Postpartum Opioid Prescribing Trends

RESEARCH ANALYSIS

Postpartum Opioid Prescribing Trends

KAYLA VALENTI, BS

Drexel University College of Medicine

SUMMARY POINTS

-       The first exposure to opioids for many women of reproductive age is following childbirth.

-       Opioids are being prescribed at much higher rates than they are being consumed among postpartum women.

-       The lack of specific guidelines from The American College of Obstetrics and Gynecologists has resulted in great variation among opioid prescription writing in the postpartum period.

-       Use-based protocols significantly reduced the number of opioid prescriptions written and the number of tablets prescribed.

ANALYSIS

Background

An individual’s first exposure to opioids often occurs following surgery, and this is no different in the pregnant population, as delivery is the most frequent reason for hospitalization (1). Thus, for many women of reproductive age, childbirth marks their first exposure to opioids (2). Minimizing this initial exposure is crucial, as opioid overdose is the leading cause of maternal death within one year of delivery (3). An increased risk of serious opioid-related events, ranging from chronic opioid use to overdose, has been found to correlate with filling an opioid prescription following vaginal delivery (4). Additionally, 1 in 300 women prescribed an opioid after a cesarean section becomes opioid-dependent (2). The health and financial burden of the opioid epidemic has disproportionately affected women of reproductive age (5). With the dual burden of physical recovery and parenthood, postpartum women face heightened risks from opioid prescribing (6). Understanding current postpartum opioid prescription trends can help reduce overprescribing, pill diversion, and the future risk of opioid dependence in new mothers.

Findings

Between the years 2003 and 2015, an estimated one-quarter of women who gave birth were being discharged with an opioid prescription. Of these women, 30% had vaginal deliveries and 87% had cesarean sections when broken down by delivery type (1,5). Additionally, women undergoing cesarean sections had a greater morphine milligram equivalent (MME) and number of tablets than their vaginal delivery counterparts; 300 MME and 30 tablets compared to 200 MME and 24 tablets, respectively. Oxycodone was found to be the most prescribed opioid, followed closely by codeine (1).

It was not until 2021 that the American College of Obstetricians and Gynecologists (ACOG) issued guidelines for opioid prescribing in the postpartum period. For vaginal deliveries, ACOG recommends acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs), with opioids only if needed. For cesarean sections, the same non-opioid medications are recommended, with the option to add a "low-dose, low-potency, short-acting" opioid for the shortest reasonable duration. While the guidelines suggest a stepwise, multimodal approach, they lack explicit prescription limits or expected opioid needs (7).

Figure 1. Opioid pills prescribed versus used.

Many studies have reported that opioids are being prescribed at much higher rates than they are being consumed by postpartum women. One study found that there was an average of 10 pills in vaginal births and 7.5 pills in cesarean births that went unused four to six weeks following discharge (Figure 1). Furthermore, only 2 of the 37 participants in the study disposed of their unused pills (2). If these prescribing trends were to continue, an estimated 10,921 unused pills would enter the community annually. Unused opioids can contribute to nonmedical use, abuse, chronic use, pill diversion, or accidental ingestion. This would worsen the opioid crisis, as more than 50% of people abusing opioids report receiving pills for free from friends or family (1).

Figure 2. Variation in postpartum opioid prescriptions following uncomplicated vaginal births by state.

While ACOG places an emphasis on a personalized approach to postpartum pain management, many studies have shown that there is more variability in practitioner and hospital level characteristics compared to patient characteristics. Figure 2 highlights the findings of a study examining opioid prescribing rates geographically, in which they concluded that southern states had the highest rates and mid-Atlantic states had the lowest (8). Another study interviewed 38 physicians and found that each had unique opioid prescriptions written (9). In evaluating provider and hospital characteristics responsible for this variation, it was found that individual practitioners influenced prescription rates, while hospital characteristics contributed more to prescription size (Figure 3) (6). Lower prescribing rates were associated with nurse-midwife or family medicine training, and with hospitals performing fewer than 500 annual births (6). Without specific prescribing guidelines, providers and hospitals often rely on personal experience or precedent, highlighting a need for policy-based improvements in opioid stewardship.

Figure 3. Variation between practitioner and hospital level prescribing patterns.

Figure 4 demonstrates additional variation in postpartum opioid prescribing. When assessing MME consumption during the final 24 hours of hospitalization, no significant difference was found in discharge MME between women who consumed 0 MME and those who consumed more. A similar trend was observed between women with a pain score of 0 and those reporting pain scores greater than 0. Regardless of prior opioid consumption or reported pain, women were discharged with similar amounts of opioids (1). This suggests a lack of standardization and individualized assessment in discharge opioid prescribing.

Figure 4. Discharge MME range by inpatient MME and last reported pain score following both vaginal and cesarean deliveries.

Discussion

The studies above clearly demonstrate the inconsistency in the opioid prescribing patterns during the postpartum period. Providing appropriate pain control while minimizing the potential harm of opioid prescribing following birth is crucial for helping postpartum patients navigate childbirth recovery while simultaneously transitioning to parenthood. European countries have been found to prescribe opioids to a much lesser degree following both vaginal and cesarean deliveries, suggesting there are alternative pain management regimens that can be equally as effective in minimizing postpartum pain while also decreasing the risks associated with opioid use. This can be attributed to the difference in pain management, as the United States has shifted to treating pain as the “fifth vital sign” (6). Additionally, postpartum pain is characterized by different types and intensities both within and between individuals. Future research should look at improving the clinical assessment of pain beyond the current 0-10 rating scale to tailor patient treatment based on their manifested pain type (11).

Recent studies are assessing the efficacy of use-based opioid prescribing protocols following cesarean sections. Oxycodone was prescribed based on the patient’s consumption 24 hours prior to discharge and only if needed following acetaminophen and NSAIDs. This use-based protocol significantly reduced both the number of prescriptions and tablets given, without increasing 30-day refill requests. This suggests an effective alternative for managing postpartum pain while reducing the number of unused opioids entering the community (12). Future studies are needed to confirm the efficacy of use-based prescribing and to encourage standardized protocols from ACOG to minimize prescribing variability and protect this vulnerable population.

REFERENCES

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