Pandemic Erased Decline in Scripts for Postpartum Opioids

A steady downward trend in opioids prescribed to women after giving birth reversed course with the start of the pandemic, a cross-sectional study suggested.

The proportion of women with a filled opioid prescription after delivery dropped progressively from more than 41% in 2018 to about 36% by the beginning of 2020. That number was expected to continue to drop to 35% for March to December 2020 but instead jumped to 37.8% — 2.8 percentage points more than projected.

Moreover, those who gave birth in 2020 after the pandemic started filled more potent (schedule II) opioid prescriptions and filled them more often than before March, Shelby R. Steuart, MPA, of the University of Georgia in Athens, and colleagues reported in JAMA Network Open.

The increase accrued particularly among cesarean births, with a 4.5 percentage point jump in opioid prescription fills compared with the prepandemic trend (71.2% actual vs 66.7% expected).

“Postpartum women are a particularly important population to study, given high rates of severe pain, and the fact that most postpartum opioid prescribing is to new opioid users, who may be particularly vulnerable to adverse health effects from opioids,” Steuart and colleagues wrote.

In addition to an increase in prescriptions after March 1, 2020, a higher dosage and strength of opioid were prescribed to postpartum women than expected from the prepandemic trend:

• Morphine milligram equivalents per day averaged 35.8 compared with the expected 34.1
• Number of opioid prescription fills per patient averaged 0.54 vs 0.49 forecasted
• Proportion with schedule II opioid prescriptions filled was 31.5% vs 28.7% anticipated

At least one opioid prescription was filled by 38.1% of all women in the entire cohort within 6-months postpartum.

Despite a possible increased need for opioids, the researchers noted, “increases in opioid prescriptions may be associated with increased risk of opioid misuse, opioid use disorder, and opioid-related overdose among postpartum women.”

“Our findings are particularly concerning given that the COVID-19 pandemic has exacerbated the effects of the U.S. opioid crisis,” they added.

Overall U.S. monthly opioid-related overdose deaths increased following the March 23, 2020, stay-at-home order; opioid-related overdose deaths surpassed 100,000 annually. Given these factors, the potential implications for treating postpartum women necessitates a delicate balance between those who need pain relief and those who may have trouble stopping opioid use, the researchers explained.

On one hand, the researchers wrote, “poor management of postpartum pain can increase the risk of postpartum depression and chronic pain; thus, increased opioid use may represent more appropriate treatment of severe pain for some postpartum women.”

And on the other hand, “overprescription of opioids can lead to persistent misuse,” they noted, adding that this is particularly true for racial and ethnic minority individuals, “who are often undertreated for pain relative to white individuals in the U.S.”

Moreover, “while clinicians were prescribing more potent opioids more frequently in hopes of preventing excessive postpartum pain, if their patients develop an opioid use disorder it will take longer to diagnose and treat,” Steuart and colleagues warned.

The study used the Optum Clinformatics Data Mart of administrative health claims for members of large commercial and Medicare Advantage health plans, representing some 5% of all U.S. births and 14% of those among privately insured women. The researchers looked at prescriptions given to 460,371 insured postpartum women (mean age 29) who gave birth to one child during the study period and had 6 months of insurance thereafter.

Over the study period, women who had a cesarean delivery were more likely to receive an opioid prescription (67.0%) when compared with those who had a vaginal birth (23.8%).

Filled prescriptions averaged a 4.4 days’ supply of opioids over the study period, with a mean of 4.7 after cesarean deliveries compared with 4.1 after vaginal deliveries.

Overall, fills of schedule II opioids were more frequent than fills of schedule III or higher opioids, with 35.1% of all women filling a schedule II opioid and 3.7% of women filling a schedule III or higher opioid. Schedule II prescriptions were more numerous among those with a cesarean birth (63.2%) compared to vaginal birth (21.1%).

The study was limited by lack of differentiation between initial fills and refills of opioid prescriptions. In addition, there was missing information about delivery method (cesarean vs vaginal) in less than 10% of records.