Despite intervention, most women still prescribed opioids after cesarean delivery
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Despite the implementation of protocols to reduce opioid prescriptions during hospitalizations, approximately 90% of women who underwent cesarean delivery and did not use opioids in the hospital were discharged with an opioid prescription, according to findings from two related studies presented at Anesthesiology 2019.
“The two-step intervention was important because it showed that heavy education of prescribers, and the nurses in particular, on the postpartum floor allowed us to significantly reduce the amount of opioids [prescribed in the hospital],” Ruth Landau, MD, director of obstetric anesthesia at Columbia University Medical Center, told Healio Primary Care.
However, the related study of opioids prescribed at discharge showed that the intervention’s “messaging and our information didn’t trickle through to what our patients were sent home with,” Landau said.
In 2017, Columbia University Medical Center began using an intervention that educated obstetrics health care providers about stepwise multimodal opioid-sparing analgesia and a change in orders for post-cesarean delivery pain management. Under the new protocol, women were given ibuprofen 600 mg and acetaminophen 975 mg every 6 hours while hospitalized following cesarean delivery. Opioids were only prescribed for persistent pain: 5 mg every 4 hours for moderate pain and every 3 hours for severe pain.
Opioid consumption during hospitalization was monitored in 491 women prior to the protocol being implemented, and in 1,125 women after it was implemented.
Researchers found that after the protocol was implemented, 82.8% of nurses were adherent to it, and the cumulative median oxycodone dosage decreased from 60 mg to 25 mg. In addition, the percentage of women who did not use opioids at all during hospitalization after cesarean delivery increased from 9.6% to 29.8%.
In a related study, researchers evaluated opioid prescriptions made during cesarean delivery hospitalizations and at discharge in 2018, after the protocol was initiated.
A total of 1,503 women who were discharged after undergoing cesarean delivery were included in the study. Researchers found that 96.4% of women in the cohort were prescribed opioids at discharge and half (49.9%) were overprescribed the medication.
In addition, 456 (30.3%) of women in the study did not use opioids while they were hospitalized for cesarean delivery, but 406 (89%) of those were prescribed opioids at discharge.
Although 817 women (54.4%) were not given opioids in the last 24 hours of hospitalization, 750 (91.8%) of those were still prescribed opioids at discharge.
On average, patients were prescribed 19.5 opioid pills when they were discharged.
Based on the findings, researchers estimated that up to 15,000 leftover pills accumulated in patients’ homes, opening the door to opioid abuse, misuse, diversion or accidental ingestion.
“What we identified through the dashboard is that despite the very robust and structured intervention for what patients would be getting at the hospital, there was absolutely no correlation with what they would be sent home with,” Landau said.
She noted that shared decision making between patients and their providers could help reduce opioid prescriptions at discharge after cesarean delivery. – by Erin Michael
Reference:
Landau, et al. Abstract 2204. Presented at: Anesthesiology 2019; Oct. 19-23; Orlando.
Shatil, et al. Abstract 2105. Presented at: Anesthesiology 2019; Oct. 19-23; Orlando.
Disclosures: Landau reports no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures.
Perspective
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Alex F. Peahl, MD
The findings from Dr. Landau’s work recently presented at the Anesthesiology 2019 annual meeting highlight two important themes from post-delivery opioid research: 1) we are sending many women home with too many opioid pills after their delivery, and 2) we can do more to reduce opioid use through stepwise, multimodal analgesia and tailored prescribing. Dr. Landau and her team demonstrated that although over a third of women used no opioid following their delivery, 90% were nevertheless sent home with a prescription, averaging 19.5 tabs per patient. Why are maternity care providers continuing to provide these prescriptions to women who are not using them? Perhaps opioid prescribing has become dogma, institution-level protocols have not yet responded to growing evidence of overuse, or patients’ concerns about navigating the postoperative and postpartum period is driving prescribing. Others, such as Yee and colleagues, have noted the lack of correlation between opioid use and prescription size, and work by Osmundson and Bateman has demonstrated the impact of tailored postpartum prescribing (using individual’s inpatient opioid use to inform shared decision-making to identify the best prescription size). Tailored prescribing, in conjunction with opioid-sparing regimens as recommended by the ERAS Society guidelines, have shown great promise in studies out of Kaiser Permanente and several medical centers across the United States. These protocols have demonstrated great success, though their impact on actual opioid consumption (not just prescribing) remains unknown. Dr. Landau and her team add to a growing body of knowledge around peripartum opioid use that will hopefully improve the quality cesarean pain management without risking the harms of opioid overprescribing.
References:
Badreldin N, et al. Am J Obstet Gynecol. 2018;doi:10.1016/j.ajog.2018.04.003.
Caughey AB, et al. Am J Obstet Gynecol. 2018;doi:10.1016/j.ajog.2018.08.006.
Hedderson M, et al. Obstet Gynecol. 2019;doi:10.1097/AOG.0000000000003406.
Macones GA, et al. Am J Obstet Gynecol. 2019;doi:10.1016/j.ajog.2019.04.012.
Osmundson SS, et al. Obstet Gynecol. 2018;doi:10.1097/AOG.0000000000002782.
Prabhu M, et al. Obstet Gynecol. 2019;doi:10.1097/AOG.0000000000002789.
Wilson RD, et al. Am J Obstet Gynecol. 2018;doi:10.1016/j.ajog.2018.09.015.
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