Evaluation of a Quality Improvement Intervention That Eliminated Routine Use of Opioids After Cesarean Delivery

Implementability of opioid deprescribing interventions at transitions of care: A scoping review

Continuation of opioids at transitions of care increases the risk of long-term opioid use and related harm. To our knowledge, no study has examined the implementability of opioid deprescribing interventions at transitions of care. Our scoping review aimed to identify the type of opioid deprescribing interventions employed at transitions of care and assess the implementability of tested interventions. Nine electronic databases were searched on 15 May 2023 for English-language studies of adults transitioning between care settings, where opioid deprescribing interventions targeting patients, clinicians or health systems were implemented. Implementability was assessed using the Cochrane Intervention Complexity Assessment Tool for Systematic Reviews to determine intervention complexity, and mapped to the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework to understand the process evaluation. A total of 79 studies were identified, with 94.0% (n = 74) examining hospital-to-home transitions. Mixed interventions (combination of pharmacological and nonpharmacological) were tested in 49.0% (n = 39) of studies. Pharmacological interventions were identified in 31.0% (n = 24) of studies, and the remaining 20.0% (n = 16) applied nonpharmacological interventions. Mixed interventions comprising multiple components were the most complex and resulted in reduced opioid use across transitions of care in 28.0% (n = 22) of studies. Few studies reported on RE-AIM dimensions including implementation (5.0% of studies), reach (4.0%), adoption (4.0%) and maintenance (0%). Most opioid deprescribing interventions targeted hospital to home care transition with mixed results in opioid deprescribing. Further research should consider the implementability of interventions during transitions of care to elucidate the impact of opioid deprescribing interventions across care settings.

Shared Decision-Making and Collaborative Care Models for Pain Management: A Scoping Review of Existing Evidence

This article aims to summarize the existing evidence on shared decision-making and collaborative care models for acute and chronic pain management. We searched the PubMed database for articles published between 1980 and 2023 and scanned included articles' references to identify additional sources. Two reviewers independently screened titles and abstracts. Studies met inclusion criteria if they implemented or evaluated shared decision-making or collaborative care interventions in patients with acute or chronic pain. A total of 690 articles were reviewed, with 32 full text articles meeting inclusion criteria. Most studies assessed changes in prescription opioid quantities and patient-reported pain levels. Secondary measures generally included patient satisfaction, 30-day refill rate, and use of non-opioid analgesics. Shared decision-making and collaborative care models are promising interventions to improve pain management. These interventions are effective at reducing opioid consumption among acute and chronic pain patients without compromising patient-reported pain levels. There is further research needed to evaluate how shared decision-making and collaborative care interventions impact patient-centered outcomes such as patient satisfaction, quality of life, and patient-provider communication.

Integrative Review of Opioid Use and Protocol Adherence in Hospitals After Implementing Enhanced Recovery After Surgery Protocols for Cesarean Birth

OBJECTIVE

To evaluate the enhanced recovery after surgery (ERAS) protocols used and amount of opioids administered during hospitalization for cesarean birth after the ERAS protocols were implemented.

DATA SOURCES

A search was conducted in CINAHL Complete, Scopus, and PubMed for sources published in English between January 2018 and December 2023. Search terms were cesarean AND opioid∗ AND eras OR erac OR enhanced recovery.

STUDY SELECTION

Eligible studies were conducted in the United States, used key pain management components from the ERAS guidelines, and reported results for in-patient postsurgical opioid use.

DATA EXTRACTION

Data obtained were for post-ERAS implementation only and included authors, date, sample size, study location, participant inclusion and exclusion criteria, methods, interventions used (ERAS guideline components), and morphine milligram equivalents (MME) used during the hospital stay.

DATA SYNTHESIS

Weighted averages were calculated for results reported as means and percentages. Descriptive summaries were used for the remainder of the results.

RESULTS

Twenty-six studies were found, accounting for 19,961 individuals' post-ERAS experiences. Although 30% of participants experienced a scheduled cesarean birth, 70% experienced all types of cesarean births, including scheduled, urgent, or emergent. There was substantial heterogeneity of the data reported, especially for how opioid use was measured and analyzed and time frames for opioid use. In 11 studies that reported MME as means, the weighted average for in-patient opioid use was 54 MME per stay. In only 17 studies, researchers reported the number of women who experienced an opioid-free recovery, which averaged 40% of the women.

CONCLUSION

While implementation of key components of the ERAS protocol is associated with reduced opioid exposure for women experiencing scheduled and nonscheduled cesarean births, a benchmark for the amount of in-patient opioid use was not established. Still, this review offers evidence regarding best practices, lessons learned, and outcome analysis strategies. These findings can support perinatal teams who are considering implementing ERAS for cesarean birth, or those looking for further improvements.

Changes in Postpartum Opioid Prescribing After Implementation of State Opioid Prescribing Limits

Importance

In response to the growing opioid crisis, states implemented opioid prescribing limits to reduce exposure to opioid analgesics. Research in other clinical contexts has found that these limits are relatively ineffective at changing opioid analgesic prescribing.

Objective

To examine the association of state-level opioid prescribing limits with opioid prescribing within the 30-day postpartum period, as disaggregated by type of delivery (vaginal vs cesarean) and opioid naivete.

Design, Setting, and Participants

This retrospective, observational cohort study used commercial claims data from January 1, 2014, to December 31, 2021, from 49 US states and a difference-in-differences staggered adoption estimator to examine changes in postpartum opioid prescribing among all deliveries to enrollees between the ages of 18 and 44 years in the US.

Exposures

The implementation of a state opioid prescribing limit between 2017 and 2019.

Main Outcomes and Measurements

The primary outcomes for this analysis were the number of prescriptions for opioid analgesics, proportion of prescriptions with a supply greater than 7 days, and milligrams of morphine equivalent (MMEs) per delivery between 3 days before and 30 days after delivery.

Results

A total of 1 572 338 deliveries (enrollee mean [SD] age, 30.20 [1.59] years) were identified between 2014 and 2021, with 32.3% coded as cesarean deliveries. A total of 98.4% of these were to opioid-naive patients. The mean MMEs per delivery was 310.79, with higher rates in earlier years, states that had an opioid prescribing limit, and cesarean deliveries. In a covariate-adjusted difference-in-differences regression analysis, opioid prescribing limits were associated with a decrease of 148.70 MMEs per delivery (95% CI, -657.97 to 360.57) compared with states without such limits. However, these changes were not statistically significant. The pattern of results was similar among other opioid-prescribing outcomes and types of deliveries.

Conclusions and Relevance

The results of this cohort study suggest that opioid prescribing limits are not associated with changes in postpartum opioid prescribing regardless of delivery type or opioid naivete, which is consistent with research findings on these limits in other conditions or settings. Future research could explore what kinds of prevention mechanisms reduce the risk of opioid prescribing during pregnancy and postpartum.

The French Ambulatory Cesarean Section: Safety and Recovery Characteristics

OBJECTIVES

The French AmbUlatory Extraperitoneal Cesarean Section (FAUCS) is aimed at improving patients' birth experience and recovery. However, data are scarce regarding its maternal and neonatal safety. This study seeks to compare maternal and neonatal outcomes between FAUCS and conventional cesarean deliveries at term.

METHODS

This was a retrospective cohort study involving women who underwent scheduled cesarean deliveries at term. We compared a total of 810 cases using the FAUCS technique with 217 cases using conventional cesarean deliveries. Surgical complications, adverse neonatal events, and maternal recovery parameters were compared.

RESULTS

The incidence of overall surgical complications was comparable between the 2 groups, with rates of 1.97% for FAUCS and 1.85% for the conventional cesarean deliveries. The rates of specific complications such as bladder injury (0.1%), bowel injury (0.1%), blood transfusion (1.35%), and postpartum hemorrhage (1%) were consistent with existing literature. Neonatal outcomes, including neonatal acidemia and admission rates to the neonatal intensive care unit, were comparable between the groups and demonstrated favourable comparisons with previously reported data. Notably, women in the FAUCS group required less analgesia, with only 0.8% receiving morphine, as opposed to 38% in the control group. Furthermore, the FAUCS group demonstrated significantly quicker recovery, with 86% achieving autonomy and early discharge at their discretion within 48 hours after operation, in contrast to only 17% in the control group.

CONCLUSIONS

When performed by experienced practitioners, FAUCS proves to be a safe procedure, with no increased risk for maternal or neonatal complications. Its significant benefits in terms of enhancing maternal recovery are noteworthy.

A bundle of opioid-sparing strategies to eliminate routine opioid prescribing in a urogynecology practice

BACKGROUND

Current evidence supports that many patients do not use prescribed opioids following reconstructive pelvic surgery, yet it remains unclear if it is feasible to eliminate routine opioid prescriptions without a negative impact on patients or providers.

OBJECTIVE

To determine if there is a difference in the proportion of patients discharged without opioids after implementing a bundle of opioid-sparing strategies and tiered prescribing protocol compared to usual care after minimally invasive pelvic reconstructive surgery (transvaginal, laparoscopic, or robotic). Secondary objectives include measures of patient-perceived pain control and provider workload.

STUDY DESIGN

The bundle of opioid-sparing strategies and tiered prescribing protocol intervention was implemented as a division-wide evidence-based practice change on August 1, 2022. This retrospective cohort compares a 6-month postintervention (bundle of opioid-sparing strategies and tiered prescribing protocol) cohort to 6-month preintervention (usual care) of patients undergoing minimally invasive pelvic reconstructive surgery. A 3-month washout period was observed after bundle of opioid-sparing strategies and tiered prescribing protocol initiation. We excluded patients <18 years, failure to consent to research, combined surgery with other specialties, urge urinary incontinence or urinary retention procedures alone, and minor procedures not typically requiring opioids. Primary outcome was measured by proportion discharged without opioids and total oral morphine equivalents prescribed. Pain control was measured by pain scores, postdischarge prescriptions and refills, phone calls and visits related to pain, and satisfaction with pain control. Provider workload was demonstrated by phone calls and postdischarge prescription refills. Data were obtained through chart review on all patients who met inclusion criteria. Primary analysis only included patients prescribed opioids according to the bundle of opioid-sparing strategies and tiered prescribing protocol protocol. Two sample t tests compared continuous variables and chi-square tests compared categorical variables.

RESULTS

Four hundred sixteen patients were included in the primary analysis (207 bundle of opioid-sparing strategies and tiered prescribing protocol, 209 usual care). Baseline demographics were similar between groups, except a lower proportion of irritable bowel syndrome (13% vs 23%; P<.01) and pelvic pain (15% vs 24.9%; P=.01), and higher history of prior gynecologic surgery (69.1% vs 58.4%; P=.02) in the bundle of opioid-sparing strategies and tiered prescribing protocol cohort. The bundle of opioid-sparing strategies and tiered prescribing protocol cohort was more likely to be discharged without opioids (68.1% vs 10.0%; P<.01). In those prescribed opioids, total oral morphine equivalents on discharge was significantly lower in the bundle of opioid-sparing strategies and tiered prescribing protocol cohort (48.1 vs 81.8; P<.01). The bundle of opioid-sparing strategies and tiered prescribing protocol cohort had a 20.6 greater odds (confidence interval 11.4, 37.1) of being discharged without opioids after adjusting for surgery type, arthritis/joint pain, IBS, pelvic pain, and contraindication to nonsteroidal anti-inflammatory drugs. The bundle of opioid-sparing strategies and tiered prescribing protocol cohort was also less likely to receive a rescue opioid prescription after discharge (1.4% vs 9.5%; P=.03). There were no differences in opioid prescription refills (19.7% vs 18.1%; P=.77), emergency room visits for pain (3.4% vs 2.9%; P=.76), postoperative pain scores (mean 4.7 vs 4.0; P=.07), or patient satisfaction with pain control (81.5% vs 85.6%; P=.21). After bundle of opioid-sparing strategies and tiered prescribing protocol implementation, the proportion of postoperative phone calls for pain also decreased (12.6% vs 21.5%; P=.02). Similar results were identified when nonadherent prescribing was included in the analysis.

CONCLUSION

A bundle of evidence-based opioid sparing strategies and tiered prescribing based on inpatient use increases the proportion of patients discharged without opioids after minimally invasive pelvic reconstructive surgery without evidence of uncontrolled pain or increased provider workload.

A Quality Improvement Effort to Reduce Inpatient Opioid Consumption following Cesarean Delivery

OBJECTIVE

The amount of opioid prescribed following cesarean delivery (CD) is commonly in excess of patients' needs. An additional concern in a breastfeeding mother is neonatal opioid exposure. A maximum daily dose of 30 mg of oxycodone is recommended in breastfeeding women. Inadequate pain control can inhibit breastfeeding, as well as other negative consequences. We aimed to evaluate the effect of reducing the as-needed opioid ordered following CD on inpatient opioid consumption and analgesia.

STUDY DESIGN

At our tertiary-care institution, our standard as-needed opioid order was reduced from oxycodone 5 to 10 mg every 4 hours to oxycodone 5 mg every 6 hours, in May 2019. Orders for scheduled acetaminophen and nonsteroidal anti-inflammatory drugs were unchanged. We compared opioid use and pain scores before (February 2019-April 2019) and after (May 2019-July 2019) the order modification. Our primary outcome was the proportion of patients using >30 mg of oxycodone in the 24 hours prior to hospital discharge. We further assessed 48-hour opioid consumption and patient-reported verbal pain scores.

RESULTS

There were 559 patients who met inclusion criteria; 241 preintervention patients and 318 postintervention patients. In the preintervention group, 14.5% (35/241) used >30-mg oxycodone in the 24 hours before discharge, compared with 5.0% (16/318) after the order set change (relative risk [RR] = 0.34, 95% confidence interval [CI]: 0.19, 0.61; number needed to treat [NNT] = 10.5). There was no change in the proportion of women with one or more pain score >7 (preintervention: 44.4% [107/241], postintervention: 43.1% [137/318], p = 0.756) or >4 and ≤7 (preintervention: 36.9% [89/241], postintervention: 36.9% [125/318], p = 0.567), nor was there a change in mean pain score (mean ± standard deviation [SD]: preintervention = 2.8 ± 1.6 and postintervention = 2.7 ± 1.4, p = 0.464).

CONCLUSION

Reducing the amount of opioid ordered after CD reduced the proportion of post-CD patients exceeding the maximum recommended daily oxycodone dose for breastfeeding women.

KEY POINTS

· Inpatient opioid prescribing influences usage.. · Opioid orders influence consumption.. · Reducing opioids may not increase pain..

Brief Assessment of Patient Phenotype to Explain Variability in Postsurgical Pain and Opioid Consumption after Cesarean Delivery: Performance of a Novel Brief Questionnaire Compared to Long Questionnaires

BACKGROUND

Understanding factors that explain why some women experience greater postoperative pain and consume more opioids after cesarean delivery is crucial to building an evidence base for personalized prevention. Comprehensive psychosocial assessment with validated questionnaires in the preoperative period can be time-consuming. A three-item questionnaire has shown promise as a simpler tool to be integrated into clinical practice, but its brevity may limit the ability to explain heterogeneity in psychosocial pain modulators among individuals. This study compared the explanatory ability of three models: (1) the 3-item questionnaire, (2) a 58-item questionnaire (long) including validated questionnaires (e.g., Brief Pain Inventory, Patient Reported Outcome Measurement Information System [PROMIS]) plus the 3-item questionnaire, and (3) a novel 19-item questionnaire (brief) assessing several psychosocial factors plus the 3-item questionnaire. Additionally, this study explored the utility of adding a pragmatic quantitative sensory test to models.

METHODS

In this prospective, observational study, 545 women undergoing cesarean delivery completed questionnaires presurgery. Pain during local anesthetic skin wheal before spinal placement served as a pragmatic quantitative sensory test. Postoperatively, pain and opioid consumption were assessed. Linear regression analysis assessed model fit and the association of model items with pain and opioid consumption during the 48 h after surgery.

RESULTS

A modest amount of variability was explained by each of the three models for postoperative pain and opioid consumption. Both the brief and long questionnaire models performed better than the three-item questionnaire but were themselves statistically indistinguishable. Items that were independently associated with pain and opioid consumption included anticipated postsurgical pain medication requirement, surgical anxiety, poor sleep, pre-existing pain, and catastrophic thinking about pain. The quantitative sensory test was itself independently associated with pain across models but only modestly improved models for postoperative pain.

CONCLUSIONS

The brief questionnaire may be more clinically feasible than longer validated questionnaires, while still performing better and integrating a more comprehensive psychosocial assessment than the three-item questionnaire.

EDITOR’S PERSPECTIVE

Nonsteroidal anti-inflammatory drug "allergy" labeling is associated with increased postpartum opioid utilization

BACKGROUND

Current guidelines recommend a stepwise approach to postpartum pain management, beginning with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), with opioids added only if needed. Report of a prior NSAID-induced adverse drug reaction (ADR) may preclude use of first-line analgesics, despite evidence that many patients with this allergy label may safely tolerate NSAIDs.

OBJECTIVE

We assessed the association between reported NSAID ADRs and postpartum opioid utilization.

METHODS

We performed a retrospective cohort study of birthing people who delivered within an integrated health system (January 1, 2017, to December 31, 2020). Study outcomes were postpartum inpatient opioid administrations and opioid prescriptions at discharge. Statistical analysis was performed on a propensity score-matched sample, which was generated with the goal of matching to the covariate distributions from individuals with NSAID ADRs.

RESULTS

Of 38,927 eligible participants, there were 883 (2.3%) with an NSAID ADR. Among individuals with reported NSAID ADRs, 49.5% received inpatient opioids in the postpartum period, compared to 34.5% of those with no NSAID ADRs (difference = 15.0%, 95% confidence interval 11.4-18.6%). For patients who received postpartum inpatient opioids, those with NSAID ADRs received a higher total cumulative dose between delivery and hospital discharge (median 30.0 vs 22.5 morphine milligram equivalents [MME] for vaginal deliveries; median 104.4 vs 75.0 MME for cesarean deliveries). The overall proportion of patients receiving an opioid prescription at the time of hospital discharge was higher for patients with NSAID ADRs compared to patients with no NSAID ADRs (39.3% vs 27.2%; difference = 12.1%, 95% confidence interval 8.6-15.6%).

CONCLUSION

Patients with reported NSAID ADRs had higher postpartum inpatient opioid utilization and more frequently received opioid prescriptions at hospital discharge compared to those without NSAID ADRs, regardless of mode of delivery.

The association of obesity with post-cesarean inpatient opioid consumption

BACKGROUND

Obesity and prescription opioid misuse are important public health concerns in the United States. A common intersection occurs when women with obesity undergo cesarean birth and receive narcotic medications for postpartum pain.

OBJECTIVE

To examine the association between obesity and inpatient opioid use after cesarean birth.

METHODS

A retrospective cohort study of patients that underwent cesarean birth in 2015-2018. Primary outcome was post-cesarean delivery opioid consumption starting 24 h after delivery measured as morphine milliequivalents per hour (MME/h). Secondary outcome was MME/h consumption in the highest quartile of all subjects. Opioid consumption was compared between three BMI groups: non-obese BMI 18.5-29.9 kg/m2; obese BMI 30.0-39.9 kg/m2; and morbidly obese BMI ≥ 40.0 kg/m2 using univariable and multivariable analyses.

RESULTS

Of 1620 patients meeting inclusion criteria, 496 (30.6%) were in the non-obese group, 753 (46.5%) were in the obese group, and 371 (22.9%) were in the morbidly obese group. In the univariate analysis, patients with obesity and morbid obesity required higher MME/h than patients in the non-obese group [1.3 MME/h (IQR 0.1, 2.4) vs. 1.6 MME/h (IQR 0.5, 2.8) vs. 1.8 MME/h (IQR 0.8, 2.9), for non-obese, obese, and morbidly obese groups respectively, p < 0.001]. In the multivariable analysis, this association did not persist. In contrast, subjects in the obese and morbidly obese groups were more likely to be in the highest quartile of MME/h opioid consumption compared with those in the non-obese group (23.5% vs. 48.1% vs. 28.4%, p < 0.001, respectively); with aOR 1.42 (95% CI 1.07-1.89, p = 0.016) and aOR 1.60 (95% CI 1.16-2.22, p = 0.005) for patients with obesity and morbid obesity, respectively.

CONCLUSION

Maternal obesity was not associated with higher hourly MME consumption during inpatient stay after cesarean birth. However, patients with obesity and morbid obesity were significantly more likely to be in the top quartile of MME hourly consumption.

A Prospective Longitudinal Quality Initiative toward Improved Enhanced Recovery after Cesarean Pathways

OBJECTIVE

This study aimed to evaluate whether enhanced recovery after cesarean (ERAC) pathways reduces inpatient and outpatient opioid use, pain scores and improves the indicators of postoperative recovery.

STUDY DESIGN

This is a prospective, longitudinal, quality improvement study of all patients older than 18 undergoing an uncomplicated cesarean delivery (CD) at an academic medical center. We excluded complicated CD, patients with chronic pain disorders, chronic opioid use, acute postpartum depression, or mothers whose neonate demised before their discharge. Lastly, we excluded non-English- and non-Spanish-speaking patients. Our study compared patient outcomes before (pre-ERAC) and after (post-ERAC) implementation of ERAC pathways. Primary outcomes were inpatient morphine milligram equivalent (MME) use and the patient's delta pain scores. Secondary outcomes were outpatient MME prescriptions and indicators of postoperative recovery (time to feeding, ambulation, and hospital discharge).

RESULTS

Of 308 patients undergoing CD from October 2019 to September 2020, 196 were enrolled in the pre-ERAC cohort and 112 in the post-ERAC cohort. Patients in the pre-ERAC cohort were more likely to require opioids in the postoperative period compared with the post-ERAC cohort (81.6 vs. 64.3%, p < 0.001). Likewise, there was a higher use of MME per stay in the pre-ERAC cohort (30 [20-49] vs. 16.8 MME [11.2-33.9], p < 0.001). There was also a higher number of patients who required prescribed opioids at the time of discharge (98 vs. 86.6%, p < 0.001) as well as in the amount of MMEs prescribed (150 [150-225] vs. 150 MME [112-150], p < 0.001; different shape of distribution). Furthermore, the patients in the pre-ERAC cohort had higher delta pain scores (3.3 [2.3-4.7] vs. 2.2 [1.3-3.7], p < 0.001).

CONCLUSION

Our study has illustrated that our ERAC pathways were associated with reduced inpatient opioid use, outpatient opioid use, patient-reported pain scores, and improved indicators of postoperative recovery.

KEY POINTS

· Implementation of ERAC pathways is associated with a higher percentage of no postpartum opioid use.. · Implementation of ERAC pathways is associated with lower delta (reported - expected) pain scores.. · The results of ERAC pathways implementation are increased by adopting a patient-centered approach..

Understanding the Postpartum Cesarean Pain Experience Among Individuals With Publicly Funded Insurance: A Qualitative Investigation

INTRODUCTION

Pain is the most common postpartum concern and has been associated with adverse outcomes, such as difficulty with neonatal bonding, postpartum depression, and persistent pain. Furthermore, racial and ethnic disparities in the management of postpartum pain are well described. Despite this, less is known regarding patients' lived experiences regrading postpartum pain. The purpose of this study was to assess patient experiences related to postpartum pain management after cesarean birth.

METHODS

This is a prospective qualitative study of patients' experiences with postpartum pain management after cesarean birth at a single large tertiary care center. Individuals were eligible if they had publicly funded prenatal care, were English or Spanish speaking, and underwent a cesarean birth. Purposive sampling was used to ensure a racially and ethnically diverse cohort. Participants underwent in-depth interviews using a semistructured interview guide at 2 time points: postpartum day 2 to 3 and 2 to 4 weeks after discharge. Interviews addressed perceptions and experiences of postpartum pain management and recovery. Data were analyzed using the constant comparative method.

RESULTS

Of 49 participants, 40.8% identified as non-Hispanic Black and 40.8% as Hispanic. The majority (59.2%) had experienced a cesarean birth with a prior pregnancy. Thematic analysis yielded 2 overarching domains: (1) experience of pain after cesarean birth and (2) pain management and opioid use after cesarean birth. Themes related to the experience of pain included pain as a meaningful experience, pain not aligned with expectations, and limitations caused by pain. All participants discussed limitations caused by their pain, voicing frustration with pursuing activities of daily living, caring for home and family, caring for neonate, and impact on mood. Themes related to pain management and opioid use addressed a desire for nonpharmacologic pain management, positive and negative experiences using opioids, and hesitancy and perceived judgement regarding opioid use. Several participants described experiences of judgement regarding the request for opioids and needing stronger pain medications, such as oxycodone.

DISCUSSION

Understanding experiences regarding postpartum cesarean pain management and recovery is essential to improving patient-centered care. The experiences identified by this analysis highlight the need for individualized postpartum pain management, improved expectation counseling, and the expansion of multimodal pain management options.

Antepartum depressive symptoms are associated with significant postpartum opioid use

BACKGROUND

Antepartum depression is common, and outside of childbirth preoperative anxiety and depression have been associated with heightened postoperative pain. In light of the national opioid epidemic, the relationship between antepartum depressive symptoms and postpartum opioid use is particularly relevant.

OBJECTIVE

This study evaluated the association between antepartum depressive symptoms and significant postpartum opioid use during birth hospitalization.

STUDY DESIGN

This retrospective cohort study at an urban academic medical center from 2017 to 2019 included patients who received prenatal care at the medical center and linked pharmacy and billing data with electronic medical records. The exposure was antepartum depressive symptoms, defined as Edinburgh Postnatal Depression Scale ≥10 during the antepartum period. The outcome was significant opioid use, defined as: (1) any opioid use following vaginal birth and (2) the top quartile of total opioid use following cesarean delivery. Postpartum opioid use was quantified using standard conversions for opioids dispensed on postpartum days 1 to 4 to calculate morphine milligram equivalents. Poisson regression was used to calculate risk ratios and 95% confidence intervals, stratified by mode of delivery and adjusted for suspected confounders. Mean postpartum pain score was a secondary outcome.

RESULTS

The cohort included 6094 births; 2351 births (38.6%) had an antepartum Edinburgh Postnatal Depression Scale score. Of these, 11.5% had a maximum score ≥10. Significant opioid use was observed in 10.6% of births. We found that individuals with antepartum depressive symptoms were more likely to have significant postpartum opioid use, with an adjusted risk ratio of 1.5 (95% confidence interval, 1.1-2.0). When stratified by mode of delivery, this association was more pronounced for cesarean births, with an adjusted risk ratio of 1.8 (95% confidence interval, 1.1-2.7), and was no longer significant for vaginal births. Mean pain scores after cesarean delivery were significantly higher in parturients with antepartum depressive symptoms.

CONCLUSION

Antepartum depressive symptoms were associated with significant postpartum inpatient opioid use, especially following cesarean delivery. Whether identifying and treating depressive symptoms in pregnancy may impact the pain experience and opioid use postpartum warrants further investigation.

A comparison of postpartum opioid consumption and opioid discharge prescriptions among opioid-naïve patients and those with opioid use disorder

BACKGROUND

Management of patients with opioid use disorder during the acute postpartum period remains clinically challenging as obstetricians aim to mitigate postdelivery pain while optimizing recovery support.

OBJECTIVE

This study aimed to evaluate postpartum opioid consumption and opioids prescribed at discharge among patients with opioid use disorder treated with methadone, buprenorphine, and no medication for opioid use disorder, as compared with opioid-naïve counterparts.

STUDY DESIGN

We conducted a retrospective cohort study of pregnant patients who underwent delivery at >20 weeks' gestation at a tertiary academic hospital between May 2014 and April 2020. The primary outcome of this analysis was the mean daily quantity of oral opioids consumed after delivery while inpatient, in milligrams of morphine equivalents. Secondary outcomes included the following: (1) quantity of oral opioids prescribed at discharge, and (2) prescription for oral opioids in the 6 weeks after hospital discharge. Multiple linear regression was used to compare differences in the primary outcome.

RESULTS

A total of 16,140 pregnancies were included. Patients with opioid use disorder (n=553) consumed 14 milligrams of morphine equivalents per day greater quantities of opioids postpartum than opioid-naïve women (n=15,587), (95% confidence interval, 11-17). Patients with opioid use disorder undergoing cesarean delivery consumed 30 milligrams of morphine equivalents per day greater quantities of opioids than opioid-naïve counterparts (95% confidence interval, 26-35). Among patients who underwent vaginal delivery, there was no difference in opioid consumption among patients with and without opioid use disorder. Compared with patients prescribed methadone, patients prescribed buprenorphine, and those prescribed no medication for opioid use disorder consumed similar opioid quantities postpartum following both vaginal and cesarean delivery. Among patients undergoing cesarean delivery, opioid-naïve patients were more likely to receive a discharge prescription for opioids than patients with opioid use disorder (77% vs 68%; P=.002), despite lower pain scores and less inhospital opioid consumption.

CONCLUSION

Patients with opioid use disorder, regardless of treatment with methadone, buprenorphine, or no medication for opioid use disorder consumed significantly greater quantities of opioids after cesarean delivery but received fewer opioid prescriptions at discharge.

Long-Acting Bupivacaine for Pain Control After Cesarean Birth

OBJECTIVE

To evaluate women's postcesarean pain levels and total opioid use for standard opioid pain management compared with local anesthetic with patient-requested opioids.

DESIGN

Retrospective cohort study.

SETTING/LOCAL PROBLEM

Rural southeast Ohio. Ohio had a higher rate of opioid use disorder (1.4%) than both the regional average (0.8%) and the national average (0.7%).

PARTICIPANTS

We performed a retrospective study of 402 medical records of women who gave birth by caesarean.

INTERVENTION

Women were provided one of three types of perioperative anesthesia: routine spinal (standard of care group), wound infiltration with liposomal bupivacaine (LB INF), and transversus abdominis plane (TAP) block with liposomal bupivacaine (LB TAP).Data were collected on the amount of opioids taken postoperatively (measured as morphine milligram equivalents [MME]), pain scores, and history of opioid use.

RESULTS

The LB INF and LB TAP groups had significantly lower total and average MME per day than the standard of care group (p < .001). Pain scores for the LB INF group were lower on postoperative day (POD) 0 and POD1, whereas LB TAP pain scores were lower than standard of care pain scores on POD1 (p < .004). Women with a prior history of substance use disorders reported higher pain scores, took more total opioids. and stayed in the hospital longer regardless of type of anesthesia received (p < .001).

CONCLUSION

LB INF and LB TAP were associated with lower amounts of opioids used and with lower postcesarean pain scores compared with the standard of care.

Increased Scheduled Intravenous Ketorolac After Cesarean Delivery and Its Effect on Opioid Use: A Randomized Controlled Trial

OBJECTIVE

To evaluate the efficacy of scheduled ketorolac in reducing opioid use after cesarean delivery.

METHODS

This was a single-center, randomized, double-blind, parallel-group trial to assess pain management after cesarean delivery with scheduled ketorolac compared with placebo. All patients undergoing cesarean delivery with neuraxial anesthesia received two doses of 30 mg intravenous ketorolac postoperatively and then were randomized to receive four doses of 30 mg of intravenous ketorolac or placebo every 6 hours. Additional nonsteroidal anti-inflammatory drugs were held until 6 hours after the last study dose. The primary outcome was total morphine milligram equivalents (MME) used in the first 72 postoperative hours. Secondary outcomes included the number of patients who used no opioid postoperatively, postoperative pain scores, postoperative change in hematocrit and serum creatinine, and postoperative satisfaction with inpatient care and pain management. A sample size of 74 per group (n=148) provided 80% power to detect a population mean difference in MME of 32.4, with an SD for both groups of 68.7 after accounting for protocol noncompliance.

RESULTS

From May 2019 to January 2022, 245 patients were screened and 148 patients were randomized (74 per group). Patient characteristics were similar between groups. The median (quartile 1-3) MME from arrival in the recovery room until postoperative hour 72 was 30.0 (0.0-67.5) for the ketorolac group and 60.0 (30.0-112.5) for the placebo group (Hodges-Lehmann median difference -30.0, 95% CI -45.0 to -15.0, P <.001). In addition, participants who received placebo were more likely to have numeric rating scale pain scores higher than 3 out of 10 ( P= .005). The mean±SD decrease from baseline hematocrit to postoperative day 1 was 5.5±2.6% for the ketorolac group and 5.4±3.5% for the placebo group ( P =.94). The mean±SD postoperative day 2 creatinine was 0.61±0.06 mg/dL in the ketorolac group and 0.62±0.08 mg/dL in the placebo group ( P =.26). Participant satisfaction with inpatient pain control and postoperative care was similar between groups.

CONCLUSION

Compared with placebo, scheduled intravenous ketorolac significantly decreased opioid use after cesarean delivery.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT03678675.

Variation in Opioid Prescribing After Vaginal and Cesarean Birth: A Statewide Analysis

INTRODUCTION

Our aim was to evaluate variation in opioid prescribing rates and prescription size following childbirth across providers and hospitals.

METHODS

This retrospective cohort study analyzed claims data from a single-payer Preferred Provider Organization from June 2014 to May 2019 in 84 hospitals in a statewide quality collaborative. All patients aged 12-55 years, undergoing childbirth, with continuous enrollment in pregnancy were included. The primary outcome was the predicted rate of postpartum opioid fills from 7 days before birth to 3 days after discharge. Secondary outcomes included postpartum opioid prescription size in oral morphine equivalents, a standardized measure that includes the number of pills prescribed times the strength of the medication. Multilevel regression models accounted for clustering. We calculated attributable variation in opioid fills using the intraclass correlation coefficient.

RESULTS

Of 41,427 births, 15,459 patients (37.2%) filled a postpartum opioid prescription (vaginal, 4,624/27,536 [16.8%]; cesarean, 10,835/13,891 [78.0%]). The median postpartum prescription size was 150 oral morphine equivalents (interquartile range [IQR], 30) (vaginal, 135; [IQR, 45]; cesarean, 150 [IQR, 75]). In adjusted models, the rates of opioid prescribing after vaginal birth differed from cesarean birth (vaginal median, 12.1% [range, 1.1%-60.0%]; cesarean median, 80.4% [range, 43.6%-90.2%]). More variation in postpartum opioid fills was attributable to providers and hospitals for vaginal (provider, 29%; hospital, 24%) than cesarean birth (provider, 8%; hospital, 6%). Variation in prescription size was driven by providers for vaginal birth (provider, 27%; hospital, 6%) and providers and hospitals for cesarean birth (provider, 29%; hospital, 21%).

CONCLUSIONS

Across a statewide quality collaborative, variation in postpartum opioid prescribing is attributable to providers and hospitals. Future efforts at the provider and hospital levels are needed to implement best practices for postpartum opioid prescribing.

Effectiveness of organizational interventions on appropriate opioid prescribing for noncancer pain upon hospital discharge: A systematic review

This study aims to summarize the effectiveness of organizational interventions on appropriate opioid prescribing for noncancer pain upon hospital discharge. A systematic search was conducted on 6 electronic databases by 2 independent reviewers. We included original research articles reporting on quantitative outcomes of organizational interventions targeting appropriate opioid prescribing on hospital discharge. Quality assessment was performed by 2 independent reviewers. The protocol for this review was prospectively registered on PROSPERO (ID: CRD42020156104). Out of 173 full texts assessed for eligibility, 43 were included in this review. The majority of studies had a moderate to serious risk of bias (33 out of 43). Most of the studies implemented a multifaceted organizational intervention (16 studies). Other interventions included guideline implementation, prescriber education and default opioid-prescribing quantity changes in electronic medical records. Multiple studies found that the dissemination of patient-specific and procedure-specific guidelines reduced the quantity of opioids prescribed by 44 to 57%. Prescriber education provided with feedback was implemented in 4 studies and resulted in a 33 to 44% decrease in prescribing rates. Lowering the default quantities in the electronic medical records produced a 40% decrease in opioids prescribed in 1 study. Guideline implementation, prescriber education and default opioid-prescribing quantity changes all appear effective in improving the appropriate prescribing of opioids on hospital discharge. However, the extent of reduction of opioid prescribing upon hospital discharge after the implementation of multifaceted intervention strategies appears similar to that of simpler interventions which require fewer resources.

Interventions to Reduce Inpatient and Discharge Opioid Prescribing for Postpartum Patients: A Systematic Review

INTRODUCTION

As deaths related to opioids continue to rise, reducing opioid use for postpartum pain management is an important priority. Thus, we conducted a systematic review of postpartum interventions aimed at reducing opioid use following birth.

METHODS

From database inception through September 1, 2021, we conducted a systematic search in Embase, MEDLINE, Cochrane Library, and Scopus including the following Medical Subject Heading (MeSH) terms: postpartum, pain management, opioid prescribing. Studies published in English, restricted to the United States, and evaluating interventions initiated following birth with outcomes including an assessment of change in opioid prescribing or use during the postpartum period (<8 weeks postpartum) were included. Authors independently screened abstracts and full articles for inclusion, extracted data, and assessed study quality using the Grading of Recommendations, Assessment, Development, and Evaluation tool and risk of bias using the Institutes of Health Quality Assessment Tools.

RESULTS

A total of 24 studies met inclusion criteria. Sixteen studies evaluated interventions aimed at reducing postpartum opioid use during the inpatient hospitalization, and 10 studies evaluated interventions aimed at reducing opioid prescribing at postpartum discharge. Inpatient interventions included changes to standard order sets and protocols for the management of pain after cesarean birth. Such interventions resulted in significant decreases in inpatient postpartum opioid use in all but one study. Additional inpatient interventions, including use of lidocaine patches, postoperative abdominal binder, valdecoxib, and acupuncture were not found to be effective in reducing postpartum opioid use during inpatient hospitalization. Interventions targeting the postpartum period included individualized prescribing and state legislative changes limiting the duration of opioid prescribing for acute pain both resulted in decreased opioid prescribing or opioid use.

DISCUSSION

A variety of interventions aimed at reducing opioid use following birth have shown efficacy. Although it is not known if any single intervention is most effective, these data suggest that implementation of any number of interventions may be advantageous in reducing postpartum opioid use.

Use of Scheduled Nonopioid Analgesia to Decrease Inpatient Opioid Consumption After Scheduled Cesarean Birth

OBJECTIVE

To compare opioid use and pain scores in women who had scheduled cesarean birth before and after implementing a scheduled nonopioid analgesia practice guideline.

DESIGN

Quality improvement project with a comparison of pre-/postintervention.

SETTING/LOCAL PROBLEM

A 170-bed community hospital where the administration of postcesarean pain medications was unstandardized.

PARTICIPANTS

Convenience sample of 175 individuals who were scheduled for cesarean birth (106 in preintervention group and 69 in postimplementation group).

INTERVENTION/MEASUREMENTS

All participants had received a dose of 150 mcg of intrathecal morphine intraoperatively. Care of participants in the postimplementation group included a new practice guideline using preoperative oral acetaminophen 1 g and postoperative intravenous ketorolac 30 mg that transitioned to ibuprofen 600 mg orally every 6 hours until discharge. Acetaminophen 1 g every 6 hours also continued until discharge. For breakthrough pain, oxycodone 5 mg to 10 mg was available.

RESULTS

Results were analyzed using the chi-square and t test. There was a statistical difference in the mean milligram morphine equivalent consumed after scheduled cesarean birth (preintervention = 21.15 vs. postintervention = 3.91, p < .001). Postimplementation, 84.1% of participants did not consume any opioids beyond the intrathecal dose compared to 47.2% of participants preintervention. Mean pain scores decreased from 2.49 to 1.62 (p < .001), and there was an observed decrease of the highest reported pain score from 5.39 to 4.03 (p < .001).

CONCLUSION

The results of this project support the current literature indicating that the administration of a scheduled nonopioid multimodal analgesia regimen to individuals with scheduled cesarean birth is an effective postoperative pain management strategy. This approach to managing surgical birth pain can decrease subjective reports of pain and overall opioid consumption during the hospital stay.

Impact of timing of multimodal analgesia in enhanced recovery after cesarean delivery protocols on postoperative opioids: A single center before-and-after study

STUDY OBJECTIVE

Enhanced recovery after cesarean delivery (ERAC) programs aim to decrease maternal morbidity and aid in maternal recovery and return to baseline. Multimodal analgesia is an important element of ERAC protocols, but no consensus exists on the timing of medication administration. We compared maternal pain outcomes following scheduled cesarean delivery with modification of the timing of administration of multimodal analgesia with non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen.

DESIGN

Before-and-after study.

SETTING

Labor and delivery unit at a single academic institution.

INTERVENTION

NSAIDs and acetaminophen were administered as a fixed-interval alternating regimen every 3 h for the initial ERAC group (ERAC 1) and fixed-interval combined regimen every 6 h for the modified ERAC group (ERAC 2). ERAC 1 and ERAC 2 groups were compared to historical controls (Pre-ERAC).

PATIENTS

520 women undergoing scheduled cesarean delivery (Pre-ERAC n = 179, ERAC 1 n = 179, and ERAC 2 n = 162).

MEASUREMENTS

The primary outcomes were postoperative total and daily opioid utilization as measured in morphine milligram equivalents (MME). Secondary outcomes included postoperative length of stay, maximum pain scores, and racial disparities in care.

MAIN RESULTS

The modified schedule of non-opioid analgesics involving combined administration (ERAC 2) versus alternating administration (ERAC 1) of multimodal analgesia resulted in decreased total postoperative opioid utilization (median = 26.3 vs 52.5 MME, Bonferroni corrected P = 0.002). Total postoperative opioid utilization among the ERAC 2 group was also significantly reduced compared to the Pre-ERAC group (median = 26.3 vs 105.0 MME, Bonferroni corrected P < 0.0001).

CONCLUSIONS

Multidisciplinary teams developing or modifying ERAC protocols for scheduled cesarean delivery should consider a combined administration at fixed intervals of NSAIDs and acetaminophen throughout the hospital stay to optimize postoperative pain management.

Temporal Trends in Postpartum Opioid Prescribing, Opioid Use, and Pain Control Satisfaction

OBJECTIVE

The objective was to assess temporal trends in postpartum opioid prescribing, opioid use, and pain control satisfaction.

STUDY DESIGN

This is a prospective observational study of postpartum patients who delivered at a large tertiary care center (May 2017-July 2019). Inpatient patients were screened for eligibility; those meeting eligibility criteria who used inpatient opioids were approached for prospective survey participation which probed inpatient and outpatient postpartum pain control. The amount of opioids used during inpatient hospitalization and the amount of opioids prescribed at discharge were obtained from medical records. The primary outcome was the difference in opioid prescribing at discharge over time, measured by (1) the proportion of participants who received an opioid prescription at discharge and (2) for those who received an opioid prescription, the total morphine milligram equivalents of the prescription. Additional outcomes were inpatient and outpatient opioid use and patient-reported satisfaction with postpartum pain control. Trends over time were evaluated using nonparametric tests of trend.

RESULTS

Of 2,503 postpartum patients screened for eligibility, a majority (N = 1,425; 60.8%) did not use an opioid as an inpatient. Over the study period, there was a significant decline in the proportion of patients who used an opioid while inpatient (z-score =  - 11.8; p < 0.01). Among these participants enrolled in the prospective survey study (N = 494), there was a significant decline over time in the amount of inpatient opioid use (z-score =  - 2.4; p = 0.02), the proportion of participants who received an opioid prescription upon discharge (z-score =  - 8.2; p < 0.01), and, when an opioid was prescribed at discharge, the total prescribed morphine milligram equivalents (z-score =  - 4.3; p < 0.01). Both inpatient and outpatient satisfactions with pain control were unchanged over this time (z-score = 1.1, p = 0.27; z-score = 1.1, p = 0.29, respectively).

CONCLUSION

In this population, both the frequency and amount of opioid use in the postpartum period declined from 2017 to 2019. This decrease in opioid prescribing was not associated with changes in patient-reported satisfaction with pain control.

KEY POINTS

· From 2017 to 2019, there was a decrease in inpatient and outpatient postpartum opioid use.. · Both the proportion of postpartum patients receiving opioid prescriptions and the amount prescribed decreased.. · Patient satisfaction with postpartum pain control remained unchanged..

Obstetricians' prescribing practices for pain management after delivery

Aim: To examine postpartum opioid prescribing practices. Materials & methods: Obstetricians were interviewed about opioids: choice of opioid, clinical factors considered when prescribing, thoughts/beliefs about prescribing, and typical counseling provided. Inductive thematic analyses were used to identify themes. Results: A total of 38 interviews were analyzed. Several key points emerged. The choice of opioid, dosing and number of pills prescribed varied widely. The mode of delivery is the primary consideration for prescribing opioids. All providers would prescribe opioids to breastfeeding women. Some providers offered counseling on nonopioid treatment of pain. Discussion: At two large tertiary centers in Pennsylvania, the 38 physicians interviewed wrote 38 unique opioid prescriptions. Patient counseling addressed short-term pain management, but not the chronic overuse of opioids.

Perioperative Opioids, the Opioid Crisis, and the Anesthesiologist

This review summarizes current evidence related to perioperative opioid prescription fulfillment and use and discusses the role of personalized anesthesia care in mitigating opioid-related harms without compromising analgesia.

The Effect of an Automated Order on Postpartum Opioid Use After Uncomplicated Vaginal Deliveries

Background: To address the opioid epidemic, physicians are encouraged to identify means of reducing patient opioid exposure. Electronic medical records (EMRs) often include default order sets with automated orders for opioid medications, which may influence how much opioids physicians prescribe. Objective: We sought to evaluate the impact of de-selecting an automated order for oxycodone-acetaminophen from an EMR order set for postpartum vaginal deliveries on inpatient opioid exposure by comparing the proportion of patients who received an opioid after an uncomplicated vaginal delivery before and after the EMR change. As secondary outcomes, the impact on average total morphine milligram equivalents (MMEs) and discharge opioid prescriptions was investigated. Methods: A quality improvement study was conducted through retrospective chart review of uncomplicated vaginal deliveries for the four quarters before and after the EMR order set change occurred. The total proportion of patients who received an opioid in the postpartum period was then determined for the preexposure and postexposure groups. The total average MME consumed for patients who received an opioid in each group was determined and the total proportion of patients who received an opioid prescription at discharge was compared. Results: A total of 5826 records of uncomplicated vaginal deliveries met the criteria for analysis. In the preintervention group, 32.9% of patients received an opioid postpartum, compared to 12.5% of patients in the postintervention group, representing a decrease of 62.0% (p < 0.001). Of those who received opioids, the preintervention mean total opioid consumption was 28.4 MME (±27.6) compared to 33.6 MME (±46.4) postintervention, and there was no significant difference in median total opioid consumption: 22.5 MME (interquartile range [IQR]: 7.5-47.5) preintervention compared with 20.8 MME (IQR: 7.5-45.0) postintervention (p = 0.902). No significant difference was found with discharge opioid prescriptions between the two groups. Conclusion: Order sets within EMR systems appear to have a significant influence on physician prescribing behaviors and removing these automated orders for opioids should be considered.

Nurses' Perspectives on Postpartum Pain Management

Introduction:

There is variation in postpartum opioid use by prescriber characteristics that cannot be explained by patient or birth factors. Thus, our objective was to evaluate nursing training, clinical practices, and perspectives on opioid use for postpartum pain management.

Materials and Methods:

In this survey study, postpartum bedside nurses at a single, large academic center were asked about training, factors influencing clinical decisions, and viewpoints regarding pain management and opioid use. Findings were summarized using descriptive analyses.

Results:

A total of 92 nurses completed the survey. A majority (77%) reported having received some formal training on opioid use for pain management. About a quarter (25.7%) felt their training was not adequate. Regarding clinical practices, the majority (71% and 70%, respectively) reported that “routine habit” and “patient preference” most influenced the type and amount of pain medication they administered. Finally, nurses' perspectives on pain management demonstrated a wide range of beliefs. Most nurses strongly agreed with the importance of maximizing nonopioid pain medication before opioid administration. The majority agreed that patient-reported pain score is important to consider when deciding to administer opioids. Conversely, most nurses disagreed that patients should be encouraged to endure as much pain as possible before using an opioid. Similarly, beliefs about the reliability of use of vital signs in assessing pain intensity varied widely.

Conclusions:

Bedside nurses rely on routine habits, patient preference, and patient-reported pain score when administering opioids for postpartum pain management. Increased training opportunities to improve consistency and standardization of opioid administration may be beneficial.

A comparison of acute pain management strategies after cesarean delivery

BACKGROUND

There are approximately 1.2 million cesarean deliveries performed each year in the United States alone. While traditional postoperative pain management strategies previously relied heavily on opioids, practitioners are now moving toward opioid-sparing protocols using multiple classes of nonnarcotic analgesics. Multimodal pain management systems have been adopted by other surgical specialties including gynecology, although the data regarding their use for postoperative cesarean delivery pain management remain limited.

OBJECTIVE

To determine if a multimodal pain management regimen after cesarean delivery reduces the required number of morphine milligram equivalents (a unit of measurement for opioids) compared with traditional morphine patient-controlled analgesia while adequately controlling postoperative pain.

STUDY DESIGN

This was a prospective cohort study of postoperative pain management for women undergoing cesarean delivery at a large county hospital. It was conducted during a transition from a traditional morphine patient-controlled analgesia regimen to a multimodal regimen that included scheduled nonsteroidal anti-inflammatory drugs and acetaminophen, with opioids used as needed. The data were collected for a 6-week period before and after the transition. The primary outcome was postoperative opioid use defined as morphine milligram equivalents in the first 48 hours. The secondary outcomes included serial pain scores, time to discharge, and exclusive breastfeeding rates. Women who required general anesthesia or had a history of substance abuse disorder were excluded. The statistical analyses included the Student t test, Wilcoxon rank-sum, and Hodges-Lehman shift, with a P value <.05 being considered significant.

RESULTS

During the study period, 877 women underwent cesarean delivery and 778 met the inclusion criteria-378 received the traditional morphine patient-controlled analgesia and 400 received the multimodal regimen. The implementation of a multimodal regimen resulted in a significant reduction in the morphine milligram equivalent use in the first 48 hours (28 [14-41] morphine milligram equivalents vs 128 [86-174] morphine milligram equivalents; P<.001). Compared with the traditional group, more women in the multimodal group reported a pain score ≤4 by 48 hours (88% vs 77%; P<.001). There was no difference in the time to discharge (P=.32). Of the women who exclusively planned to breastfeed, fewer used formula before discharge in the multimodal group than in the traditional group (9% vs 12%; P<.001).

CONCLUSION

Transition to a multimodal pain management regimen for women undergoing cesarean delivery resulted in a decrease in opioid use while adequately controlling postoperative pain. A multimodal regimen was associated with early successful exclusive breastfeeding.

Association Between Patient-Prescriber Racial and Ethnic Concordance and Postpartum Pain and Opioid Prescribing

Objective:

To evaluate whether patient-prescriber racial and ethnic concordance is associated with postpartum opioid prescribing patterns and patient-reported pain scores.

Methods

This is a retrospective cohort study of patients who delivered at a tertiary care center between December 1, 2015 and November 30, 2016. Self-identified non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, or Asian patients were included. Patient-prescriber pairs were categorized as racially and ethnically concordant if they shared the same racial and ethnic identity; the prescriber was defined as the obstetrical provider who was responsible for the postpartum discharge of the patient. Multivariable regression models controlling for demographic and clinical confounders were used to assess the relationship of patient-prescriber racial and ethnic concordance with receipt of an opioid prescription and patient-reported pain score at discharge.

Results

Of 10,242 patients included in this analysis, 62.3% identified as NHW, 19.1% Hispanic, 9.7% NHB, and 8.9% Asian. About half (52.8%) of patients were discharged by a racially and ethnically concordant prescriber. Patient-prescriber racial and ethnic concordance was not associated with receipt of an opioid prescription (adjusted odds ratio [aOR] 0.82, confidence interval [95% CI] 0.67–1.00) or reporting a pain score ≥5 (aOR 0.90, 95% CI 0.69–1.16). However, NHB and Hispanic patients were less likely to receive an opioid prescription (aOR 0.73, 95% CI 0.56–0.95; aOR 0.73, 95% CI 0.57–0.92, respectively) and significantly more likely to report a pain score ≥5 (aOR 2.13, 95% CI 1.51–3.00; aOR 1.48 95% CI 1.08–2.01, respectively) than NHW patients, even when accounting for concordance.

Conclusion

Disparities in postpartum opioid prescribing and pain perception are not ameliorated by patient-prescriber racial and ethnic concordance.

Association of Inpatient Postpartum Opioid Use with Bedside Nurse

INTRODUCTION

Our objective was to assess the association between the nurse providing bedside care and women's postpartum opioid use.

METHODS

Retrospective study of all women who birthed at a single center (December 2015 to November 2016). Patient, prescriber, and clinical data were abstracted. The postpartum nurse and total opioid use during the first 12-hour postpartum shift after birth were determined. A high amount of opioid use was defined as morphine milligram equivalents greater than or equal to 90% for this population (stratified by vaginal and cesarean births). A logistic regression model was fit with covariates entered in a step-wise manner to identify the extent to which individual nurses were associated with a greater likelihood of high opioid use by establishing one model in which the only covariate was nurse (model 1) and assessing whether the addition of patient (model 2), birth (model 3), and prescriber factors (model 4) altered the association. Kendall rank correlation assessed rank changes between models.

RESULTS

Of the 8376 and 2957 women who had vaginal and cesarean births, 17.9% and 10.2%, respectively, had high opioid use. In the vaginal cohort, women cared for by 46 of 200 nurses were significantly less likely to have high opioid use. Following adjustment, patients cared for by 53 of 200 bedside nurses (model 4) had significantly lower odds of having high opioid use. The rank order of nurses, with respect to the likelihood of opioid use, remained similar after adjustment for patient, birth, and prescriber factors (Τ = 0.84). Findings were similar for the cesarean cohort: 35 of 113 nurses were associated with a significantly lower likelihood of their patients having high opioid use, and the rank order remained similar after covariate adjustment (Τ = 0.78).

DISCUSSION

There is significant variation in postpartum women's opioid use based on the nurse that is not explained by patient, birth, or prescriber factors.

A multimodal approach to reducing post-caesarean opioid use: a quality improvement initiative

OBJECTIVE

To evaluate the impact of a QI initiative to reduce post-caesarean opioid use.

DESIGN

Retrospective cohort study.

SETTING

Academic hospital in the USA.

POPULATION

Women over 18 years undergoing caesarean section.

METHODS

A quality improvement (QI) initiative titled Reduced Option for Opioid Therapy (ROOT) was implemented in women undergoing caesarean section. The intervention included implementation of a postpartum order set maximising the use of scheduled NSAIDs and acetaminophen. Additionally, nursing education promoted non-opioid therapy as first-line, with opioids reserved for breakthrough pain. Performance feedback was provided to nursing staff on a bimonthly basis. Post-caesarean opioid use was reviewed in the 6 months before and after implementation of ROOT.

MAIN OUTCOME MEASURES

The primary outcome was the total morphine milligram equivalents (MME) consumed during the postpartum admission. Secondary outcomes included opioid use per postoperative day, the proportion of opioid-free admissions, the percentage of patients discharged with a prescription for opioids, prescription size, and pain scores.

RESULTS

Following implementation of ROOT, median inpatient opioid use decreased by more than 60%, from 75 to 30 MME per admission (P < 0.001). The proportion of opioid-free admissions increased from 12.6% pre-intervention to 30.7% post-intervention (P < 0.001). Additionally, the median opioid dose prescribed at discharge decreased in the post-intervention cohort, and the proportion of patients discharged without an opioid prescription increased. The reduction in opioids was associated with a slight decrease in patient-reported pain scores.

CONCLUSIONS

Implementation of ROOT significantly reduced opioid use while achieving comparable pain control.

Evaluation of a quality improvement bundle aimed to reduce opioid prescriptions after Cesarean delivery: an interrupted time series study

Purpose

To evaluate whether opioid prescriptions at discharge after Cesarean delivery decreased following implementation of a quality improvement bundle.

Methods

A quality improvement bundle was instituted at Mount Sinai Hospital in Toronto. Interventions included opioid prescribing instructions in resident orientation, nursing and patient education, and standard electronic prescriptions. We used an interrupted time series study design and included patients who had a Cesarean delivery six months pre intervention and six months post intervention. Primary outcome data (opioids prescribed at discharge in morphine milliequivalents [MME]), were aggregated (averaged) by calendar week and analyzed using interrupted time series. Secondary outcomes were assessed using bivariate methods and included opioid use for breakthrough pain in hospital, and amount of opioids prescribed by prescriber specialty and training level.

Results

We included 2,578 women in our analysis. Based on the segmented regression analysis, prescribed opioids decreased from 97.6 MME in 2018 to 35.8 MME in 2019 (difference in means, − 61.7; 95% confidence interval [CI], − 72.2 to − 51.3; P < 0.001), and this decrease was sustained over the study period. Post intervention, there were no visits to our postnatal assessment clinic for inadequate pain control.

Conclusion

A quality improvement bundle was associated with a marked and sustained decrease in discharge prescriptions of opioids post Cesarean delivery at a large Canadian tertiary academic hospital.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12630-021-02143-7.

The Association between Implementation of an Enhanced Recovery after Cesarean Pathway with Standardized Discharge Prescriptions and Opioid Use and Pain Experience after Cesarean Delivery

OBJECTIVE

This study was aimed to evaluate opioid use after cesarean delivery (CD) and to assess implementation of an enhanced recovery after CD (ERAS-CD) pathway and its association with inpatient and postdischarge pain control and opioid use.

STUDY DESIGN

We conducted a baseline survey of women who underwent CD from January to March 2017 at a single, urban academic hospital. Patients were called 5 to 8 days after discharge and asked about their pain and postdischarge opioid use. An ERAS-CD pathway was implemented as a quality improvement initiative, including use of nonopioid analgesia and standardization of opioid discharge prescriptions to ≤25 tablets of oxycodone of 5 mg. From November to January 2019, a postimplementation survey was conducted to assess the association between this initiative and patients' pain control and postoperative opioid use, both inpatient and postdischarge.

RESULTS

Data were obtained from 152 women preimplementation (PRE) and 137 women post-implementation (POST); complete survey data were obtained from 102 women PRE and 98 women POST. The median inpatient morphine milligram equivalents consumed per patient decreased significantly from 141 [range: 90-195] PRE to 114 [range: 45-168] POST (p = 0.002). On a 0- to 10-point scale, median patient-reported pain scores at discharge decreased significantly (PRE: 7 [range: 5-8] vs. POST 5 [range: 3-7], p < 0.001). The median number of pills consumed after discharge also decreased significantly (PRE: 25 [range: 16-30] vs. POST 17.5 [range: 4-25], p = 0.001). The number of pills consumed was significantly associated with number prescribed (p < 0.001). The median number of leftover pills and number of refills did not significantly differ between groups. Median patient-reported pain scores at the week after discharge were lower in the POST group (PRE: 4 [range: 2-6] vs. POST 3[range: 1-5], p = 0.03).

CONCLUSION

Implementing an ERAS-CD pathway was associated with a significant decrease in inpatient and postdischarge opioid consumption while improving pain control. Our data suggest that even fewer pills could be prescribed for some patients.

KEY POINTS

· An ERAS-CD pathway was associated with decreased opioid use.. · Outpatient opioid consumption after cesarean warrants further study.. · Physician prescribing drives patients' opioid consumption..

Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG Clinical Consensus No. 1

SUMMARY

Pain in the postpartum period is common and considered by many individuals to be both problematic and persistent (1). Pain can interfere with individuals' ability to care for themselves and their infants, and untreated pain is associated with risk of greater opioid use, postpartum depression, and development of persistent pain (2). Clinicians should therefore be skilled in individualized management of postpartum pain. Though no formal time-based definition of postpartum pain exists, the recommendations presented here provide a framework for management of acute perineal, uterine, and incisional pain. This Clinical Consensus document was developed using an a priori protocol in conjunction with the authors listed. This document has been revised to incorporate more recent evidence regarding postpartum pain.

A standardized post-cesarean analgesia regimen reduces postpartum opioid use

BACKGROUND

Optimal post-cesarean pain control is important. With the rising opioid epidemic it is imperative to maximize non-opioid based primary approaches to post-cesarean pain control. In 2018, we implemented a standardized post-cesarean analgesia regimen.

OBJECTIVE

To determine if implementation of a standardized postoperative analgesic regimen decreases opioid use following cesarean birth.

STUDY DESIGN

A standardized postoperative analgesia protocol was implemented in June 2018, which included scheduled oral acetaminophen (975 mg every 6 h) and nonsteroidal anti-inflammatory drugs (NSAIDs) (ketorolac 15 mg IV every 6 h for 5 doses followed by ibuprofen 600 mg oral every 6 h) with opioids available for breakthrough pain. There was no prior standardized protocol. A before-and-after study design was used to compare oral morphine milligram equivalents (MME) for nine months prior to and nine months after this protocol was implemented, excluding the two month period of protocol rollout. Women with opioid use disorder or postoperative intubation were excluded. The primary outcome was the cumulative MME used in the first 72 h postoperatively. Total dose at 12, 24, and 48 h were also compared.

RESULTS

Of 2340 women who underwent cesarean birth during the study period (1 July 2017 - 30 April 2019), 2001 women met inclusion criteria (914 before 10 April 2018 (pre-protocol) and 1087 after 17 June 2018 (post-protocol)). Baseline characteristics of the two groups were similar, including gestational age at delivery, maternal body mass index (BMI), planned versus unplanned cesarean birth, and type of intraoperative anesthesia used. The cumulative opioid dose in the first 72 h postoperatively was 216.3 ± 84.3 MME prior to implementation compared to 171.5 ± 91.5 MME following implementation (p < .001). The average cumulative MME use was higher in the pre-protocol period compared to post-protocol at all time periods: 12 h (57.3 ± 23.8 vs 48.6 ± 26.2 MME, p < .001), 24 h (98.1 ± 34.1 vs 82.1 ± 38.8 MME, p < .001), and 48 h (165.8 ± 58.3 vs 134.9 ± 66.2 MME, p < .001). The average pain scores were lower in the pre-protocol group (3 vs 3.3, p < .001).

CONCLUSION

Scheduled administration of acetaminophen and NSAIDs following cesarean birth significantly decreased the cumulative dose of opioids used in the first 72 h postoperatively.

Implementation of an Enhanced Recovery after Surgery Pathway to Reduce Inpatient Opioid Consumption after Cesarean Delivery

OBJECTIVE

 Opioid prescription after cesarean delivery is excessive and can lead to chronic opioid use disorder. We assessed the impact of an enhanced recovery after surgery (ERAS) pathway on inpatient opioid consumption after cesarean delivery.

STUDY DESIGN

 An ERAS pathway was implemented as a quality improvement initiative in December 2019. Preintervention (PRE) data were collected from March to May 2019 to assess baseline opioid consumption. Postintervention (POST) data were collected from January to March 2020. The primary outcome was inpatient postoperative opioid consumption in morphine milligram equivalents (MME). Secondary outcomes included the consumption of any opioids, postpartum length of stay, and opioid prescription at discharge.

RESULTS

 A total of 92 women were in the PRE group and 91 were in the POST group. Inpatient opioid consumption decreased by 87.3% from PRE to POST, from 124.7 (interquartile range [IQR]: 10-181.6) MME to 15.8 (IQR: 0-75) MME (p < 0.001). There was no difference in median postpartum length of stay (3.4 days PRE vs. 3.3 days POST; p = 0.12). The proportion of women who did not consume any opioids increased by 75.4% from PRE to POST (p = 0.02). The proportion of women discharged with an opioid prescription decreased by 25.6% from PRE to POST (p = 0.007), despite no formal change to prescribing practices. After adjustment for differences in race/ethnicity and gravidity, there was still a reduction in total inpatient opioid consumption (p < 0.001) and an increase in the proportion of women not consuming any opioids (adjusted relative risk (RR): 2.14, 95% confidence interval [CI]: 1.18-3.87), but the difference in rate of prescription of opioids at discharge was no longer statistically significant (adjusted RR: 0.70, 95% CI: 0.48-1.02).

CONCLUSION

 Adoption of an ERAS pathway for cesarean delivery resulted in a marked reduction in inpatient opioid consumption. Such a pathway can be implemented across institutions and may be a powerful tool in combating the opioid epidemic.

KEY POINTS

· ERAS after cesarean reduces inpatient opioid consumption.. · ERAS after cesarean increases the proportion of women not consuming any opioids.. · This pathway can be feasibly adopted elsewhere..

Opioid prescription-use after cesarean delivery: an observational cohort study

OBJECTIVE

To evaluate current opioid prescription practices following a cesarean delivery.

METHODS

Women were asked to participate in a prospective observational cohort study following a cesarean delivery. Participants were asked about their opioid use after discharge, amount leftover, subjective pain score, and satisfaction.

RESULTS

A total of 344 women had cesarean deliveries during the study period, 242 were approached, 171 met eligibility criteria, and 109 were included in the analysis. Women in our study were predominantly African American (66.1%), high school graduates (32.1%), publicly insured (65.1%), single (55%) working mothers (68.8%). Most had been previously prescribed opioids (70.6%), of which 58.4% had a prior cesarean delivery. Only 78.8% of study participants took their opioid prescriptions, and 89.6% had an average of 17 pills leftover. The number of pills taken correlated with those prescribed in the study. Improved satisfaction in pain control with opioid and non-opioid alternatives was associated with a decrease in opioids used. Similarly, the participants' perception of their abundant prescription quantity was associated with a decrease in prescription taken.

CONCLUSION

Women were prescribed excess opioids. Excess opioids accounted for 63.3% of all pills filled, a total of 1670 pills leftover, most of which were stored in an unlocked location (75.6%). Our data showed a discrepancy of pills prescribed (24) compared to those used (10), which was also perceived as enough or too many by our participants. Our study demonstrates that women would benefit from fewer opioid pills and a discussion based on their pain perception.

Educational Video on Pain Management and Subsequent Opioid Use After Cesarean Delivery: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether viewing an educational video on pain management reduces opioid use after cesarean delivery.

METHODS

We conducted a randomized, controlled trial of women aged 18 years or older who underwent cesarean delivery at a tertiary care center. Eligible women were randomized in a 1:1 ratio to usual discharge pain medication instructions plus an educational video on pain management or to usual discharge pain medication instructions alone. All women received the same opioid prescription at discharge: Twenty 5-mg oxycodone tablets. Participants were contacted at 7 days and at 14 days after delivery to assess the number of oxycodone tablets used, adjunct medication (acetaminophen and ibuprofen) use, pain scores, and overall satisfaction of pain control. The primary outcome was the number of oxycodone tablets used from discharge through postpartum day 14. A sample size of 23 per group (n=46) was planned to detect a 25% difference in mean number of oxycodone tablets used between groups, as from 20 to 15.

RESULTS

From July 2019 through December 2019, 61 women were screened and 48 were enrolled-24 in each group. Women who viewed the educational video used significantly fewer opioid tablets from discharge through postpartum day 14 compared with women who received usual pain medication instructions (median 1.5, range 0-20 vs median 10, range 0-24, P<.001). Adjunct medication use, pain scores, and satisfaction with pain control did not differ significantly between groups.

CONCLUSION

Among women who underwent cesarean delivery, viewing an educational video on pain management reduced postdischarge opioid use.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03959969.

A Quality Improvement Project to Reduce Postcesarean Opioid Consumption

BACKGROUND

The opioid epidemic is a public health emergency in the United States, stemming in part from widespread misuse and overprescribing of opioids following surgery. Approximately 1 in 300 women with no prior exposure to opioids develops an opioid use disorder following cesarean birth. Effective management of postcesarean pain requires individualized treatment and a balance of the woman's goals for optimal recovery and ability to safely care for her newborn. The American College of Obstetricians and Gynecologists recommends a multimodal approach to pain management after cesarean birth.

METHODS

In April 2019, a multidisciplinary team was formed at New York University Langone Health to study opioid use postcesarean. The team used the Plan, Do, Study, Act process model for continuous quality improvement to launch a postcesarean pathway called "Your Plan After Cesarean," a standardized visual tool with quantifiable milestones. It facilitates integration of women's preferences in their postcesarean care, and emphasizes providers' routine use of nonpharmacological interventions to manage pain.

RESULTS

During the pilot period of the project, postcesarean high consumption of 55 to 120 mg of opioids was reduced from 25% to 8%. By January 2020, 75% of women postoperative cesarean took little-to-no opioids during their hospital stay. By February 2021, the total number of opioids consumed by women after cesarean birth in-hospital was reduced by 79%. Satisfaction among women with pain management after cesarean continued to be high.

CLINICAL IMPLICATIONS

Reduction in postcesarean opioid administration and the number of opioids prescribed at hospital discharge can be accomplished without having a negative effect on women's perceptions of post-op pain relief. These changes can potentially be a factor in helping to avoid an opioid-naive woman who has a cesarean birth from developing an opioid use disorder.

Opioid Education in Obstetrics and Gynecology Training Programs

OBJECTIVE

Our primary objective was to assess the current state of pain and opioid education in obstetrics and gynecology (OBGYN) by performing a detailed review of the national educational curricula guiding OBGYN residency and fellowship training programs in the United States.

METHODS

From 2019 to 2020 we reviewed seven documents created to guide learning and structure educational training for OBGYN residency and fellowship programs in the United States: the Council on Resident Education in Obstetrics and Gynecology (CREOG) Educational Objectives Core Curriculum in Obstetrics and Gynecology, the 2016 Educational Objectives-Fellowship in Minimally Invasive Gynecologic Surgery, and the 2018 Guides to Learning in Complex Family Planning, Female Pelvic Medicine & Reconstructive Surgery, Gynecologic Oncology, Maternal Fetal Medicine, and Reproductive Endocrinology and Infertility. Each document was reviewed by two authors to assess for items referring to pain or opioids.

RESULTS

The CREOG educational objectives, used to inform educational curricula for residency programs, were the most comprehensive, mentioning pain and/or opioid educational objectives the highest number of times and including the most categories. The CREOG document was followed by the Guides to Learning for Gynecologic Oncology and for Minimally Invasive Gynecologic Surgery. The Reproductive Endocrinology and Infertility Guide to Learning did not mention pain and/or opioids in the educational objectives.

CONCLUSIONS

Our study identifies an opportunity for consistent and appropriate opioid and pain management education in OBGYN training.

Effects of State Law Limiting Postoperative Opioid Prescription in Patients After Cesarean Delivery

BACKGROUND

The impact of the Florida State law House Bill 21 (HB 21) restricting the duration of opioid prescriptions for acute pain in patients after cesarean delivery is unknown. Our objective was to assess the association of the passage of Florida State law HB 21 with trends in discharge opioid prescription practices following cesarean delivery, necessity for additional opioid prescriptions, and emergency department visits at a large tertiary care center.

METHODS

This was a retrospective cohort study conducted at a large, public hospital. The 2 cohorts represented the period before and after implementation of the law. Using a confounder-adjusted segmented regression analysis of an interrupted time series, we evaluated the association between HB 21 and trends in the proportions of patients receiving opioids on discharge, duration of opioid prescriptions, total opioid dose prescribed, and daily opioid dose prescribed. We also compared the need for additional opioid prescriptions within 30 days of discharge and the prevalence of emergency department visits within 7 days after discharge.

RESULTS

Eight months after implementation of HB 21, the mean duration of opioid prescriptions decreased by 2.9 days (95% confidence interval [CI], 5.2-0.5) and the mean total opioid dose decreased by 20.1 morphine milligram equivalents (MME; 95% CI, 4-36.3). However, there was no change in the proportion of patients receiving discharge opioids (95% CI of difference, -0.1 to 0.16) or in the mean daily opioid dose (mean difference, 5.3 MME; 95% CI, -13 to 2.4). After implementation of the law, there were no changes in the proportion of patients who required additional opioid prescriptions (2.1% vs 2.3%; 95% CI of difference, -1.2 to 1.5) or in the prevalence of emergency department visits (2.4% vs 2.2%; 95% CI of difference, -1.6 to 1.1).

CONCLUSIONS

Implementation of Florida Law HB 21 was associated with a lower total prescribed opioid dose and a shorter duration of therapy at the time of hospital discharge following cesarean delivery. These reductions were not associated with the need for additional opioid prescriptions or emergency department visits.

Patient Experience with Postpartum Pain Management in the Face of the Opioid Crisis

INTRODUCTION

Professional societies have urged providers to reduce opioid use for pain management. Accordingly, the objective of this study was to assess patient experiences related to postpartum pain management in an effort to better understand potential paths to achieve such a reduction.

METHODS

This is a planned secondary analysis of a prospective observational study of opioid use following birth. In the primary study, women who received opioids as inpatients were queried about their pain management, including questions about pain experience, pain satisfaction, perceived areas for practice improvement, and the opportunity to leave additional comments. Participants who were prescribed opioids upon discharge completed postdischarge surveys with a similar opportunity for qualitative input. Data were analyzed using the constant comparative method to identify themes and subthemes.

RESULTS

Of the 493 women enrolled in the primary analysis, 125 provided qualitative data. Three overarching themes regarding pain management were identified: positive experiences (n = 22), negative experiences (n = 19), and beliefs and preferences on opioid use and pain management (n = 28). Women with positive experiences reported satisfaction with timely pain medication administration and appreciation of open dialogue with their care team. In contrast, several negative experiences centered on tardy administration of pain medications, resulting in increased pain. Patients also perceived judgment, accusation, and excessive lecturing by staff when requesting opioid medications. Finally, participants expressed the necessity for opioids for postpartum pain management, as well as their desires for limiting opioid use, improved options for multimodal pain management, and increased communication with providers about pain regimens.

DISCUSSION

Understanding women's perspectives and experiences regarding postpartum pain control is essential to improving care. Amid growing research on the role of maternity care providers in addressing the opioid crisis, women's voices are rarely solicited. These findings stress the importance of open and frequent dialogue between patients and providers and a need for multimodal pain management options.

Guidelines for Patient-CenteredOpioid Prescribing and Optimal FDA-Compliant Disposal of Excess Pills after Inpatient Operation: Prospective Clinical Trial

BACKGROUND

To optimize responsible opioid prescribing after inpatient operation, we implemented a clinical trial with the following objectives: prospectively validate patient-centered opioid prescription guidelines and increase the FDA-compliant disposal rate of leftover opioid pills to higher than currently reported rates of 20% to 30%.

STUDY DESIGN

We prospectively enrolled 229 patients admitted for 48 hours or longer after elective general, colorectal, urologic, gynecologic, or thoracic operation. At discharge, patients received a prescription for both nonopioid analgesics and opioids based on their opioid usage the day before discharge: if 0 oral morphine milligram equivalents (MME) were used, then five 5-mg oxycodone pill-equivalents were prescribed; if 1 to 29 MME were used, then fifteen 5-mg oxycodone pill-equivalents were prescribed; if 30 or more MME were used, then thirty 5-mg oxycodone pill-equivalents were prescribed. We considered patients' opioid pain medication needs to be satisfied if no opioid refills were obtained. To improve FDA-compliant disposal of leftover pills, we implemented patient education, convenient drop-box, reminder phone call, and questionnaire.

RESULTS

Our opioid guideline satisfied 93% (213 of 229) of patients. Satisfaction was significantly higher in lower opioid usage groups (p = 0.001): 99% (99 of 100) in the 0 MME group, 90% (91 of 101) in the 1 to 29 MME group, and 82% (23 of 28) in the 30 or more MME group. Overall, 95% (217 of 229) of patients used nonopioid analgesics. Sixty percent (138 of 229) had leftover pills; 83% (114 of 138) disposed of them using an FDA-compliant method and 51% (58 of 114) used the convenient drop-box. Of 2,604 prescribed pills, only 187 (7%) were kept by patients.

CONCLUSIONS

This clinical trial prospectively validated a patient-centered opioid discharge prescription guideline that satisfied 93% of patients. FDA-compliant disposal of excess pills was achieved in 83% of patients with easily actionable interventions.

Enhanced discharge counseling to reduce outpatient opioid use after cesarean delivery: a randomized clinical trial

BACKGROUND

Strategies to curb overprescribing have focused primarily on the prescriber as the point of intervention. Less is known about how to empower patients to use fewer opioids and decrease the quantity of leftover opioids. Previous studies in nonobstetrical populations suggest that patient counseling about appropriate opioid use improves disposal of unused opioids and overall knowledge about opioid use. Less is known about whether counseling reduces opioid use after hospital discharge.

OBJECTIVE

This study examines whether enhanced discharge counseling on optimal analgesic use after cesarean delivery reduces opioid use and improves proper disposal of unused opioids and opioid use knowledge after hospital discharge.

STUDY DESIGN

Women who underwent an uncomplicated cesarean delivery were randomized to enhanced counseling on optimal analgesic use or usual care. Enhanced counseling addressed the following 4 points: (1) pain is normal after cesarean delivery; (2) scheduled ibuprofen should be taken to maintain baseline pain control; (3) opioids should be used sparingly and should be tapered over several days; and (4) all unused opioids should be returned to pharmacy or flushed in a toilet. All participants received 30 tablets of 5 mg hydrocodone-acetaminophen and 30 tablets of 600 mg ibuprofen at discharge. They were contacted 14 days later to determine opioid use and location of leftover opioids and to complete a 10-question analgesic strategies quiz with a score of 1 to 10. We estimated that outcome data on 172 women total would provide an 80% power to detect a 30% reduction in postdischarge opioid use with enhanced counseling.

RESULTS

Notably, 79% of eligible women consented to the study and 175 of 196 participants (84 enhanced counseling, 91 usual care) completed the follow-up. Compared with usual care, the enhanced counseling group was more likely to follow recommendations for proper opioid disposal (risk ratio, 2.3; 95% confidence interval, 1.3-3.9). They also scored significantly higher on the analgesic strategies quiz (10 points [interquartile range, 9-10] vs 8 points [interquartile range, 7-9]; P<.001) than the usual care group. Although the enhanced counseling group used less opioids (7.5 tablets [interquartile range, 2-15] vs 10.0 tablets [interquartile range, 2-16]; P=.55) and a smaller proportion of prescribed opioids (25.0% [6.7-50.0] vs 33.3% [6.7-53.3], P=.55) than the usual care group, differences were not statistically significant. There was no statistically significant evidence of interaction between participant education level and any of the study outcomes.

CONCLUSION

Enhanced discharge opioid counseling doubled the frequency of participants reporting proper opioid disposal and improved overall knowledge about the risks associated with opioids. This intervention did not decrease opioid use in a population of women with low overall opioid use. These findings highlight possible methods to intervene on the short-term (misuse and diversion) and long-term (persistent opioid use) consequences of overprescribing.

Effect of a stepwise opioid-sparing analgesic protocol on in-hospital oxycodone use and discharge prescription after cesarean delivery

INTRODUCTION

Opioid exposure during hospitalization for cesarean delivery increases the risk of new persistent opioid use. We studied the effectiveness of stepwise multimodal opioid-sparing analgesia in reducing oxycodone use during cesarean delivery hospitalization and prescriptions at discharge.

METHODS

This retrospective cohort study analyzed electronic health records of consecutive cesarean delivery cases in four academic hospitals in a large metropolitan area, before and after implementation of a stepwise multimodal opioid-sparing analgesic computerized order set coupled with provider education. The primary outcome was the proportion of women not using any oxycodone during in-hospital stay ('non-oxycodone user'). In-hospital secondary outcomes were: (1) total in-hospital oxycodone dose among users, and (2) time to first oxycodone pill. Discharge secondary outcomes were: (1) proportion of oxycodone-free discharge prescription, and (2) number of oxycodone pills prescribed.

RESULTS

The intervention was associated with a significant increase in the proportion of non-oxycodone users from 15% to 32% (17% difference; 95% CI 10 to 25), a decrease in total in-hospital oxycodone dose among users, and no change in the time to first oxycodone dose. The adjusted OR for being a non-oxycodone user associated with the intervention was 2.67 (95% CI 2.12 to 3.50). With the intervention, the proportion of oxycodone-free discharge prescription increased from 4.4% to 8.5% (4.1% difference; 95% CI 2.5 to 5.6) and the number of prescribed oxycodone pills decreased from 30 to 18 (-12 pills difference; 95% CI -11 to -13).

CONCLUSIONS

Multimodal stepwise analgesia after cesarean delivery increases the proportion of oxycodone-free women during in-hospital stay and at discharge.

Postoperative Opioid Prescribing and Consumption after Hysterectomy: A Prospective Cohort Study

STUDY OBJECTIVE

To examine opioid prescribing and consumption patterns after hysterectomy and identify factors associated with postoperative opioid consumption.

DESIGN

Prospective cohort study.

SETTING

Single university medical center.

PATIENTS

Women undergoing hysterectomy for benign, nonobstetric indications.

INTERVENTIONS

Participant preoperative and surgical characteristics were obtained through chart review and patient report of baseline pain score. During the third postoperative week, participants completed a telephone interview, including a direct count of remaining opioid pills and assessment of satisfaction with pain management. We assessed factors associated with opioid consumption in oral morphine equivalents (OME) using a linear regression model.

MEASUREMENTS AND MAIN RESULTS

Of the 129 participants, 113 (88%) completed the postoperative survey after hysterectomy: 16 vaginal, 43 robotic-assisted, 42 conventional laparoscopic, and 12 abdominal hysterectomies. The median amount of opioid prescribed was 150 OME (interquartile range [IQR] 113-200), while the median amount consumed was 75 (IQR 10-135), reflecting an average consumption of about 50% of the prescription. Opioid prescription size was associated with consumption; for every additional oral morphine equivalent prescribed, on average, an additional 0.5 was consumed (p <.001). If the indication for hysterectomy was related to pain, participants consumed 25.3 additional OME (p = .04). The amount of opioid prescribed was inversely correlated with pain management satisfaction; every additional point on a 1 through 5 Likert scale of increasing satisfaction was associated with 44 fewer OME prescribed (standard error 9 OME, p <.001). For the 1464 total unused pills among the 104 participants with leftover opioids, only 20% reported an Food and Drug Administration -compliant opioid disposal plan.

CONCLUSION

Gynecologic surgeons can respond to the opioid epidemic by reducing excess opioid pills after hysterectomy by providing both the smallest effective prescription size and concrete resources for safe opioid disposal. These actions may contribute to a reduction in opioid use disorder cases or overdose deaths.

Evaluation of a new departmental policy to decrease routine opioid prescribing after vaginal delivery

BACKGROUND

In line with a nationwide commitment to decrease opioid prescribing, in October 2017, our department implemented a new departmental policy to cease routine provision of opioid prescriptions at the time of discharge following vaginal delivery.

OBJECTIVE

This study aimed to evaluate the effect of this policy on the number of discharge opioid prescriptions provided and outpatient encounters observed postpartum.

STUDY DESIGN

This was a retrospective cohort study of patients who underwent vaginal delivery at our institution from November 2016 to January 2018. We reviewed delivery and postpartum records for patients 18 years or older, without chronic opioid use or contraindication to nonsteroidal antiinflammatory medication use. The primary outcome was the proportion of patients provided with an opioid prescription at the time of discharge following vaginal delivery. The secondary outcome was the number of unscheduled patient encounters related to pain in the 6-week postpartum period. Fisher's exact test was used to compare these outcomes before and after implementation of the new departmental opioid-prescribing policy.

RESULTS

A total of 1188 charts were reviewed; among those charts, 810 met the inclusion criteria. Notably, 405 patients delivered before the guideline, and 405 patients delivered after its implementation. After the implementation of the new departmental policy, there was a 10-fold decrease in opioid prescriptions provided from 323 (79.8%) to 29 (7.2%) (P<.01). Although the number of unscheduled outpatient encounters postpartum increased slightly from 22 to 37 encounters after the implementation of the new departmental policy, this difference was not statistically significant (P=.08).

CONCLUSION

Limiting opioid prescribing after vaginal delivery is associated with a considerable decrease in the number of discharge opioid prescriptions provided and does not significantly increase the number of outpatient encounters related to pain postpartum.