Childbirth is the most common reason for hospitalization in the United States. Pain after vaginal and caesarean delivery is common, and opioids are commonly prescribed in this setting. About 25% to 30% of women receive an opioid prescription after vaginal delivery and around 75% receive an opioid prescription after vaginal delivery. There is a growing body of evidence to indicate that use of prescription opioids may increase subsequent risk for persistent opioid use and opioid use disorder. Several recent studies have examined patterns of opioid use in women receiving opioid prescriptions for pain management after delivery.
Analyzing data from the Medicaid Analytic eXtract 2009-2014, researchers identified a nationwide cohort of 459,829 pregnant Medicaid beneficiaries in the United States who delivered vaginally between 2009 and 2013. They identified patients who had received prescription opioids within 7 days of delivery. They compared patterns of opioid use in women who received or did not receive prescription opioids during the first week postpartum.
Persistent opioid use was defined as 10 or more opioid fills or greater than 120 days’ supply dispensed during the first year postpartum. They also identified women with opioid use disorder and overdose during the same period of observation.
Among the 459,829 pregnancies with vaginal delivery, 140,807 (30.62%) received an opioid prescription within 7 days of delivery. Women who received an initial opioid prescription were more likely to develop persistent opioid use during the first year (4.10%) than women who did not receive prescription opioids (0.84%). After adjusting for potential confounding variables, the risk remained higher among women receiving an opioid prescription after delivery, with a relative risk of 2.57 (95% CI, 2.43-2.72).
Risk for a newly diagnosed opioid use disorder or overdose was also increased among women who received an opioid prescription after delivery, with adjusted relative risks of 1.48 (95% CI, 1.40-1.57) and 1.92 (95% CI, 1.20-3.09), respectively.
The findings derived from the Medicaid Analytic eXtract may not be generalizable to all populations of women; however, a similar study examining patterns of postpartum opioid use in a cohort of 988,036 commercially insured women also demonstrated higher rates of persistent opioid use in women receiving opioids after delivery. In this cohort, peripartum opioid prescriptions were filled by 27.0% of women with vaginal deliveries and 75.7% of women with cesarean deliveries. Women who received an initial opioid prescription were more likely to develop persistent opioid use (1.7% of women with vaginal deliveries and 2.2% with cesarean deliveries) compared to women who did not receive prescription opioids after delivery (0.5% with vaginal delivery and 1.0% with cesarean delivery). The overall prevalence of persistent opioid use is lower among commercially insured women; however, whether women were on Medicaid or had commercial insurance, receiving a prescription for opioids after delivery was associated with a 2-3 fold increase in risk of persistent opioid use.
Based on these findings of increased rates of persistent opioid use, opioid use disorder, and overdose in women receiving prescription opioids for postpartum pain management, the authors clearly state, “Opioid prescriptions to women after vaginal delivery should be avoided, except in rare circumstances.” The American College of Obstetricians and Gynecologists (ACOG) recommends a stepwise multimodal approach to postpartum pain management, urging clinicians to use opioids only for breakthrough symptoms, after other attempts at analgesia have failed, and to carefully weigh the benefits of initiating opioid therapy versus the risks.
Ruta Nonacs, MD PhD
ACOG Committee Opinion No. 742: Postpartum Pain Management Obstet Gynecol, July 2018.
Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management (ACOG Clinical Consensus, September 2021)
Peahl AF, Dalton VK, Montgomery JR, Lai YL, Hu HM, Waljee JF. Rates of New Persistent Opioid Use After Vaginal or Cesarean Birth Among US Women. JAMA Netw Open. 2019 Jul 3;2(7):e197863. Free article.
Zhu Y, Huybrechts KF, Desai RJ, Franklin JM, Hernandez-Diaz S, Krumme A, Straub L, Neuman M, Wunsch H, Levin R, Mogun H, Bateman BT. Prescription opioid use after vaginal delivery and subsequent persistent opioid use and misuse. Am J Obstet Gynecol MFM. 2021 Mar;3(2):100304.