Fewer prescribed opioids at discharge with individualized protocol, shared decision-making

Key takeaways:

• Pain at 1 week after discharge was similar for the individualized opioid-prescription protocol and fixed quantity.
• The individualized opioid-prescription protocol vs. fixed quantity led to fewer opioid tablets.

An individualized opioid-prescription protocol with shared decision-making was associated with similar pain reports as fixed-quantity opioid prescriptions but with fewer prescribed opioids at hospital discharge following cesarean births.

“An individualized opioid-prescription protocol (IOPP) uses a postpartum person’s opioid use in the 24 hours before discharge as a starting point and then incorporates shared decision-making to determine a discharge opioid quantity. This intervention decreased the number of opioid tablets prescribed at hospital without compromising pain management at 1 week postpartum after a cesarean birth,” Marcela C. Smid, MD, MA, MS, associate professor in the division of maternal-fetal medicine in the department of obstetrics and gynecology at the University of Utah Health Sciences Center, told Healio. “IOPP with shared decision-making has the potential to decrease opioid quantity after cesarean birth both for individuals and at the population level, an important step in addressing the opioid epidemic.”

Smid and colleagues conducted a multicenter, randomized controlled, noninferiority trial, published in Obstetrics & Gynecology, from September 2020 to March 2022 with data from 5,521 new mothers from 31 centers participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. All women had uncomplicated cesarean births with follow-up until 12 weeks after hospital discharge. Researchers randomly assigned women to the IOPP with shared decision-making (n = 2,748) or a fixed quantity with 20 tablets of oxycodone 5 mg (n = 2,773).

In the IOPP group, researchers estimated recommended quantities of oxycodone based on opioid use 24 hours before discharge and women selected oxycodone quantity, of up to 20 tablets, after an educated module and shared decision-making.

Primary outcome was moderate to severe pain scored as four points or higher on the Brief Pain Inventory at 1 week after discharge.

IOPP with shared decision-making was noninferior to fixed-quantity protocol in reports of moderate to severe pain at 1 week after discharge (risk difference = 0.67%; 95% CI, –2.03 to 3.37). At 90 days postpartum, the proportion of women who filled an opioid prescription beyond what was prescribed at discharge was similar between the two groups (RR = 1.22; 96.25% CI, 0.99-1.51).

In addition, at 90 days postpartum, the number of unused opioid tablets was lower in the IOPP with shared decision-making group compared with the fixed-quantity group (median difference = –5; 97.5% CI, –6.5 to –3.5). The IOPP with shared decision-making group received fewer opioid tablets overall compared with the fixed-quantity group through 90 days postpartum (median, 14 vs. 20; P < .001).

“Next steps would be to conduct an implementation study in the ‘real world,’” Smid said. “Individualized opioid-prescription protocol with shared decision-making has efficacy, but we would need to study its effectiveness when implemented outside of a clinical trial.”

For more information:

Marcela C. Smid, MD, MA, MS, can be reached at marcela.smid@hsc.utah.edu.