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Michigan Medicine – University of Michigan study: One in 100 new mothers go on to long-term opioid painkiller use; risk rises with size of Rx

28 Jul

American Pregnancy posted, Using Narcotics For Pain Relief During Childbirth:

Using Narcotics for Pain Relief During Labor: Types & Side Effects
Many women end up relying on some type of method to reduce the physical pain of childbirth. As you prepare for labor, it is important to become familiar with the pain medications that are available, how they work, their risks and their benefits.
The method you choose for pain relief will depend on your personal preference, your health care provider’s recommendation, and the availability of medications at your birthing facility.
What are Opiates?
Opiates are a type of analgesic given to relieve pain. When used during childbirth, opiates are considered the first option after natural methods for pain relief such as labor in water, deep breathing, and massage.
Opiates are given in small doses and usually administered during the early stages of labor in an attempt to avoid potential side effects for both the mother and baby.
What are the advantages of using opiates during childbirth?
Opiates offer pain relief and do not interfere with a woman’s ability to push during labor. Unlike an epidural, an opiate does not numb the pain; it instead helps to take some“edge” off of the pain. Opiates can help reduce anxiety and improve the mother’s ability to cope with painful contractions.
What are the potential side effects of opiates?
Mothers can experience the following side effects:
• Nausea
• Vomiting
• Itching
• Dizziness
• Sedation
• Decreased gastric motility
• Loss of protective airway reflexes
• Hypoxia due to respiratory depression
How will the opiates affect my baby?
Opiates cross the placenta during labor and can produce the following side effects in the baby:
• Central nervous system depression
• Respiratory depression
• Impaired early breastfeeding
• Altered neurological behavior
• Decreased ability to regulate body temperature
For these reasons, your baby might need other medication to counteract the effects of the opiate. Naloxone is a medication given in small doses that can reverse the respiratory depression that opiates can cause in a baby. It is usually given intravenously and its effects can be seen within a few minutes and can last up to 2 hours.
What types of opiates are used during childbirth?
The most frequently used narcotic medications are:
• Morphine
• Stadol
• Fentanyl
• Nubain
• Demerol
Demerol:
Demerol is a popular choice for pain relief during labor. Demerol alters how the mother recognizes the pain she is experiencing by binding to the receptors found in the central nervous system.
The advantages of Demerol include:
• Can be given by injection into the muscle, the vein or by a Patient Controlled Analgesia (PCA) pump
• Fast-acting – starts working in less than 5 minutes
How can Demerol affect me and my baby?
Demerol can cause drowsiness, nausea, vomiting, respiratory depression, and maternal hypotension (low blood pressure). If injected within 2-4 hours of delivery, Demerol has been found to cause breathing difficulties in some babies.
Morphine:
In recent years, morphine has not been routinely used as a method of pain relief during labor because it has been found to depress the baby’s ability to breathe.
Stadol:
Stadol has been found to relieve pain when given in the first stage of labor. This narcotic is considered more potent than Demerol. It is usually given intravenously in small doses, usually 1 to 2 mg.
The advantages of using Stadol include:
• Starts working in less than five minutes
• Is a sedative
• Has minimal fetal effects
• Causes minimal nausea
How can Stadol affect me and my baby?
Stadol can cause the mother to have respiratory depression, dizziness, and dysphoria (a state of feeling unwell and unhappy). Stadol can cause respiratory depression in the baby.
Fentanyl:
Fentanyl is a synthetic opiate that provides mild to moderate sedation. The advantages of using Fentanyl include:
• Begins working quickly (although, usually only lasts 45 minutes)
• Minimal sedation
• Minimal fetal effects
How can Fentanyl affect me and my baby?
You and your baby can experience some sedation and/or nausea. According to Danforth’s Obstetrics and Gynecology, babies born to mothers who used Fentanyl to relieve pain during labor were less likely to need naloxone (medication to help with breathing) than babies born to mothers who used Demerol.
Nubain:
Nubain is an opiate agonist-antagonist comparable to morphine. The advantages of using Nubain include:
• Begins working within 5 minutes of administration
• Minimal nausea
• Minimal fetal effects
How can Nubain affect me and my baby?
Nubain can cause the mother to have sedation and dysphoria (a state of feeling unwell and unhappy)…. https://americanpregnancy.org/labor-and-birth/narcotics/

A University of Michigan study found that some mothers go on to long-term use of opioid painkillers.

Science Daily reported in One in 100 new mothers go on to long-term opioid painkiller use; risk rises with size of Rx:

Nearly half of American women having a baby in the last decade received a prescription for a powerful opioid painkiller as part of their birth experience, a new study shows.
And one or two in every hundred were still filling opioid prescriptions a year later — especially those who received birth-related opioid prescriptions before the birth, and those who received the largest initial doses.
In a study of records from more than 308,000 women who gave birth from 2008 to 2016, researchers from the University of Michigan find the percentage of women filling opioid prescriptions in the days and months after giving birth declined over time. This may have resulted from growing awareness of the broader national epidemic.
But they note that there is still ample room for providers to adopt effective pain control strategies — for both vaginal and Caesarean births — that don’t include giving new mothers opioid pills if other pain treatments work for them.
Writing in JAMA Network Open, U-M obstetrician and health services researcher Alex Friedman Peahl, M.D., and her colleagues explore opioid prescribing to women with private insurance who hadn’t received opioids for a year before delivering. They limited the study to women who didn’t suffer major birth complications or have any other procedures in the year after a birth.
“Overall, we see rates of opioid persistence higher than previously documented for women having C sections, at about two percent,” says Peahl. “For women who delivered vaginally, one-quarter received opioid prescriptions, although current guidelines call for a step-wise approach to pain management, starting with non-narcotic medications such as ibuprofen and acetaminophen. One percent of vaginal birth mothers were still receiving opioids months later.”
Peahl and her colleagues hope their findings bolster efforts by national groups to help birth care teams adopt opioid-sparing pain care methods. Birth care at Von Voigtlander Women’s Hospital, part of the U-M academic medical center Michigan Medicine, already includes such approaches.
Peahl says she tells her birthing patients, “Pain after birth is like a mountain: once you’re at the peak, it is harder to get down. Using non-narcotic pain medications before opioids can help better manage your pain by preventing you from reaching that peak.”
Alternatives to opioids
Peahl’s experience treating birth pain with fewer opioids extends back to her training in Rhode Island, where birthing women once routinely went home from the hospital with prescriptions for 20 to 40 opioid painkiller pills. Then, the state legislature passed a limit of 20 pills for acute pain prescriptions, and she worked with the birth team where she trained to develop alternate pain care approaches.
Using long-lasting opioids for the height of birth pain as part of an epidural, and reserving oral opioids for “breakthrough” post-birth pain, is possible, says Peahl.
Acetaminophen, and non-steroidal anti-inflammatory drugs such as ibuprofen can provide effective pain relief in the days after birth, Peahl says, especially if women receive education during birth preparation about their proper use. She recently presented data at a conference showing such an approach can reduce post-discharge opioid painkiller use.
A team of U-M obstetric clinicians also recently published a paper in the American Journal of Obstetrics & Gynecology that laid out the case for opioid-sparing approaches to pain care after C-section births. Such an approach, called Enhanced Recovery After Surgery or ERAS, has already risen in popularity for other OB/Gyn procedures such as hysterectomy… https://www.sciencedaily.com/releases/2019/07/190726111025.htm

Citation:

One in 100 new mothers go on to long-term opioid painkiller use; risk rises with size of Rx
Date: July 26, 2019
Source: Michigan Medicine – University of Michigan
Summary:
Nearly half of American women having a baby in the last decade received a prescription for a powerful opioid painkiller as part of their birth experience, a new study shows. And one or two in every hundred were still filling opioid prescriptions a year later — especially those who received birth-related opioid prescriptions before the birth, and those who received the largest initial doses.

Journal Reference:
Alex F. Peahl, Vanessa K. Dalton, John R. Montgomery, Yen-Ling Lai, Hsou Mei Hu, Jennifer F. Waljee. Rates of New Persistent Opioid Use After Vaginal or Cesarean Birth Among US Women. JAMA Network Open, 2019; 2 (7): e197863 DOI: 10.1001/jamanetworkopen.2019.7863

Here is the press release from University of Michigan:

Kara Gavin

July 26, 2019 11:15 AM

1 in 75 New Moms Go on to Long-Term Opioid Painkiller Use
Examination of post-birth pain care patterns over time finds declines in opioid prescribing, but opportunities for more non-opioid-based care.

Nearly half of American women having a baby in the last decade received a prescription for a powerful opioid painkiller as part of their birth experience, a new study shows.
And one or two in every hundred were still filling opioid prescriptions a year later – especially those who received birth-related opioid prescriptions before the birth, and those who received the largest initial doses.
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In a study of records from more than 308,000 women who gave birth from 2008 to 2016, researchers from the University of Michigan found the percentage of women filling opioid prescriptions in the days and months after giving birth declined over time. This may have resulted from growing awareness of the broader national epidemic.
But they note that there is still ample room for providers to adopt effective pain control strategies – for both vaginal and caesarean births – that do not include giving new mothers opioid pills if other pain treatments work for them.
In the new issue of JAMA Network Open, U-M obstetrician and health services researcher Alex Friedman Peahl, M.D., and her colleagues explore opioid prescribing to women with private insurance who had not received opioids for a year before delivering. They limited the study to women who did not suffer major birth complications or have any other procedures in the year after a birth.
“Overall, we saw rates of opioid persistence higher than previously documented for women having c-sections, at about 2%,” says Peahl. “For women who delivered vaginally, one-quarter received opioid prescriptions, although current guidelines call for a step-wise approach to pain management, starting with non-narcotic medications such as ibuprofen and acetaminophen. One percent of vaginal birth mothers were still receiving opioids months later.”
Peahl and her colleagues hope their findings bolster efforts by national groups to help birth care teams adopt opioid-sparing pain care methods. Birth care at Von Voigtlander Women’s Hospital, part of the U-M academic medical center Michigan Medicine, already includes such approaches.
Peahl says she tells her birthing patients, “Pain after birth is like a mountain: once you’re at the peak, it is harder to get down. Using non-narcotic pain medications before opioids can help better manage your pain by preventing you from reaching that peak.”
Alternatives to opioids
Peahl’s experience treating birth pain with fewer opioids extends back to her training in Rhode Island, where birthing women once routinely went home from the hospital with prescriptions for 20 to 40 opioid painkiller pills. Then, the state legislature passed a limit of 20 pills for acute pain prescriptions, and she worked with the birth team where she trained to develop alternate pain care approaches.
Using long-lasting opioids for the height of birth pain as part of an epidural, and reserving oral opioids for “breakthrough” post-birth pain, is possible, says Peahl.
Acetaminophen, and non-steroidal anti-inflammatory drugs such as ibuprofen can provide effective pain relief in the days after birth, Peahl says, especially if women receive education during birth preparation about their proper use. She recently presented data at a conference showing such an approach can reduce post-discharge opioid painkiller use.
A team of U-M obstetric clinicians also recently published a paper in the American Journal of Obstetrics & Gynecology that laid out the case for opioid-sparing approaches to pain care after c-section births. Such an approach, called Enhanced Recovery After Surgery or ERAS, has already risen in popularity for other OB/Gyn procedures such as hysterectomy.
Building on surgical opioid studies
Peahl, a National Clinician Scholar at the U-M Institute for Healthcare Policy and Innovation (IHPI), teamed up with IHPI members from the Michigan Opioid Prescribing and Engagement Network for the new study. Senior author Jennifer Waljee, M.D., M.P.H., M.S., helped Peahl adopt an approach already used to study opioid prescriptions after inpatient surgery.
Using IHPI-purchased data, they looked at women who filled an opioid prescription in the immediate week before giving birth, up to the third day afterward. This allowed them to include women whose doctors wrote a prescription to have on hand before they went to the hospital.
They defined persistent use as those women who filled at least one more opioid prescription within three months of delivering, and another up to a year after delivering. In addition to excluding women with prior opioid use and those in treatment for substance abuse, the study left out women who had any sort of medical procedure within a year of having a baby, including readmission for additional surgical procedures, and women whose birth hospitalization lasted more than a month.
“The silver lining in these data is that we see drops of several percentage points in the filling of initial prescriptions over time, although nearly 24% of women who delivered vaginally in 2016, and nearly 73% of those who had a c-section, still had these pills on hand,” says Peahl.
Women most at risk of persistent use
While the researchers could not tell from the data how many opioid pills the women actually took, they note that unused pills can pose a risk of their own. Excess opioids can be misused by others, diverted for illicit sale, or discovered by curious children.
Looking more closely at the data, they showed that risk of opioid persistence was higher in certain groups of women. Women who had their babies in their teens or early 20s, and those who had more medical issues at the time of birth, especially diagnoses related to pain or mental health, had higher rates of persistence. So did mothers in the South and Midwest and women who used tobacco during pregnancy.
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But the biggest factors – and the one that health care providers can actually modify – was the size of the initial prescription for opioids that the women filled and the timing of when that prescription was given. The larger the vial, the more likely they were to refill multiple prescriptions in the months after giving birth. Similarly, women who filled prescriptions prior to birth were more likely to develop new persistent use.
This is similar to what Waljee and her colleagues have seen in surgical patients, which has led them to create prescribing guidelines for surgical teams that are based on what patients say they actually needed to take for pain control. The guidelines for c-sections published on the Michigan-OPEN site recommend that women receive between zero and 20 five-milligram oxycodone tablets or the equivalent.
Next steps
Peahl and her colleagues are currently contacting new mothers who received opioid painkillers to find out how many pills they took out of the total number they were prescribed and given. This could inform more evidence-based recommendations in the near future. They are also assessing the impact of a new ERAS protocol that was launched on July 8, which includes more robust patient education and shared decision making about opioid prescriptions at the time of discharge.
They also hope to study Medicaid data on a national level, expanding on the single-state analysis others have done. And, they hope to study data on the half of women who could notbe included in the current study because they had received opioid prescriptions in the year before they had their baby.
“No matter which way they deliver, women should be able to get up and spend time with their new baby,” says Peahl. “Pain, and the effects of pain control medications, should not get in the way of their birth experience and bonding with their infant.”
In addition to Peahl and Waljee, the study’s authors include Vanessa K. Dalton, M.D., John R. Montgomery, M.D., Yen-Ling Lai and Hsou Mei Hu. Peahl, Dalton, and Waljee are members of IHPI. The study was funded by Peahl’s IHPI NCSP fellowship.
DOI: 10.1001/jamanetworkopen.2019.7863

Nancy D. Campbell, PhD wrote in When Should Screening and Surveillance Be Used during Pregnancy?

Ethics in the kinds of risky situations described above is not a mere preoccupation with abstract principles—nor should ethics be understood as limited to technical details. Ethics is practical, often arising as a result of specific cases with particular histories of harm and injustice. Enjoined to do no harm, physicians arguably have a duty to reduce harm and certainly to provide care that does not coerce, stigmatize, or criminalize.
Physicians share responsibility to ensure access to the full range of reproductive health care and drug treatment for their patients who need it. Physicians also share with drug-using pregnant women responsibility to bring about healthy births and humane treatment for all concerned—mothers, babies, and children. Ensuring access to the full range of evidence-based drug treatment should be considered part of these affirmative duties. Biomedical surveillance should be conducted only for clinical purposes having to do with ensuring access to and delivering quality health care. Just because we have surveillance technology does not mean we should use it against the very women who need to be enrolled in caring for their infants. “Mom” is part of the cure, and compassionate care demands that surveillance be judiciously used in therapeutic spaces…. https://journalofethics.ama-assn.org/article/when-should-screening-and-surveillance-be-used-during-pregnancy/2018-03

Resources:

Prescription opioids during pregnancy https://www.marchofdimes.org/pregnancy/prescription-opioids-during-pregnancy.aspx

Using Narcotics For Pain Relief During Childbirth               https://americanpregnancy.org/labor-and-birth/narcotics/

Opioid use during pregnancy                                                      https://www.mayoclinic.org/opioid-use-during-pregnancy/art-20380741/in-depth/art-20380741
Doctors’ responsibility in opioid crisis                              http://cmajnews.com/2016/11/18/doctors-responsibility-in-opioid-crisis-cmaj-109-5359/

Untangling the medical ethics of prescribing opioids                                            https://www.ama-assn.org/delivering-care/ethics/untangling-medical-ethics-prescribing-opioids

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