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Poeran J, Park CH. Postpartum Opioid Prescribing and Persistent Use in Western Countries. Anesth Analg 2024; 138:967-969. [PMID: 38621284 DOI: 10.1213/ane.0000000000006953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Affiliation(s)
- Jashvant Poeran
- From the Departments of Orthopaedic Surgery
- Anesthesiology, Perioperative and Pain Medicine
- Medicine, Institute for Healthcare Delivery Science
- Departments of Population Health Science & Policy
| | - Chang H Park
- Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Peahl AF, Low LK, Langen ES, Moniz MH, Aaron B, Hu HM, Waljee J, Townsel C. Drivers of variation in postpartum opioid prescribing across hospitals participating in a statewide maternity care quality collaborative. Birth 2023. [PMID: 38158784 DOI: 10.1111/birt.12809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 10/06/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND We describe variation in postpartum opioid prescribing across a statewide quality collaborative and assess the proportion due to practitioner and hospital characteristics. METHODS We assessed postpartum prescribing data from nulliparous, term, singleton, vertex births between January 2020 and June 2021 included in the clinical registry of a statewide obstetric quality collaborative funded by Blue Cross Blue Shield of Michigan. Data were summarized using descriptive statistics. Mixed effect logistic regression and linear models adjusted for patient characteristics and assessed practitioner- and hospital-level predictors of receiving a postpartum opioid prescription and prescription size. Relative contributions of practitioner and hospital characteristics were assessed using the intraclass correlation coefficient. RESULTS Of 40,589 patients birthing at 68 hospitals, 3.0% (872/29,412) received an opioid prescription after vaginal birth and 87.8% (9812/11,177) received one after cesarean birth, with high variation across hospitals. In adjusted models, the strongest patient-level predictors of receiving a prescription were cesarean birth (aOR 899.1, 95% CI 752.8-1066.7) and third-/fourth-degree perineal laceration (aOR 25.7, 95% CI 17.4-37.9). Receiving care from a certified nurse-midwife (aOR 0.63, 95% CI 0.48-0.82) or family medicine physician (aOR 0.60, 95%CI 0.39-0.91) was associated with lower prescribing rates. Hospital-level predictors included receiving care at hospitals with <500 annual births (aOR 4.07, 95% CI 1.61-15.0). A positive safety culture was associated with lower prescribing rates (aOR 0.37, 95% CI 0.15-0.88). Much of the variation in postpartum prescribing was attributable to practitioners and hospitals (prescription receipt: practitioners 25.1%, hospitals 12.1%; prescription size: practitioners 5.4%, hospitals: 52.2%). DISCUSSION Variation in postpartum opioid prescribing after birth is high and driven largely by practitioner- and hospital-level factors. Opioid stewardship efforts targeted at both the practitioner and hospital level may be effective for reducing opioid prescribing harms.
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Affiliation(s)
- Alex F Peahl
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lisa Kane Low
- School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth S Langen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michelle H Moniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Bryan Aaron
- Medical School, University of Michigan, Ann Arbor, Michigan, USA
| | - Hsou Mei Hu
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer Waljee
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Courtney Townsel
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
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Zanfini BA, Di Muro M, Biancone M, Catarci S, Piersanti A, Frassanito L, Ciancia M, Toni F, Santantonio MT, Draisci G. Ultrasound-Guided Bilateral Erector Spinae Plane Block vs. Ultrasound-Guided Bilateral Posterior Quadratus Lumborum Block for Postoperative Analgesia after Caesarean Section: An Observational Closed Mixed Cohort Study. J Clin Med 2023; 12:7720. [PMID: 38137789 PMCID: PMC10744071 DOI: 10.3390/jcm12247720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/10/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023] Open
Abstract
ESP block (ESPB) and posterior Quadratus Lumborum Block (pQLB) have been proposed as opioid-sparing techniques for the management of pain after abdominal surgery. Between December 2021 and October 2022, we conducted a retrospective comparative study at the delivery suite of Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy, to compare the efficacy of ESPB and pQLB in preventing postoperative pain after an elective caesarean section (CS). The primary outcome was total morphine consumption in the first 24 h. Secondary outcomes were time to first opioid request; Numerical Pain Rating Scale (NPRS) at 0, 2, 6, 12 and 24 h; vital signs; adverse events. Fifty-two women were included. The total cumulative dose of morphine was not significantly different between the two groups of patients (p = 0.897). Time to first dose of morphine, NPRS values and haemodynamic parameters were not statistically different between the two groups. NPRS values significantly increased (p < 0.001) at the different time intervals considered. The need for rescue doses of morphine was lower in the ESPB group compared to the pQLB group (hazard ratio of 0.51, 95% CI (0.27 to 0.95), p = 0.030). No adverse event was reported. ESPB seems to be as effective as pQLB in providing analgesia after CS.
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Affiliation(s)
- Bruno A. Zanfini
- Department of Anaesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
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Variation in Opioid Prescribing After Vaginal and Cesarean Birth: A Statewide Analysis. Womens Health Issues 2023; 33:182-190. [PMID: 36151029 DOI: 10.1016/j.whi.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Our aim was to evaluate variation in opioid prescribing rates and prescription size following childbirth across providers and hospitals. METHODS This retrospective cohort study analyzed claims data from a single-payer Preferred Provider Organization from June 2014 to May 2019 in 84 hospitals in a statewide quality collaborative. All patients aged 12-55 years, undergoing childbirth, with continuous enrollment in pregnancy were included. The primary outcome was the predicted rate of postpartum opioid fills from 7 days before birth to 3 days after discharge. Secondary outcomes included postpartum opioid prescription size in oral morphine equivalents, a standardized measure that includes the number of pills prescribed times the strength of the medication. Multilevel regression models accounted for clustering. We calculated attributable variation in opioid fills using the intraclass correlation coefficient. RESULTS Of 41,427 births, 15,459 patients (37.2%) filled a postpartum opioid prescription (vaginal, 4,624/27,536 [16.8%]; cesarean, 10,835/13,891 [78.0%]). The median postpartum prescription size was 150 oral morphine equivalents (interquartile range [IQR], 30) (vaginal, 135; [IQR, 45]; cesarean, 150 [IQR, 75]). In adjusted models, the rates of opioid prescribing after vaginal birth differed from cesarean birth (vaginal median, 12.1% [range, 1.1%-60.0%]; cesarean median, 80.4% [range, 43.6%-90.2%]). More variation in postpartum opioid fills was attributable to providers and hospitals for vaginal (provider, 29%; hospital, 24%) than cesarean birth (provider, 8%; hospital, 6%). Variation in prescription size was driven by providers for vaginal birth (provider, 27%; hospital, 6%) and providers and hospitals for cesarean birth (provider, 29%; hospital, 21%). CONCLUSIONS Across a statewide quality collaborative, variation in postpartum opioid prescribing is attributable to providers and hospitals. Future efforts at the provider and hospital levels are needed to implement best practices for postpartum opioid prescribing.
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Araújo KMD, Ferraro LHC, Sun SY, Mattar R. Randomized Clinical Trial Comparing Quadratus Lumborum Block and Intrathecal Morphine for Postcesarean Analgesia. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:1083-1089. [PMID: 36580935 PMCID: PMC9800151 DOI: 10.1055/s-0042-1759728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To compare the efficacy of quadratus lumborum (QL) block and intrathecal morphine (M) for postcesarean delivery analgesia. METHODS Thirty-one pregnant women with ≥ 37 weeks of gestation submitted to elective cesarean section were included in the study. They were randomly allocated to either the QL group (12.5 mg 0.5% bupivacaine for spinal anesthesia and 0.3 ml/kg 0.2% bupivacaine for QL block) or the M group (12.5 mg bupivacaine 0.5% and 100 mcg of morphine in spinal anesthesia). The visual analog scale of pain, consumption of morphine and tramadol for pain relief in 48 hours, and side effects were recorded. RESULTS Median pain score and/or pain variation were higher in the morphine group than in the QL group (p = 0.02). There was no significant difference in the consumption of morphine or tramadol between groups over time. Side effects such as pruritus, nausea, and vomiting were observed only in the morphine group. CONCLUSION Quadratus lumborum block and intrathecal morphine are effective for analgesia after cesarean section. Patients undergoing QL block had lower postoperative pain scores without the undesirable side effects of opioids such as nausea, vomiting, and pruritus.
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Affiliation(s)
- Karoline Moura de Araújo
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil,Address for correspondence Karoline Moura de Araújo Escola Paulista de Medicina, Universidade Federal de São PauloRua Napoleão de Barros, 715, 04024002, São Paulo, SPBrazil
| | | | - Sue Yasaki Sun
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Rosiane Mattar
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Quadratus lumborum block for postoperative analgesia after cesarean section: a meta-analysis of randomized controlled trials with trial sequential analysis. Sci Rep 2021; 11:18104. [PMID: 34518565 PMCID: PMC8438068 DOI: 10.1038/s41598-021-96546-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 07/23/2021] [Indexed: 11/09/2022] Open
Abstract
The aim of this study was to assess the analgesic efficacy of QLB versus controls in women undergoing cesarean section (CS). We systematically searched Cochrane Library, PUBMED, EMBASE, VIP, WANFANG, and China National Knowledge Infrastructure. Trials were eligible if parturients received QLB during CS. GRADE system was used to assess the certainty of evidence and Trial sequential analyses (TSA) were performed to determine whether the results are supported by sufficient data. Thirteen studies involving 1269 patients were included. Compared to controls, QLB significantly reduced the cumulative postoperative intravenous opioid consumption (in milligram morphine equivalents) at 24 h (MD, - 11.51 mg; 95% CI - 17.05 to - 5.96) and 48 h (MD, - 15.87 mg; 95% CI - 26.36 to - 5.38), supported by sufficient data confirmed by TSA. The postoperative pain scores were significantly reduced by QLB at 4 h, 6 h, 12 h, 24 h, and 48 h postoperatively by QLB compared with control. Moreover, the time to first request for rescue analgesic and the incidence of PONV were also significantly reduced by QLB. The quality of evidence of most results were low and moderate assessed by GRADE.
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Wiese AD, Osmundson SS, Mitchel E, Adgent M, Phillips S, Patrick SW, Horn A, Samuels LR, Griffin MR, Grijalva CG. Prescription Opioid Dose After Vaginal Delivery and the Risk of Serious Opioid-Related Events: A Retrospective Cohort Study. Womens Health Issues 2021; 31:376-383. [PMID: 33865673 DOI: 10.1016/j.whi.2021.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/21/2020] [Accepted: 03/05/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE Postpartum opioid use remains common among women with uncomplicated vaginal delivery and may increase the risk of serious opioid-related events. Therefore, we examined the association between the dose of the first filled opioid prescription after vaginal delivery and the subsequent risk of serious opioid-related events. METHODS We conducted a retrospective cohort study among women enrolled in Tennessee Medicaid with a vaginal delivery (2007-2015). We used Cox proportional hazards regression to model adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for serious opioid-related events after delivery according to the dose (morphine milligram equivalents [MME]) of the first postpartum opioid prescription, accounting for comorbidities, medication use, parity, and delivery complications. Serious opioid-related events were defined as the occurrence of persistent opioid use, a methadone or buprenorphine fill, opioid use disorder diagnosis, opioid overdose, or opioid-related death. We used filled pharmacy data to characterize the dose of the first postpartum opioid prescription filled within 4 days after delivery. RESULTS More than one-half of women (53.2%; n = 147,598) filled an opioid prescription within 4 days of a vaginal delivery. After accounting for baseline risk factors, filling a postpartum opioid prescription was associated with an increased risk of serious opioid-related events across all dose categories, compared with women filling none (aHR 1-99 MME, 1.52; 95% CI, 1.33-1.74; aHR 100-149 MME, 1.41; 95% CI, 1.26-1.58; aHR 150-199 MME, 1.40; 95% CI, 1.26-1.57: and aHR ≥200 MME, 1.60; 95% CI, 1.43-1.78). CONCLUSIONS Filling a postpartum opioid prescription after a vaginal delivery was associated with an increased risk of serious opioid-related events, regardless of dose. Prescribing guidelines should discourage the routine prescribing of opioids after vaginal delivery.
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Affiliation(s)
- Andrew D Wiese
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Sarah S Osmundson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Edward Mitchel
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Margaret Adgent
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sharon Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen W Patrick
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Arlyn Horn
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lauren R Samuels
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marie R Griffin
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee; Mid-South Geriatric Research Education and Clinical Center, VA Tennessee Valley Health Care System, Nashville, Tennessee
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Adshead D, Wrench I, Woolnough M. Enhanced recovery for elective Caesarean section. BJA Educ 2021; 20:354-357. [PMID: 33456917 DOI: 10.1016/j.bjae.2020.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2020] [Indexed: 12/20/2022] Open
Affiliation(s)
- D Adshead
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - I Wrench
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - M Woolnough
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Prescription opioid use after vaginal delivery and subsequent persistent opioid use and misuse. Am J Obstet Gynecol MFM 2020; 3:100304. [PMID: 33383232 DOI: 10.1016/j.ajogmf.2020.100304] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 12/19/2020] [Accepted: 12/23/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Vaginal delivery is the most common reason for hospitalization in the United States, and approximately 30% of women fill an opioid prescription after vaginal delivery, making this a common source of opioid exposure in women of reproductive age. OBJECTIVE This study aimed to evaluate the effect of receiving an opioid prescription after vaginal delivery on the risk of subsequent persistent opioid use, opioid use disorders, and overdose. STUDY DESIGN We assembled a nationwide cohort of Medicaid beneficiaries in the United States using the Medicaid Analytic eXtract 2009-2014. The study population included pregnant women who delivered vaginally between 2009 and 2013 and were continuously enrolled in Medicaid from 90 days before to 365 days after delivery. We identified patients with prescription opioids dispensed within 7 days of the date of vaginal delivery. Persistent opioid use was defined as ≥10 opioid fills or >120 days' supply dispensed from 30 to 365 days after delivery. Incident diagnoses of opioid use disorder and overdose were ascertained during the same interval. Propensity score matching was used to control for potential confounding factors. RESULTS Among 459,829 pregnancies ending in vaginal deliveries, 140,807 (30.62%) had an opioid dispensed within 7 days of delivery. Overall, 5770 of 140,807 (4.10%) women who filled an opioid prescription vs 2668 of 319,022 (0.84%) unexposed women had subsequent persistent opioid use, with an unadjusted relative risk of 4.90 (95% confidence interval, 4.68-5.13) and a risk difference of 3.26% (95% confidence interval, 3.15-3.37). After propensity score matching, the risk remained higher among pregnancies with an opioid prescription dispensed, with a relative risk of 2.57 (95% confidence interval, 2.43-2.72) and a risk difference of 2.21% (95% confidence interval, 2.08-2.33), which was confirmed by the instrumental variable analysis with a risk difference of 1.31% (95% confidence interval, 1.06-1.56) by using the rate of opioid prescribing at the delivery facility in a given geographic region as the instrument. The adjusted relative risk of newly diagnosed opioid use disorder and overdose was 1.48 (95% confidence interval, 1.40-1.57) and 1.92 (95% confidence interval, 1.20-3.09), respectively. CONCLUSION Opioid dispensing following vaginal delivery is associated with future persistent opioid use and misuse, independent of confounding factors. Opioid prescriptions to women after vaginal delivery should be avoided, except in rare circumstances.
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Managing opioid consumption after caesarean delivery: a quality improvement initiative. Ir J Med Sci 2020; 189:1069-1072. [PMID: 32048204 DOI: 10.1007/s11845-020-02201-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 02/05/2020] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Caesarean delivery is the most common major surgical procedure performed worldwide and pain management after caesarean delivery remains challenging. Finding a balance between sufficient postoperative pain relief and excess sedation secondary to opioids is often difficult in this patient population. This quality improvement project aimed to manage the amount of opioid consumption after caesarean delivery using a new postoperative analgesic regimen. METHODS The current practice was analysed in 52 patients before introducing the new regimen. Oxycodone consumption, pain scores and quality of recovery were recorded. Following this pre-implementation audit, a new postoperative analgesic protocol was introduced. All patients received standard doses of intrathecal morphine, paracetamol and diclofenac. Regular oxycodone sustained-release (SR) was replaced with oxycodone immediate-release (IR) as needed. These changes also coincided with education to improve midwifery assessment of pain and the delivery of analgesia. RESULTS The outcome measures were re-audited in 178 patients which showed that oxycodone consumption had reduced median (IQR) 30 mg (20-40) vs 10 mg (5-15) (p < 0.001). There was no significant difference in the pain scores between the before and after groups at rest median (IQR) 2.0 (0-4.8) vs 2.0 (0.8-4.0) or at movement 5.0 (3.0-6.0) vs 5.0 (3.0-6.3) (p = 0.292, p = 0.482 respectively). The quality of recovery scores were also equivalent mean (SD) 78.6 (20.6) vs 77.8 (19.0) (p = 0.792). CONCLUSION The results of this study suggest that postoperative opioid consumption can be reduced with specific analgesic protocols and allow us to improve patient's quality of recovery.
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Irwin R, Stanescu S, Buzaianu C, Rademan M, Roddy J, Gormley C, Tan T. Quadratus lumborum block for analgesia after caesarean section: a randomised controlled trial. Anaesthesia 2019; 75:89-95. [DOI: 10.1111/anae.14852] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2019] [Indexed: 12/13/2022]
Affiliation(s)
- R. Irwin
- Department of Anaesthesia and Peri‐operative Medicine Coombe Women and Infants University Hospital Dublin Ireland
| | - S. Stanescu
- Department of Anaesthesia and Peri‐operative Medicine Coombe Women and Infants University Hospital Dublin Ireland
| | - C. Buzaianu
- Department of Anaesthesia and Peri‐operative Medicine Coombe Women and Infants University Hospital Dublin Ireland
| | - M. Rademan
- Department of Anaesthesia and Peri‐operative Medicine Coombe Women and Infants University Hospital Dublin Ireland
| | - J. Roddy
- Department of Anaesthesia and Peri‐operative Medicine Coombe Women and Infants University Hospital Dublin Ireland
| | - C. Gormley
- Department of Anaesthesia and Peri‐operative Medicine Coombe Women and Infants University Hospital Dublin Ireland
| | - T. Tan
- Department of Anaesthesia and Peri‐operative Medicine Coombe Women and Infants University Hospital Dublin Ireland
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Peahl AF, Smith R, Johnson TR, Morgan DM, Pearlman MD. Better late than never: why obstetricians must implement enhanced recovery after cesarean. Am J Obstet Gynecol 2019; 221:117.e1-117.e7. [PMID: 31055033 DOI: 10.1016/j.ajog.2019.04.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/07/2019] [Accepted: 04/26/2019] [Indexed: 12/20/2022]
Abstract
Despite persistent concerns about high cesarean delivery rates internationally, there has been less attention on improving perioperative outcomes for the millions of women who will experience a cesarean delivery each year. Enhanced recovery after surgery, a standardized, evidence-based, interdisciplinary protocol, has been successfully used in other surgical specialties including gynecology to improve quality of care and patient satisfaction while reducing overall health care costs through reduced length of stay. Enhanced recovery after surgery society guidelines for cesarean delivery were just released in August 2018. Obstetric patients, who face the dual challenge of being postpartum and postoperative, could benefit greatly from protocols that optimize their return to physiological function and reduce surgical morbidity. Although enhanced recovery after surgery has been widespread in other surgical specialties, uptake of this protocol in obstetrics has lagged behind. We believe enhanced recovery after surgery for cesarean delivery can effectively address 3 challenges faced by obstetrician/gynecologists. These are: (1) improving care for the high number of women undergoing cesarean deliveries; (2) using evidence-based care bundles to prevent maternal morbidity and mortality, address disparities, and reduce costs; and (3) limiting postoperative opioid prescribing in response to the opioid crisis. Enhanced recovery after surgery for cesarean delivery and other standardized care protocols have the potential to reduce the disproportionately high rates of maternal morbidity and mortality in the United States, and ensure all patients, regardless of demographics or location, receive the same level of high-quality peripartum care.
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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; 2:e197863. [PMID: 31348508 PMCID: PMC6661716 DOI: 10.1001/jamanetworkopen.2019.7863] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
IMPORTANCE Research has shown an association between opioid prescribing after major or minor procedures and new persistent opioid use. However, the association of opioid prescribing with persistent use among women after vaginal delivery or cesarean delivery is less clear. OBJECTIVE To assess the association between opioid prescribing administered for vaginal or cesarean delivery and rates of new persistent opioid use among women. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used national insurance claims data for 988 036 women from a single private payer from January 1, 2008, to December 31, 2016. Participants included reproductive age, opioid-naive women with 1 year of continuous enrollment before and after delivery. For participants with multiple births, only the first birth was included. EXPOSURES Peripartum opioid prescription (1 week before delivery to 3 days after discharge) captured by pharmacy claims, including prescription timing and size in oral morphine equivalents. Multivariable adjusted odds ratios were estimated using regression models. MAIN OUTCOMES AND MEASURES Rates of new persistent opioid use, defined as pharmacy claims for 1 or more opioid prescription 4 to 90 days after discharge and 1 or more prescription 91 to 365 days after discharge among women who filled peripartum opioid prescriptions. RESULTS In total, 308 226 deliveries were included: 195 013 (63.3%) vaginal deliveries and 113 213 (36.7%) cesarean deliveries. Participant mean (SD) age was 31.3 (5.3) years, and 70 567 (51.0%) were white patients. Peripartum opioid prescriptions were filled by 27.0% of women with vaginal deliveries and 75.7% of women with cesarean deliveries. Among them, 1.7% of those with vaginal deliveries and 2.2% with cesarean deliveries had new persistent opioid use. By contrast, among women not receiving a peripartum opioid prescription, 0.5% with vaginal delivery and 1.0% with cesarean delivery had new persistent opioid use. From 2008 to 2016, opioid prescription fills decreased for vaginal deliveries from 26.9% to 23.8% (P < .001) and for cesarean deliveries from 75.5% to 72.6% (P < .001), and fewer women had new persistent use (vaginal delivery, from 2.2% to 1.1%; P < .001; cesarean delivery, from 2.5% to 1.3%; P < .001). The strongest modifiable factor associated with new persistent opioid use after delivery was filling an opioid prescription before delivery (adjusted odds ratio, 1.40; 95% CI, 1.05-1.87). For vaginal deliveries, receiving a prescription equal to or more than 225 oral morphine equivalents was associated with new persistent opioid use (adjusted odds ratio, 1.25; 95% CI, 1.06-1.48). Women who underwent cesarean delivery and had a hysterectomy were more likely to develop persistence (AOR, 2.75; 95% CI, 1.33-5.70), although women who underwent a nonelective (AOR, 0.97; 95% CI, 0.88-1.07) or repeat cesarean (AOR, 1.45; 95% CI, 0.93-2.28) were not more likely. For cesarean deliveries, risk factors were associated with patient attributes such as tobacco use (adjusted odds ratio, 1.82; 95% CI, 1.56-2.11), psychiatric diagnoses, history of substance use (adjusted odds ratio, 1.43; 95% CI, 1.10-1.86), and pain conditions. CONCLUSIONS AND RELEVANCE The results of the present study suggested that opioid prescribing and new persistent use after vaginal delivery or cesarean delivery have decreased since 2008. However, modifiable prescribing patterns were associated with persistent opioid use for patients who underwent vaginal delivery, and risk factors following cesarean delivery mirrored those of other surgical conditions. Judicious opioid prescribing and preoperative risk screening may be opportunities to decrease new persistent opioid use after childbirth.
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Affiliation(s)
- Alex F. Peahl
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor
| | - Vanessa K. Dalton
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor
- Program on Women’s Healthcare Effectiveness Research, University of Michigan, Ann Arbor
| | | | - Yen-Ling Lai
- Michigan Opioid Prescribing Engagement Network, Department of Surgery, University of Michigan, Ann Arbor
| | - Hsou Mei Hu
- Michigan Opioid Prescribing Engagement Network, Department of Surgery, University of Michigan, Ann Arbor
| | - Jennifer F. Waljee
- Department of Surgery, University of Michigan, Ann Arbor
- Michigan Opioid Prescribing Engagement Network, Department of Surgery, University of Michigan, Ann Arbor
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Ecker J, Abuhamad A, Hill W, Bailit J, Bateman BT, Berghella V, Blake-Lamb T, Guille C, Landau R, Minkoff H, Prabhu M, Rosenthal E, Terplan M, Wright TE, Yonkers KA. Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine. Am J Obstet Gynecol 2019; 221:B5-B28. [PMID: 30928567 DOI: 10.1016/j.ajog.2019.03.022] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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