Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
Am J Obstet Gynecol MFM. 2021 Mar;3(2):100304. doi: 10.1016/j.ajogmf.2020.100304. Epub 2020 Dec 28.
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.
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.
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.
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.
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.
阴道分娩是美国最常见的住院原因，大约 30%的女性在阴道分娩后会开阿片类药物处方，这使得这成为生育年龄妇女中阿片类药物暴露的常见来源。
本研究旨在评估阴道分娩后开具阿片类药物处方对随后持续使用阿片类药物、阿片类药物使用障碍和过量的风险的影响。
我们使用美国医疗补助分析提取 2009-2014 年的数据，组建了一个全国性的医疗补助受益人群队列。研究人群包括 2009 年至 2013 年间阴道分娩的孕妇，并且在分娩后 90 天至 365 天期间持续参加医疗补助。我们确定了在阴道分娩后 7 天内开出阿片类药物的患者。持续使用阿片类药物定义为在分娩后 30 至 365 天期间开出 ≥10 次阿片类药物处方或 ≥120 天的供应量。在同一时间段内确定新诊断的阿片类药物使用障碍和过量的病例。使用倾向评分匹配来控制潜在的混杂因素。
在 459829 例以阴道分娩结束的妊娠中，有 140807 例（30.62%）在分娩后 7 天内开出了阿片类药物处方。总体而言，与 319022 名未暴露的女性中的 2668 名（0.84%）相比，在开出阿片类药物处方的 140807 名女性中，有 5770 名（4.10%）随后出现持续使用阿片类药物，未经调整的相对风险为 4.90（95%置信区间，4.68-5.13），风险差异为 3.26%（95%置信区间，3.15-3.37）。在进行倾向评分匹配后，开具阿片类药物处方的妊娠风险仍然较高，相对风险为 2.57（95%置信区间，2.43-2.72），风险差异为 2.21%（95%置信区间，2.08-2.33），这一结果通过使用特定地理位置分娩机构的阿片类药物处方率作为工具进行的工具变量分析得到了证实，风险差异为 1.31%（95%置信区间，1.06-1.56）。新诊断的阿片类药物使用障碍和过量的调整后相对风险分别为 1.48（95%置信区间，1.40-1.57）和 1.92（95%置信区间，1.20-3.09）。
阴道分娩后开具阿片类药物处方与未来持续使用阿片类药物和滥用有关，独立于混杂因素。除了在极少数情况下，应避免在阴道分娩后给女性开阿片类药物处方。
