title: Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naïve women.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Obstetric Anesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Harvard Medical School, Boston, MA. Electronic address: bbateman@partners.org.
authors.forename: Brian T
authors.initials: BT
authors.lastname: Bateman
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Jessica M
authors.initials: JM
authors.lastname: Franklin
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Katsiaryna
authors.initials: K
authors.lastname: Bykov
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Jerry
authors.initials: J
authors.lastname: Avorn
authors.affiliation: CVS Health, Woonsocket, RI.
authors.forename: William H
authors.initials: WH
authors.lastname: Shrank
authors.affiliation: CVS Health, Woonsocket, RI.
authors.forename: Troyen A
authors.initials: TA
authors.lastname: Brennan
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Joan E
authors.initials: JE
authors.lastname: Landon
authors.affiliation: Departments of Anesthesia and Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: James P
authors.initials: JP
authors.lastname: Rathmell
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Krista F
authors.initials: KF
authors.lastname: Huybrechts
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Fischer
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Niteesh K
authors.initials: NK
authors.lastname: Choudhry
mesh_terms: D000328:Adult; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D000928:Antidepressive Agents / Q000627:therapeutic use; D001416:Back Pain / Q000188:drug therapy / Q000453:epidemiology; D001569:Benzodiazepines / Q000627:therapeutic use; D002585:Cesarean Section; D016208:Databases, Factual; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D004363:Drug Utilization / Q000706:statistics & numerical data / Q000639:trends*; D005260:Female; D006801:Humans; D008881:Migraine Disorders / Q000188:drug therapy / Q000453:epidemiology; D015999:Multivariate Analysis; D010149:Postoperative Pain / Q000188:drug therapy*; D011247:Pregnancy; D012307:Risk Factors; D012907:Smoking / Q000453:epidemiology; D019966:Substance-Related Disorders / Q000453:epidemiology; D014481:United States / Q000453:epidemiology; D055815:Young Adult
chemical_list: D000701:Analgesics, Opioid; D000928:Antidepressive Agents; D001569:Benzodiazepines
keywords: cesarean delivery; cohort; opioids; pain; pregnancy studies