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.

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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.

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  • All these so called professors are giving you their opinions if they never had 4 wisdom teeth pulled at the same time they would beg for pain medication or never gave birth or have to live there life in pain every moment of every day don’t have any right to be making these decisions I say to president Trump take a stand on this issue because it’s going to take more lives do to suicide and also more illegal drug use this is and will happen

  • Why punish 98% of mothers due to the actions of 2% and risk encouraging new Moms to resort to even more dangerous illicit drugs for pain relief or alcohol use? Is heroin or vodka really a better solution than a handful of hydrocodone or oxycodone pills? Why not just limit the initial prescription to 6 weeks without follow up and medical justification for a refill? Seems more reasonable than this knee jerk reaction to advocate outright prohibition. Didn’t we learn the hard way in the 1900’s that prohibition doesn’t work? I don’t want to help give the drug cartels even more customers and more power. Let’s be responsible with our solutions rather than giving decision makers another reason to head towards total government take over of health care. We are the land of the free, home of the brave, and we fought and died for freedom against govenment tyranny, yet so many seem ready to surrender our rights and freedoms in exchange for abandoning the fundamental ideas of individual accountability and responsibility. Let grown ups be grown up and stop treating everyone like a deliquent bent on self-destruction, and figure out Why not figure out what is causing the 2% to end up on long term use and solve that problem in a manner that doesn’t harm the 98%?

  • How hard are you going to work to make an issue out of 2%? Let me ask you this: Do you know how many of these women were on opioids whenever they came in? Do you know if they had any complications during delivery? You do say that prior pain disorders were related. Well… DUH. The meaningful contextual information has been omitted from this publication.

    Please, stop stigmatizing patients. DO NO HARM. I’m really tired of reading biased materials. The real story is the cocaine busts and fentanyl-laced heroin. I thought you would share higher quality material. Please vet your content appropriately. This does not rise to the level of a “study.”

  • Kathryn,

    How many children have you had? Vaginal, C-section, or Vback? How old were you at the time of each birth? Were there any complications prior to or after delivery? Were any other procedures done during or after delivery?

    Just because women have been giving birth since “Adam & Eve” doesn’t mean that some women don’t need pain control after birth. Over 8 years, there were only 300,000 women that they looked at for this study. Half were given prescriptions, but only 2% had a refill or another prescription for opioids within the following year. Plus, there is NO data on whether these women even took any of the subsequent prescription! This study jumps to TOO many conclusions, and so do you. If you think that a short prescription is “abhorrent” after some procedures, then don’t take them. Just because you would rather have a woman give birth while working out in the fields than have medical care during birth doesn’t make it right.

    This study also lacks ANY information on whether the mothers had any painful diseases or conditions prior to the birth, which one would think would be an important statistic. Also, there is NO data on how many of these mothers had any procedures right after birth. So out of all of this, all we know is that 6000 of these women had a subsequent prescription, which the pharmacy may have refilled without direct orders from the patient, and we don’t even know if any of those pills were taken. Honestly, I’m *very* surprised that this study was even found fit for publication… oh, wait, no I’m not, because it has to do with the Big Bad Opioid. So even though it has more holes than a colander, let’s publish it and then go on to make sweeping generalizations about what it means. And for heaven’s sake, let’s not throw the baby out with the bath water.

  • I am a mother, and I am shocked. Women have delivered babies since Adam & Eve – without opioids. It is abhorrent that opioids get prescribed for a process that is very painful but only a necessary evil. This is absolute overkill, and indeed also very easily prevented. MD’s that prescribe opioids for deliveries need to get their cages rattled – they are NOT doing their patient any service. Women are stronger than that – or at least : they ought to be.

    • I’m not saying it isn’t important kathryn, but its only 2% of this group. The government is using this statistic along with the fact that only about 1% of pain patients are abusing opioids to justify their war on drugs with the opioid epidemic…These are low numbers! It’s absurd and the majority of people who are being harmed the most are pain patients, who use opioids are prescribed, and who desperately need these medications.

    • How do you know babies have been delivered since Adam & Eve without opioids, since they have existed for 4,000 years? How many died in childbirth before the advent of opioid analgesics? Could some of those deaths been prevented by reasonable pain control? What about those who have had a C-Section, not just natural labor? Perhaps we don’t need any medications whatsoever nor any physicians either – just let nature take its course. Survival of the fittest – law of the jungle. Forget all the work done by researchers to bring solutions to market to empower MDs to use their clinical judgement. Let government dictate every medical decision because bureaucrats have much better knowledge than well trained physicians.

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