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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

Opioid dispensing after vaginal delivery: a nationwide cohort study

Abstract Number: S3B-3
Abstract Type: Original Research

Malavika Prabhu MD1 ; Elizabeth M Garry MPH2; Sonia Hernandez-Diaz MD, DrPH3; Sarah C MacDonald ScM4; Krista F Huybrechts MS PhD5; Brian T Bateman MD MSc6

Objective: The national opioid epidemic has led to a critical reappraisal of the circumstances in which opioids are prescribed in an effort to reduce unnecessary exposure to these addictive medications and to limit the supply introduced into communities due to leftover medications. Nationwide patterns of opioid dispensing after vaginal delivery (VD) have not been described.

Methods: We performed a retrospective cohort study of a large, nationwide, commercially insured population from 2003-2015. We identified women having a VD who were opioid-naïve for 12 weeks prior to admission, and had continuous prescription and medical coverage from 12 weeks prior to admission to 1 week post-delivery admission. We excluded those with a diagnosis of opioid or substance use disorder or a peripartum hysterectomy. We assessed the proportion of women dispensed an oral opioid within 1 week of discharge, and the associated median oral morphine milligram equivalent (MME) dose dispensed. We also evaluated predictors of opioid dispensing using multivariable logistic regression. Finally, we assessed the frequency of opioid refill during the 6 weeks post-discharge.

Results: Among 1,345,244 women having a VD, 28.5% were dispensed an opioid, with a median (interquartile range, IQR; 10th-90th percentile) dose of 150 (113-225; 80-345) MME. This dose is equivalent to 20 tablets of oxycodone 5mg (15-30; 11-46). The most commonly dispensed opioids were hydrocodone (44.7%), oxycodone (34.6%), and codeine (13.1%).

In regression analysis, opioids were more commonly dispensed to women who smoke (adjusted odds ratio [aOR] 1.46, 95% confidence interval [CI] 1.39-1.52), use benzodiazepines (aOR 1.87, 95% CI 1.74-2.02) or antidepressants (aOR 1.63, 95% CI 1.59-1.66), and undergo tubal ligation (aOR 3.78, 95% CI 3.68-3.89), operative VD (aOR 1.52, 95% CI 1.50-1.54), or third- or fourth-degree perineal laceration repair (aOR 2.13, 95% CI 2.09-2.17). In addition, as compared to women in the Northeast, women in the South [aOR 4.70, 95% CI 4.63-4.77), West (aOR 2.95, 95% CI 2.90-3.00), and North Central (aOR 2.76, 95% CI 2.72-2.81) regions were more likely to be dispensed opioids. Median MME dose did not vary by additional procedures (operative VD, tubal ligation, third- or fourth-degree perineal laceration repair) performed at the time of delivery.

By 6 weeks, 8.5% filled at least one additional opioid prescription. The frequency of refill was not associated with initial dose dispensed.

Discussion: Opioid dispensing after VD is common, and often at high doses. Codeine represented the third most common opioid prescription, despite a Food and Drug Administration warning of its risks with breastfeeding. As studies suggest many patients experience only mild-to-moderate pain after VD, opioid prescribing in this clinical setting is likely excessive. With greater than 3 million vaginal deliveries annually, curbing unnecessary opioid prescribing could have a significant public health impact.

SOAP 2018