Given the country’s opioid epidemic, physicians are looking for ways to reduce unnecessary prescribing of the drugs. A recent study published in Obstetrics and Gynecology found that opioid dispensing after vaginal delivery is common and often occurs at high doses and may represent a source of over-prescription in the United States.
Using the Truven Health Analytics MarketScan database, the authors performed a nationwide retrospective cohort study of commercially insured beneficiaries who underwent vaginal delivery between 2003 and 2015 and were also opioid-naive for 12 weeks before delivery. They examined the ratio of women who were prescribed an oral opioid within 1 week of discharge, the median oral morphine milligram equivalent dose dispensed, and the frequency of opioid refills by the patient during the 6 weeks of discharge.
The researchers found that of the more than 1.3 million women included in the study, 28.5% were dispensed an opioid with 1 week of discharge. Hydrocodone (44.7%), oxycodone (34.6%) and codeine (13.1%) were the most commonly prescribed opioids among the study population. In addition, codeine accounted for 15.2% of opioids dispensed, which the authors note as worrisome given the US Food and Drug Administration’s warning against use of the drug in breastfeeding women because of variability in metabolism and risk to the infant.
In multivariable regression analysis, the adjusted odds ratio (OR) for dispensing an opioid prescription was 4.70 (95% CI, 4.63-4.77) among women in the south, adjusted OR 2.94 (95% CI, 2.90-2.99) among women from the west, and adjusted OR 2.77 (95% CI 2.72-2.81) among women from the midwest as compared to women from the northeast. The odds for dispensing the prescription were also higher for those using benzodiazepines (adjusted OR 1.87; 95% CI 1.73-2.02) and antidepressants (adjusted OR 1.63; 95% CI 1.59-1.66) and smokers (adjusted OR 1.44; 95% CI 1.38-1.51). Patients who had undergone tubal ligation, operative vaginal delivery and who had higher-order perineal lacerations also had increased rates of receiving an opioid prescription.
The median dose of opioids dispensed was 150 morphine milligram equivalents (approximately 20 tablets of 5- mg oxycodone). Among the 366,691 women with at least 6 weeks’ follow-up, 8.5% (95% CI 8.4-8.6%) had at least one refill during that time period.
The authors highlighted a few limitations of their study. Because the analysis focused just on opioid dispensing, it did not capture the number of prescriptions that were not filled or were filled and paid for out of pocket. Nor can the quantity of opioids consumed be determined from the data. They also noted that the procedure and diagnostic codes used to define deliveries favored specificity over sensitivity because a linkage to infants, which can be used in insurance claims to confirm that the encounter resulted in a birth, was not used. However, the authors point out that when their data are generalized to all women delivering vaginally in the United States, the results suggest that 850,000 women are given an opioid prescription per year. So, limiting unnecessary opioid prescribing in this clinical setting could have a significant effect on public health and the opioid epidemic.