Associate Professor, Maternal Fetal Medicine, University of Colorado Departments of Obstetrics and Gynecology and Psychiatry, Wheat Ridge, CO
Dr. Hoffman reports no financial relationships relevant to this field of study.
SOURCE:Smith AM, et al. Multimodal stepwise approach to reducing in-hospital opioid use after cesarean delivery: A quality improvement initiative. Obstet Gynecol 2019;133:700-706.
SYNOPSIS:These investigators found that the routine use of acetaminophen alone rather than a combination acetaminophen-opioid significantly reduced overall and daily opioid use. In addition, there was no worse effect on overall pain score or length of stay.
Prescription opioid use, and subsequent misuse, has resulted in a grand public health issue and, unfortunately, is responsible for claiming numerous lives each year. These authors from the Naval Medical Center in Portsmouth, VA, assessed delivery population data before and after a quality improvement (QI) initiative to evaluate a “standardized, structured approach to in-hospital post-cesarean delivery pain management.” The main goal of this initiative was to uncouple scheduled acetaminophen prescribing (stop using combination acetaminophen-hydrocodone or acetaminophen-oxycodone) from opioid prescribing in the electronic order set. In addition to scheduling acetaminophen alone, the initiative also included scheduled nonsteroidal anti-inflammatory drugs (NSAIDs) and limited opioid use to breakthrough pain after acetaminophen and NSAIDs. A significant drop in overall opioid use — quantified by median morphine milligram equivalents per stay (75% reduction) and per day (77% reduction) — resulted from this subtle yet powerful change. There was no difference in pain score, amount of NSAIDs used, or length of stay. There were significant increases in acetaminophen use and the proportion of patients who used no opioids during their hospital stay (6% pre-QI vs. 19% post-QI).
COMMENTARY
Many women experience their first exposure to opioids with cesarean delivery. About 30% of deliveries are by cesarean. Of women who are opioid-naïve at the time of delivery, about one in 300 will become persistent opioid users after this first episode of exposure.1 This is a part of the opioid crisis in which the obstetrician/gynecologist has power and influence.
We are taught to control pain post-cesarean, since undertreatment of postpartum pain has been associated with greater opioid use, delayed recovery of function, persistent pain, and increased rates of postpartum depression.2 On the other hand, excessive opioid exposure resulting in an opioid use disorder leads to pain, suffering, and increased risk of death. Fortunately, our anesthesiology colleagues provide the greatest “layer” of pain control post-cesarean with long-acting neuraxial opioids; however, oral pain medication also is the rule following cesarean delivery.3
In this study, Smith et al sought to evaluate whether the implementation of a simple quality improvement measure would decrease the use of opioids. We learned that not only did the routine use of acetaminophen alone, instead of combination acetaminophen-opioid, significantly reduce overall and daily opioid use, this simple measure also had no worse effect on overall pain score or length of stay. This demonstrates that women did not appear to be suffering more at the “lack” of opioids. Furthermore, there was a significant increase in the percentage of women who used no opioids at all during their stay to almost 20%.
Based on this simple tweak of the electronic medical record’s order set, here are some suggestions for minimizing post-cesarean delivery opioid use at your institution AND for minimizing postpartum opioid use in general:
- Make this change in your own electronic medical record’s order set, or put in specific orders to uncouple acetaminophen from opioids (combination acetaminophen-hydrocodone or oxycodone).
- Schedule NSAIDs and acetaminophen as first-line treatments for postoperative pain.
- Take scheduled opioids off the menu, and inform patients that they may request additional medications after standing orders for acetaminophen and NSAIDs have been administered.
- Discharge home with fewer opioid pills. In a study assessing post-discharge opioid use after cesarean delivery, 83% of women used opioids for a median of only eight days (interquartile range, six to 13 days), and 75% had unused tablets.4
REFERENCES
- Bateman BT, et al. Persistent opioid use following cesarean delivery: Patterns and predictors among opioid-naïve women. Am J Obstet Gynecol 2016;215:353e1-18.
- Eisenach JC, et al. Severity of acute pain after childbirth, but not type of delivery, predicts persistent pain and postpartum depression. Pain 2008;140:87-94.
- ACOG Committee Opinion No. 742: Postpartum pain management. Obstet Gynecol 2018;132:252-253.
- Osmundson SS, et al. Postdischarge opioid use after cesarean delivery. Obstet Gynecol 2017;130:36-41.