Original Research
Obstetrics
Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naïve women

https://doi.org/10.1016/j.ajog.2016.03.016Get rights and content

Background

The incidence of opioid-related death in women has increased 5-fold over the past decade. For many women, their initial opioid exposure will occur in the setting of routine medical care. Approximately 1 in 3 deliveries in the United States is by cesarean, and opioids are commonly prescribed for postsurgical pain management.

Objective

The objective of this study was to determine the risk that opioid-naïve women prescribed opioids after cesarean delivery will subsequently become consistent prescription opioid users in the year following delivery and to identify predictors for this behavior.

Study Design

We identified women in a database of commercial insurance beneficiaries who underwent cesarean delivery and who were opioid naïve in the year prior to delivery. To identify persistent users of opioids, we used trajectory models, which group together patients with similar patterns of medication filling during follow-up, based on patterns of opioid dispensing in the year following cesarean delivery. We then constructed a multivariable logistic regression model to identify independent risk factors for membership in the persistent user group.

Results

A total of 285 of 80,127 (0.36%, 95% confidence interval, 0.32–0.40), opioid-naïve women became persistent opioid users (identified using trajectory models based on monthly patterns of opioid dispensing) following cesarean delivery. Demographics and baseline comorbidity predicted such use with moderate discrimination (c statistic = 0.73). Significant predictors included a history of cocaine abuse (risk, 7.41%; adjusted odds ratio, 6.11, 95% confidence interval, 1.03–36.31) and other illicit substance abuse (2.36%; adjusted odds ratio, 2.78, 95% confidence interval, 1.12–6.91), tobacco use (1.45%; adjusted odds ratio, 3.04, 95% confidence interval, 2.03–4.55), back pain (0.69%; adjusted odds ratio, 1.74, 95% confidence interval, 1.33–2.29), migraines (0.91%; adjusted odds ratio, 2.14, 95% confidence interval, 1.58–2.90), antidepressant use (1.34%; adjusted odds ratio, 3.19, 95% confidence interval, 2.41–4.23), and benzodiazepine use (1.99%; adjusted odds ratio, 3.72, 95% confidence interval, 2.64–5.26) in the year prior to the cesarean delivery.

Conclusion

A very small proportion of opioid-naïve women (approximately 1 in 300) become persistent prescription opioid users following cesarean delivery. Preexisting psychiatric comorbidity, certain pain conditions, and substance use/abuse conditions identifiable at the time of initial opioid prescribing were predictors of persistent use.

Section snippets

Data source

Study data were derived from the Clinformatics Data Mart, a database of health care utilization drawn from the transactions of the nationwide commercial US health insurer, UnitedHealthcare, for the years 2003–2011. The database contains transactional data on reimbursement for outpatient pharmacy dispensings, inpatient and outpatient services, and procedures and associated diagnoses (recorded using International Classification of Diseases, ninth edition CM codes). Only those beneficiaries with

Cohort

Our analytic cohort consisted of 80,127 women who underwent cesarean delivery from 2003 to 2011 and who were opioid naïve in the year prior to delivery (Figure 1). Patterns of opioid dispensing for each group estimated by the trajectory model in 12 30 day periods of follow-up are presented in Figure 2. For groups 1–3 (n = 76,557, 95.5% (95% confidence interval, 95.4–95.7%) of cohort), fewer than 10% of the group members filled an opioid prescription in each month of the follow-up period,

Comment

We found that opioid-naïve women who filled a prescription for an opioid analgesic after cesarean delivery have a small risk, approximately 1 in 300, of becoming persistent users of prescription opioids in the year following delivery. This frequency is relatively low, which should be reassuring to physicians and patients. However, because approximately 1.3 million women undergo cesarean delivery in the United States (and many more worldwide) annually, the absolute number of persistent opioid

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    This study was supported by an unrestricted research grant from CVS Caremark to Brigham and Women’s Hospital and the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health (award number K08HD075831).

    The authors report no conflicts of interest.

    Cite this article as: Bateman BT, Franklin JM, Bykov K, et al. Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naïve women. Am J Obstet Gynecol 2016;215:353.e1-18.

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