies. Across the U.S., however, Medicaid covers more than 40% of deliveries. Using stricter definitions for persistent use, Desai and his colleagues reported in a presentation to the Society for Epidemiologic Research rates of persistent opioid use as high as 4.6% among women covered by Medicaid.
Painful conditions and complications can occur during vaginal deliveries. The biggest of these linked to new persistent opioid use was tubal ligation. However, the amount of opioids prescribed and the timing — filling an opioid prescription before delivery — had even greater effects. Among women who delivered by C-section, only one complication, a rare and emergency hysterectomy (removal of the uterus), was associated with increased rates of new persistent opioid use.
Other well-known factors, such as tobacco use, prior substance use disorder, and prior pain disorders, were also linked to persistent use.
“This study shows that there continues to be a chance to really intervene on the prevention side,” said Marian Jarlenski, an assistant professor of health policy and management at the University of Pittsburgh Graduate School of Public Health, who was not involved in this study. The decision to write an initial prescription is a low-hanging-fruit point of intervention, she said.
The outcome that Peahl and colleagues used in their study, “new persistent use,” is not the same as persistent use disorder, formerly called substance abuse (a term abandoned by the Diagnostic and Statistical Manual of Mental Disorders in 2013). It’s possible that use of this definition overestimated the number of women who went on to persistent opioid use after delivery, Desai and Jarlenski said. Another limitation, said the study team, is that they were not able to determine if the pills in the prescriptions were actually taken.
“I think it first gives us a validity check that what we’re finding in this population is similar to other populations,” said Peahl. “Pain can be very complicated and affected by a variety of factors. Understanding how to prevent new persistent use, and ultimately abuse, requires really an interdisciplinary nuanced approach to helping patients navigate complex situations.”
To help manage pain following C-section, for example, Peahl and her colleagues at the University of Michigan use opioid-sparing pain protocols, which include steps to help patients prepare for pain control and shared-decision making before and throughout their hospitalization.
The American College of Obstetricians and Gynecologists offer guidelines for managing pain after childbirth that include opioids and alternatives to them. According to a spokesperson, the college reviews its guidelines every 18-24 months, or more frequently based on new information.