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Inpatient Opioid Use After Vaginal Delivery

Badreldin, N.; Grobman, W.A.; Yee, L.M.

doi: 10.1097/01.aoa.0000575056.81027.f4
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(Am J Obstet Gynecol. 2018;219:608.e1–608)

Inpatient opioid use may serve as a first opioid exposure for many patients undergoing labor and delivery, as well as result in subsequent opioid abuse or dependence. However, data regarding this issue in this patient population are limited; current literature largely focuses on outpatient opioid prescription and treatment for the management of postdelivery pain. Therefore, this study evaluated opioid use in women during postpartum hospitalization and identified both maternal and prescribing provider characteristics associated with opioid prescription and use.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL

This was a retrospective case-control study of adult (above 18 y old), opioid-naive women undergoing vaginal delivery (VD) at a single institution. Women were excluded if they had a nonsteroidal antiiinflammatory drug (NSAID) or morphine allergy, recent opioid use, peripartum hysterectomy, prolonged postpartum stay, or intensive care unit admission. The standard prescription practices for inpatient analgesia were 600 mg ibuprofen every 6 hours and 650 mg acetaminophen 6 hours pro re nata. Postpartum opioid orders required a separate order at provider discretion. Patient demographic and clinical data were collected from electronic medical records and provider data were collected from administrative databases. The primary outcome was use of any oral opioid taken during the last 24 hours of inpatient admission following VD. Secondary outcomes included opioid analgesia type and strength [morphine milligram equivalents (MMEs)]. A subgroup analysis of women who underwent an uncomplicated VD was also performed. Bivariable comparisons, hierarchical multivariable logistic regression models accounting for clustering and confounders, and random effects models were used for statistical analysis.

Of the 9038 women included in the analysis, 24.8% (n=2242) used an opioid during the last 24 hours of inpatient hospitalization. Overall, these women used a median of 20 MMEs. In women with uncomplicated vaginal deliveries (55.74%), 20.5% (n=1032/5038) used an opioid during the last 24 hours of inpatient hospitalization. Similarly, these women also used a median of 20 MMEs, with a range of 5 to 120 MMEs (1 to 10 tablets). Of the providers (n=389), 70.4% were female and the average age was 38.5 (±10) years. In terms of maternal characteristics significantly associated with the primary outcome, women who used opioids were more likely to have a greater body mass index, a history of smoking, substance abuse, depression/anxiety, have utilized intrapartum regional analgesia, have undergone a vaginal birth after cesarean delivery, and experienced perineal lacerations, postpartum hemorrhage, or infectious complication. Women who used an opioid were also more likely to have orders written by a trainee physician [unadjusted odds ratio (OR), 1.36; 95% confidence interval (CI), 1.23-1.51]. After adjusting for these characteristics, a greater number of acetaminophen doses (adjusted OR, 0.81; 95% CI, 0.77-0.85) and orders written by an advanced practitioner (adjusted OR, 0.46; 95% CI, 0.29-0.73) were associated with decreased odds of using an opioid. In the uncomplicated delivery subgroup, after multivariable analysis, higher body mass index and intrapartum regional analgesia were associated with increased odds of opioid use during the last 24 hours of postpartum hospitalization. Asian race/ethnicity, use of a greater number of NSAID and acetaminophen doses, and having orders written by an advanced practitioner, remained associated with decreased odds of inpatient opioid use. Limitations of this study were its retrospective nature, single institution design, and effect of potential confounders.

In summary, ∼25% of women who underwent VD and 20% of women with uncomplicated VD received an opioid during the last 24 hours of their hospitalization. Provider type as well as the use of acetaminophen or NSAIDs can significantly affect the variation seen with inpatient postpartum opioid use following VD. Providers should use different approaches to postpartum pain management and minimize opioid prescriptions after VD.

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COMMENT

In 2017, >47,000 Americans died from an opioid overdose including prescription opioids, heroin, and illicitly manufactured fentanyl, a powerful synthetic opioid. Approximately 21% to 29% of patients prescribed opioids for chronic pain misuse them and about 80% of the people who use heroin first misused prescription opioids. This issue has become a national and public health crisis with severe devastating consequences but can exposure to inpatient opioids subsequently lead to dependence or misuse outside the hospital?

Badreldin et al report the findings of a retrospective case-control study of all opioid-naive parturients who underwent a VD at a single institution over a period of 1 year. Data were collected on opioid use during the last 24 hours of the postpartum hospitalization and statistical analyses applied to identify patient and provider factors associated with any opioid use after VD and opioid use with an uncomplicated VD.

Nearly 25% of women received an opioid during the last 24 hours of their hospitalization following VD, and of the women who underwent an uncomplicated VD, up to 1 in 5 utilized an opioid during the last 24 hours of their postpartum hospitalization. In addition, both the use of a greater number of NSAIDs/acetaminophen and the presence of an advanced practitioner as the prescriber decreased the odds of inpatient opioid use.

This study contributes to the evidence that for a substantial number of healthy women experiencing one of the most common events in life (childbirth), the use of opioid even when the process is uncomplicated, is a common occurrence. This might be a first time experience for some women that may continue and culminate in misuse outside the hospital. The thought of such a possibility compels us as health care providers to become conscientious and intentional about our prescribing practices, especially as some variation in inpatient opioid use was attributed to provider prescribing practices. Not surprisingly, the use of multimodal analgesia can also decrease the need for inpatient opioid and could be “scheduled” to optimize its efficacy.

Strengths of this study include a large sample size with the availability of detailed patient and provider-level data. Limitations, however, are common drawbacks seen with any retrospective and single-site study—the presence of possible unmeasured confounders especially with provider characteristics, questionable generalizability of findings given the variable culture in different practice settings and a slightly skewed patient population.

In conclusion, childbirth remains one of the most common events in life. The majority of patients experiencing childbirth do it vaginally and the majority of these deliveries are uncomplicated. In other words, the beauty of this study lies in the simplicity of its conclusions! For such a formidable national crisis, addressing a “low-hanging fruit” such as this, with a target easy to achieve, could produce high-yield results. This study very elegantly provides an important first step in understanding both patient level but more importantly, provider-level predictors of opioid use. Future studies involving randomized clinical trials and multicenter settings need to be performed to further evaluate the use of opioids for VD in both opioid naïve and opioid tolerant parturients as well as practical interventions necessary to address this epidemic.

Comment by Onyi C. Onuhoa, MD, MPH

Keywords:

Nonobstetric maternal disease; Pharmacology

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